Cultural Competence: A Systematic Review of Healthcare Provider Education Interventions Mary Catherine Beach, MD, MPH Eboni G. Price, MD Tiffany L. Gary, PhD Karen A. Robinson, MSc Aysegul Gozu, MD Carole Smarth, MD Ana Palacio, MD, MPH Mollie W. Jenckes, MHS, RN Carolyn Feuerstein, BA Eric B. Bass, MD, MPH Neil R. Powe, MD, MPH, MBA Lisa A. Cooper, MD, MPH The Johns Hopkins Evidence-based Practice Center, Baltimore, MD Funded by the Agency for Healthcare Research and Quality

Cultural Competence of Health Professionals The ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences 1 Suggested to reduce disparities in healthcare for racial/ ethnic minority patients Required by ACGME for professionalism Little systematic evaluation of its potential 1 Cooper LA, Roter DL. in Unequal Treatment. Washington, DC: Natl Academies Press, 2003

Study Aim To determine the effectiveness and costs of interventions designed to improve cultural competence of health professionals

Study Design Systematic review of all interventions to reduce disparities or improve healthcare quality for racial/ethnic minorities Electronic Searches –MEDLINE, the Cochrane CENTRAL Register of Controlled Clinical Trials, EMBASE, and specialty databases Hand Searches –Reference lists of all eligible articles

Inclusion Criteria Exclusion Criteria Intervention focused on cultural competence Intervention targeted at health professionals Adequate evaluation of intervention (pre/post or controlled trial) Published prior to 1980 Not in English No original data Meeting abstract (no full article for review)

Review Process 2 reviewers reviewed all abstracts and articles for eligibility Differences between reviewers adjudicated If article eligible, we –Graded article quality using previously validated, standardized forms –Abstracted data related to targeted providers and settings, curricular content, teaching methods, evaluation methods, and outcomes

Synthesis/ Evidence Grading Overall Score Domains QuantityConsistency Quality BiasObjective Assessment A - Excellent>=3Consistent>= 1 RCT>=75% studies B – GoodReasonably consistent >= 1 controlled trial >=50% C - Fair>=2InconsistentNo controlled trials >=25% D - Poor>=1<25%

Results: Literature Search and Eligibility Electronic Databases 4309 Hand Searching 79 Retrieved 4388 Abstract Review 3709 Article Review 281 Eligible articles 34 Duplicates 679 Excluded 3421 Unable to Review 7 Excluded 247

Characteristics of Studies (N=34) nn Study DesignSetting Pre/Post20 U.S.29 Control14Subjects Physicians18 Publication YearsObjective Evaluation Yes Intervention Description > Complete16

Curricular Methods and Content Methods nContent n Lectures19Specific Cultures26 Discussion17General Concepts19 Case Scenarios13Language10 Role Play12MD-PT Interactions 8 Small Group11Access 3 Clinical Experience10Racism 2 Interaction with others 9SES 2 Audio-visual 9 Cultural Immersion 8

Effects of Cultural Competence Training

Interventions that Improved Patient Satisfaction/ Adherence InterventionTargetDuration Spanish languageED physicians20 hours Training in attitudes that low-income AA women might bring to counseling Mental health counselors 4 hours State mandated training program including cultural competence Mental health clinics 3 days

Summary of Effectiveness Level of EvidenceOutcome Excellent evidenceProvider knowledge and attitudes Good evidenceProvider skills and patient satisfaction Poor evidencePatient adherence No evidenceImpact on patient health Which types of training are most effective

Costs Costs of international travel (3 articles) –all required students to pay part or all of the costs ~ $ per student Costs of classroom instruction (2 articles) –20 hours of Spanish-language classes for 9 physicians = $2000 (2000) –60 hours of classroom instruction for 19 students $3000 (1994)

Conclusions Excellent or good evidence that cultural competence training can improve provider knowledge, attitudes, and skills and patient satisfaction Poor or no evidence that cultural competence training can improve patient adherence or health outcomes More comprehensive and rigorous studies are needed to guide education in cultural competence

Limitations of Literature Each curricular intervention was different; generalizability across studies difficult No standard instruments for measuring cultural competence Few studies –describe interventions well enough to permit replication –measured patient outcomes –included data on costs

Implications for Future Research Use study designs that minimize bias Develop/ use reliable instruments to measure cultural competence Assess outcomes objectively and include patient outcomes Replicate existing curricula Compare different curricular methods Include data on costs