website that you have to use for Aboriginal assessment 3 Cultural Competency in Health Services for Indigenous People

What We Know

• Cultural competency is a key strategy for reducing inequalities in healthcare access and improving the quality and effectiveness of care for Indigenous people.
• Cultural competence is more than cultural awareness—it is the set of behaviours, attitudes, and policies that come together to enable a system, agency, or professionals to work effectively in cross-cultural situations.
• Developing and embedding cultural competence in health services requires a sustained focus on knowledge, awareness, behaviour, skills and attitudes at all levels of service, including at the operational or administrative service level, health practitioner level, practitioner-patient level and student-training level.
• In Australia, past efforts to increase levels of cultural competence have been largely designed for particular situations. There has been an absence of a coherent approach to its inclusion or teaching and a lack of national standards for the provision of culturally competent health services.
• Research on cultural competence is overwhelmingly descriptive and there are few evaluation studies that are methodologically strong. In particular, there was a lack of Australian specific evidence about what strategies are most effective for improving culturally competent healthcare delivery to Indigenous Australians.

What Works

• The limitations in the evidence base meant that it was not possible to draw definitive conclusions about the effectiveness of culturally competent practices and frameworks in providing health care benefits for Indigenous people. But there was both international and Australian evidence of its potential in a number of studies.
• There were some studies that found that bringing together the cultures of health care organisations with Indigenous communities can improve access to health care for Indigenous Australians. This process involves health care organisations:
  • consulting with Indigenous Australian health services and communities
  • tailoring service delivery to the needs and preferences of specific communities
  • embedding cultural competence within the health care organisational culture, governance, policies and programs.
• Education for health care students that incorporates cultural perspectives and experiences can improve health students’ preparedness for working in Indigenous health and their future commitment to working for change.
  • It can lead to more open attitudes, increased awareness, more effective advocacy, a preparedness to engage with Indigenous people, and a better understanding of Indigenous health issues.
  • Field experience can also make an important and positive contribution to health students’ perspectives.
• Several studies suggested that key to reducing health disparities for Indigenous populations was health care workers developing partnerships, eliminating bias through self-reflection, and building relationships with Indigenous people.
• Embedding cultural competency principles within legislation or policy (as has been done in the United States and New Zealand) is a strategy that could be useful across Australia’s health systems as part of an ongoing commitment to Indigenous Australians and delivering culturally competent care.
• Internationally validated instruments that measure health service access and use, service quality, perceived discrimination, language barriers and trust of practitioners could be useful if tailored to Indigenous Australian health services.

What Doesn't Work

• Cultural awareness training is not enough in itself.
  • While such training might be expected to impart knowledge upon which behavioural change will develop, it has generally not been enough when it is delivered in isolation or rapidly delivered over short timeframes.
• Program transfer and implementation without cultural-tailoring are ineffective.
  • There are no homogenous approaches to developing and implementing cultural competence.
  • Cultural competency programs that are successful in one context cannot be assumed to work in another.
  • Programs need to be developed and delivered in partnership with and input from local Indigenous people.

What We Don't Know

• There is neither a clear definition nor consistent terminology around cultural competence.
• There is inconclusive evidence on the effectiveness of culturally competent interventions and frameworks in relation to health care access and outcomes for Indigenous Australians.
• More needs to be done using validated indicators to measure what works in efforts to develop culturally competent health services for Indigenous Australians.
• More work is also required to determine the best combination of strategies to improve cultural competence in healthcare.

Introduction

• Inequalities in healthcare access, service provision, and health outcomes for global Indigenous populations have prompted regulatory bodies, health services, and professionals to examine how they can better meet the healthcare needs of Indigenous groups.
• There is ample evidence of inequalities in health status and healthcare between Aboriginal and Torres Strait Islander Australians (referred to as Indigenous Australians in this report) and non-Indigenous Australians. These inequalities are particularly apparent in chronic and communicable diseases, infant health, mental health, and life expectancy (AIHW 2013; AIHW 2015; ATSISJC 2005; SCRGSP 2013).
• Many factors contribute to these inequalities, with perhaps the largest contributors being those related to social factors that lie outside the healthcare system (Osborne et al. 2013).
• There is also evidence that inequitable access to quality healthcare based on ethnicity has contributed to health disparities (Betancourt et al. 2003; SCRGSP 2013).
• Globally, researchers and others have long reported the negative impacts that ethnocentric health service provision has on the health status of Indigenous populations (Downing et al. 2011).
• The lack of Indigenous health workers in health service delivery systems leads to Indigenous people delaying going to services and contributes to the under-use of healthcare services (LaVeist et al. 2003).
• There is increasing evidence that health disparities between Indigenous Australians and non-Indigenous Australians are linked to accessibility. Accessibility is influenced by economic and geographic factors and a variety of sociocultural factors (Thomson 2005).
• It is therefore important to increase efforts to improve the ability of all systems, services and practitioners to work with the diversity of patients.
• To improve the health situation of Indigenous peoples, there must thus be a fundamental shift in the concept of health so that it incorporates the cultures and world views of Indigenous peoples as central to the design and management of state health systems (Cunningham 2009:156).
• In Australia, the Aboriginal community controlled health services movement has been central in driving new directions for Indigenous healthcare delivery that account for such shifts in leadership and design (Thomas et al. 2014).
• The movement started when the need for cultural competence was first prompted by civil rights movements across Western countries in the 1960s. This movement alerted administrators to the distinct identities and long histories of oppression of Indigenous people, ethnic groups, women, gays and lesbians, people with disabilities, and others.
• Aboriginal community controlled health services were set up in response to experiences of racism in the health system and the significant financial, cultural and social barriers to health care access experienced by Indigenous Australians (Anderson 2006).
• While there are now some 140 services Australia-wide (Thomas et al. 2014), the reach and capacity of these services to meet the needs of all Indigenous Australians is still limited. This shortfall means that the balance of services is provided by mainstream health systems that generally do not sufficiently account for Indigenous cultures or holistic notions of health (Thomson 2005).
• Cultural competency is a key strategy for reducing inequalities in healthcare access and the quality and effectiveness of care received. This strategy works to enhance the capacity and ability of health service systems, organisations and practitioners to provide more responsive health care to diverse cultural groups, as discussed in the National Aboriginal and Torres Strait Islander Health Plan 2013–2023 (Commonwealth of Australia 2013), which is also known as the NATSIHP.
• In the NATSIHP, cultural competency is described through the concept of respect: respect is described elsewhere as ‘ensuring that the cultural diversity, rights, views, values and expectations of Aboriginal and Torres Strait Islander peoples are respected in the delivery of culturally appropriate health services’ (NATSIHC 2003:2).
• As well as being consistent with a key result area in the NATSIP for achieving more effective and responsive health systems for Indigenous Australians, cultural competency strategies are supported by Australia’s National Health and Medical Research Council.

Argument for Developing Culturally Competent Services

• All Australians have the right to access health care that meets their needs. In our culturally and linguistically diverse society, this right can only be upheld if cultural issues are core business at every level of the health system—systemic, organisational, professional and individual (NHMRC 2005:1).
• Cultural competence interventions have developed in Australia and internationally in response to the now considerable research evidence pointing to the need for culturally responsive care.
• The argument for developing culturally competent services and workforces is positioned in a human rights framework: the basic human right to life and health (UN 2008; Walker et al. 2014).
• The obligations of states [are] both to provide accessible, quality health care to Indigenous peoples and to respect and promote Indigenous health systems, each of which must be fulfilled in order to ensure the health of Indigenous peoples (Cunningham 2009:156).
• There is also a local strategic priority in the reform agenda of the Closing the Gap policy, which aims to improve Indigenous life outcomes.
• Although there is much evidence to suggest that cultural competence should work, health systems have little evidence about how to identify what mix of cultural competence strategies work in practice, and when and how to implement them properly. To better understand what is useful, this review examines the current evidence base in terms of strategies for improving cultural competency, measures and measurement instruments of cultural competency, and the relationship between cultural competency and health care outcomes.

Aim and Objectives of the Review

• This review aims to examine available evidence on cultural competence in health care settings to identify key approaches and strategies that can contribute to improving the development and implementation of Indigenous health services and programs.
  • define cultural competency – we consider the significance of cultural competence and how it has been defined in international and local literature, including the use of similar terms and meanings
  • report on the quantity, nature and quality of available evidence – we look at available evidence on cultural competency in Australia, New Zealand, Canada and the United States, including how cultural competence has been measured, and assess the quality of the evidence against basic methodological criteria
  • identify approaches and strategies that are effective in improving cultural competency among health services staff
  • examine the relationship between cultural competency and health outcomes
  • develop an evidence-informed conceptual framework of cultural competency.

Defining Cultural Competency

• This review used the definition of cultural competence by Cross et al. (1989). It is viewed as the most influential and most commonly cited work on the topic.

• They refer to cultural competence as:

  *Cultural competence… is… a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or amongst professionals and enables that system, agency, or those professionals to work effectively in cross-cultural situations. The word culture is used because it implies the integrated pattern of human behaviour that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group. The word competence is used because it implies having the capacity to function effectively. A culturally competent system of care acknowledges and incorporates—at all levels—the importance of culture, the assessment of cross-cultural relations, vigilance towards the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally-unique needs (Cross et al. 1989:iv/7).

• In Australia, cultural differences between service providers and Indigenous Australians have been referred to as the ‘cultural chasm’ (Thomson 2005:1).

• As far back as 1989, the National Aboriginal Health Strategy Working Party suggested that ‘scant attention has been paid in the content of health related education programs to the relevance of cultural, traditional, political, and socio-economic factors of Aboriginal history and Aboriginal society to Aboriginal health and wellbeing’ (NAHSWP 1989:90).

  • It made recommendations toward closing the ‘chasm’ that included:
    • the need for appropriate education and training for health professionals and preparation to work in the field of Indigenous health
    • the importance of relevant clinical experience as a part of formal studies
    • the need for cultural aspects to become part of continuing professional education.

• Initially, education and training in Australia was mainly focused on bolstering the knowledge and experience of clinicians and other health service providers to deliver care (Thomson 2005).

• However, the notional concept of ‘cultural awareness’ represented by this kind of education and training shifted, initially, to place emphasis on individual behaviour as well as attitudes; and it was then extended to include system-wide factors (DHCS 2005). The term ‘cultural security’ was adopted to embrace this transition in the late 1990s.

• In 2003, ‘cultural security’ was incorporated under the concept of ‘cultural respect’ and endorsed as the:

  *guiding principle in policy construction and service delivery for utilisation by jurisdictions as they implement initiatives to address their own needs, in particular mechanisms to strengthen relationships between the health care system and Indigenous peoples (SCATSIHWP 2004:3).

• The Australian Health Ministers’ Advisory Council developed the Cultural Respect Framework 2004–2009 (AHMAC 2004) as a guiding principle in policy construction and service delivery for use by different jurisdictions, and mechanisms to strengthen relationships between the health care system and Indigenous Australians.

• Bound by cultural respect, it has 7 guiding principles:

  • a holistic approach
  • health sector responsibility
  • community control of primary health care services
  • working together
  • promoting good health
  • building the capacity of health services and communities
  • accountability for health outcomes.

• The framework aimed to influence health services and their delivery to lead to:

  • improved outcomes and quality
  • more efficient and effective services
  • expenditure reduction
  • improved customer satisfaction.

Cultural Respect Framework & Key Criterion

• The Cultural Respect Framework was informed by international developments around the notions of ‘cultural safety’ (New Zealand) and ‘cultural competence’ (United States).
• It was developed and endorsed for action by health ministers of all Australian jurisdictions with the intent ‘to ensure that Indigenous peoples enjoy a healthy life equal to that of the general population that is enriched by a strong living culture, dignity and justice’ (NATSIHC 2003:7).
• Cultural respect is defined by the Australian Health Ministers’ Conference as ‘ensuring that the cultural diversity, rights, views, values and expectations of Indigenous peoples are respected in the delivery of culturally appropriate health services’ (NATSIHC 2003:2).
• Key responses to this type of criterion have been to develop capacity of Indigenous Australians in the workforce, for example by training health workers, and providing cultural awareness training for those already working in Indigenous health care.
• See Appendix A for an expansion of the nomenclature around cultural competency.

Approach Used to Review the Evidence

• Scope of the review:
  • Types of literature: The review included peer-reviewed and grey literature (including government and agency reports) relating to cultural competency in Australia, New Zealand, Canada and the United States published from January 2002 to December 2013.
  • Study population: In-scope publications focused on Indigenous Australians and Indigenous populations in countries with health care systems comparable to Australia, including New Zealand, Canada and the United States.
  • Setting: Studies included in the review related to cultural competence in a broad range of health care services (such as hospitals, primary health care settings, private practice and community health settings), and for both health care outcomes and population health outcomes.
  • Interventions: Interventions aimed at improving cultural competency for health systems, services or health professionals were included.
  • Terms: A broad range of terms was searched. Terms searched included cultural competence, cultural sensitivity, cultural safety, cultural security, cultural awareness, cultural literacy, cultural respect, cultural framework, cross-cultural, inter-cultural, cultural difference, inter-racial, racism, discrimination, cultural capability, bi-cultural and cultural inclusion. The exact combinations of search terms are identified in the search strategy (see Appendix B and Appendix C).

Methods Used to Determine the Review

• Locating the relevant literature:
  • The search strategy for this review extended and updated a previous and more wide-ranging search on cultural competency. Appendix B summarises the earlier search; Appendix C summarises the extended search (from mid-2012 to the end of 2013). Both include the databases searched, the search terms used, the exclusion criteria applied, and the classification of included studies. Evaluation and indicator studies for Indigenous populations only were extracted from the original search. The original search captured a total of 37 studies. The second search strategy comprised 5 steps.
    • Step 1: The process began with the 37 studies identified in the original search.
    • Step 2: Consultation with representatives of relevant government portfolios, (Commonwealth and state) was facilitated by the Australian Institute of Health and Welfare to identify relevant grey literature sources and review and refine the objectives and methods. Five more publications were identified, increasing the total to 42 studies.
    • Step 3: Consultation with a qualified librarian had previously identified 17 relevant electronic databases to search: Indigenous Australia; Indigenous Studies Bibliography: AIATSIS; ATSIHealth; APAIS-ATSIS; FAMILY-ATSIS; Informit Indigenous Collection; Campbell Library; EBM Reviews/Cochrane DSR/ACP Journal club/DARE; PsycINFO; PsycEXTRA; Medline; Embase; CINAHL; Global Health; PAIS; Sociological Abstracts. The searches of the 17 databases (excluding duplicates) identified a further 103 references in the updated search to give a total of 145 references.
    • Step 4: To maximise search coverage of the grey literature, we also searched websites and clearinghouses related to Indigenous people of Australia, New Zealand, Canada and the United States. Five studies not identified in the electronic database search were located.
    • Step 5: A total of 150 references were examined.
• Classification of studies
  • The titles and abstracts of the 150 identified citations were categorised as:
    • Indicators and measures of cultural competency: defined as studies that described, developed or applied measures and indicators of cultural competence (n=14).
    • Intervention evaluations: defined as studies that evaluated the effectiveness of a strategy, program or policy designed to improve cultural competency. This included studies designed to address cultural awareness of health staff; Indigenous or ethnic minority peoples’ access to health services, procedures, and culturally specific programs; the identification of Indigenous people or ethnic minorities in health service records; the provision of culturally respectful services; Indigenous health workforce participation and development (n=20).
  • Across the 2 classifications, there was an overlap of 6 studies Wiley et al. 2009; Chong et al. 2011; Hearn et al. 2011; Mooney et al. 2005; Curran et al. 2005; Cook et al. 2010).
  • Studies that did not meet any of these 2 criteria were classified as ‘other’ (n=122) and excluded.
  • In total, 28 publications related to cultural competency in health care for Indigenous populations across Australia, New Zealand, Canada and the United States formed the basis for this review.
• Data extraction from indicator and intervention studies
  • Criteria for data extraction from both types of studies were adapted from the Cochrane Collaboration Handbook for Systematic Reviews of Health Promotion and Public Health Interventions (Jackson 2007). For indicator studies, the criteria shown in Appendix D relate to the type of indicator; measurement of the indicator; application of the indicator (country, population and healthcare setting); and quality of the indicator (reliability or validity). The full cultural competence indicator papers were read to extract these criteria. For intervention studies, the criteria shown in Appendix E relate to the intervention type; target population; sample size; study design; outcome measures and effects; and the overall methodological quality of the evaluation.

Assessing the Quality of Research

• Research evidence is commonly assessed by the quality of the methodology used in the study.
• For qualitative studies, the quality of original research publications was assessed and rated as ‘strong’, ’moderate’ or ‘weak’ using the Critical Appraisal Skills Programme appraisal checklists for qualitative studies (CASP UK 2013).
• The indicator studies were rated using a quality assessment tool for quantitative studies (NCCMT 2008). Using the guidelines provided, the validity and reliability of the measurement instrument were rated as strong (evidence the instrument is valid AND reliable), moderate (evidence the instrument is valid OR reliable), or weak (no evidence the instrument is valid or reliable).

Review Findings

• Quantity and types of studies

• This systematic search of studies conducted between 2002 and 2013 identified a total of 28 publications related to cultural competency in health care for Indigenous populations across Australia, the United States, Canada and New Zealand. The publications included (1) those that described the development or application of indicators and measures of cultural competence; and (2) those that evaluated intervention strategies designed to improve cultural competence. Indigenous people from Australia, Canada, United States and New Zealand were the focus of the 28 studies. Of these 28 studies, 12 (43%) were from the United States, 11 (39%) from Australia, 3 (11%) from New Zealand, 1 (3.5%) from Canada, and 1 (3.5%) was a combined cross-national study from New Zealand and Australia. Australian and United States studies constituted 82% of the identified studies.
• Fourteen of the 28 (50%) relevant studies were classified as indicator or measurement studies; 20 (71.5%) studies were classified as evaluated intervention studies. Six studies (Chong et al. 2011; Cook et al. 2010; Curran et al. 2008; Hearn et al. 2011; Mooney et al. 2005; Wiley 2009) were intervention evaluations as well as indicator and measurement studies. Of the 28 studies, 14 (50%) reported significant health care outcomes. The summary of results and breakdown of study types is reported in Table 1.

• Fourteen studies focused on measuring the cultural competence of health service provision specifically for Indigenous clients. They included 7 Australian studies (Chong et al. 2011; Coffin 2007; Hearn et al. 2011; Mooney et al. 2005; Muecke et al. 2011; Paul et al. 2011; Reibel & Walker 2010), 3 New Zealand studies (O’Brien et al. 2003, 2004; Wiley 2009), a comparative New Zealand–Australian study (O’Brien et al. 2007), 2 United States studies (Cook et al. 2010; Winderowd et al. 2008), and 1 Canadian study (Curran et al. 2008).
• These studies developed or described indicators of cultural competence that could be used to identify examples of both good and poor cultural competency in health services, and to measure improvements in cultural competency. Overall, the type of indicators ranged from reliable, valid and objective indicators to non-validated subjective indicators, and from simple scales to complex instruments with multiple domains.
• Appendix D summarises the characteristics and quality of these 14 studies, 6 of which reported mixed levels of associated health care outcomes. Studies that did not report health outcomes included those that described the development or validation of cultural competence measurement tools, and those that described the process of applying the measurement tools to various settings.
• A range of health care settings, health issues and health disciplines was covered in these studies. Included were health training courses for medical, nursing students (Curran et al. 2008; Paul et al. 2011); primary health care settings (Coffin 2007; Hearn et al. 2011; Muecke et al. 2011); and mental health settings (O’Brien et al. 2003, 2004, 2007; Winderowd et al. 2008). Clinical records, administrative benchmarks, national racial and ethnic categories, self-reported surveys, and qualitative interviews were used to measure the indicators of cultural competence. By far the most common measurement type was self-reported survey instruments.

Quality of the Research

• Only 3 out of the 14 indicator studies were rated as ‘strong’ according to the criteria outlined in the methods section. This included 1 United States study (Winderowd et al. 2008), 1 New Zealand study (O’Brien et al. 2004), and 1 study from New Zealand and Australia (O’Brien et al. 2007). A further 3 indicator studies were rated moderate, and 8 were of weak quality (see Appendix D).

Research Findings

• The indicator studies focused on 4 areas (some studies incorporated more than one focus, but they were reviewed according to their primary focus):

  • Health service (4 studies: O’Brien et al. 2003, 2004, 2007; Reibel and Walker 2010).
    • The studies demonstrated the considerable resources invested into developing and piloting instruments to audit service performance across sectors within health (O’Brien et al. 2003, 2004, 2007; Reibel & Walker 2010).
    • A cultural competence audit tool developed in New Zealand to measure the achievement of mental health nursing practice standards in New Zealand (O’Brien et al. 2003, 2004, 2007) was considered to be relevant to mental health nursing internationally by providing a framework for improving practice against standards of expected health care:
      • the Consumer Notes Clinical Indicators audit tool was based on identification of ‘critical events’ (events crucial to achievement of practice standards) from nursing notes in consumers’ case notes
      • 25 valid and reliable indicators were considered crucial to the achievement of New Zealand standards.
  • Healthcare practitioners’ knowledge, attitudes and practice (5 studies: Chong et al. 2011; Coffin 2007; Hearn et al. 2011; Mooney et al. 2005; Muecke et al. 2011).
    • Indicators were typically self-reported measures that looked at aspects of cultural awareness, cultural knowledge, cultural skill, cultural encounters, cultural sensitivity, culture shock or adaptability, and cultural desire.
    • Muecke et al. (2011) reviewed measures of culture shock (defined as the stress, anxiety, or discomfort a person feels when they are placed in an unfamiliar cultural environment and which is due to the loss of familiar meanings and cues relating to communication and behaviour). The study recommended two measurement instruments that could be applied to non-Indigenous Australian health workers in remote Indigenous communities to measure stages of culture shock and culture shock mid-employment and placement: the Culture Shock Profile and Culture Shock Adaptation Inventory.
    • In another Indigenous Australian study, Coffin (2007) provided a simple (unvalidated) scale that could be used by health practitioners to self-rate their own processes of change or those of health services towards attainment of the end goal of sustainable cultural security.
  • Patients’ satisfaction, behaviours or health outcomes (3 studies: Cook et al. 2010; Wiley 2009; Winderowd et al. 2008).
    • Winderowd et al. (2008) used the validated American Indian Enculturation Scale to understand the traditional cultural experiences of American Indian and Alaskan native people and the connection between strong cultural ties and resilience, psychological wellbeing, substance abuse and substance abuse risk, and suicide attempts. This scale was found to be reliable, easily administered, and meaningful to individuals who completed it. The researchers encouraged the adaptation of the measure for use with Indigenous people from other nations.
    • Cook et al. (2010) has been included as a case study example (see Box 1). It had a moderate design rating and demonstrated healthcare outcomes for patient health, behaviour and patient and family satisfaction.
  • Health curricula and students’ knowledge, skills and attitudes (2 studies: Curran et al. 2008; Paul et al. 2011).
    • Paul et al. (2011) focused on developing a culturally competent health workforce as a key strategy in the struggle to provide quality healthcare services for Indigenous Australians. They implemented a comprehensive Indigenous health curriculum with medical students. A key shift in understanding and engagement occurred when students completed a comprehensive case history and discussion, including reflective comments, in relation to an Indigenous person they had seen during their rotation. Improvements were noted in students’ preparedness to work with Indigenous people, play an advocacy role, and take responsibility to work for change in Indigenous health.
    • Curran et al. (2008) considered the access barriers to nursing education for Aboriginal Canadian students. They found that access for students was improved by increasing the cultural relevance of the curriculum, including experiential and authentic learning, academic and social support and building of partnerships with health services and others.

• Box 1: Case Study of Cook et al. (2010)

  *Issue addressed: The importance of closing the health disparity gap that affects the Native Hawaiian population initiated this study. It aimed to examine the process and outcomes of healthcare among Native Hawaiians with heart disease, and to evaluate the impact of a multidisciplinary, culturally sensitive effort to improve quality of care by providing patients with the education and tools for self-management of their health.
  Method: Queen’s Heart developed a program to address the cardiometabolic health disparities of hospitalised Native Hawaiians. Importantly, the program was supported by the Board of Trustees and chief executive officer of The Queen’s Health Systems. The program focused on 3 intervention areas: education and self-care management, disease management, and stress reduction and wellness. An inpatient program was created by assembling a team of practitioners with an affinity for Native Hawaiian culture to address the healthcare needs of Native Hawaiian people. Patient educators and discharge counsellors delivered education and the tools that patients needed for self-care management as part of an Integrative Care Program that provided a holistic perspective of healing that was consistent with Native Hawaiians’ conception of health. All Native Hawaiian patients who were admitted to The Queen’s Medical Center from January 2007 to December 2008 became participants of the inpatient program. Baseline outcomes data (2006) for core cardiac measures, length of stay, 30-day re-admission rates, and adverse events were reviewed by the team before the study started and the results compared to other patient populations; data from 2008 were considered in follow-up.
  Results: While the quality of cardiovascular care at baseline was excellent, core quality measures improved across the entire patient population. Significant improvements in healthcare outcomes included: less than 30-day re- admission rates for patients with acute myocardial infarction reduced by 2%; heart failure patients with less than 30-day re-admissions decreased from 33% to 17%; length of stay for patients decreased slightly; and patient and family satisfaction was enhanced. These data indicate levels very similar to that of non-Native Hawaiian populations. However, length of stay for heart failure patients was unchanged and remains a persistent issue. It was likely that length of stay was influenced by the severity of illness at the time of admission.
  Conclusion: Culturally sensitive and patient-centred care, delivered by the team of specialists from Queen’s Heart, has allowed patients to incorporate cultural preferences into their care and recovery. Re-admission rates decreased, mortality rates improved, and patient and family satisfaction was enhanced.
  Policy and program implications: The multidisciplinary, patient-centred intervention demonstrated that a culturally informed, integrated approach to reducing disparities in cardiovascular disease can significantly raise quality of care, improve patient satisfaction, and promote the reduction of health care disparities. Cultural understandings of health must form the basis of engaging culturally diverse populations in their own care.

Intervention Strategies

• Twenty studies (summarised in Appendix E) evaluated the effectiveness of interventions designed to improve cultural competence for Indigenous populations across Australia (7 studies), United States (11 studies), Canada (1 study) and New Zealand (1 study).

Quality of the Research

• Of the 20 intervention studies, 3 (Barnett & Kendall 2011; Ka‘opua et al. 2011; Wiley 2009) were rated as strong, 4 as moderate (Chong et al. 2011; Curran et al. 2008; Dignan et al. 2005; Paul et al. 2006), and the remaining 13 were rated as weak (see Appendix E).
• Selection bias and poor attrition were common methodological deficiencies of studies using a weak or moderate study design. Selection bias and poor attrition also resulted in an overall weak rating for 1 of the 3 studies using a strong study design (D’Silva et al. 2011). Data collection methods were a common methodological strength of studies, with some studies using reliable or valid measurement instruments to measure outcomes. Four studies (20% of the intervention studies) were evaluated using qualitative methods (Barnett & Kendall 2011; Chong et al. 2011; Curran et al. 2008; Wiley 2009), and 1 used both qualitative and quantitative methods (Mak et al. 2006). Of the studies that reported on health outcomes, only 1 was rated as strong, and 2 were rated as moderate.

Research Findings

• Among the 20 studies, there were 5 main types of intervention strategies and approaches aimed at improving culturally competent healthcare delivery to Indigenous populations and making systems more responsive:
  • Reform health service and systems to facilitate culturally competent healthcare delivery (Chong et al. 2011; Wiley 2009).
    • Chong et al. used a continuous quality improvement model to improve the cultural sensitivity and environmental culture at 5 Australian hospitals. The main objective was to produce tools and processes that could help hospitals engage with local Indigenous Australian communities in a collaborative exercise of cultural reform.
    • Chong et al. found that hospitals with improved cultural sensitivity shared key characteristics. These included having relationships with Aboriginal communities and commitment to supporting their Aboriginal workforce. They concluded that hospitals need senior management to prioritise and support these changes by ensuring that processes are Aboriginal-facilitated and that staff capacity to do so is supported. The inclusion of Aboriginal specific elements in the Australian Council of Healthcare Standards was also seen as key.