Linking Cultural Competence to Functional Life Outcomes in Mental Health Care Settings

Michalopoulou G,  Falzarano P,  Butkus M,  Zeman L,  Vershave J,  Arfken C.

Linking Cultural Competence to Functional Outcomes in Mental Health Care Settings. Journal of the National Medical Association. 2014; 106(2): 41-48

Financial Disclosure: This project was conducted in par t with the suppor t of Department of Psychiatr y and Behavioral Neurosciences Wayne State University School of Medicine and the State of Michigan Joe F. Young Sr. Psychiatric Research and Training Program.Minorities in the United States have well-documented health disparities. Cultural barriers and biases by health care providers may contribute to lower quality of services which may contribute to these disparities. However, evidence linking cultural competency and health outcomes is lacking. This study, part of an ongoing quality improvement effort, tested the mediation hypothesis that patients' perception of provider cultural competency indirectly influences patients' health outcomes through process of care. Data were from patient satisfaction surveys collected in seven mental health clinics (n=94 minority patients). Consistent with our hypothesis, patients' perception of clinicians' cultural competency was indirectly associated with patients' selfreported improvements in social interactions, improvements in performance at work or school, and improvements in managing life problems through the patients' experience of respect, trust, and communication with the clinician. These findings indicate that process of care characteristics during the clinical encounter influence patients' perceptions of clinicians' cultural competency and affect functional outcomes.Key Words: Cultural competency * Ethnic health disparities * Clinicianpatient Trust * Communication * RespectINTRODUCTIONRacial and ethnic minority groups experience worse health status and increased health risks compared to non-Hispanic White Americans.1,2 These disparities are consistent across a range of illnesses and services, including both physical and mental health.1,3,4 Social determinants contribute to these observed differences but do not completely explain them. For example, African Americans have poorer health status and receive a lower quality of health care than non-Hispanic White Americans even when patients' insurance status and income, two important individual-level measures of social determinants, are controlled.1,4,5 Another contributor to these observed differences are cultural barriers between clinicians and patients.1,5-8 These barriers may result in communication difficulties,9-11 lack of trust,12-19 and patient feeling disrespected.12,20 These difficulties in the clinical interaction are considered process of care deficiencies and have been associated with reduced patient satisfaction and other measures of health status.5,21-24One approach to bridge cultural barriers, although not yet proven to consistently affect outcomes25 is to match clinicians to patients by race. Some research studies have shown African Americans tend to prefer clinicians of the same race and they rate those clinicians as providing better interpersonal care than other clinicians.6,26-28 However, given that the workforce does not reflect the multitude of cultural, racial and ethnic groups, matching for individual patients is very difficult. To provide high quality care, the goal should be for every clinician to be able to provide culturally competent care to every patient.In previous research, we found higher patient perception of clinicians' cultural competency (defined as cultural knowledge, cultural awareness and cultural skill based on a model created by Sue et al. 1996) was associated with greater satisfaction with care.29 Greater satisfaction with care in turn appears to be related to process of care variables.14,23,30 Thus clinicians' cultural competency impact on health outcomes may be mediated by process of care measures. However, we could not find any research that explicitly addressed this hypothesis.In the field of mental health it is explicitly recognized that treatment is dependent on the clinician- patient relationship (i.e. therapeutic alliance).31,32 This vital relationship is based upon mutual trust, respect and open communication between the clinician and the patient. The characteristics of this relationship are related to health outcomes.33 One measure, trust, is positively associated with self-reported health status, symptom improvement, quality of life, willingness to seek care, use of preventive screening recommendations, and adherence to treatment.16,17,34-38 Another process of care measure, communication, has been shown to elicit greater disclosure of concerns from patients.39,40 These processes of care characteristics are routinely included in patient satisfaction surveys of mental health clinics.Desirable outcomes in the mental health field include the patient-centric functional ability to live independently and fulfill role obligations.41 These outcomes specifically cover independent self care, activities of daily living, social interactions and work/school roles.42-44 Besides being valued outcomes by patients, they are used by clinicians, administrators and auditors to gauge patient improvement. As such, these functional measures are also routinely included in patient satisfaction surveys of mental health clinics.To test the mediation hypothesis that patient perspectives of clinician's cultural competency is associated with health outcomes through process of care, we will construct models using data from patient surveys of satisfaction collected within mental health settings. Based on our preliminary studies and those of others, we propose that perceived cultural competency is indirectly associated with patients' functional outcomes through measures of trust, communication and respect as perceived by patients during clinical interactions.Method Participants:As part of ongoing quality control, patient satisfaction is monitored at seven university-affiliated outpatient mental health programs in the Detroit Michigan metropolitan area using short satisfaction surveys. Two of the programs provide care to children and adolescents, and five programs provide care to adults.Patients' demographics and patients' report of the clinicians' race were included in the survey. No information is available on whether the parent of patients or the patient completed the survey. For this analysis, 20 non-Hispanic white American respondents were eliminated from the sample. Among the minority sample (n=94), we coded the visit as patient-clinician race concordant (14.9%) or discordant. Table 1 summarizes characteristics of patients across the seven clinics. Overall, 54.3% were female and 82% were African Americans.PROCEDURE:Patients are encouraged but not required to complete the anonymous survey. At the child/adolescent sites, the parents of the children are encouraged to complete the survey. Organizationally, the goal is for each clinic to hand out surveys to patients during designated times and to collect at least 25 surveys for each period. 119 surveys were completed in the fall of 2011 and they were analyzed for this study. This study was approved by Wayne State University Institutional Review Board.MEASURES:The patient satisfaction survey consisted of 22 items measuring various aspects of care (e.g., patient-clinician communication, patient clinician trust, functional life outcomes and cultural competency) (Table 2). Limited demographic information (age, gender, ethnicity of patient, perceived race and ethnicity of clinician) was collected.Perceived cultural competency was measured using three questions selected from a nine-item measure developed and validated by the investigators in an independent sample.45 The original measure was adapted from the guidelines for measuring cultural competency in mental health clinician settings.46 The conceptual scheme includes three hypothesized domains of clinician competency: (1) Cultural knowledge measures clinicians' knowledge of a given culture, including its characteristics, worldviews and expectations; (2) Cultural awareness describes clinicians' sensitivity to their cultural biases and how such biases may influence their perceptions of patients; and (3) Cultural skill encompasses a clinician's ability to interact effectively with patients in a culturally relevant manner. For the brief satisfaction survey used in this study, cultural competency items with high face validity from each of the above domains were selected. Each item was measured on a Likert scale ranging from strongly disagree (1) to strongly agree (5). For the 94 surveys, the three items had an internal reliability of .87 when summed to form a scale. However the number of valid observations dropped from 90 for cultural skill alone to 71 when combining all three items. To utilize the item most commonly reported by patients, we measured the cultural skill item only. For this item, the distribution had a bimodal distribution of "strongly agree" (45.2%) or "strongly disagree" (54.8%). Based upon this information, we dichotomized the variable as "strongly agree" or "not strongly agree".Seven process of care variables were included in the survey to measure patient trust in the clinician, perceived respect during the clinical interaction, and patient-clinician communication (Table 2). Missing data were minimal ranging from 0 for understand (The therapist/doctor helped us understand the problem), confidences (The therapist/doctor respected my confidences as well as my child's), and respect (The therapist doctor treated me and my child with courtesy and respect) to 3 for plan (Therapist/doctor helped us develop a plan for treatment). The distribution of the Likert Scale responses was similar to that of the cultural competency items in being highly skewed. "Strongly agree" was the response for approximately 69% for items related to listened (The therapist/doctor listened and took me and my child seriously) and decision (The therapist/doctor involved me and my child in decision making), 64-67% for understand, confidences, plan (Therapist/doctor helped us develop a plan for treatment) and respect. Over half (56%) of the patients strongly agreed with the item I trust the therapist/doctor. Of the 94 patients, 46.8% strongly agreed with all seven process of care items, 29.8% strongly agreed with some but not all of the process of care variables and 23.4% did not strongly agree with any of the seven process of care items.The outcome measures were satisfaction with visit and three functional measures (Table 2). For satisfaction with visit, 81.9% said they were very satisfied. For the functional measures, the responses were not as skewed. For manage, (Since coming to this clinic I / child is better able to manage problems) 35.1% of patients responded strongly agree; for get along (Since coming to this clinic I/my child is better able to get along with family and friends), 31% responded strongly agree; and for work/school (Since coming to this clinic I/child is better able to concentrate, do chores, attend school/work), 29.1% responded strongly agree. Summing the three measures yielded a mean score of 11.7 out of a potential 15. The internal reliability of the functional outcomes scale was acceptable (alpha=.89).Statistical Analyses:The analysis proceeded by first examining bivariate associations between demographic information and cultural competence, process of care, and outcomes using standard chisquare and t-tests before examining multivariate associations. A simple mediational analysis with one mediator examined the association of cultural competency with functional outcomes mediated through the process of care variable. Analysis was conducted in SPSS using a macro developed by f Preacher and Hayes.47 Their approach uses bootstrapping to derive 95% confidence intervals for effect size estimates.RESULTSOverall, 46.2% of the minority patients strongly agreed that their clinician had the cultural skill to treat patients of their ethnicity. Cultural skill was not associated with race concordance between patient and clinician (46.2% of patients who perceived race concordance with the clinician strongly agreed that the clinician had cultural skill versus 46.3% for those who perceived race discordance strongly agreed that clinician had cultural skill). Likewise, there was no difference by gender or age of the patient. The sample was too small to test for differences by race of the patient.The categorized process of care variable was not associated with race concordance between patient and clinician: 30.5% strongly agree with all seven processes of care measures, 33.6% strongly agreed with at least one but fewer than seven processes of care measures and 26.8% of the patients did not strongly agree with any of the seven process of care measures. Of those who scored process of care highest, 87.8% saw a clinician of dissimilar race compared to 79.2% for those with intermediate process of care and 86.4% for those with lowest process of care score. Likewise there was no difference by gender or age of the patient. However, process of care was strongly associated with cultural skill (chi-square=51.16, df=2, p<.001). For those who scored process of care highest, 87.8% rated their clinician as having cultural skills compared to 24% in the intermediate care and 0% for those who scored process of care lowest.Cultural skills were also strongly related to satisfaction with visit: 59% of those highly satisfied with the visit reported their clinician as having cultural skills compared to 0% of those not highly satisfied with the visit (chi-square=16.37, df=1, p<.001). Satisfaction with visit was not associated with gender, race or age of the patient. The mean score for the functional outcome scale was strongly associated with cultural skills (12.9 for high cultural skills versus 10.8 for lower cultural skills, t=3.64, df=78, p<.001) and each of its components.The satisfaction outcome and functional outcome scales were also associated with the process of care measure. For those with high process of care, 100% said they were highly satisfied with care compared to 84.6% with intermediate and 50% with low process of care scores (chi-square=26.9, df=2, p<.001). The mean score for the functional outcome scale and each of its components monotonically increased as process of care score increased. For those with lowest score on process of care, the score was 10.53 compared to 13.03 for those with the highest score (F=9.92 for any difference, df=2,81, p<.001).These variables were then entered into a mediation model. As indicated in Figure 1, the total effect of cultural skills on functional outcome was highly statistically significant (p=.0005) with patients rating their provider as being highly cultural skilled having on average 2.107 higher score on the functional outcomes than patients not rating their provider so skilled. This total effect, however, resulted from cultural skill being associated with process of care (a1=1.202, S.E.=.12, p<.001), and process of care being associated with functional outcomes (b1=1.100, S.E. =.52, p=.038). The direct effect of cultural skill on functional outcomes was not significant (p=.35).DISCUSSIONThe objective of this study was to examine the relationship between cultural competency and functional health outcomes and to better understand the manner in which cultural competency relates to health outcomes. The results confirmed that process of care characteristics trust, respect and communication are important variables that mediate the relationship between clinicians' cultural competency and patients' functional outcomes. Patients who rated their clinicians as highly culturally skilled also rated process of care the highest. Although the exact mechanism with which process of care characteristics work is not yet clear, it is not surprising that cultural skill is associated with process of care as well as patient satisfaction. Cultural competency experts have theorized that cultural skill encompasses a clinician's ability to interact with patients in a culturally relevant, but adaptive manner.48 More specifically, establishing a good interpersonal relationship; facilitating information exchange; eliciting patient concerns, expectations, needs, and functioning; reaching a shared understanding of the problem and its treatment with the patient that is concordant with the patient's values; and facilitating patient involvement in decision-making, helping patients to share power and responsibility by involving them in choices to the degree that they wish are all essential aspects of cultural skill.39,49Interestingly, a close examination of patient responses to cultural questions indicated that items corresponding to cultural awareness and knowledge were more likely to be missing than questions related to cultural skill. Although, this observation warrants further study, it may suggest that patients find cultural skill an easier concept to evaluate as it is based on their observations, interactions and general experiences during the clinical encounter than cultural awareness and cultural knowledge. This finding may also motivate further exploration of the nature of cultural skill and what it encompasses.Perceived cultural skill was not associated with patientclinician race concordance, although we had limited power to test it. Race match between clinicians and patients has been viewed as a way of providing culturally competent care and improving patient outcomes; our finding highlights the complexity of the problem. For example, the fact that a patient and a clinician are both of the same race or ethnicity does not necessarily mean that they share the same values, norms, and lifestyle. Additionally, specific cultural knowledge and membership in a specific cultural group does not necessarily imply that a clinician possesses the cultural skill necessary to meet the health needs of a patient from the same cultural background. Experts in the field of cultural competency have claimed that cultural competency is not an end state but rather a dynamic process of learning that leads to an ability to effectively respond to challenges posed by social cultural diversity.50-53 A clinician can be as knowledgeable about a specific culture as possible. However, this knowledge can only be beneficial if it is demonstrated in the patient-clinician interaction.Cultural skill was positively associated with satisfaction with the visit. Patients who rated their clinicians as highly skilled also reported high satisfaction with their care. This finding is consistent with findings from our previous research which also showed that the positive association between perceptions of clinician cultural competency and patient satisfaction remained significant even when controlling for patient clinician communication, patient participation in the visit and patient-clinician race concordance.29 Satisfaction has been shown to be associated with improved clinical outcomes.54An important implication of our findings can be found in the development of evidence-based interventions to increase patient perception of clinicians' cultural skill. Our results have identified specific process of care characteristics that may influence the perceptions and health outcomes of racially/ ethnically diverse patients. Developing an understanding of the specific behaviors that promote trust, communicate interpersonal respect and encourage participatory culturally appropriate communication will be critical for developing specific and focused approaches to educate physicians and mental health clinicians.Moreover, our results highlight the important role that patients' perceptions of interpersonal processes and cultural skill play in the provision of health care to racial ethnic minorities. Systematically collecting data that includes patient feedback relating to process of care and competency judgments of clinicians' cultural competency provide individual health care clinicians as well as health care organizations with an understanding of patients' needs, concerns, and cultural attitudes. In doing so, individual health care clinicians and health organizations can effectively evaluate their process of care and cultural competence and develop interventions that enhance qualities of health care delivery that reflect patient culture to achieve the delivery of culturally competent care. Ultimately, these efforts may improve clinical outcomes, and reduce health disparities.Our results have several limitations. First, this study was observational based on an ongoing Quality Improvement activity. As such it lacked a systematic way of sampling and collecting responses from a representative sample. The process of care, satisfaction, and outcomes measures, although they appear to have high face validity, have not been previously tested and validated. Ratings on the satisfaction surveys were solely based on patient perceptions of their quality of care, clinicians' cultural competency and clinical improvement. Improvement on clinical outcomes was not empirically tested. Patient reports were not cross referenced with objective measures or clinicians' evaluations and impressions. Moreover, we have no way of knowing that interventions to enhance cultural skill would lead to changes in patients' perceptions or if they would result in changes in outcomes indirectly through improvements in process of care variables. Finally, our sample was small and it included few non African American minorities and a small number of race concordant patient-clinician pairs.In conclusion, cultural skills appear to be related to functional outcomes of mental health patients through process of care measures. Future research efforts however, are needed to identify the specific skills during the clinical interaction that influence process of care and identify behaviors that promote trust, communicate interpersonal respect and encourage participatory culturally appropriate communication.REFERENCES1. Smedley BD, Stith AY, Nelson AR. 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Public Health Rep. 2003;118(4):293-302.Georgia Michalopoulou, Ph.D.; Pamela Falzarano, M.A.; Michael Butkus, Ph.D.; Lori Zeman, Ph.D.; Judy Vershave, COTA; Cynthia Arfken, Ph.D.Correspondence: Georgia Michalopoulou, Ph.D, e- mail: [email protected]. All authors can be reached at telephone: 313 -745-4491; fax: 313 -993 - 0282.Appendix: Individual Items of Satisfaction SurveyClinic Environment (5-item Likert scale)The telephone was answered promptly and courteously.The appointment was scheduled at a time that was best for us.&lt;/p>My child had to wait more than 15 minutes in the waiting room.Staff were polite and helpful and treated us with respect.Patient-Clinician Communication (Process of care variable was transformed to an ordinal scale with 3 levels: High, Intermediate, Low)The therapist/doctor listened and took me and my child seriously.The therapist/doctor helped us understand the problem(s).The therapist/doctor respected my confidences as well as my child's.The therapist/doctor involved me and my child in decision making.The therapist/doctor helped us develop a plan for treatment.The doctor explained the benefits and side-effects of medications.The doctor paid attention to whether my child takes the prescribed medication.Perceived Respect (Process of care variable was transformed to an ordinal scale with 3 levels: High, Intermediate, Low)The therapist/doctor treated me and my child with courtesy and respect.Patient-Clinician Trust (Process of care variable was transformed to an ordinal scale with 3 levels: High, Intermediate, Low)I trust the therapist/doctor.Functional Life Outcomes (5-item Likert scale)Since coming to this clinic my child is better able to manage problems.Since coming to this clinic my child is better able to get along with family and friends.Since coming to this clinic my child is better able to concentrate, do chores, attend school.Cultural Competency (This variable was recoded to be dichotomous with a Likert score of 5, highly satisfied or strongly agree, vs. 1-4, less satisfied or not strongly agree.)The therapist/doctor has the skills to treat patients of our ethnicity.The therapist/doctor is well-informed about our culture.The therapist/doctor is aware of cultural differences.Patient Satisfaction (This variable was recoded to be dichotomous with aLikert score of 5 highly satisfied, vs. 1-4, less satisfied)I am satisfied with the time the therapist/doctor spent with us.Overall, how would you rate your visit with the therapist/doctor?Overall, how would you rate your visit to this clinic?Race ConcordanceWhat is your ethnicity?Would you say the therapist/doctor is of the same ethnicity as you?