Noura A. Abouammoh

3.2.1 Cultural competence and quality of healthcare

The Institute of Medicine in the US has defined quality in health care as

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Lohr, 1990, p.21)

The UK NHS identifies the quality of its care by looking at patients’ safety, the effectiveness of the treatment received, and patients’ feedback about the care received (NHS, 2013 a). According to the Care Quality Commission (CQC) in the UK, these elements can be delivered by effective collaboration between patients and physicians, clear communication and explanation, and providing what they described as “compassionate” care that considers human rights when dealing with patients (NHS, 2013 b, NHS, 2013).

According to Donabedian (1988), quality can be looked at from three positions: structural quality which includes health system characteristics, process quality which is concerned with patient-physician communication, and outcome quality which proposes evidence on changes of patients’ health status. Although outcome is considered a measurement of quality, it has been argued that patients perceive quality in terms of providers’ approach in areas such as communication and rapport building style, rather than physicians’ technical styles in relieving symptoms (Chilgren, 2008).

As mentioned in 2.5, healthcare can be described as “culturally competent” if both professionals and organisations work together to equip themselves with the appropriate skills and systems. In addition, quality healthcare should be achieved at all structural, process and outcome levels. This section of the literature review focuses on the quality of care at the patient-physician interpersonal level and its relationship to quality care.

3.2.2 The effectiveness of cultural competence interventions

The plethora of literature that examined the effectiveness of cultural competence training led to several recent efforts to systematically review this issue (Allen, 2010, Beach et al., 2005, Chipps et al., 2008, Henderson et al., 2011, Lie et al., 2011, Renzaho et al., 2013). This search yielded seven systematic reviews, all of which were included to ensure coverage of all findings. Among the systematic reviews, there was an overlap of ten studies, which were included in at least two different reviews (Wade and Bernstein, 1991, Way et al., 2002, Mazor et al., 2002, Majumdar et al., 2004, Thom et al., 2006, Crandall et al., 2003, Gallagher-Thompson et al., 2000, Smith, 2000, Tang et al., 2002, Williamson et al., 1996).

The reviews differ in their scope and the population on whom they focused in order to find the effect of cultural competence interventions. Chipps et al (2008), for example, were interested in reviewing studies on the effectiveness of cultural competence training for health professionals, specifically in community-based rehabilitation centres. Additionally, some of the reviews looked at providers in general, including physicians and nurses (Chipps et al., 2008, Beach et al., 2005), others focused on nursing students (Allen, 2010) or health care professionals and/or students (Renzaho et al., 2013, Lie et al., 2011) while some were additionally interested in studies that included patients’ input concerning this issue (Lie et al., 2011). Furthermore, some of the reviews focused on patient-centred care training, which included cultural competence components (Renzaho et al., 2013) or the effect of the latter on patient-centred outcomes (Lie et al., 2011).

Beach et al., who reviewed 34 studies that evaluated cultural competence interventions on students, physicians, nurses and health workers, published their first review in 2005. The review found strong evidence that suggested that cultural competence training improves health professionals’ knowledge of patients from different cultures, as well as making their attitude towards these patients more positive, thus enhancing their skills in dealing with them. They also found that cultural competence training impacts patients’ satisfaction. A subsequent study undertaken by Carter et al. (2006) assessed the effectiveness of cultural competence workshops on 196 third year medical students’ attitudes in the US, using a cultural attitudes and belief scale which contained 11 items. Carter et al’s (2006) found significant positive attitudinal changes in relation to most of the items post-workshops compared to pre-workshops.

Similar findings were found in the Chipps et al. (2008) review, which included the former review (Beach et al., 2005), in addition to five more studies, and focused mainly on evaluating cultural competence training in community-based rehabilitation centres.

Lie et al. (2011) and Renzaho et al. (2013) examined the effectiveness of cultural competence training on patient-centred outcomes and on patient-centred care, respectively, incorporating cultural competence components. The reviews suggested that training healthcare workers in patient-centred, culturally competent care increases their awareness, knowledge levels in terms of dealing with culturally diverse populations, cultural sensitivity and patient satisfaction.

Allen (2010) in his review examined the effect of cross-cultural care and anti-racism education on nursing students. He included 13 studies in his review, and found that while cultural competence training showed positive attitudinal and belief changes, racism persisted despite anti-racism education. It should be mentioned however, that the review only found one study that included anti-racism education (Hagey and MacKay, 2000).

A systematic review by Henderson et al. (2011) looked at the effectiveness of culturally appropriate interventions to manage or prevent chronic diseases in ethnically diverse populations. The review included 24 studies focusing on the use of interpreters, bilingual providers and cultural competence training. Only four studies looked at cultural competence training for healthcare providers. These studies were conducted in three different countries, the US, Canada and Switzerland, and their findings suggested that better patient-provider communication and understanding, providers’ ability to offer more information regarding future care, and patients’ satisfaction with care, could be achieved with providers trained in cultural competency (Henderson et al., 2011).

The Cochrane Library published the most recent review on cultural competence education for health professionals, in 2014 (Horvat et al., 2014). In their review they included randomized controlled trials (RCTs) measuring primarily patient-related outcomes and health professionals-related outcomes as secondary outcomes. They included only five studies, as the majority of the papers in the literature were not RCTs, and patients’ outcomes were not part of their study design. The review referred to two of the reviews mentioned earlier (Beach et al., 2005, Lie et al., 2011), which included a broader range of studies. Beach et al, (2005) had one study in common with this review while Lie et al, (2011), which included seven studies, had four in common with this review.

All the reviews that were included provided a description of the duration and type of interventions, such as educational sessions, workshops and audio and/or visual aids. The training curricula of all the studies featured in the reviews, unless not specified, are based on previously developed models. Price et al. (2005) stated that there are no standard guidelines to help educators to effectively design cultural competence interventions.

However in general, although most of the evidence in this field was described to be of low to moderate quality (Lie et al., 2011, Chipps et al., 2008, Price et al., 2005, Horvat et al., 2014), they all showed positive changes on the providers’ side and satisfaction from patients’ perspective following cultural competence interventions. The reviews did not specify the most effective type of intervention.

It can be concluded that health professionals’ cultural competence can positively influence quality of care through improving physicians’ attitudes and skills relating to caring for patients from different cultural backgrounds, thereby improving patients’ satisfaction.