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  • Study: 'Cultural Competence' May Not Affect Health Disparities

    "Patchy" and "sparse"—those are the words used by authors of a US Department of Health and Human Services (HHS) report to describe the state of research into cultural competence and its effects on health disparities. And that patchy, sparse research could mean that the term "cultural competence" is outdated, at least when it comes to its usefulness as a way to address the equity of interventions among different populations, they say.

    The findings appear in a recently released "Comparative Effectiveness Review" from the HHS Agency for Healthcare Research and Quality (AHRQ). In the review, a multidisciplinary team describes its attempt to track down high-quality research into the kinds of cultural competence interventions used in health care, and whether those interventions actually affected health disparities. Bottom line: there isn't much research out there, much of it doesn't produce high-quality evidence, and almost none of it actually looks at the interventions' effects on disparities.

    After identifying more than 37,000 possible citations, 56 were ultimately identified as being appropriate for study. Of those, 39 were randomized controlled trials; the remaining studies were observational studies (15) or systematic reviews (2). The studies were clustered around interventions related to 3 groups: individuals with (physical and/or intellectual) disabilities; individuals in the LGBT population; and individuals who are members of racial and ethnic minorities.

    The 170-page report contains detailed information on the review process and findings for each group, but the researchers' conclusions in each area were virtually identical: "patchy" or "sparse" literature that fails to recognize intrapopulation differences, neglects the ways other cultures may intersect with the group at hand, or does not go into sufficient representative detail.

    Researchers found that the most prevalent type of cultural competence intervention was provider training, but they found "little evidence" that the trainings are effective at reducing disparities.

    "Long-term effects of such programs on provider behavior in the clinical setting and … patient health outcomes have not been evaluated," authors write. "Further, traditional provider cultural competence trainings based on attributions of a culture have the potential for unintended consequences, such as reinforcing stereotypes or increasing stigma."

    Also lacking, according to researchers, is "a better understanding of how cultural competence differs between and within groups."

    "For example, people with a physical disability experience more screening disparities because of limitations of the physical plant, whereas people with intellectual disabilities are more likely to not have secondary conditions diagnosed and treated," they write. "The interventions to address these disparities must also be different."

    Authors wonder whether the problems, and lack of good evidence, point to the need for a new approach that dispenses with the idea of "cultural competence" and focuses instead on outcomes for individuals who experience health disparities.

    "The 'cultural competency' label itself might be outdated, because it emphasizes the 'internal culture' of groups," they write. "A more useful term might be 'equity interventions,' which emphasizes equity as the desired outcome. More important than labels is that interventions address structural barriers faced by priority populations in order to attain health equity."

    APTA offers a webpage focused on racial and ethnic health disparities that includes a resource on addressing health care disparities with cultural competence in the clinic. In addition, the APTA learning center offers a professionalism module focused on cultural competence, as well as course titled "Developing Cultural Competence in a Multicultural World."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

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