CDE Appendix 1 Literature Review - Central East Local Health ...

The Culture, Diversity and Equity Project: Literature Review
Though not all training frameworks cover all of these areas equally, this tripartite framework for cultural
competence training has been likened to a three-legged stool: “the structure would fail if one ‘leg was missing”
(California Endowment, 2003).
Educational initiatives and curriculum for medical/health-care professionals, in US post-secondary institutions,
increasingly incorporate cultural competence standards. This contrasts with the trend in continuous education and
professional training for existing health care professionals.
A 2004 paper in the Journal of the American Medical Association, for instance, found that among nearly 8,000
graduate medical educational programs surveyed in the United States, 50.7 percent offered cultural competence
training in 2003–2004. This was up from 35.7 percent in 2000–2001 (Brotherton, 2004 cited in Betancourt et al.,
2005). Unfortunately, no corresponding study exists in the Canadian context.
The reason for this transformation may be a combination of ‘stick’ and ‘carrot’ approaches that the LHINs would do
well to adopt in its continuing educational initiatives for health professionals (Betancourt et al., 2005).
The ‘stick,’ in this respect, has taken the form of increasing regulatory pressures and the introduction of cultural
competence accreditation standards since 2002. In that year, the US Liaison Committee on Medical Education
(LCME) introduced the first official cultural competence accreditation standard requiring that all medical schools
integrate cultural competence into their curricula.
The US Accreditation Council of Graduate Medical Education (ACGME) has also introduced cultural competence
standards for residency programs (see ACGME, 2004). New Jersey has gone even further with the ‘stick approach,’
passing legislation in 2005 requiring cultural competence education as a condition for licenses to health care
professionals (see Salas-Lopez et al., 2007; also see Baquet et al., 2004).
The ‘carrot approach’ has also helped to move cultural competence forward in the medical education field. In 2004,
the New York State of Health modified its $33 million per year Graduate Medical Education Reform Incentive Pool
to “reward residency programs that provide eight hours of cultural competence training to at least 80 percent of
residents” (New York State Dept of Health, 2004 cited in Betancourt et al., 2005). Demonstrating the effectiveness
of this ‘carrot’ approach, “[i]n the first year, 66 of the 104 residency programs in New York State proposed new
cultural competence curricula” (ibid.). A similar method could be used by the LHINs by means of their funding
leverage.
Cultural competence training for practicing health care professionals, by contrast, remains “haphazard and varying
in quality.” This is largely due to the lack of agreed-upon evaluative criteria for assessing cultural competence
training (California Endowment, 2003).
The development of training standards in continuous educational contexts is a key area for future research. In the
meantime, standards and evaluative tools (such as the Tool for Assessment of Cultural Competence Training) for
medical school cultural competence education could be adapted to continuous learning contexts.
One of the greatest limitations of the existing cultural competence training literature is the lack of empirical
evidence substantiating the effectiveness of cultural competence training interventions. The impact of training is
rarely evaluated, and is done so using poor methodological design. Without scientific evidence it remains difficult to
determine which cultural competence training most effectively improves health outcomes for disadvantaged,
marginalized and/or ethno-racial minority clients.
While there is evidence that diversity and cultural competence training can change attitudes, research suggests that
this alone does not translate into behavioural change or better client health outcomes. According to recent
assessment by Curtis et al (2007), too many of the existing cultural competence training initiatives for health care
professionals still begin and end with awareness-building.
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