Racial and ethnic minority Americans receive lower quality health care than non-minorities in the U.S. These disparities are evident across a wide range of health care services, including the care of diabetes mellitus. Cultural competence (CC) training has become the principal vehicle adopted by the health professions to address healthcare disparities. CC has been widely endorsed and deployed in the U.S., but there is little consistency to what is offered in CC programs and little evidence that CC training as currently delivered is improving health care quality or equity as intended. Given the substantial resources and time being devoted to CC training, it is critical that CC programs are informed by evidence about what will improve the ability of providers and healthcare teams to deliver high-quality care equitably, across diverse patient populations. This project builds on prior work that: 1) defined CC among health professionals by producing a conceptual map of CC dimensions from a systematic review of conceptual frameworks; 2) used that conceptual map to develop an instrument measuring CC among primary care providers (PCPs); and 3) demonstrated that CC, as measured by the instrument, was associated with higher quality care for African American patients, and reduced racial disparity. This project will extend the study of CC beyond PCPs to include other Patient Aligned Care Team (PACT) members, and attempt to discern why higher CC is associated with more equitable care, specifically, what high CC providers are doing differently in their clinical encounters that results in higher quality care for African American patients.
The aims of the study are to: 1. Understand differences in patient-provider communication among high and low CC primary care providers. 2. Understand patients' perceptions of their interactions and relationships with high and low CC providers/PACTs. 3. Understand the contribution of CC among providers/PACTs to quality and equity of diabetes care.
These aims will be addressed using a mixed-methods approach that will include quantitative and qualitative analysis of communication behaviors observed in audiotaped clinical encounters, coupled with quantitative surveys and qualitative interviews of patients about their perceptions of the encounters and their relationships with their PCPs and PACT members. The study will be conducted in 4 VA Medical Centers. A target sample of 50 PCPs will be recruited, 25 high and 25 low on self-assessed CC. PACT teamlet members working with these PCPs will be recruited. Patients with diabetes from each PCP's primary care panel will be recruited, with a target of 5 African American and 5 white patients per PCP. Patients' visits to their PCPs will be audio- recorded and the dialogue then coded for communication content using validated communication coding systems that evaluate different types of communication behaviors. Differences in communication by provider CC will be analyzed. We will also evaluate associations between PCP/PACT CC and other outcomes, including the quality of interpersonal care, patients' perceptions of PCP/PACT CC, diabetes understanding and self-management, and glycemic control. A subsample of patients from PCPs in the top and bottom CC quintiles will be interviewed, with a goal of 1 African American and 1 white patient for each of these PCPs. Patients will listen to their audiotaped clinical encounters and offer perspectives on the interaction and their relationships with the PCP. For these patients, transcripts from both the interview and from the audio-recorded clinical encounter will be qualitatively analyzed, side-by-side. The mixed-methods approach is intended to provide both breadth and depth in understanding how provider CC manifests in clinical interactions with patients and contributes to disparities in healthcare quality and outcomes. Understanding how provider CC manifests will inform interventions that are more likely to be effective in reducing disparities, because they will be based on empirical evidence of how providers who deliver more equitable care interact with patients.

Public Health Relevance

Cultural competence training has been widely endorsed and adopted as a means to reduce racial disparities in health care delivery, but there has been little evidence to inform what effective training should look like. The purpose of this project is to generate evidence that will shape effective interventions to improve providers' and healthcare teams' ability to work effectively with minority patients, develop strong relationships, and deliver patient-centered care. The study follows from prior work demonstrating that providers' self-assessed cultural competence is associated with better patient-provider interactions and relationships, as perceived by minority veterans. The next step is to understand what providers with higher levels of cultural competence are doing differently to achieve better interactions and relationships. Understanding how cultural competence manifests in patient care interactions will help determine the skills and behaviors that should be targeted in training health professionals in a way that will improve their ability to deliver equitable patient care.

National Institute of Health (NIH)
Veterans Affairs (VA)
Non-HHS Research Projects (I01)
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HSR-2 Determinants of Patient Response to Care (HSR2)
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Portland VA Medical Center
United States
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