CULTURAL COMPETENCE TRAINING PROGRAM FOR AFRICAN IMMIGRANTS
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BRIEF OVERVIEW
There is lack of cultural competence among health care providers regarding African immigrants and this is a major contributing factor to their poor health outcomes.
The main goal of the project was to develop a cultural competence training program for providers regarding African immigrants that would improve provider cultural competence and resource allocation and referrals for African immigrants.
The project was implemented at a primary care clinic in Garland, Texas.
The conclusion is that the intervention is effective.
Background: The number of African immigrants entering and settling in the United States increases almost every year. The group has unique health care needs and most of these needs are related to their cultural practices. However, there is lack of cultural competence among health care providers regarding African immigrants and this is a major contributing factor to their poor health outcomes. Without cultural competence training, health care providers cannot effectively tackle the health care concerns of this population.
Purpose: The main goal of the project was to develop a cultural competence training program for providers regarding African immigrants that would improve provider cultural competence and resource allocation and referrals for African immigrants.
Methodology: Madeleine Leininger’s Cultural Care Model provided the conceptual framework for the project. The project utilized educational training sessions with pre and post survey questionnaires for 3 providers, the African Immigrant Cultural Competence Toolkit, and the resources toolkit. A paired-t test and percentage calculations were used for analysis of the results.
Results: There was a statistically significant improvement in the cultural competence knowledge of providers before and after the training (F (3, 11) = 17.23, p = 0.001). All of the 187 patients who visited the clinic during the 4-week period were handed resource toolkits (100%). Providers utilized the African Immigrant Cultural Competence Toolkit 50.8% of the time (95 out of 187).
Conclusion: A cultural competence training program for providers regarding African immigrants is effective in improving provider cultural competence skills and resource allocation and referrals for African immigrants.
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BACKGROUND
The number of African immigrants entering and settling in the United States increases almost every year (Purnell & Fenkl, 2019).
African immigrant group has unique health care needs and most of these needs are impacted by their cultural practices.
These individuals have been brought up in entirely different societies with completely different cultural beliefs and practices.
Health care providers should find ways of addressing these unique health care needs (Omenka et al., 2020).
The number of African immigrants entering and settling in the United States increases almost every year (Purnell & Fenkl, 2019). This is because African immigrants prefer moving to the United States in search of better living conditions, better employment opportunities, and better health care services (Seck, 2015). However, African immigrants have been brought up in entirely different societies with completely different cultural beliefs and practices (Allen et al., 2012).
The African immigrant group has unique health care needs and most of these needs are related to their cultural practices (Purnell & Fenkl, 2019). The specific needs of this population include but are not limited to : poorly controlled chronic conditions, a general bad state of health as a result of lack of access to effective care in their home countries, ineligibility to federally funded public health insurance programs in the United States, and lack of health education which was not provided in their home countries. Purnell and Fenkl (2019) reported that health care providers are not devoted to finding methods of addressing these unique health care needs of African immigrants. Omenka et al. (2020) explained that the lack of cultural competence among health care providers is a crucial contributing factor to the poor health of African immigrants. Without cultural competence training, health care providers cannot effectively tackle the health care concerns of African immigrants (Kamya, 2017).
The poor outcomes for this population include but are not limited to : poor management of chronic diseases, poor patient experience, higher rates of readmissions, higher mortality rates and lack of timely access to care. The culture of African immigrants impacts: their perceptions of health, illness, and death; beliefs about the causes of death; the types of treatments they prefer; how pain and illness are experienced and expressed; and their approaches to health promotion. Healthcare providers should familiarize themselves with these specific needs of the population and knowledge of the impacts of culture on African immigrants’ health practices. Betancourt and Green (2010) explain that cultural competence training for healthcare providers improves health outcomes for various groups, such as Asian and African immigrants.
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PROBLEM STATEMENT
Lack of cultural competence training among health care providers regarding African immigrants.
Staff has not received formal training on addressing the needs of this population.
Providers cannot deliver health services that address the cultural, social, and linguistic needs of the African immigrant group.
Results in poor health outcomes for the population.
The main problem faced at the project site is the lack of cultural competence training among health care providers, specifically regarding African immigrants. The facility is a primary care clinic in Garland, Texas that attends to various groups of people and the African immigrants group is one of them. However, the African immigrant group is different in terms of their health care needs and their culture impacts most of their health care experience. (Asare & Sharma, 2012). These specific healthcare needs and the impacts of culture on their health practices have been discussed in the previous slide. The staff has not received formal training on addressing the needs of this population; therefore, they cannot deliver health services that address the cultural, social, and linguistic needs of the African immigrant group. This results in poor health conditions for African immigrants. There are several resources available that are not being used, and this project plans to address these gaps.
The Center for Disease Control and Prevention (CDC) reported that the failure of health care providers to administer effective health care services to African immigrants puts the group at an increased risk of getting sick (CDC, 2021). The CDC reported that this has been clear, especially during the COVID-19 period, as many African immigrants have suffered from and died of COVID-19 (CDC, 2021). The proposed solution is the development of a cultural competence training program for the health care providers. This program is aimed at enabling the health care providers to gain the knowledge and techniques they can employ to provide quality health care services to African immigrants. Betancourt and Green (2010) explain that cultural competence training for healthcare providers improves health outcomes for various groups, such as Asian and African immigrants.
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OBJECTIVES
To create a cultural competence training program that would help in promoting cross-cultural awareness and competence skills needed for health care professionals to be culturally competent regarding African immigrants.
To create an African Immigrant Cultural Competence Toolkit that would be used by care providers to assess and enhance cultural competence in the organization.
To create a Resources Toolkit that would be given to African immigrant patients visiting the primary care clinic.
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LITERATURE REVIEW
Main themes identified during literature review were:
Effects of cultural incompetence
Language barriers and cultural competence
The impact of cultural competence training on health care providers
The main themes that emerged during the literature review include effects of cultural incompetence, how language barriers affect cultural competence, and the impact of cultural competence training on health care workers. These themes are the main points of emphasis when developing a cultural competence program for African immigrants. Focusing on these themes will guarantee the success of the cultural competence program for African immigrants.
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LITERATURE REVIEW:
Effects of cultural incompetence
Providers fail to take into consideration the patients’ beliefs and their religious backgrounds.
Providers fail to ask the patients the type of treatment they prefer based on their cultural health practices.
Providers cannot efficiently deliver health services that cater to the cultural, social, and linguistic needs of the African immigrant patients (Purnell & Fenkl, 2019).
In addition to other issues, cultural incompetence contributes to the risk that makes African immigrants two to three times more likely to suffer from various health-related issues compared to other groups (Seck, 2015).
The main issue observed in the project is the lack of cultural sensitivity and competence within the health care profession regarding African immigrants. Examples include the providers failing to take into consideration the patients’ beliefs and their religious backgrounds, and failing to ask them the type of treatment they preferred based on their cultural health practices. This issue has a negative impact on the healthcare received by African immigrants. Because of the disparity in cultural competence, the health care providers cannot efficiently deliver health services that cater to the cultural, social, and linguistic needs of the African immigrant patients (Purnell & Fenkl, 2019). Some of these social determinants of health are housing quality, access to healthy foods, and education. Seck (2015) explained that African immigrants have unfavorable social determinants of health which contribute to their lack of quality healthcare. This leads to their poor health experiences because health care workers are not taught their social determinants of health. Clough et al. (2013) explained that African immigrants are two to three times more likely to suffer from various health-related issues compared to other groups, such as White people. This is due to poorly controlled chronic conditions, a general bad state of health as a result of lack of access to effective care in their home countries, ineligibility to federally funded public health insurance programs in the United States, a lack of health education which was not provided in their home countries, and the lack of cultural competence among providers. The cultural incompetence of health care workers makes African immigrants, who are primarily Black, suffer severely and longer from easily preventable diseases (Wamwayi et al., 2019).
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LITERATURE REVIEW:
Language Barriers and Cultural Competence
Language is an aspect of culture (Seck, 2015).
Language barriers play a huge role in miscommunication between patients and medical providers.
Providers have an incomplete understanding of the situations of patients, poorly assess patients, prescribe treatment incompletely, or cause delayed treatment or misdiagnoses (Wamwayi & Murray, 2019).
This negatively affects the quality of healthcare services and patient satisfaction.
Language is an aspect of culture that affects the quality of treatment in African immigrant groups (Seck, 2015). There are four main languages spoken by African immigrants, and they include Swahili, Amharic, Igbo, and Yoruba (Omenka et al., 2020s). Language barriers play an important role in miscommunication between patients and medical providers, which negatively affects the quality of healthcare services and patient satisfaction regarding the African immigrant group (Allison et al., 2016). Due to language barriers, health care professionals have an incomplete understanding of the situations of patients, poorly assess patients, prescribe treatment incompletely, or cause delayed treatment or misdiagnoses (Wamwayi & Murray, 2019). As a result of language barriers, African immigrants end up having decreased satisfaction with health care services, complications arising from medication, and a reduced level of understanding of their diagnosis even if they have access to healthcare (Venters et al., 2019). To reduce the language barrier, healthcare providers can use interpretation services such as Google Translate, use visuals, ask the institution to hire a translator or interpreter, and do some language training on the common words and phrases that African immigrants are likely to use in a hospital setting (Purnell & Fenkl, 2019).
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LITERATURE REVIEW:
Impact of Cultural Competence Training
Cultural competence training among health care providers has social, health, and business benefits for health care organizations and African immigrants (Omenka et al., 2020).
Enables improved patient data collection for African immigrants and reduces the health care disparities in the African immigrant population.
Reduces barriers that slow the progress of the health care experience of African immigrants.
Enables culture-specific practices into health promotion activities.
Training programs and cultural competence among health care workers have social, health, and business benefits for health care organizations and African immigrants (Omenka et al., 2020). Cultural competence training programs would increase mutual respect and understanding between African immigrants and health care providers (Kamya, 2017). Being culturally competent would also enable health care workers to have improved patient data collection for African immigrants and reduce the health care disparities in the African immigrant population (Asare & Sharma, 2012). When healthcare workers undergo cultural competence training programs, they will incorporate diverse ideas, perspectives, and strategies when deciding about African immigrants. Barriers that slow the progress of the health care experience of African immigrants would also be decreased and the efficiency of these care services will be improved (Omenka et al., 2020). It enables providers to incorporate culture-specific attitudes and values into health promotion activities for this group (Kamya, 2017).
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CONCEPTUAL MODEL:
MADELEINE LEININGER’S CULTURAL CARE THEORY
Theory focuses on the definition of what pertains to transcultural nursing and how nurses comprehend the beliefs and practices of diverse cultural groups (Leininger, 1988).
Goal of the cultural care theory is to enable improved health outcomes for individuals of different cultural backgrounds (Leininger, 1988).
Major tenets were used to identify how nurses can bridge the cultural gap.
Tenets included cultural care preservation or maintenance, cultural care accommodation or negotiation, and cultural care repositioning or restructuring.
The theoretical underpinning or conceptual framework for this project will be provided by Madeleine Leininger’s cultural care theory. Leininger’s theory focuses on the definition of what pertains to transcultural nursing and how nurses comprehend the beliefs and practices of diverse cultural groups (Leininger, 1988). This theory is the most appropriate for this DNP project since it aims at explaining how nurses can provide culturally congruent care through taking actions that are mainly designed to suit the individual’s, group’s, or institution’s cultural values, lifeways, and beliefs (Leininger, 1988). The goal of the cultural care theory is to enable improved health outcomes for individuals of different cultural backgrounds (Leininger, 1988).
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Project Design
Population of Interest
Setting
Stakeholders
Project Design
Instruments/Tools
Data Collection methodology
IMPLEMENTATION
Implemented using the Plan-Do-Study-Act Model.
Implemented over 5 weeks with 3 participants (providers).
The training session was done in the first week, and other interventions were done from Week 2 to Week 5.
Interventions included:
cultural competence training session for the providers; pretest and post surveys before and after the training session,
providing the providers with toolkits,
and providing participants with resource toolkits that they handed out to African immigrant patients.
The project was implemented using the PDSA model that is made up of four repeating phrases that are cyclical in nature. The interventions included a cultural competence training session for the providers, pretest and post surveys before and after the training session, providing the providers with toolkits that they would use as reference while attending to African immigrant patients, and providing providers with resource toolkits that they handed out to African immigrant patients who visited the clinic during the project implementation period. The project was implemented over 5 weeks. The training session was done in the first week, and other interventions were done from Week 2 to Week 5.
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EVALUATION
There was a statistically significant improvement in the cultural competence knowledge of providers before and after the training (F (3, 11) = 17.23, p = 0.001).
All of the 187 patients who visited the clinic during the 5-week period were handed resource toolkits (100%).
Providers utilized the African Immigrant Cultural Competence Toolkit 50.8% of the time (95 out of 187).
All the objectives of the project were met.
There was a statistically significant improvement in the cultural competence knowledge of providers before and after the training (F (3, 11) = 17.23, p = 0.001). All of the 187 patients who visited the clinic during the 4-week period were handed resource toolkits (100%). Providers utilized the African Immigrant Cultural Competence Toolkit 50.8% of the time (95 out of 187). The providers had to use the African Immigrant Cultural Competence Toolkit only if they needed to make a reference to it while attending to a patient. Therefore, the providers only felt the need to refer to the toolkit during about half of the time they interacted with African immigrant patients. This is why the African Immigrant Cultural Competence Toolkit utilization rate is 50.8%. The main limitation in this approach was the lack of a standardized way to determine when to refer to the toolkit during an interaction with an African immigrant patient.
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CONCLUSION
A cultural competence training program for providers regarding African immigrants is effective in improving provider cultural competence skills and resource allocation and referrals for African immigrants.
The results of the project are consistent with previous literature.
The project will encourage providers’ acknowledgement and acceptance of differences in appearance, behavior and culture.
The health outcomes of the African immigrant population will improve.
A cultural competence training program for providers regarding African immigrants is effective in improving provider cultural competence skills and resource allocation and referrals for African immigrants. In this case, “resource allocation and referrals” refers to the ability of providers to hand out documents or discuss with the patients the avenues where they can obtain help in matters of food, finances, employment, housing, health, or legal issues. The results of the project are consistent with previous literature in the same subject area. The project will encourage providers’ acknowledgement and acceptance of differences in appearance, behavior and culture between themselves and the African immigrant patients. The health outcomes of the African immigrant population will improve since the providers will be in a better position to provide care in a culturally-competent manner.
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DISSEMINATION
Plans to present results to the facility’s stakeholders, including management, providers, and nurses, in order to redesign the study to continue with cultural competence training for all stakeholders.
Sharing the project’s outcomes with the stakeholders using a PowerPoint presentation and executive summary.
Disseminated through publication in nursing journals.
Disseminated through oral presentation of findings during local nursing conferences.
Dissemination of this project’s findings is critical to optimizing health care delivery. The project lead plans to present results to the facility’s stakeholders, including management, providers, and nurses, in order to redesign the project to continue with cultural competence training for all stakeholders. The dissemination aims to increase awareness of the need to become culturally competent when examining patients from diverse cultural backgrounds. The project lead will share the project’s outcomes with the stakeholders using a PowerPoint presentation and executive summary. This evidence-based project will be disseminated through publication in nursing journals (Journal of Research in Nursing, Advanced Practices in Nursing Journals, and Diversity and Equality in Healthcare Journal) and presentation of findings during local nursing conferences (Texas Healthcare Summer Conference and Texas Nursing Practitioners Conference). The project will also be disseminated to TUN facility and student peers, DNP project repository, and through posters or oral presentations.
Sustaining and optimizing the effectiveness of this project’s cultural competence intervention are critical, and planning is necessary to achieve this. First, an adherence committee will be appointed to maintain the support, oversight of progress, and guidance. The committee is made up of top executives, employee representatives, human resources professionals, and members of the ethics committee. Second, the project lead and the adherence committee will help develop the facility’s cultural competency policy. Third, providers will be invited regularly to discuss the program’s components in which they feel competent and those in which they might be experiencing challenges. Consequently, the project lead aims to achieve sustainability through formal discussions/feedback and real-time support. The project will be adjusted based on the results and will be implemented again at the site with similar objectives but improved approaches.
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REFERENCES
Betancourt, J. R., & Green, A. R. (2010). Commentary: Linking cultural competence training to improved health outcomes: Perspectives from the field. Academic Medicine, 85(4), 583– 585.
Kamya, H. A. (1997). African immigrants in the United States: The challenge for research and practice. Social Work, 42(2), 154–165. http://dx.doi.org/10.1093/sw/42.2.154
Omenka, O. I., Watson, D. P., & Hendrie, H. C. (2020). Understanding the healthcare experiences and needs of African immigrants in the United States: A scoping review. BMC Public Health, 20(1), 1–13.
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REFERENCES
Purnell, L. D., & Fenkl, E. A. (2019). Transcultural diversity and health care. In Handbook for culturally competent care (pp. 1–6). Springer, Cham.
Seck, M. M. (2015). West African immigrants in the United States: Challenges and empowering strategies. Social Development Issues, 37(2), 68–79.
Wamwayi, M. O., Cope, V., & Murray, M. (2019). Service gaps related to culturally appropriate mental health care for African immigrants. International Journal of Mental Health Nursing, 28(5), 1110–1118. https://doi.org/10.1111/inm.12622
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