Erin A. Strong
JSNMA Peer Editor
MPH Candidate 2010, California State University, San Bernardino
Scholarly articles on the topic of cultural competence commonly cite three realities (Betancourt, Green, Carrillo & Park, 2005). First, the population of the United States is rapidly becoming more diverse in its racial and ethnic demography (U.S. Census Bureau, 2009). Second, significant disparities exist between racial and ethnic groups in the U.S. population (Smedley, 2002). Finally, in order to prevent these disparities from worsening and to eventually eliminate health disparities, it is necessary to develop a more diverse and culturally competent health care workforce and delivery system (Smedley, 2004). While the rationale behind efforts to promote cultural competence is relatively straightforward, the number of studies that report quantifiable outcomes for such interventions is limited. The growing body of evidence suggests, however, that culturally competent interventions implemented at multiple levels of the health care system can be effective in improving health outcomes in minority populations.
Before exploring the results of cultural competence interventions, it is important to understand the term. Different sources offer different definitions, but cultural competence can generally be defined as a set of congruent attitudes, behaviors, knowledge and skills that enable health care organizations and professionals to effectively provide care for patients and populations of diverse social and cultural backgrounds (The Commonwealth Fund, 2002). In order for strategies in cultural competence to be effective, interventions should be implemented at all levels of the health care system. Betancourt et al. (2003) describe the need for interventions at the organizational level addressing leadership and workforce, the structural level addressing processes of care delivery, and the clinical level addressing patient-provider interaction. Interventions are needed at the educational, policy and community levels as well.
A review of the current literature was conducted to identify studies that documented quantitative improvements in health outcomes resulting from cultural competence interventions at the clinical and community levels. The review was limited to interventions addressing chronic diseases, such as hypertension, stroke, cancer, diabetes, asthma and cardiovascular disease, in racial and ethnic minority groups. Programs that promoted healthy eating, physical activity and weight loss as a means of relieving or preventing chronic diseases were also considered.
Studies described a wide variety of approaches to planning, implementing and evaluating the cultural competence interventions reviewed. In general, the interventions incorporated language, music, dance, ethnic food choices, common health-related values, beliefs and customs, and community contexts. In African-American communities, churches and faith-based organizations served as sites for participant recruitment and program implementation (Erwin, Spatz, Stotts, & Hollenberg, 1999; Fitzgibbon, Stolley, Schiffer, Sanchez-Johnson, Wells, & Dyer, 2005). In Latino and Hispanic communities, interventions were organized around promotoras and community health workers (Balcazar, Alvarado, Hollen, Gonzalez-Cruz, & Pedregón, 2005; Culica, Walton, Harker, & Prezio, 2008; Balcazar, Alvarado, Cantu, Pedregón, & Fulwood, 2009). Settings such as beauty salons, barbershops and schools were also utilized (Kleindorfer, Miller, Sailor-Smith, Moomaw, Khoury, & Frankel, 2008; William, Noble, 2008). These studies suggest that the use of community resources, including facilities and local residents, along with community input in the process of program development, contributes to the success of culturally competent interventions.
The quantitative outcomes of the interventions were organized into the following three categories: 1) improved metabolic or physiological control, 2) disease knowledge and self-management, and 3) utilization of services and reduced health care expenditures.
First, a number of improved physiological outcomes were reported, depending on the intervention’s targeted chronic disease. Common measures included glycosylated hemoglobin, fasting blood glucose, body mass index, weight, cholesterol, triglycerides and blood pressure (Brown & Hanis, 1999; Anderson-Loftin, et al., 2002; Brown, 2002; Balcazar 2005; Balcazar 2009). Reduced dietary fat intake was also listed as an improvement in health outcomes for diabetes education programs (Anderson-Loftin, et al., 2005; Stolley, Sharp, Oh, & Schiffer, 2009), as well as trends in reduced lipids (Anderson-Loftin, 2002; Anderson-Loftin, 2005).
Second, improved knowledge of chronic disease and self-management were reported. In a study documenting a stroke education program targeting African-American women in beauty shops, Kleindorfer et al. (2008) found that participants had an increased knowledge of warning signs for stroke and knew to contact emergency services when those symptoms were observed. In a study by Williams and Noble (2008), elementary school children were taught about stroke localization, stroke terminology, and the appropriate use of emergency services. Improved disease knowledge was also an important outcome for diabetes education programs (Brown, 2002). Outcomes showed that culturally competent interventions had the potential to increase patient participation and retention in educational and care management programs (Corkery, Palmer, Foley, Schechter, Frisher, & Roman, 1997; Galasso, Amend, Melkus, & Nelson, 2005; Hornberger, Itakura, & Wilson, 1997).
Finally, culturally competent interventions addressed utilization of health care services and related health expenditures and costs. In a study by Earp et al. (2002), lay health advisors were utilized to reach an increase of six percentage points for mammography use among African-American women in a rural community. The study also found an increase of 12 percentage points for mammography use among participants at a lower level of income. While increased use of screening and preventive services was important to cancer interventions, a decrease in service utilization was the goal of interventions for asthma and diabetes. Tatis et al. (2005) found that emergency department visits and hospitalizations decreased among Latino adults suffering from asthma in an inner-city population. Similarly, Canino et al. (2008) found that Puerto Rican children whose families participated in the intervention were less likely to make emergency visits or to be hospitalized as a result of complications due to asthma. A reduction in such acute care visits was also related to reduction in health care costs, as was found in a study by Anderson-Loftin et al. (2002) addressing diabetes in a rural African-American community.
Common limitations were noted among the studies, including lack of control group for the intervention (Kleindorfer, 2008; Williams, 2008; Stolley, 2009), small sample size (Stolley, 2009), potential selection bias (Fitzgibbon, 2005; Kleindorfer, 2008), and drop-out bias (Fitzgibbon, 2005, Kleindorfer, 2008). Another limitation was that community-based interventions are often specific to their sample populations and the cultural and social contexts of those populations. Therefore, it is difficult to generalize the results (Fitzgibbon, 2005; Williams, 2008; Stolley, 2009). Still, researchers concluded that the positive outcomes were sufficient to encourage continued and expanded culturally competent interventions in the future as an effective means to combat chronic disease in underserved and disadvantaged communities.
Cultural competence is a growing field within health care with the potential to significantly reduce the barriers that patients from racial and ethnic minorities face in receiving adequate health care. Cultural competence may also play a key role in eliminating the health disparities that exist between groups in the United States. The body of literature that validates the relationships between cultural competence and minority medicine is still developing. This review was not exhaustive, but a brief overview of the available literature shows that appropriate interventions can yield quantitative improvements. Researchers have concluded that these positive outcomes are sufficient to encourage continued and expanded cultural interventions in the future as an effective means to combat health disparities in racial and ethnic communities. Future research should move toward establishing documented successful interventions as evidence-based best practices in minority medicine and public health.
Anderson-Loftin, W., Barnett, S., Bunn, P., Sullivan, P., Hussey, J., & Tavakoli, A. (2005). Soul food light: culturally competent diabetes education. Diabetes Education. 31(4): 555-663.
Anderson-Loftin, W., Barnett, S., Sullivan, P., Bunn, P.S., & Tavakoli, A. (2002). Culturally competent dietary education for southern rural African Americans with diabetes. Diabetes Education. 28(2): 245-257.
Balcazar, H., Alvarado, M., Cantu, F., Pedregón, V., & Fulwood, R. (2009). A promotora de salud model for addressing cardiovascular disease risk factors in the US-Mexico border region. Preventing Chronic Disease. 6(1): A02.
Balcazar, H., Alvarado, M., Hollen, M.L., Gonzalez-Cruz, Y., & Pedregón, V. (2005). Evaluation of Salud Para Su Corazón (Health for Your Heart) – National Council of La Raza Promotora Outreach Program. Preventing Chronic Disease. 2(3): A09.
Betancourt, J.R., Green, A.R., Carrillo, J.R., & Ananeh-Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports. 118(4): 293-302.
Betancourt, J.R., Green, A.R., Carrillo, J.R., & Park, E.R. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499-505.
Brown, S. A., Garcia, A.A., Kouzekanani, K., & Hanis, C.L. (2002). Culturally competent diabetes self-management education for Mexican Americans: the Starr County border health initiative. Diabetes Care. 25(2): 259-68.
Brown, S.A. & Hanis, C.L. (1999). Culturally competent diabetes education for Mexican Americans: The Starr County Study. Diabetes Education. 25(2): 226-236.
Canino, G., Vila, D., Normand, S.L., Acosta-Perez, E., Ramirez, R., Garcia, P., & Rand, C. (2008). Reducing asthma health disparities in poor Puerto Rican children: The effectiveness of a culturally tailored family intervention. J Allergy Clin Immunol 121(3): 665-670.
Commonwealth Fund. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York, NY: Betancourt, J.R., Green, A.R., Carrillo, J.E.
Corkery, E., Palmer, C., Foley, M.E., Schechter, C.B., Frisher, L., & Roman, S.H. (1997). Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population. Diabetes Care. 20(3): p. 254-7.
Culica, D., Walton, J.W., Harker, K., & Prezio, E.A. (2008). Effectiveness of a community health worker as sole diabetes educator: Comparison of CoDE with similar culturally appropriate interventions. J Health Care Poor Underserved. 19(4): 1076-1095.
Earp, J. A., Eng, E., O’Malley, M.S., Altpeter, M., Rauscher, G., Mayne, L., … Qaqish, B. (2002). Increasing use of mammography among older, rural African American women: results from a community trial. Am J Public Health. 92(4): 646-654.
Erwin, D.O., Spatz, T.S., Stotts, R.C., & Hollenberg, J.A. (1999). Increasing use of mammography among older, rural African American women: Results from a community trial. Cancer Practice, 7(2): 78-85.
Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Sanchez-Johnson, L.A., Wells, A.M., & Dyer, A. (2005). A combined breast health/weight loss intervention for Black women. Preventive Medicine, 40(4): 373-383.
Galasso, P., Amend, A., Melkus, GD, & Nelson, GT. (2005). Barriers to medical nutrition therapy in black women with type 2 diabetes mellitus. Diabetes Education. 31(5): p. 719-25.
Hornberger, J., Itakura, H., & Wilson, S.R. (1997). Bridging language and cultural barriers between physicians and patients. Public Health Reports. 112(5): p. 410-7.
Kleindorfer, D., Miller, R., Sailor-Smith, S., Moomaw, C.J., Khoury, J., & Frankel, M. (2008). The challenges of community-based participatory research: The beauty shop stroke education project. Stroke. 39(8): 2331-2335.
Smedley, B.D., Stith, A.Y., & Nelson, A.R., (Eds.). (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington: National Academies Press.
Smedley, B.D., Butler, A.S., & Bristow, L.R., (Eds.). (2004). In the nation’s compelling interest: Ensuring diversity in the health care workforce. Washington: National Academies Press.
Stolley, M. R., Sharp, L.K., Oh, A., & Schiffer, L. (2009). A weight loss intervention for African American breast cancer survivors, 2006. Preventing Chronic Disease. 6(1): A22.
Tatis, V., Remache, D., & DiMango, E. (2005). Results of a culturally directed asthma intervention program in an inner-city Latino community. Chest 128(3): 1163-7.
U.S. Bureau of the Census. (2009). Population Division National Estimates, “Annual Estimates of the Resident Population for the United States, Regions, and Puerto Rico: April 1, 2000 to July 1, 2008. Retrieved from http://www.census.gov/popest/states/NST-ann-est.html.
William, O., Noble, J.M. (2008). ‘Hip-hop’ stroke: A stroke education program for elementary school children living in a high-risk community. Stroke. 39(10): 2809-2816.
This article first appeared in the Summer 2010 JSNMA, Volume 15, Number 4
Filed Under: Scientific Focus
About the Author: firstname.lastname@example.org