Does Cultural Competency Training Improve Quality of Care?

Awareness of not only the existence but also the extent of the healthcare disparities experienced by racial and ethnic minorities in the US has been growing for some time among physicians and allied healthcare professionals. A considerable body of literature has been created that addresses this issue from a number of angles, including the social, cultural, economic, and other causes of the disparities; their effects on health and quality of life in various patient populations; and the ways in which physicians contribute to and alleviate unequal outcomes. The role played by physicians in this has been subject to particularly intense scrutiny, with much attention devoted to the subject of culturally competent care—how it is defined, how its absence can negatively affect minority patients’ healthcare experience, and how physicians can learn to modify their behaviors and biases in order to deliver care that meets the needs of their patients. While there seems to be a developing consensus regarding the importance of culturally competent care and the desirability of ensuring physicians are capable of delivering it, it has been argued that the evidence base for its effectiveness is relatively insubstantial.

Is this true? Are the enthusiasm and good intentions surrounding this project supported by the weight of evidence? A quick search online reveals a somewhat inconclusive picture: although there are a variety of studies that demonstrate cultural competence training improves the knowledge, skills, and attitudes of physicians, and that greater cultural competence (however it is defined) on the part of physicians translates into improved patient satisfaction with the healthcare experience, there is less substantial evidence supporting claims that it positively affects some desirable patients behaviors (such as treatment adherence) or that it leads to better health outcomes. Many researchers and study authors do however call for additional, more comprehensive investigations, noting several shortcomings of existing studies.

Representative studies include:

Development and evaluation of a cultural competency training curriculum

The authors assert that although “cultural competency training for physicians is increasingly promoted, relatively few studies evaluating the impact of training have been published.” They also note that, although the intervention they designed for their study failed to “effect a significant measurable change in patient-perceived physician behaviors,” it suffered from several limitations (brief duration training, irregular reinforcement, etc). Paraphrasing Joseph Betancourt, MD, they also caution that “the pathway from training providers in cross-cultural care to improving patient health outcomes is a long one, and traversing the path requires successfully connecting training to changes in behavior, and changes in behavior to improved patient outcomes.”

Cultural competence: A systematic review of health care provider educational interventions

The authors of this 2005 study reviewed more than 30 studies of interventions designed to improve the cultural competence of health professionals and found that there is “excellent evidence that cultural competence training improves the knowledge of health professionals” and good evidence that cultural competence training improves “the attitudes and skills of health professionals” and patient satisfaction. They found poor evidence that cultural competence training impacts patient adherence, although they point out that “the one study designed to do this demonstrated a beneficial effect,” and report they found “no studies that have evaluated patient health status outcomes.”

Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model

The authors’ hedging language mirrors the scarcity of outcomes evidence: “The conceptual model shows how these techniques could theoretically improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations, thereby improving outcomes and reducing disparities… while there is substantial research evidence to suggest that cultural competency should in fact work, health systems have little evidence about which cultural competency techniques are effective and less evidence on when and how to implement them properly.”

Have more recent studies demonstrated empirical evidence of positive effects on treatment outcomes attributable to greater cultural competency on the part of practitioners? Do readers know of specific cross-cultural training strategies, initiatives, or programs that have been shown to improve outcomes or affect adherence or other patient behaviors?