Assessing Cultural Competency and Public Health Outcomes

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Gilbert Michaud
October 19, 2017

As a means to address the level of racial and ethnic disparities in the provision of health care, cultural competency creation is a commonly proposed approach toward improving patient outcomes. However, there remains a basic need in terms of gathering evidence that cultural competency training truly reduces health disparities. Many state Departments of Public Health or similar agencies would like to better understand the level of cultural competence of nurses and other public health practitioners and whether this aligns with the satisfactory level of health care delivery. This is important and worth studying since periodic cultural competency training programs may be an approach to ensuring an advanced level of health care provision – it is often speculated that if health care providers can serve clients while considering their languages/traditions and respecting their approaches of health, there should be an increasing client satisfaction with quality of care and an eradication of inequalities in health care.

As the U.S. demographic makeup continues to become more diverse, it becomes of increasing importance for health care professionals to seek out a higher sense of cultural knowledge and competence. According to Hawala-Druy & Hill, cultural competence refers to the “process in which the health care provider continuously strives to achieve the ability to work effectively within the cultural context of a client, individual, family or community.” Numerous research reports have cited cultural competency as a key determining factor to health disparities in different settings, which Berkowitz and McCubbin define as “population-specific differences in the presence of disease, health outcomes, or access to health care.”

Various studies have addressed the cultural competency issue in the health arena, with an assortment of outcomes. Several have employed cluster randomized control trials to evaluate the impact of cultural competency training on patient outcomes, often focused on client trust and satisfaction, but sometimes also on specific health measurements such as cholesterol levels and blood pressure levels. One thought-provoking study by Sequist showed that cultural competency training increased “clinician awareness of racial disparities in diabetes care but did not improve clinical outcomes among black patients.” A variety of other studies (see Majumdar and Zajacova, Rogers, & Johnson-Lawrence) have found similar results, surprisingly citing no or marginal impact of training programs on patient satisfaction measures or specific health outcomes.

Nevertheless, many more researchers have found a strong positive correlation between levels of cultural competency and patient outcomes. For instance, Mancoske conducted a study of a public children’s mental health program using a quasi-randomized controlled trial of a convenience sample (primarily African-American), finding significant relationships between “cultural competence of the provider and better overall clinical outcomes including access, participation, satisfaction and service outcomes.” A variety of other studies have cited a conclusive affiliation between cultural competency levels and health care outcomes (see Lucas; Mazor; McElmurray; and Starr & Wallace).

Certainly, inconsistencies exist among variables and ways to explain the relationship between levels of cultural competency and health care outcomes. The inconsistency among prior findings creates a need for administrators and policymakers to conduct their own research about hospitals in their jurisdictions that seek to answer whether higher levels of cultural competency truly positively impacts patients’ healthcare outcomes. In turn, having a better understanding of this issue, particularly in specific geographies, helps inform whether competency training is a worthy activity, and, more broadly, decisions regarding hospital staffing, budgets, etc.

One existing tool to make such assessments is the Nurse Cultural Competency Scale (NCCS). The NCCS was developed based on extensive research and the need for a strategy/tool to accurately assess cultural competency among nurses. The scale is comprised of 41 items which measure factors such as cultural knowledge, sensitivities and awareness. If administrators were to employ such a tool, this would not only help to clarify the effectiveness of cultural competency training for health care providers, but also raise the question as to whether such training ought to be explored in other service-related professions.

Due to the complexities that exist with regard to patient data and confidentiality, future studies should use these types of tools and explore quantifying health disparities in terms of a patient’s perceived health care outcome, perhaps focused on patient satisfaction and trust. This is a much more unobtrusive way of measuring and gathering data, and self-rated health care outcomes/conditions are a widely employed method in previous research. Not only are there too many complications in terms of authorization and privacy of specific health outcomes, but there is also difficulty in providing clarity and consistency among the range of diseases, illnesses and reasons for hospital visits.

It is apparent that many complexities exist when exploring the level of cultural competency among nurses and related health care practitioners today. In recent years, public officials and health care administrators have been progressively concerned with developing a robust system of health provision, yet the debate remains as to what approach(es) should be taken. This issue needs to be better understood through evidence-based, practical approaches so that administrators can assess the feasibility of using public funds to conduct such trainings for their employees.

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Author: Dr. Gilbert Michaud is an Adjunct Assistant Professor & Cluster Analyst at the Voinovich School of Leadership and Public Affairs at Ohio University. Michaud can be reached at [email protected].

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