Primary Care Provider Cultural Competence and Racial Disparities in HIV Care and Outcomes

Abstract

BACKGROUND: Health professional organizations have advocated for increasing the "cultural competence" (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care. OBJECTIVE: To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS. DESIGN AND PARTICIPANTS: Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S. MAIN MEASURES: Providers' self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients' receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression. KEY RESULTS: Providers' mean age was 44 years; 56 % were women, and 64 % were white. Patients' mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50-25.7), self-efficacy (3.77, 1.24-11.4), and viral suppression (13.0, 3.43-49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32-1.61; self-efficacy: 1.14, 0.59-2.22; viral suppression: 1.20, 0.60-2.42). CONCLUSIONS: Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.

Assessing Problematic Substance Use in HIV Care: Which Questions Elicit Accurate Patient Disclosures?

“…Additional details about the ECHO study are available in previous publications. [23][24][25][26][27][28] …”

The Appeal and Problems of a Cultural Competence Approach to Reducing Racial Disparities

“…With this measure, they find that for minority race patients, there is a positive effect of provider cultural competence. 3 These findings suggest that better cultural competence among providers will reduce disparities. Yet, we must proceed cautiously before making that conclusion.…”

“…3 In cultural competence terms, Saha et al present important findings based on high quality clinical and survey data and methods. 3 In this editorial, I will describe both their contribution, as well as my view that the foundation for cultural competence's popularity is also the source of its fundamental problems.…”

“…Saha et al tackle this problem by evaluating whether health care providers who rate their cultural competence higher have patients with better HIV management and whether there is a stronger positive effect among minority race patients. 3 In order to assess providers' cultural competence, Saha and colleagues had to first define the construct. 3 Starting from the notion that cultural misunderstanding is a primary source of racial disparities, cultural competence programs began with efforts to reduce racial disparities by teaching about the "cultures" of non-white racial and ethnic groups.…”

“…3 In order to assess providers' cultural competence, Saha and colleagues had to first define the construct. 3 Starting from the notion that cultural misunderstanding is a primary source of racial disparities, cultural competence programs began with efforts to reduce racial disparities by teaching about the "cultures" of non-white racial and ethnic groups. Quickly, criticism arose that this approach reinforces stereotypes about racial and ethnic minorities, suggests that racial groups have homogenous cultures, and fails to recognize how white racism and other systems of inequality affect care.…”