Overcoming challenges to cultural competence in research requires that: (check all that apply)

SOCRA Source. Author manuscript; available in PMC 2015 Aug 1.

Published in final edited form as:

SOCRA Source. 2014 Aug; 81: 12–21.

PMCID: PMC4357168

NIHMSID: NIHMS621292

Mary Ellen Lawless, MA, RN,1 Jeanmarie Muellner, MPA,1,2 Ashwini R. Sehgal, MD,1,2 Charles L. Thomas,2,3 and Adam T. Perzynski, PhD2,3

Abstract

Background

Little attention has been given to the cultural competence education needs for researchers.

Objectives

To describe the planning and implementation of a neighborhood visit approach to cultural competency education in the community.

Methods

A committee of community partners and academics planned, conducted and evaluated the visit. The cultural competence and confidence (CCC) model was used to engage researchers. An evaluation survey assessed participant satisfaction and experiences.

Results

Of the 74 attendees 64 (84%) completed the conference evaluation. Attendees expressed that the visit and conference objectives were met and that the content was relevant to their work. Nearly all (95%) responded they would incorporate what they learned into practice.

Conclusion

A neighborhood visit approach is feasible and acceptable to researchers and community partners. Evaluation of this community based education program showed preliminary evidence of changing both the way researchers think about the community and conduct research.

Introduction

Changes in population demographics and the persistence of health disparities have focused attention on the importance of providing cultural · competence education and training to healthcare providers. However, little attention has been given to training needs and curriculum format for health researchers.1-4

Cultural competence refers to the ability to work effectively with individuals of different cultural backgrounds. 1,3,7 While cultural competence training is becomi11g more widespread for clinicians, little is being done to provide such education for clinical and health services researchers.3,6 A lack of cultural competence on the part of researchers may hinder engagement with certain communities, such as minority or non-English speaking individuals, and may lead researchers to impose their beliefs, values, and patterns of behavior upon those from other cultural backgrounds. 8 There are numerous advantages to medical researchers pursuing skills in cultural competence, including the contextualization of research knowledge and an increase in the community relevance of research findings. 2 Health care providers and clinical researchers increasingly care for and conduct research on persons from diverse cultural backgrounds. A recent survey of clinical researchers found that they wanted to learn more about the needs and perspectives of different groups.1,3 Here we use an established, relativistic definition of cultural differences, “Culturally different clients are clients whose racial, ethnic, gender, socioeconomic, and /or religious backgrounds and/or identities are different from the health care professional”. 5

Conceptual Framework and Model: Experiential Learning Framework and The Cultural Competence and Confidence (CCC) Model

The CCC model defines cultural competence as a multidimensional and lifelong learning process that integrates transcultural skills in cognitive, practical and affective dimensions and involves self-efficacy (confidence) as a major influencing factor. 5 The cognitive domain consists of knowledge concerning the ways cultural factors may influence care. The practical domain encompasses applied skills such as communicating effectively with clients of different cultural backgrounds to learn about their values and beliefs. The affective domain considers the learner's attitudes, values, and beliefs.5 Defining cultural competence as a learning process rather than an achieved status emphasizes that these domains can change over time as the result of formalized education and other learning experiences, as well as the fact that cultures themselves are dynamic.5

Cultural Competency Neighborhood Visit and Conference (CCNVC)

A needs assessment was completed with 56 attendees from a prior university based, lecture-format cultural competency conference to identify preferences for conference format, including using a number of neighborhoods to visit. The survey results indicated that direct visits to Cleveland neighborhoods would be potentially acceptable to future participants.

The objectives of the CCNVC as described to attendees are presented in Table 1. Our hope was that meeting these objectives would enable the researchers participating to develop new insights about communities in Cleveland and relate and apply their experience of the neighborhoods to research interests and projects. To accomplish these objectives the visit sought to bring researchers directly to three distinct urban neighborhoods where community representatives and resources were being mobilized to surmount challenges. to the health of neighborhood residents. The neighborhoods were purposively selected because of the existence of established academic and community partnerships. As shown in Table 2, the three neighborhoods (1. Asiatown, 2. Hough and 3. Stockyards) have considerable differences across socioeconomic and racial/ ethnic indicators. It is important to emphasize that we do not assume that these neighborhoods share a common culture or that persons in these neighborhoods are somehow representative of their respective racial and ethnic categories. Our goal was to have researchers visit these neighborhoods and learn from community representatives. Among the authors of this paper and the planning committee, some were very concerned that this effort might be seen as reflecting a notion that all or most minorities live in disadvantaged urban neighborhoods, and that researchers just need to visit such neighborhoods to fully learn about the culture of minority groups. We see the CCNV effort as a small step along the pathway to strengthening the social bonds between researchers and community members.

TABLE 1

CCNV Objectives

TABLE 2

Neighborhood Demographic Characteristics

During development of the conference and visit some researchers voiced skepticism and concerns about the implicit assumption that bringing researchers to diverse neighborhoods would promote learning about the varied cultures of the people in the neighborhoods. From the beginning we recognized this challenge and a primary strategy to overcome it was to include community representatives on the conference committee, and involve these community representatives throughout all stages of the planning, implementation and evaluation processes.

Planning of the CCNV started about six months in advance. We began by identifYing partners, contacts and neighborhoods. General steps in planning the visit included contact between the CCNV program chair and the program director of a neighborhood federally qualified health center to discuss current health issues in the community and visit concept. Joint goals and objectives were agreed upon during three face to face meetings and that email communication included all other members of the community. Alignment of interests was neighborhood specific. In one neighborhood, based on community feedback, facilities visits and a power point presentation of one of the facilities were suggested. The power point presentation included: mission, vision, history, service area, funding sources, programs, other collaborative relationships and how care is accessed. The walking visit of the facility highlighted where the services and programs are located in the building. This approach allowed the federally qualified health center and visit participants to get to know each other, and to discuss the possibility of relating and aligning interests.

Each trolley served as a mobile classroom in that a microphone system was in place and was used by presenters to interact with trolley participants while driving from site to site. The trolley seats up to 38 people in an open environment that promotes conversation. To appreciate not only the health center of the neighborhood, other aspects of the built environment were suggested by community representatives to be incorporated into the visit. Two neighborhood residents conducted this portion of the visit and decided what drive route to take, where to stop and explore the neighborhood and what to discuss.

As mentioned, the neighborhoods chosen were those with recent or current projects in progress and included neighborhoods with distinct distributions of racial and ethnic groups .(Table 2). We developed a list of dozens of community partners and researchers on the planning and development committee then emailed, phoned, and set up meetings to discuss the purpose of the conference. Other partners were identified from the primary contacts. Site visits were conducted in which community representatives talked about what they felt were important things community residents have access to (resources) and things residents need to go through when trying to live healthy lives (obstacles). Discussions were generally framed in terms of composition, context and collective aspects of the built environment. Composition explanations drew attention to the characteristics of individuals concentrated in particular places. Contextual explanations drew attention to opportunity structures in the local physical and social environment. Collective explanations drew attention to socio-cultural and historical features' of communities.9 A full list of potential topics is presented in Appendix A.

Four resources, existing maps developed for the community, websites of the community's redevelopment corporation, a university based health disparities course, and a review of the literature, served as the foundation for discussion points. The first resource, existing maps developed for community, with school locations, recreation / fitness centers, police and fire stations, food stores, health centers, community organizations, scenic vistas, city wide bike routes and' green space were used. The second resource, websites of the community's redevelopment corporation with the neighborhood history and progress toward revitalization talked about many aspects of the built environment. For example, one neighborhood has an online walking tour and neighborhood list of organizations. Other highlights such as news and views, getting involved, shopping, and business, social service, entertainment, recreation, churches, schools, development and homes for sale were noted. The third resource, a class on health disparities and the faculty instructors at Case Western Reserve University provided curricular guidance and suggestions for how to define and identifY health disparities, the organizations work in addressing it and trying to reduce it also acted as a reference point. The fourth resource, a review of the literature found many articles citing the social determinants of health, how those impact health, and, basically, place matters. An outline of topics was compiled from those articles. In preparing these resources together with the presenters, it was suggested that they emphasize context and their own priorities for discussion of what helps keep people healthy in their neighborhood.9-11

We used two trolleys to conduct the neighborhood visit. Each trolley functioned as a mobile classroom; a microphone system was in place and was used by presenters and organizers to interact with trolley participants while driving from site to site. One trolley visited a health center and family center in Hough and another trolley visited a grocery store and health center in Stockyards. Both trolleys also visited Asiatown and ended with a snack at a community bakery. Routes were purposively planned and selected by community representatives. Presenters included community clinic physicians, a grocery store owner, a city councilman and community development personneL Presenters on the trolley and at the stops drew attention to changes in the neighborhood, renovations and initiatives and the availability of health services. Presenters were able to describe subtleties not obvious to the casual observer, such as the recent work of community coalitions, infrastructure changes and developments in urban agriculture.

Methods

This study was approved by the MetroHealth and Case Western Reserve University Institutional Review Boards.

Sample

Researchers at health research institutions in the Cleveland area (including Metro Health, University Hospital, and Cleveland Clinic Foundation, the Veterans Administration Hospital, and Case Western Reserve University) were invited to the CCNV via advertising through multiple methods: word of mouth, institutional research offices, a save the date card distributed to lists of researchers, the CTSC website calendar, and mass emails to the schools of medicine, nursing and social work. Of the 103 total conference attendees, the first 74 (trolley maximum capacity) researchers to respond were chosen and participated in the neighborhood visits; the remaining 29 researchers attended only the conference activities taking place after the visits and are excluded from the current analysis. Researchers requesting Continuing Medical Education Credit completed an evaluation form (84% of the sample). Of those who took a trolley visit, 28 completed self-administered paper and pencil surveys which were collected at the end of the trolley visit.

Study Participant Characteristics

Study participant characteristics were collected at the time of registration, using a registration form. Participants were asked to describe their organizational affiliations and role in the research process. All CCNY participants were researchers, but the disciplinary background of the researchers included registered nurses (38%), physicians (8%), health educators (10%), social workers (8%), researcher administrators (7%) and other roles (30%) including sociologists, dietitians, and biostatisticians.

The registration form also asked participants to list all of the types of research they were currently involved in. Nearly half(47%) described themselves as conducting community or population research, 32% were working on clinical trials and 30% were conducting research on evidence based guidelines and dissemination. None of the participants were involved in laboratory research.

Evaluation Data: The day-long CCNVC was approved for six continuing medical education (CME) and Continuing Research Education (CREC) credits. Attendees wanting to receive credits were required to complete evaluation forms at the end of the day. At the time of exiting the trolley, each attendee was also invited to complete a supplemental evaluation form focused on insights gained as a result of the visit.

The brief end-of-day evaluation survey included four “yes” or “no” questions. The supplemental trolley exit survey included a single “yes” or “no” question, a five category Likert-type question, and a series of open-ended questions about the visit experience.

Data Analysis (Quantitative)

The neighborhood data (presented in Table 2) come from Cuyahoga County and the 2010 Census and American Community Survey. Given the relatively small sample size and the descriptive (rather than comparative) nature of the evaluation design we report only descriptive, univariate statistics. Participant survey data from the paper and pencil surveys were hand-entered into data management software. Data were cleaned, checked for meeting distributional assumptions and analyzed using SPSS, a widely available and well known statistical package. 12 List wise deletion was used to handle missing responses. Frequency distributions and descriptive statistics (mean, median, percent) were calculated in order to examine responses to closed-ended survey questions.

Data Analysis (Qualitative)

The responses to open ended questions were transcribed and then analyzed qualitatively using a modified thematic constant comparative approach.13-15 The evaluation team (MEL, KKP, JM, IT, and AP) began bY. open coding the full set of transcribed textual responses. The initial set of themes was condensed and revised after a series of team meetings in which coding definitions were elaborated and disagreements over the application of a particular code or theme were resolved. The iterative analysis evolved into a formal coding framework for understanding and categorizing all responses. Results of the open coding process were then input into SPSS in order to calculate frequencies and percentages.

Results

Responses to questions evaluating the CCNY quantitatively were overwhelmingly positive. In response to the yes/no question, “The objectives were met,” 100% said “yes.” For the question, “The information presented is relevant to my practice,” 90% said “yes”. When asked “Due to information presented, I will consider how I practice,” 66% said “yes.” ·In response to the question, “Will you incorporate a part of this experience into your work?” the vast majority of the participants, 93%, responded “yes.” On the supplemental survey taken at the end of the trolley visit, on a 5 point Likert-type, “Overall, how would you rate the neighborhood visit experience?” respondents were also exceptionally positive in their reactions. None of the respondents selected “poor,” “fair,” or “average,” 32% rated the tour as “good” and 68% rated the visit as “excellent.”

While the above results illustrate the CCNVC met objectives and was perceived as useful, open-ended responses described how participants were influenced, and provided valuable details with regard to the depth and range of the learning process as experienced by the attendees.

The result of coding and analysis were two broad thematic categories: 1) Thinking & Doing and 2) Expectations & Observations. The Thinking & Doing theme consists of survey responses that describe how the tour influenced a person's thinking and/or actions. For example, the statement, “I realized that with this population, poverty becomes a significant risk factor,” was coded as a thinking statement. “Doing” statements were coded when a respondent indicated that they intended to engage in a new action. For example, one researcher described their intention to seek out more information, “Learn more about the community by incorporating myself into the neighborhood (shop, walk around, see sites}; involve myself” The Thinking & Doing themes are consistent with the CCC model for cognitive and practical dimensions of cultural competence.

The Expectations/Observations theme is consistent with the affective domain of the CCC model and was coded when participants described the impressions of the neighborhood they held before the visit and if that view changed, after the visit, as expressed in their responses to the trolley exit survey. Using this framework we constructed a matrix describing the valence, or direction of both expectations and observations (positive, neutral or negative).

This analysis presents exploratory idiographic evidence of the extent to which preconceived expectations of the neighborhoods were altered by the trolley visit experience.

When expectations and observations had a neutral valence, or it was not possible to make an inference we classified such text as neutral/ unclear. Neutral expectation/positive observation and neutral expectation/ negative observation were used to describe statements that did not indicate a changed viewpoint or opinion. These statements were just general positive or negative statements about the neighborhood, the visit, or whether or not the respondent gained any further understanding of cultural competency. For example, one respondent wrote, “Very helpful to learn more about the culture and neighborhood of the patients I see.” This respondent did not convey an expectation and observed something positive, thus the response was coded neutral expectation/positive observation.

Of the participants completing supplemental surveys, 96% responded with statements indicating Thinking as a consequence of taking the trolley visit and 71% responded with a Doing statement. Illustrative Thinking & Doing quotations are presented in Table 3.

TABLE 3

Thinking and Doing Responses to Trolley Visit Exit Survey (n=28)

Illustrative Expectation & Observation quotations are presented in Table 4. Nearly all of the survey participants (96%) wrote answers that included a neutral expectation/ positive observation statement suggesting that the vast majority of respondents learned something positive that changed their view about the community on the visit. About a third (32%) answered with a negative expectation/positive observation statement, suggesting a transformation of perspective (see the response from Educator 4 in Table 4). An additional 46% answered with a neutral expectation/negative observation statement, suggesting that a substantial portion of the respondents had negative impressions of the community.

TABLE 4

Illustrative Quotations from Trolley Visit Exit Survey Participants Describing Expectations and Observations (n=28)

Discussion

Much can be learned from the process of developing and implementing the CCNY. First, at our site, interest in this type of activity was high suggesting that planning teams should be prepared to accommodate a large number of researchers. Second, input from community partners and a resident are valuable at all stages · from planning to implementation. Direct participation of community representatives as visit guides was instrumental to the success of the CCNV. The guides were able to share insider perspectives from their communities. Third, evidence from the visit evaluations suggests that this type of education fonnat is an effective way to conduct cultural competency education among researchers that is consistent with the cognitive, practical and affective domains of the CCC model.

The descriptive results of the closed-ended evaluation questions suggest that the CCNVC content was relevant, informative and successful at meeting objectives. The qualitative results of the supplemental trolley exit survey further indicate that the researchers participating developed new ways of thinking about the communities and in some cases even engaged in actions to conduct more culturally competent research. Doing statements indicated positive practical changes for the Cultural Competency Visit participants. As evidenced by the juxtaposition of expectations with observations in the qualitative results, some participants gained a new perspective. In some cases, the trolley visit of the neighborhoods and community resources was an eye-opening experience in which expectations about the neighborhoods were countered with firsthand experiential knowledge gained from seeing the built environment and hearing from community representatives. Many participants had never previously visited the communities in which their research volunteers live. Furthern1ore, the researchers expressed a desire for more cultural competency education and stressed the importance of it taking place in the community.

To the best of our knowledge this is the first study of a program designed to promote cultural competence among clinical and health services researchers. Our findings among researchers parallel those of studies of cultural competency training for clinicians.16 In their review of 34 studies, the authors found overwhelming evidence that cultural competency educational programs improved the knowledge, attitudes and behavior of health care providers. 16 Our results suggest that educational and experiential efforts to promote cultural competence among researchers are worthwhile and deserving of further study, but come with some important limitations.

The most important limitation of our evaluation of the CCNV C is that while 84% completed the closed ended questions on the Continuing Medical Education Evaluation, just 38% completed the open-ended supplementary evaluation form. It is possible that participants not completing surveys had views and opinions about the neighborhood visit that were different from those who completed the exit and follow-up surveys. Further this study was not randomized and had no control group. Given the positive results of this study, such a design is warranted in future efforts to validate our findings. No subjects expressed negative views of the visit, and such feedback could have been valuable for future efforts. Nonetheless the overwhelming consistency of the quantitative responses complemented by the supporting idiographic evidence from the open-ended responses leads us to conclude that this neighborhood visit was an effective educational tool for promoting cultural competency and community engagement among researchers.

While this evaluation suggests that the trolley visit is effective, our study made no comparison with more didactic, non-experiential forms of cultural competency education. In addition, our evaluation focused on the potential cultural competency gains for researchers, and not on changes in community perceptions pursuant to the interactions facilitated by the trolley visit. However, anecdotal responses from the community leaders who helped design the trolley visit experiences were overwhelmingly positive.

A key feature of this project was the inclusion of community members in the planning phase, in which community representatives from multiple neighborhood institutions were able to design and plan the activities that the researchers would be involved in. Our experience suggests that future projects should consider this as a critical step in the design of cultural competency education curricula for researchers. On.the other hand, another weakness of our project is the lack of participation of some specific clinical and allied health disciplines. For example, no pharmacists participated in the tour. Inclusion of clinical research from additional disciplines in the planning process, (e.g. pharmacy and rehabilitation) could greatly enrich the composition and impact of the neighborhood tour approach.

A key criticism received anecdotally by the evaluation team was that while it was beneficial to experience the neighborhoods and hear from community representatives, the neighborhood visit did little to engage researchers in specific longer-term activities that would further erode the barriers between researchers and the neighborhoods. Thus, a focal recommendation for future activities in conjunction with a neighborhood visit would be to include a fonn of “task achievement” as part of the curriculum.17 Goal setting combined with tangible achievements for the researchers in the CCNVC would have the potential to demonstrate and foster collaborative partnerships. It would not require much extra planning to ask community members and representatives to help plan a practical activity to complete with the resealtchers during the visit. For example, one of the community members and one of the researchers who met on the visit suggested having a visit stop where they could work together in one of the urban community gardens. Such an activity would engage researchers and community members as equals in a practical task already identified as benefitting the community.

For educational program managers and coordinators planning to implement a trolley visit, our experience suggests that it is best to build upon existing community partnerships. The community partners’ knowledge of the community far exceeded that of the team members from the university and was instrumental in the success of the neighborhood visit. This strength includes identifying other community partners to include and collaborate. For example, community partners were able to identify the best trolley routes and stops that would more effectively communicate the depth and range of active community resources.

In the Stockyards neighborhood, the neighborhood federally qualified health center, (Neighborhood Family Practice) had previously partnered with some of the study investigators. Representatives of the health center informed the conference planning staff that they had recently completed a renovation that physically connected the health center space to the grocery store's pharmacy department. The Health Center community director had worked with the grocery store manager to discuss the renovation and was able to facilitate a meeting between the CCNVC chair and the store manager. At the outset, the grocery store manager was skeptical of the benefits of clinical researchers visiting the community and learning cultural competency. A series of meetings and discussions motivated the grocery store manager to lead a visit of the store that provided important insights into the food selections and other consumption patterns of potential interest to researchers. This particular store maintains a massive and diverse inventory of foods and products consumed by Hispanic residents. The store also provides Spanish language signage and information, and has many bilingual employees, a level of cultural competence not yet attained at many of the area academic medical centers. For further details and more specific conference logistics beyond those available in the article appendices, contact the first author.

In summary, community based cultural competency education using a trolley visit approach is feasible and acceptable to researchers. Participants in the CCNVC gained a new appreciation for the challenges faced and resources mobilized by persons in three culturally diverse and geographically proximate urban neighborhoods. The importance of cultural competency training taking place in the community was evident in the evaluation which found changes in both the way people think about the community and changes in the way people conduct research. For participants who had never entered these communities or who had not visited the communities for more than ten years, the trolley visit proved to be a worthwhile experience. •

Acknowledgements

The authors wish to acknowledge the community partners and residents of the Stockyards, Hough and Asiatown neighborhoods who met regularly to plan and assist with the visit stops. We particularly thank the Stockyards neighborhood and Neighborhood Family Practice, NFP -Jose Estremera, Director of Community Relations and Project Management and Jean Therian-Nurse Manager, and Ann Reichsman MD; Dave's Mercado- Doug Deacon, Store Manager; Stockyards Redevelopment Organization -Megan Meister; Cleveland City Councilman Matt Zone; Hough neighborhood at Northeast Ohio Neighborhood Health Services, NEON, Teri Clemons Clark, Development Officer and Kimberly Sanders, Program Director; Fatima Family Center- LaJean Ray, Director; Keith Benford and Jackie Rogers, residents; Asiatown-St Clair Superior Development Corporation- Cory Riordan, Assistant Director and Asian Services In Action, Inc. Michae.l Byun and Kitty Leung, Children, Youth, and Family Services Manager; Klara Papp, PhD and Tran Tran, BA.

We also want to acknowledge additional members of the CCNVC planning committee: Michele Abraham, Meia Jones, Janeen Leon, Shury Meriweather and Marilyn Alejandro Rodriguez. Visit Information: Hough: Kimberly Sanders, MP A; Vickie Marie, M.Ed.; Terri Clemons; Asia Town: Michael Byun; Steve Hom; Stockyard: Jose Estremera; Matt Zone; Megan Meister, MSSA, LSW; Doug Deacon

This work was supported by grants MD002265 and UL1TR000439 from the National Institutes of Health, Bethesda, Maryland

Appendix

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