Concordance facilitates access in diabetes care-service provider perspectives of service improvement and cultural competency

Aims Inequalities between different ethnic groups in diabetes care and outcomes are well documented in the UK. This research sought to explore and understand how national and local policy interventions impacted upon access and the development of culturally competent diabetes services from the care provider perspective. Methods This paper describes the care provider perspective of access to diabetes care in ethnically mixed populations from a thematic analysis of 14 semi-structured interviews conducted with professionals, at three study sites, with different roles in the diabetes care pathway. Results National policy level initiatives to improve quality have led to quality improvements at a practical level. These achievements, however, have been unable to address all aspects of care that service providers identified as important in facilitating access for all patient groups. Concordance emerged as a key process in improving access to care within local systems and barriers to this exist at different levels and are greater for some groups of patients compared with others. Conclusions Concordance is a key concept that underpins access and cultural competency in diabetes service improvement. A focus on concordance at different levels within local systems may improve access to quality diabetes care for ethnic minority groups.     

The Role of a Community-Based Satellite Clinic in the Perinatal Care of Non-English-Speaking Immigrants

In the provision of health care to non-English-speaking immigrants, cultural and linguistic barriers often deter both access to and use of needed services. This is especially true of the preventive health interventions such as perinatal care and family planning that contribute significantly to reproductive health.Alternative approaches to overcoming barriers to care are being taken in an urban health department clinic serving as a satellite perinatal resource to a group of low-income Chinese-speaking immigrants. The clinic, with service linkages to San Francisco General Hospital Medical Center and the Health Department of San Francisco City and County, is an example of culturally appropriate comprehensive perinatal care. Such an institution has helped recent immigrants adapt to their new environment and learn to use health services effectively.     

The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care

Diverse advocacy groups have pushed for the recognition of cultural differences in health care as a means to redress inequalities in the U.S., elaborating a form of biocitizenship that draws on evidence of racial and ethnic health disparities to make claims on both the state and health care providers. These efforts led to federal regulations developed by the U.S. Office of Minority Health requiring health care organizations to provide Culturally and Linguistically Appropriate Services. Based on ethnographic research at workshops and conferences, in-depth interviews with cultural competence trainers, and an analysis of postings to a moderated listserv with 2,000 members, we explore cultural competence trainings as a new type of social technology in which health care providers and institutions are urged to engage in ethical self-fashioning to eliminate prejudice and embody the values of cultural relativism. Health care providers are called on to re-orient their practice (such as habits of gaze, touch, and decision-making) and to act on their own subjectivities to develop an orientation toward Others that is “culturally competent.” We explore the diverse methods that cultural competence trainings use to foster a health care provider’s ability to be self-reflexive, including face-to-face workshops and classes and self-guided on-line modules. We argue that the hybrid formation of culturally appropriate health care is becoming detached from its social justice origins as it becomes rationalized by and more firmly embedded in the operations of the health care marketplace.     

The Changing Alaskan Experience—Health Care Services and Cultural Identity

Before Western contact, Alaskan Native populations were self-sufficient in their health practices. Slowly, the Native health care system was replaced by a Western one which was highly effective in treating infectious diseases. As infectious diseases were brought under control by the Indian Health Service, the emergent leading health problems were related to violence, attributed in part to cultural disintegration. New types of Native health providers and new Native-controlled institutions evolved to provide culturally appropriate health and mental health services and to promote a stronger cultural identity.     

Race and ethnicity are not primary determinants in utilizing veterinary services in underserved communities in the United States

A retrospective database analysis (2011–2015) evaluated associations between race and ethnicity and veterinary service utilization by sampling 83,260 companion animals whose guardians (owners) self-identified as White, Black, or Latino/a from 39 Humane Society of the United States Pets for Life (PFL) sites across the United States. Controlling for socioeconomic status, the percentage of nonhuman animals sterilized through PFL whose owners were Latino/a or Black was substantially higher than in previously reported findings. While Latinos/as had the highest mean number of days from first contact with the program to consent, they also had the highest percentage of owners accepting the voucher during initial contact. Logistic regression models suggested that although meaningful, race and ethnicity were not primary determinants of veterinary service utilization. When veterinary and animal welfare organizations deliberately remove structural barriers embedded with racial inequalities, individuals, regardless of race and ethnicity, proceed with companion-animal sterilization. Therefore, service providers must use unbiased, informed, and culturally competent practices to improve companion-animal welfare through the optimization of veterinary services, including spay and neuter.     

Ethnic Elders and American Health Care—A Physician's Perspective

The aging process is a fugue composed of innumerable themes; the theme of “ethnicity” is by far one of its more dominant. Due to the increasing incidence of chronic, progressive infirmity and acute, catastrophic illness, the elderly are thrust into direct contact with the health care systems of their society. The experiences of ethnic elders in American health care situations are fraught with conflict and mutual dissatisfaction with the physician-patient relationship. Both providers and consumers of health care services harbor differing culture-bound perceptions of health, illness and the healing process; these cultural beliefs define personal and professional needs and expectations and notions of how those needs are to be met by others. Both physicians and patients can enhance their communication and their compassion for one another by acknowledgment of cultural differences and by increased willingness to interpret motives and behavior within native context.It behooves us in medicine to examine the cultural traditions underlying our own attitudes, beliefs and values about the aged in a universal sense, as well as in a culturally specific sense, that we may gain insight that will be helpful in serving elderly persons more effectively, and in solving some of the problems inherent in the aging process.     

“If You Tell People That You Had Sex with a Fellow Man,It Is Hard to Be Helped and Treated”: Barriers and Opportunities for Increasing Access to HIV Services among Men Who Have Sex with Men in Uganda

Background

Despite the high HIV prevalence among men who have sex with men (MSM) in sub-Saharan Africa, little is known about their access to HIV services. This study assessed barriers and opportunities for expanding access to HIV services among MSM in Uganda.

Methods

In October-December 2013, a cross-sectional qualitative study was conducted in 12 districts of Uganda. Semi-structured in-depth interviews were conducted with 85 self-identified MSM by snowball sampling and 61 key informants including HIV service providers and policy makers. Data were analysed using manifest content analysis and Atlas.ti software.

Results

Three quarters of the MSM (n = 62, 72.9%) were not comfortable disclosing their sexual orientation to providers and 69 (81.1%) felt providers did not respect MSM. Half (n = 44, 51.8%) experienced difficulties in accessing health services. Nine major barriers to access were identified, including: (i) unwelcoming provider behaviours; (ii) limited provider skills and knowledge; (iii) negative community perceptions towards MSM; (iv) fear of being exposed as MSM; (v) limited access to MSM-specific services; (vi) high mobility of MSM, (vii) lack of guidelines on MSM health services; viii) a harsh legal environment; and ix) HIV related stigma. Two-thirds (n = 56, 66%) participated in MSM social networks and 86% of these (48) received support from the networks to overcome barriers to accessing services.

Conclusions

Negative perceptions among providers and the community present barriers to service access among MSM. Guidelines, provider skills building and use of social networks for mobilization and service delivery could expand access to HIV services among MSM in Uganda.     

A Multiple Case Study of Mental Health Interventions in Middle Income Countries: Considering the Science of Delivery

In the debate in global mental health about the most effective models for developing and scaling interventions, there have been calls for the development of a more robust literature regarding the "non-specific", science of delivery aspects of interventions that are locally, contextually, and culturally relevant. This study describes a rigorous, exploratory, qualitative examination of the key, non-specific intervention strategies of a diverse group of five internationally-recognized organizations addressing mental illness in middle income countries (MICs). A triangulated approach to inquiry was used with semi-structured interviews conducted with service recipients, service providers and leaders, and key community partners (N = 159). The interview focus was upon processes of implementation and operation. A grounded theory-informed analysis revealed cross cutting themes of: a holistic conceptualization of mental health problems, an intensive application of principles of leverage and creating the social, cultural, and policy “space” within which interventions could be applied and resourced. These findings aligned with key aspects of systems dynamic theory suggesting that it might be a helpful framework in future studies of mental health service implementation in MICs.     

The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review

Diabet. Med. 29, 1237-1252 (2012) ABSTRACT: Aim To examine the evidence on culturally competent interventions tailored to the needs of people with diabetes from ethnic minority groups. Methods MEDLINE (NHS Evidence), CINAHL and reference lists of retrieved papers were searched from inception to September 2011; two National Health Service specialist libraries were also searched. Google, Cochrane and DARE databases were interrogated and experts consulted. Studies were included if they reported primary research on the impact of culturally competent interventions on outcome measures of any ethnic minority group with diabetes. Paper selection and appraisal were conducted independently by two reviewers. The heterogeneity of the studies required narrative analysis. A novel culturally competent assessment tool was used to systematically assess the cultural competency of each intervention. Results Three hundred and twenty papers were retrieved and 11 included. Study designs varied with a diverse range of service providers. Of the interventions, 64% were found to be highly culturally competent (scoring 90-100%) and 36% moderately culturally competent (70-89%). Data were collected from 2616 participants on 22 patient-reported outcome measures. A consistent finding from 10 of the studies was that any structured intervention, tailored to ethnic minority groups by integrating elements of culture, language, religion and health literacy skills, produced a positive impact on a range of patient-important outcomes. Conclusions Benefits in using culturally competent interventions with ethnic minority groups with diabetes were identified. The majority of interventions described as culturally competent were confirmed as so, when assessed using the culturally competent assessment tool. Further good quality research is required to determine effectiveness and cost-effectiveness of culturally competent interventions to influence diabetes service commissioners.     

Multi-Level Factors Affecting Entry into and Engagement in the HIV Continuum of Care in Iringa,Tanzania

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.     

WPA guidance on mental health and mental health care in migrants

The purpose of this guidance is to review currently available evidence on mental health problems in migrants and to present advice to clinicians and policy makers on how to provide migrants with appropriate and accessible mental health services. The three phases of the process of migration and the relevant implications for mental health are outlined, as well as the specific problems of groups such as women, children and adolescents, the elderly, refugees and asylum seekers, and lesbian, gay, bisexual and transgender individuals. The concepts of cultural bereavement, cultural identity and cultural congruity are discussed. The epidemiology of mental disorders in migrants is described. A series of recommendations to policy makers, service providers and clinicians aimed to improve mental health care in migrants are provided, covering the special needs of migrants concerning pharmacotherapies and psychotherapies.     

Genetic support groups in the delivery of comprehensive genetic services.

This research sought information about the services provided by genetic support groups, their members' experiences in obtaining genetic and related services, and members' recommendations for improving services. Results from a survey of 43 directors of genetic support groups showed that these organizations not only provide their members with a wide range of informational and supportive services but also address the need for education of both the public and health professionals about genetic disorders. A second survey of 931 members of genetic support groups found that, although they obtained genetic information from a variety of professional and informal sources, many of them experienced barriers to obtaining sufficient genetic information. Respondents called for professionals to improve their interpersonal skills in working with clients and to assist families in obtaining a wider variety of services. On the basis of these findings, a service model and priorities are proposed to bring together genetic specialists, community professionals, and genetic support groups for the delivery of comprehensive services to individuals and families with genetic disorders.     

Improving prevention,monitoring and management of diabetes among ethnic minorities: contextualizing the six G’s approach

Objective

People from Black, Asian and Minority Ethnic (BAME) groups are known to have an increased risk of developing diabetes and face greater barriers to accessing healthcare resources compared to their ‘white British’ counterparts. The extent of these barriers varies by demographics and different socioeconomic circumstances that people find themselves in. The purpose of this paper is to present and discuss a new framework to understand, disentangle and tackle these barriers so that improvements in the effectiveness of diabetes interventions for BAME communities can be achieved.

Results

The main mediators of lifestyle behavioural change are gender, generation, geography, genes, God/religion, and gaps in knowledge and economic resources. Dietary and cultural practices of these individuals significantly vary according to gender, generation, geographical origin and religion. Recognition of these factors is essential in increasing knowledge of healthy eating, engagement in physical activity and utilisation of healthcare services. Use of the six G’s framework alongside a community centred approach is crucial in developing and implementing culturally sensitive interventions for diabetes prevention and management in BAME communities. This could improve their health outcomes and overall wellbeing.

     

Advancing theory development: exploring the leadership–climate relationship as a mechanism of the implementation of cultural competence

Background

Leadership style and specific organizational climates have emerged as critical mechanisms to implement targeted practices in organizations. Drawing from relevant theories, we propose that climate for implementation of cultural competence reflects how transformational leadership may enhance the organizational implementation of culturally responsive practices in health care organizations.

Methods

Using multilevel data from 427 employees embedded in 112 addiction treatment programs collected in 2013, confirmatory factor analysis showed adequate fit statistics for our measure of climate for implementation of cultural competence (Cronbach’s alpha?=?.88) and three outcomes: knowledge (Cronbach’s alpha?=?.88), services (Cronbach’s alpha?=?.86), and personnel (Cronbach’s alpha?=?.86) practices.

Results

Results from multilevel path analyses indicate a positive relationship between employee perceptions of transformational leadership and climate for implementation of cultural competence (standardized indirect effect?=?.057, bootstrap p?<?.001). We also found a positive indirect effect between transformational leadership and each of the culturally competent practices: knowledge (standardized indirect effect?=?.006, bootstrap p?=?.004), services (standardized indirect effect?=?.019, bootstrap p?<?.001), and personnel (standardized indirect effect?=?.014, bootstrap p?=?.005).

Conclusions

Findings contribute to implementation science. They build on leadership theory and offer evidence of the mediating role of climate in the implementation of cultural competence in addiction health service organizations.

     

Using the ALPHA form in practice to assess antenatal psychosocial health

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form''s reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.     

Assessing the Potential of Indigenous-Run Demographic/Health Surveys: the 2005 Shuar Survey,Ecuador

Despite improved national censuses and “micro-demographic” studies, demographic processes and health conditions among indigenous populations in Amazonia and elsewhere in lowland Latin America are not well understood. A new source of demographic and health data has emerged in the past decade, namely meso-scale surveys initiated and administered by indigenous organizations. These surveys offer the potential for filling information gaps, shedding light on culturally specific factors that shape demographic processes and health, and empowering indigenous organizations with data that could inform health initiatives. This article assesses the indigenous-run survey “2005 Health Analysis of the Shuar and Achuar Nations” of eastern Ecuador in which the authors were involved, which reached 1,943 households in 257 communities in Morona-Santiago Province. We present findings on fertility, migration, sanitation, and health, and assess the strengths and weaknesses of the survey. We argue that despite flaws in the survey design and implementation, this survey revealed important linkages among fertility, migration, and health. Such surveys have the potential to provide much needed detail, representativeness, and cultural specificity that macro and micro data sources cannot provide. We conclude with recommendations to improve surveys of this type.     

Barriers to uptake of services for coronary heart disease: qualitative study

ObjectivesTo identify factors within the South Yorkshire coalfields that influence use of health services by people with angina.DesignQualitative study using semistructured individual and group interviews.SettingGeneral practice and community settings in Barnsley and Rotherham health authorities.Participants14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners.ResultsA complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness.ConclusionsMany of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral.

What is already known on this topic

An inverse correlation has been shown between deprivation and cardiac revascularisationFear of hospitals, denial of ill health, and low expectations may prevent people with angina accessing health services

What this study adds

Fear, denial, and low expectations were important barriers to accessing health services, reinforcing earlier findingsOther factors may be specific to the study population—for example, coping, independence, and attributing symptoms to industrially related lung diseaseMany of the barriers operate before general practitioners are involved, making it difficult to identify solutions     

Building International Indigenous People’s Partnerships for Community-Driven Health Initiatives

In this article we present an international Indigenous people’s partnership project co-led by two Indigenous communities, Musqueam (Coast Salish, Canada) and Totoras (Quichua, Ecuador), as a community-driven health initiative. The Musqueam-Totoras partnership includes Indigenous organizations, universities, international agencies, government, and nongovernmental organizations to address Indigenous health concerns in both communities. Our collaborative approach provides a framework to (a) increase the development expertise of Indigenous people internationally, (b) increase skills among all participants, and (c) facilitate Indigenous knowledge mobilization and translation to promote cultural continuity. This international Indigenous people’s partnership between north and south reflects the diversity and commonalities of Indigenous knowledge, contributes to cultural revitalization, and minimizes the impact of assimilation, technology, and globalization. Indigenous people’s partnerships contribute to self-determination, which is a prerequisite to the building and maintenance of healthy communities and the promotion of social justice. The exchange of Indigenous knowledge upholds Indigenous values of respect, reciprocity, relevance, and responsibility. Given the history of colonization and the negligence of governments in the exercising of these values with respect to Indigenous communities, this contemporary exchange among Indigenous people in the Americas serves to reclaim these values and practices. International cooperation empowering Indigenous people and other marginalized groups has become fundamental for their advancement and participation in globalized economies. An international Indigenous people’s partnership provides opportunities for sharing cultural, historical, social, environmental, and economic factors impacting Indigenous health. These partnerships also create beneficial learning experiences in community-based participatory research and community-driven health initiatives, provide culturally sensitive research ethics frameworks, increase capacity building, and address basic human needs identified by participating communities.     

Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS)

Background

Rural induced abortion service has declined in Canada. Factors influencing abortion provision by rural physicians are unknown. This study assessed distribution, practice, and experiences among rural compared to urban abortion providers in the Canadian province of British Columbia (BC).

Methods

We used mixed methods to assess physicians on the BC registry of abortion providers. In 2011 we distributed a previously-published questionnaire and conducted semi-structured interviews.

Results

Surveys were returned by 39/46 (85%) of BC abortion providers. Half were family physicians, within both rural and urban cohorts. One-quarter (17/67) of rural hospitals offer abortion service. Medical abortions comprised 14.7% of total reported abortions. The three largest urban areas reported 90% of all abortions, although only 57% of reproductive age women reside in the associated health authority regions. Each rural physician provided on average 76 (SD 52) abortions annually, including 35 (SD 30) medical abortions. Rural physicians provided surgical abortions in operating rooms, often using general anaesthesia, while urban physicians provided the same services primarily in ambulatory settings using local anaesthesia. Rural providers reported health system barriers, particularly relating to operating room logistics. Urban providers reported occasional anonymous harassment and violence.

Conclusions

Medical abortions represented 15% of all BC abortions, a larger proportion than previously reported (under 4%) for Canada. Rural physicians describe addressable barriers to service provision that may explain the declining accessibility of rural abortion services. Moving rural surgical abortions out of operating rooms and into local ambulatory care settings has the potential to improve care and costs, while reducing logistical challenges facing rural physicians.     

Discrimination and Other Barriers to Accessing Health Care: Perspectives of Patients with Mild and Moderate Intellectual Disability and Their Carers

Background

People with intellectual disability have a higher prevalence of physical health problems but often experience disparities in accessing health care. In England, a number of legislative changes, policies and recommendations have been introduced to improve health care access for this population. The aim of this qualitative study was to examine the extent to which patients with intellectual disability and their carers experience discrimination or other barriers in accessing health services, and whether health care experiences have improved over the last decade years.

Method and Main Findings

Twenty nine participants (14 patient and carer dyads, and one carer) took part in semi-structured interviews. The interviews were audio-taped and transcribed and analysed using thematic analysis. Eight themes were identified. Half the participants thought that the patient had been treated unfairly or had been discriminated against by health services. There were accounts of negative staff attitudes and behaviour, and failure of services to make reasonable adjustments. Other barriers included problems with communication, and accessing services because of lack of knowledge of local services and service eligibility issues; lack of support and involvement of carers; and language problems in participants from minority ethnic groups. Most participants were able to report at least one example of good practice in health care provision. Suggestions for improving services are presented.

Conclusion

Despite some improvements to services as a result of health policies and recommendations, more progress is required to ensure that health services make reasonable adjustments to reduce both direct and indirect discrimination of people with intellectual disability.