Promoting inclusion in clinical trials-a rapid review of the literature and recommendations for action.

BACKGROUND: Without inclusion of diverse research participants, it is challenging to understand how study findings will translate into the real world. Despite this, a lack of inclusion of those from under-served groups in research is a prevailing problem due to multi-faceted barriers acting at multiple levels. Therefore, we rapidly reviewed international published literature, in relation to clinical trials, on barriers relating to inclusion, and evidence of approaches that are effective in overcoming these. METHODS: A rapid literature review was conducted searching PubMed for peer-reviewed articles that discussed barriers to inclusion or strategies to improve inclusion in clinical trial research published between 2010 and 2021. Grey literature articles were excluded. RESULTS: Seventy-two eligible articles were included. The main barriers identified were language and communication, lack of trust, access to trials, eligibility criteria, attitudes and beliefs, lack of knowledge around clinical trials, and logistical and practical issues. In relation to evidence-based strategies and enablers, two key themes arose: [1] a multi-faceted approach is essential [2]; no single strategy was universally effective either within or between trials. The key evidence-based strategies identified were cultural competency training, community partnerships, personalised approach, multilingual materials and staff, communication-specific strategies, increasing understanding and trust, and tackling logistical barriers. CONCLUSIONS: Many of the barriers relating to inclusion are the same as those that impact trial design and healthcare delivery generally. However, the presentation of these barriers among different under-served groups may be unique to each population's particular circumstances, background, and needs. Based on the literature, we make 15 recommendations that, if implemented, may help improve inclusion within clinical trials and clinical research more generally. The three main recommendations include improving cultural competency and sensitivity of all clinical trial staff through training and ongoing personal development, the need to establish a diverse community advisory panel for ongoing input into the research process, and increasing recruitment of staff from under-served groups. Implementation of these recommendations may help improve representation of under-served groups in clinical trials which would improve the external validity of associated findings.

Establishing evidence to inform culturally competent mental health services: A mixed methods study protocol.

BACKGROUND: COVID-19 has exacerbated the significant and longstanding mental health inequalities for ethnic minorities, who were less likely to access mental health support in primary care but more likely to end up in crisis care compared to the majority ethnic group. Services were poorly offered and accessed to respond to the increased mental health challenges. AIM: To 1) establish evidence on which changes to mental health services provided in response to COVID-19 are beneficial for ethnic minorities who experience mental health difficulties in the North of England, and 2) to inform what and how culturally competent mental health services should be routinely provided. METHODS: A mixed methods approach comprising 1) a rapid review to map services and models of care designed or adjusted for mental health during the pandemic, 2) an observational study of retrospective routine data to assess changes to mental health services and associated outcomes, 3) qualitative interviews to understand experiences of seeking care and factors associated with high-quality service provision, and 4) a Delphi study to establish consensus on key features of culturally competent services. From the selected areas in the North of England, adults from ethnic minorities who experience mental health difficulties will be identified from the primary, community and secondary care services and local ethnic minority communities. DISCUSSION: This study will identify ways to tackle health inequalities and contribute to mental health service recovery post pandemic by providing practice recommendations on equitable and effective services to ensure culturally competent and high-quality care. A list of services and features on what and how mental health services will be provided. Working with study collaborators and public and patient involvement partners, the study findings will be widely disseminated through presentations, conferences and publications and will inform the subsequent funding application for intervention development and evaluation.

A Culturally Competent Vaccine Hesitancy Educational Model for Community Pharmacists to Increase Vaccine Uptake, Louisiana, 2021-2022.

In February 2022, an educational model was launched to train Louisiana pharmacists to become positive influencers of vaccination decisions via targeted, culturally competent interventions, with the objective of improving COVID-19 vaccine uptake in communities. A total of 47 pharmacists completed the course, and more than 90% noted that the education would help them optimize vaccine acceptance in their community practice settings. The pharmacists will participate in vaccine surveillance to assess the success of the educational model intervention and predictors of vaccine uptake. (Am J Public Health. 2022;112(S9):S900-S903. https://doi.org/10.2105/AJPH.2022.307070).

Registered nurses' experiences and perceptions of supervising international nursing students in a clinical setting - A qualitative study.

AIM: The aim of the study was to examine the experiences and perceptions of Indian RNs who supervise Norwegian undergraduate nursing students during their clinical practice in India. BACKGROUND: The globalization process has generated a need for registered nurses (RNs) to develop cultural competence. As a result, nursing education and policy need to respond to the challenging nature of global health and prepare RNs to work with diverse cultures by enhancing their cultural competence to help them encounter patients from different cultural backgrounds. Yet, the research investigating the experience of supervisors in non-western countries receiving students from western countries is sparse DESIGN: An exploratory descriptive design. METHODS: Eight individual semi-structured interviews were undertaken by Indian Registered nurses, supervising Norwegian nursing students. Three of the interviews were conducted in their workplace in India, while the rest were carried out using Zoom conference due to the COVID19 pandemic. The interviews were conducted between January - December 2020. Inductive qualitative content analysis was used to analyse the data. RESULTS: Thematic analysis elicited four main themes: 1) Preparation to receive international students, 2) The role of supervising international students, 3) Learning from the students, 4) Challenges of supervising international students CONCLUSIONS: Participants provided valuable insights into the role of supervising international nursing students in India. This insight is considered important since many students from Western countries go to non-Western countries for international exchanges. The study highlights the fact that the method of supervision is connected to the culture and is different in Western and non-Western countries. Even though they acknowledged several challenges with having international students, supervisors emphasized that having international students was a positive experience and that they learned from them.

Factors Affecting Cultural Competence in a Sample of Nursing Students during the Prolonged COVID-19 Pandemic in Republic of Korea: A Cross-Sectional Study.

Globally, foreign citizens, particularly ethnic and racial minorities, experienced discrimination and received imbalanced medical services and insufficient economic resources during the COVID-19 pandemic. This study aimed to examine the factors that affect the cultural competence of nursing students. This is descriptive cross-sectional study adheres to Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. A convenience sample of 235 nursing students from two nursing colleges in D city completed an online Google Forms questionnaire from 9 August to 12 August 2022. The self-report questionnaire included a sociodemographic data form, a cultural intelligence scale, an ethnocentrism scale, a global competence scale, and a cultural competence scale. The mean score of cultural competence was 95.39 ± 15.64 (out of 135 points); cultural competence was significantly positively correlated with cultural intelligence and global competence (p < 0.001), and significantly negatively correlated with ethnocentrism (p < 0.001). The factors that significantly affected cultural competence were cultural intelligence (ß = 0.31, p < 0.001) and global competence (ß = 0.37, p < 0.001). The explanatory power of these effects was 47.3%. To improve the cultural competence of nursing students, it is necessary to develop, apply, and evaluate the results of curriculum and programs that can enhance the cultural intelligence and global competence of nursing students.

Mechanisms Driving Postgraduate Health and Social Science Students' Cultural Competence: An Integrated Systematic Review.

PURPOSE: The COVID-19 pandemic revealed a global urgency to address health care provision disparities, which have largely been influenced by systematic racism in federal and state policies. The World Health Organization recommends educational institutions train clinicians in cultural competence (CC); however, the mechanisms and interacting social structures that influence individuals to achieve CC have received little attention. This review investigates how postgraduate health and social science education approaches CC and how it accomplishes (or not) its goals. METHOD: The authors used critical realism and Whittemore and Knafl's methods to conduct a systematic integrated review. Seven databases (MEDLINE, CINAHL, PsycINFO, Scopus, PubMed, Web of Science, and ERIC) were searched from 2000 to 2020 for original research studies. Inclusion criteria were: the use of the term "cultural competence" and/or any one of Campinha-Bacote's 5 CC factors, being about postgraduate health and/or social science students, and being about a postgraduate curriculum or a component of it. Thematic analysis was used to reveal the mechanisms and interacting social structures underlying CC. RESULTS: Thirty-two studies were included and 2 approaches to CC (themes) were identified. The first theme was professionalized pedagogy, which had 2 subthemes: othering and labeling. The second theme was becoming culturally competent, which had 2 subthemes: a safe CC teaching environment and social interactions that cultivate reflexivity. CONCLUSIONS: CC conceptualizations in postgraduate health and social science education tend to view cultural differences as a problem and CC skills as a way to mitigate differences to enhance patient care. However, this generates a focus on the other, rather than a focus on the self. Future research should explore the extent to which insight, cognitive flexibility, and reflexivity, taught in safe teaching environments, are associated with increasing students' cultural safety, cultural humility, and CC.

Improving Cultural Competence and Self-Efficacy Among Postgraduate Nursing Students: Results of an Online Cultural Care Training Program.

INTRODUCTION: Since nurses and nursing students interact with culturally diverse clients in health care settings, training programs are required to improve cultural competence and self-efficacy among them. This study aimed to investigate the effect of an online cultural care training program on cultural competence and self-efficacy among postgraduate nursing students. METHODS: The present interventional study used random sampling to allocate 80 postgraduate nursing students into the intervention and control groups. Cultural care training program was held for the intervention group. RESULTS: No significant difference in cultural competence and self-efficacy scores was found between the intervention and control groups in the pretest. However, the intervention group scored higher in terms of cultural competence and self-efficacy after the intervention. DISCUSSION: Given cultural diversity and prevalence of medical tourism, nursing instructors need to pay special attention to cultural care education at all academic levels.

Nursing Education and Social Determinants of Health: A Content Analysis.

BACKGROUND: By integrating a social determinants of health (SDOH) perspective into nursing programs, there is potential to reduce health disparities shaped by these forces. However, little is known about the extent to which nursing program curricula include SDOH education. METHOD: This study used course descriptions from 32 nursing programs in the United States to perform a frequency and content analysis on required course offerings. Healthy People 2020 was referenced to determine coding categories. RESULTS: Although 18.5% of courses implicitly referenced SDOH, only 1% made explicit references to SDOH. Implicit references were likely to include themes such as cultural sensitivity and diversity, or social, cultural, economic, and political factors influencing health. CONCLUSION: Although several required nursing course descriptions made implicit references to SDOH, explicit use of the term SDOH is still limited. Faculty, administrators, and program accrediting bodies must push to incorporate SDOH more thoroughly into nursing education. [J Nurs Educ. 2022;61(9):516-523.].

Development and Cultural Adaptation of Psychological First Aid for COVID-19 Frontline Workers in American Indian/Alaska Native Communities.

The coronavirus disease 19 (COVID-19) pandemic is broadly affecting the mental health and well-being of people around the world, and disproportionately affecting some groups with already pre-existing health inequities. Two groups at greater risk of physical and/or mental health detriments from COVID-19 and more profoundly impacted by the pandemic include frontline workers and American Indian/Alaska Native (AI/AN) communities. To provide support and prevent long-term mental health problems, we culturally adapted a psychological first aid guide specifically for COVID-19 frontline workers serving AI/AN communities. We engaged a diverse, collaborative work group to steer the adaptation content and process. We also held two focus group discussions with frontline workers in AI/AN communities to incorporate their perspectives into the adapted guide. Results from the group discussions and the collaborative work group were compiled, analyzed to extract themes and suggestions, and integrated into the adapted content of the guide. Main adaptations included updating language (i.e., to be more culturally appropriate, less prescriptive, and less text heavy), framing the guide from a harm-reduction lens, incorporating cultural activities, values, and teachings common across diverse AI/AN communities (e.g., importance of being a good relative), and validating feelings and experiences of frontline workers. The resulting adapted guide includes four modules and is available as a free online training. Our adaptation process may serve as a guiding framework for future adaptations of similar resources for specific groups. The adapted guide may stand as an enduring resource to support mental well-being, the prevention of mental health problems, and reduction of health inequities during the pandemic and beyond.

Effects of an internationalization at home (IAH) programme on cultural awareness among medical and nursing students in Hong Kong and Indonesia during the COVID-19 pandemic: a mixed-methods study.

BACKGROUND: The COVID-19 pandemic has severely impacted the learning experience of students by limiting their opportunities for face-to-face intercultural exchanges. Given the importance of cultural competence in medical education, there is a need to develop a programme that promotes cultural awareness, but that offers more flexibility in terms of outbound mobility. This study aims to evaluate the effectiveness of an internationalization at home programme and to explore the learning experiences of medical and nursing students from Hong Kong and Indonesia. METHODS: Students were recruited from two universities in Hong Kong and Indonesia. They attended an online internationalization at home programme designed by members of the research team from both countries. A mixed-methods study was conducted using a concurrent triangulation approach. A pre-test post-test design was used to evaluate the effects of the programme on cultural awareness, and four focus groups were conducted to explore the students' experiences in the programme. Quantitative and qualitative data were analysed by T-test and reflexive thematic analysis, respectively. Data were integrated and triangulated using joint displays by comparing findings from both sources. RESULTS: One hundred and forty-eight students from Hong Kong and Indonesia participated in the study. After the programme, there was a significant improvement in cultural awareness. Three themes were identified: (1) learning process: enjoyable, but a desire remains for face-to-face cross-cultural communication; (2) learning outcomes: gained cultural awareness, developed cultural sensitivity, had an opportunity to practice language and learn about new learning styles; (3) factors influencing learning outcomes: facilitators (micro-movie and active communication) and barriers (language barrier, inappropriate time arrangement, insufficient prior briefing). CONCLUSION: This programme achieved the learning outcomes by successfully enhancing the cultural awareness of students during a time of pandemic when outbound student exchanges were not possible. Further adaptations of the programme are required to enhance different learning outcomes.

Factors Affecting the Global Health and Cultural Competencies of Nursing Students.

Recently, various global health issues, including coronavirus disease 2019 (COVID-19), have been observed in relation to rapid changes in world health conditions; consequently, nurses' global health and cultural knowledge have become increasingly important. Therefore, this study aimed to identify factors affecting the global health and cultural competencies of nursing students. The study design was a cross-sectional study with 108 participants; all participants were fourth-year nursing college students in S and C cities. Global health competency, cultural competency, global health confidence, cultural nursing confidence, and metacognition were surveyed online, and the data were collected from October 30 to November 7, 2018. The collected data were analyzed using descriptive statistics, independent t-test, Pearson's correlation, and hierarchical multiple regression. The total mean scores for global health competency and the cultural nursing competency were 63.01 ± 8.78 and 134.94 ± 17.78, respectively. Global health competency had a positive correlation with cultural competency (r = 0.49, p < 0.001), cultural nursing confidence (r = 0.26, p = 0.006), and metacognition (r = 0.22, p = 0.023). Cultural competency showed a positive correlation with global health confidence (r = 0.31, p = 0.001), cultural nursing confidence (r = 0.51, p < 0.001), and metacognition (r = 0.40, p < 0.001). Cultural competency was found to be a significant factor affecting global health competency, with an explanatory power of 23.1% (F = 17.10, p < 0.001). Cultural nursing confidence and metacognition had significant effects on cultural competency, with an explanatory power of 34.3% (F = 14.97, p < 0.001). Cultural confidence and metacognition were important factors influencing cultural competency, and cultural competency was shown to be an important factor influencing global health competency.

Exploring and Developing a New Culturally-Appropriate Diabetes Distress Scale in Taiwan.

Introduction: The aim of this study was to develop and validate a new diabetes distress scale suitable for Chinese and Taiwanese culture. Methods: This study collected the current diabetes distress measurement tools, re-organized current definitions about the domains of diabetes distress, and then developed a new tool. Three hundred and ninety-five participants from four hospitals in northern Taiwan were recruited by cluster randomized sampling for validity test. Results: We found the new diabetes distress scale had appropriate reliability and validity, including an acceptable model fit for the 12-item scale. Conclusions: This new diabetes distress scale might be more directly related to emotional distress issues blood glucose control, improve the clinical conspicuity of diabetes distress, and even benefit the overall care of diabetic patients in Taiwan. Further studies about the validity and reliability of this new tool in a nationwide setting are needed.

COVID-19 Vaccine Distribution in a Community With Large Numbers of Immigrants and Refugees.

Refugee and immigrant populations are extremely vulnerable to the consequences of the COVID-19 pandemic. COVID-19 vaccination is a critical tool in mitigating these consequences, but these same communities often lack access to COVID-19 vaccines. We describe the efforts of a community-based primary care clinic in Clarkston, Georgia to provide access to COVID-19 vaccines in a culturally sensitive manner to address this health disparity and vaccine hesitancy.

Cultural Competence and Cultural Intelligence of Healthcare Professionals Providing Emergency Medical Services.

BACKGROUND: There are more and more foreigners in Poland who become clients of the Polish healthcare system. They use, among others, emergency medical services provided by healthcare professionals: doctors, nurses, and paramedics. Skillful care for culturally different patients requires cultural competencies and cultural intelligence to ensure good quality of care and cultural safety. The study aimed to measure and assess the cultural competencies and cultural intelligence of medical professionals working in hospital emergency departments (HEDs) and hospital emergency rooms (HERs) in Malopolska, a region in southern Poland. METHODS: The following questionnaires were used in the study: the Cross-Cultural Competence Inventory (CCCI), the Cultural Intelligence Scale (CQS), and Questionnaire on Attitudes Towards Culturally Divergent People. In total, 709 medical professionals participated in the study, including 363 nurses, 223 paramedics, and 123 doctors. RESULTS: Cultural intelligence-the overall score and the scores on the metacognitive, cognitive, motivational, and behavioral subscales were significantly higher among HED and HER doctors. Cultural competencies-the overall score and the score on the cultural adaptation subscale were also significantly higher among HED and HER doctors. The CCCI and CQS scores were influenced by selected variables: taking care of and close interactions with representatives of other cultural circles; staying outside Poland for more than a month. Doctors were the group of medical professionals that were most tolerant and most positive towards people from other cultures. CONCLUSIONS: The research results confirm the positive impact of contact of medical professionals with people from other cultures on their cultural competencies and cultural intelligence. They indicate the need for training in acquiring cultural competencies and developing cultural intelligence, especially among nurses. They demonstrate the need to raise awareness among HED and HER medical professionals about issues in intercultural care and to increase diversity efforts, especially among nurses.

Perception and Experience of Transcultural Care of Stakeholders and Health Service Users with a Migrant Background: A Qualitative Study.

INTRODUCTION: While European health policies do frequently take into consideration the ideas and experiences of their users, the voices of minority and marginalized communities are not often heard. European healthcare services must address this issue as the number of healthcare users with an MM background increases. AIM: To explore the perspectives of key stakeholders and healthcare users with an MM background on transcultural care in four European countries. DESIGN: Qualitative phenomenological study. METHODS: Semi-structured, individual interviews were conducted with stakeholders and MM users. Interviews were translated and transcribed verbatim and were carried out from February to May 2021. Descriptive statistics was used to describe the characteristics of the sample; qualitative data were analyzed thematically following Braun and Clarke's phases, resulting in 6 themes and 18 subthemes. RESULTS: For stakeholders and MM users with long-established residence in their respective countries, cultural differences involve different family and community norms, religious beliefs, lifestyles, and habits. These components are perceived as in tension with healthcare norms and values, and they mediate in two key and related aspects of the relationship between MM users and healthcare providers: accessibility and communication. CONCLUSIONS: Communication and access to healthcare are key to MM health service users, and they are the most frequent sources of misunderstanding and conflict between them and healthcare professionals. IMPACT: It is important to extend the investigation of cultural issues in healthcare to stakeholders and MM users. There is no doubt that healthcare professionals should be trained in cultural competence; however, cultural competence training is not the only area for improvement. There should be a change in paradigm in healthcare services across Europe: from individual to organizational integration of culture and diversity.