A Mixed-methods Examination of Culturally Responsive Adaptation to an Evidence-based Parent-mediated Intervention Implemented for Autistic Children.

Parent-mediated interventions (PMIs) are considered an evidence-based practice for fostering social communication skills in young autistic children and for promoting parent responsivity and empowerment, yet barriers to caregiver engagement are evident when PMIs are implemented within historically underserved community settings. Issues of caregiver engagement can reflect a lack of fit between PMIs and the needs of diverse families. We used a mixed methods approach to examine barriers to participating in an evidence-based PMI, Project ImPACT (Ingersoll & Dvortcsak, 2019), within an outpatient setting, as well as strategies that clinicians reported using to deliver and adapt Project ImPACT for minoritized families. Participants included 134 caregivers of a child 13 to 48 months with autism or other social communication differences and six clinicians delivering Project ImPACT. Findings suggest that caregivers experience barriers to participating in Project ImPACT and that these barriers are associated with caregivers' ability to complete the program. Although quantitative findings indicate that adaptation to Project ImPACT did not differ by caregiver and child background, qualitative findings highlighted that clinicians attempt to deliver Project ImPACT to respond to the needs of families from minoritized backgrounds by actively considering the family's culture, psychosocial experiences, goals, and specific barriers. Further, both qualitative and quantitative findings suggest that culturally responsive care and adaptations may support caregiver engagement, including rapport, trust, buy-in, and attendance. Approaches to center cultural alongside contextual/psychosocial considerations within family-centered care in the implementation of PMIs are also highlighted.

Black men in white coats - Barriers black men face in medicine, implications to decreased representation, and potential interventions at the uniformed services university of the health sciences.

The number of black male applicants to US medical schools has remained stagnant over the last 30 years. The etiology behind the lack of applicants is multifaceted and involves greater systemic barriers, specifically, educational and social barriers. The lack of representation of black males in medicine also has downstream implications for the health of the African American/black community. African Americans exhibit some of the lowest levels of trust in the healthcare system, have less access to care than their non-minority peers, and have, comparatively, poorer healthcare outcomes than other populations in the US. Research has demonstrated that patient-provider race concordance improves communication, outcomes, culturally competent care, and satisfaction with care. The greater the gap between these two populations, the harder it becomes to improve healthcare outcomes, maintain a medically ready fighting force in the US military, and improve trust in the healthcare system. This article provides an analysis of the multifactorial barriers black male applicants face applying, matriculating, and graduating medical school and how decreased representation may affect healthcare delivery. Furthermore, this review explores next steps and potential implementations at the Uniformed Services University of the Health Sciences to address the above deficiencies.

Care of Sexual and Gender Minorities in the Emergency Department: A Scoping Review.

STUDY OBJECTIVE: This scoping review was conducted to collate and summarize the published research literature addressing sexual and gender minority care in the emergency department (ED). METHODS: Using PRISMA-ScR criteria, an electronic search was conducted of CINAHL, Embase, Ovid Medline, and Web of Science for all studies that were published after 1995 involving sexual and gender minorities, throughout all life stages, presenting to an ED. We excluded non-US and Canadian studies and editorials. Titles and abstracts were screened, and full-text review was performed independently with 4 reviewers. Abstraction focused on study design, demographics, and outcomes, and the resulting data were analyzed using an ad hoc iterative thematic analysis. RESULTS: We found 972 unique articles and excluded 743 after title and abstract screening. The remaining 229 articles underwent full-text review, and 160 articles were included. Themes identified were HIV in sexual and gender minorities (n=61), population health (n=46), provider training (n=29), ED avoidance or barriers (n=23), ED use (n=21), and sexual orientation/gender identity information collection (n=9). CONCLUSION: The current literature encompassing ED sexual and gender minority care cluster into 6 themes. There are considerable gaps to be addressed in optimizing culturally competent and equitable care in the ED for this population. Future research to address these gaps should include substantial patient stakeholder engagement in all aspects of the research process to ensure patient-focused outcomes congruent with sexual and gender minority values and preferences.

"The talking bit of medicine, that's the most important bit": doctors and Aboriginal interpreters collaborate to transform culturally competent hospital care.

BACKGROUND: In hospitals globally, patient centred communication is difficult to practice, and interpreters are underused. Low uptake of interpreters is commonly attributed to limited interpreter availability, time constraints and that interpreter-medicated communication in healthcare is an aberration. In Australia's Northern Territory at Royal Darwin Hospital, it is estimated around 50% of Aboriginal patients would benefit from an interpreter, yet approximately 17% get access. Recognising this contributes to a culturally unsafe system, Royal Darwin Hospital and the NT Aboriginal Interpreter Service embedded interpreters in a renal team during medical ward rounds for 4 weeks in 2019. This paper explores the attitudinal and behavioural changes that occurred amongst non-Indigenous doctors and Aboriginal language interpreters during the pilot. METHODS: This pilot was part of a larger Participatory Action Research study examining strategies to achieve culturally safe communication at Royal Darwin Hospital. Two Yolŋu and two Tiwi language interpreters were embedded in a team of renal doctors. Data sources included interviews with doctors, interpreters, and an interpreter trainer; reflective journals by doctors; and researcher field notes. Inductive thematic analysis, guided by critical theory, was conducted. RESULTS: Before the pilot, frustrated doctors unable to communicate effectively with Aboriginal language speaking patients acknowledged their personal limitations and criticised hospital systems that prioritized perceived efficiency over interpreter access. During the pilot, knowledge of Aboriginal cultures improved and doctors adapted their work routines including lengthening the duration of bed side consults. Furthermore, attitudes towards culturally safe communication in the hospital changed: doctors recognised the limitations of clinically focussed communication and began prioritising patient needs and interpreters who previously felt unwelcome within the hospital reported feeling valued as skilled professionals. Despite these benefits, resistance to interpreter use remained amongst some members of the multi-disciplinary team. CONCLUSIONS: Embedding Aboriginal interpreters in a hospital renal team which services predominantly Aboriginal peoples resulted in the delivery of culturally competent care. By working with interpreters, non-Indigenous doctors were prompted to reflect on their attitudes which deepened their critical consciousness resulting in behaviour change. Scale up of learnings from this pilot to broader implementation in the health service is the current focus of ongoing implementation research.

Strengthening Culturally Competent Health Communication.

Vulnerable refugee communities are disproportionately affected by the ongoing COVID-19 pandemic; existing longstanding health inequity in these communities is exacerbated by ineffective risk communication practices about COVID-19. Culturally and linguistically appropriate health communication following health literacy guidelines is needed to dispel cultural myths, social stigma, misinformation, and disinformation. For refugee communities, the physical, mental, and social-related consequences of displacement further complicate understanding of risk communication practices grounded in a Western cultural ethos. We present a case study of Clarkston, Georgia, the "most diverse square mile in America," where half the population is foreign born and majority refugee. Supporting marginalized communities in times of risk will require a multipronged, systemic approach to health communication including: (1) creating a task force of local leaders and community members to deal with emergent issues; (2) expanding English-language education and support for refugees; (3) including refugee perspectives on risk, health, and wellness into risk communication messaging; (4) improving cultural competence and health literacy training for community leaders and healthcare providers; and (5) supporting community health workers. Finally, better prepared public health programs, including partnerships with trusted community organizations and leadership, can ensure that appropriate and supportive risk communication and health education and promotion are in place long before the next emergency.

Considering difference: clinician insights into providing equal and equitable burns care for Aboriginal and Torres Strait Islander children.

OBJECTIVE: To better understand issues driving quality in burn care related to equity of outcomes and equality of provision for Aboriginal and Torres Strait Islander children. METHODS: Seventy-six interviews with team members who provide care for Aboriginal and Torres Strait Islander children in six paediatric burn units across five Australian jurisdictions were completed. Interface research methodology within a qualitative design guided data collection and analysis. RESULTS: Three themes were identified: i) Burn team members who identify the requirement to meet the specific needs of Aboriginal and Torres Strait Islander children and deliver differential care; ii) Burn team members who believe in equal care, but deliver differential care based on the specific needs of Aboriginal and Torres Strait Islander children; and iii) Burn team members who see little need for provision of differential care for Aboriginal and Torres Strait Islander children and rather, value the provision of equal care for all. CONCLUSION: Burn team members conflate equitable and equal care, which has implications for the delivery of care for Aboriginal and Torres Strait Islander children. Equitable care is needed to address disparities in post-burn outcomes, and this requires clinicians, healthcare services and relevant system structures to work coherently and intentionally to reflect these needs. Implications for public health: Changes in health policy, the embedding of Aboriginal and Torres Strait Islander liaison officers in burn care teams and systems that prioritise critical reflexive practice are fundamental to improving care.

Midwives' experiences of cultural competency training and providing perinatal care for migrant women a mixed methods study: Operational Refugee and Migrant Maternal Approach (ORAMMA) project.

BACKGROUND: The number of international migrants continues to increase worldwide. Depending on their country of origin and migration experience, migrants may be at greater risk of maternal and neonatal morbidity and mortality. Having compassionate and culturally competent healthcare providers is essential to optimise perinatal care. The "Operational Refugee and Migrant Maternal Approach" (ORAMMA) project developed cultural competence training for health professionals to aid with providing perinatal care for migrant women. This presents an evaluation of ORAMMA training and explores midwives' experiences of the training and providing care within the ORAMMA project. METHODS: Cultural competence was assessed before and after midwives (n = 35) received ORAMMA compassionate and culturally sensitive maternity care training in three different European countries. Semi-structured interviews (n = 12) explored midwives' experiences of the training and of caring for migrant women within the ORAMMA project. RESULTS: A significant improvement of the median score pre to post-test was observed for midwives' knowledge (17 to 20, p < 0.001), skills (5 to 6, p = 0.002) and self-perceived cultural competence (27 to 29, p = 0.010). Exploration of midwives' experiences of the training revealed themes of "appropriate and applicable", "made a difference" and "training gaps" and data from ORAMMA project experiences identified three further themes; "supportive care", "working alongside peer supporters" and "challenges faced". CONCLUSIONS: The training improved midwives' knowledge and self-perceived cultural competence in three European countries with differing contexts and workforce provision. A positive experience of ORAMMA care model was expressed by midwives, however clearer expectations of peer supporters' roles and more time within appointments to assess the psychosocial needs of migrant women were desired. Future large-scale research is required to assess the long-term impact of the ORAMMA model and training on practice and clinical perinatal outcomes.

A qualitative evaluation of the implementation of a cultural competence project in rural Victoria.

OBJECTIVE: To explore the complex factors influencing the implementation of cultural competency frameworks for Aboriginal and Torres Strait Islander peoples within rural, Victorian, mainstream health and community service organisations. METHODS: Semi-structured telephone interviews were conducted with key individuals from 20 public health and community services in rural Victoria who had participated in the Koolin Balit Aboriginal Health Cultural Competence Project (KB-AHCC project). Interviews were recorded and transcribed verbatim and a content analysis was undertaken. The findings informed the selection of six case study sites for more in-depth analysis. Following this, an expert reference group provided feedback on the findings. Findings from the different data were triangulated to identify eight factors. RESULTS: Key factors acting as barriers and/or enablers to implementing cultural competence frameworks were: comprehensive, structured tools; project workers; communication; organisational responsibility for implementation; prioritising organisational cultural competence resourcing; resistance to focussing on one group of people; and accountability. CONCLUSIONS: Embedding cultural competence frameworks within rural, mainstream health and community services requires sustained government resourcing, prioritisation and formal accountability structures. Implications for public health: Findings will inform and guide the future development, implementation and evaluation of organisational cultural competence projects for rural public health and community services.

A Study Looking at a Lower Cost Option for Cultural Competence Education.

To meet the growing demands in the US healthcare system caused by multiculturalism and the expansion of health inequities, due diligence must be given to testing the efficacy of tools used in teaching nurses to provide culturally competent care. This project assessed the utility of a free US government-developed training module. The team found an improved trend in nurse-patient communication scores and improved willingness to ask for help with cultural issues for the intervention unit. The use of no-cost, publicly available resources may be a cost-effective option for training materials.

Future forward: AGS initiative addressing intersection of structural racism and ageism in health care.

The American Geriatrics Society is committed to taking purposeful steps to address racism in health care, given its impact on older adults, their families, and our communities. In fall 2020, AGS added a statement to our vision for the future, which reflects that our commitment is central to mission: "We all are supported by and able to contribute to communities where ageism, ableism, classism, homophobia, racism, sexism, xenophobia, and other forms of bias and discrimination no longer impact healthcare access, quality, and outcomes for older adults and their caregivers." In 2021, we will be working to flesh out a multi-year, multi-pronged initiative that addresses the intersection of structural racism and ageism in health care. This will include engaging members in identifying strategies and with the goal of increasing member engagement around the idea that it will take all of us working together to achieve our vision for a collective future that is free of discrimination and bias. The Society has set as the first objective that by 2031, 100% of research presented at the AGS Annual Scientific Meeting and published in the Journal of the American Geriatrics Society (JAGS) will reflect the diversity of the population being studied. Other immediate efforts include undertaking a complete update of the Geriatrics Cultural Navigator, development of corresponding public education materials, and a webinar series focused on helping us all understand our own implicit bias, recognize implicit and explicit bias, and consider actions that we each might take to address bias when we observe it.

Yo soy Polígono. Proceso de intervención comunitaria intercultural y salud en el barrio del Polígono de Toledo / I Am Polygon. Intercultural and health community process in the Toledo polygon district

INTRODUCCIÓN: En julio de 2014 se inició en el barrio del Polígono de Toledo un proceso comunitario en las áreas de salud y educación. OBJETIVO: Exponer los resultados que diferentes estrategias de salud comunitaria han obtenido en la capacitación territorial y la mejora de la convivencia ciudadana del barrio del Polígono de Toledo. MÉTODOS: El proceso supone la aplicación de un modelo científico de trabajo para la mejora de la convivencia y la cohesión social en territorios de alta diversidad; partiendo de una monografía comunitaria y diagnósticos compartidos, se llega a una programación comunitaria, en donde instituciones, profesionales y ciudadanía acuerdan trabajar por los mismos retos. RESULTADOS: En estos años de desarrollo, se ha podido dotar al barrio de una estructura de participación propia para estos tres protagonistas. Al entrar en escena diferentes actores con relevancia en el enfoque promocional de la salud, se ha llegado a conformar una mesa técnica de salud desde donde se han ido dando forma a iniciativas que apuestan por una ciudadanía más activa en el manejo de su propio bienestar. DISCUSIÓN: Para poder desarrollar estrategias sólidas de promoción y prevención, es necesario implicar a todos los actores relacionados de un territorio, traducir sus potenciales en términos de salud y articular nuevos espacios de relación y coordinación sanitaria a través de procesos comunitarios sostenibles en el tiempo

INTRODUCTION: A community process in the health and education areas began in the Polígono de Toledo neighbourhood in July 2014. OBJECTIVE: To present the results that different community health strategies have obtained in territorial training and improved citizen coexistence in the Polígono de Toledo neighbourhood. METHODS: The process entails application of a scientific work model to improve coexistence and social cohesion in high diversity territories. Departing from a Community Monograph and Shared Diagnostics, Community Programming is attained where institutions, professionals and citizens agree to work on the same challenges. RESULTS: In these years of development, it has been possible to provide the neighbourhood with its own participation structure for these three protagonists. As different actors with a role to play in promoting healthcare entered the scene, a Technical Healthcare Roundtable was created, from where initiatives that went for citizens being more active in managing their own well-being were devised. DISCUSSION: In order to develop solid promotion and prevention strategies, all related actors in a region need to be involved. Their potential in terms of health must become a reality and new spaces for health relationship and coordination have to be articulated by means of sustainable community processes over time

Diálogo intercultural como herramienta de construcción en políticas de salud. Amazonía Colombiana / Intercultural dialogue as a tool for construction in health policies. Colombian Amazon

OBJETIVO: Describir el diálogo intercultural como herramienta para la construcción de políticas públicas de salud que respondan a la diversidad cultural indígena colombiana. MÉTODOS: Investigación cualitativa: observación participante, entrevistas en profundidad y análisis documental durante 2010 a 2019, desde la experiencia en la Asociación Indígena Zonal de Arica (AIZA) en la Amazonía colombiana. RESULTADOS: El diálogo intercultural en la construcción de las políticas públicas en salud relativas a los pueblos indígenas se describe a nivel comunitario, departamental y nacional. En AIZA, el diálogo se realiza entre las etnias muina, p++nemina e inga de manera constante y fluida, promoviendo el desarrollo de un proceso de salud que tiene como meta el fortalecimiento de la medicina tradicional y complementarla con la occidental. A nivel departamental, el diálogo entre las asociaciones indígenas es constructivo y colaborativo; entre asociaciones e instituciones gubernamentales, el diálogo depende de la voluntad de los funcionarios de turno. A nivel nacional, el diálogo entre las asociaciones e instituciones nacionales es precario. Las instituciones tienen objetivos de corto plazo; no comprenden que se requieren metas de largo plazo, y ello dificulta la construcción de políticas en salud pertinentes con la diversidad cultural. DISCUSIÓN: El diálogo intercultural como herramienta avanza en cada nivel, bien sea comunitario, departamental y nacional, de manera distinta y única, confluyendo diferentes factores

OBJECTIVE: Intercultural dialogue is reported as a tool to devise public health policies that respond to the indigenous cultural reality of Colombia. METHODS: Qualitative research strategies involving participant observation, in-depth interviews and documentary analysis over the period 2010 to 2019; from the experience in the Arica Zonal Indigenous Association (AIZA) in the Colombian Amazon. RESULTS: Intercultural dialogue in the drawing up of public health policies related to indigenous peoples at community, departmental and national level. In AIZA dialogue between the muina, p++ nemina and inga ethnic groups is constant and fluid. This enables developing a healthcare process whose aim is to strengthen traditional medicine complementary to its western counterpart. At departmental level, dialogue with indigenous associations is constructive and collaborative. However, dialogue between governmental associations and institutions depends on the will of the officials on duty. At national level dialogue between national associations and institutions is precarious. Institutionalism has short term aims and there is no understanding that long term goals are required. This hinders building health policies relevant to cultural diversity. DISCUSSION: Intercultural dialogue as a tool advances at each level, be it community, departmental and national in a different and unique way where different factors converge

Cuidados enfermeros para el abordaje de la salud comunitaria en población indígena de la Amazonia peruana / Nursing care to address community health of the indigenous population in the Peruvian Amazon

La comunidad nativa Shonori la componen familias asháninkas de la Amazonia peruana. Este trabajo aborda la salud comunitaria mediante una valoración y plan de cuidados de enfermería basado en el modelo de competencia cultural de Purnell y la taxonomía estandarizada enfermera (NANDA, NIC, NOC). La valoración se sustenta en 12 dominios relacionados con la herencia y ecología biocultural, comunicación, roles y organización familiar, conductas de riesgo, nutrición, embarazo, rituales de muerte y espiritualidad y prácticas y proveedores de cuidados de salud. Se detecta como diagnóstico una «salud deficiente de la comunidad relacionada con recursos insuficientes y manifestada por problemas de salud padecidos por la comunidad». Los criterios de resultados esperados en el plan de cuidados son: competencia social, estado de salud de la comunidad y control del riesgo social relacionado con las enfermedades transmisibles. Las intervenciones consisten en fomentar la salud comunitaria, analizar e identificar la situación de salud y riesgos, y controlar y proteger de enfermedades transmisibles y de riesgos ambientales. Intervenciones de la red pública de abastecimiento de agua y subvenciones para el apoyo agrícola y a las viviendas permitieron disminuir vectores, sufragar gastos del abastecimiento de agua segura y comprar alimentos para mejorar la nutrición infantil. El uso de la medicina tradicional fue potenciado y se desarrollaron campañas de salud y educación sexual en coordinación con el sistema oficial de salud. Se hizo un seguimiento durante 40 días, que corroboró la mejora de la salud comunitaria y la necesidad de un abordaje grupal con todos los actores

The native community Shonori is made up of Ashaninka families of the Peruvian Amazon. This paper addresses community health through an assessment and nursing care plan based on the Purnell cultural competency model and the standardized nurse taxonomy (NANDA, NIC, NOC). The assessment is based on 12 domains related to inheritance and biocultural ecology, communication, roles and family organization, risk behaviours, nutrition, pregnancy, death and spirituality rituals, and health care providers and practices. A diagnosis of «Poor health of the community r /t insufficient resources m/b health problems suffered by the community» is detected. The expected results criteria in the care plan are: social competence, community health status and control of social risk related to communicable diseases. The interventions consist of promoting community health, analyzing and identifying the health situation and risks, and controlling and protecting from communicable diseases and environmental risks. Interventions of the public water supply network and subsidies for agricultural and housing support, allowed vectors to be reduced, costs of safe water supply to be covered, and food to be bought to improve child nutrition. The use of traditional medicine was enhanced and health and sexual education campaigns were carried out in coordination with the official health system. A follow-up was carried out for 40 days, corroborating the improvement of community health, and the need for a group approach with all actors