The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review

Review

The effectiveness of culturally appropriate interventions to manage or prevent

chronic disease in culturally and linguistically diverse communities: a

systematic literature review

Saras Henderson RN BAppSc (Nursing) M.Ed. PhD, Elizabeth Kendall BA PhD Post Grad Dip. (Psych) and Laurenne

See B Psych (Hons)

Griffith Health Institute, Griffith University, Gold Coast Campus, Queensland, Australia

Accepted for publication 04 October 2010

CorrespondenceDr Saras HendersonGriffith Health InstituteGO5 Health Sciences, Room 2.13Gold Coast campusGriffith University QLD 4222AustraliaE-mail: [email protected]

What is known about this topic

• The prevalence of chronic disease in culturallyand linguistically diverse (CALD) communities ishigh compared with the general population.

• Access and usage of health services by CALDcommunities tends to be lower than expected.

• CALD communities have difficulty in accessinghealth services due to lack of knowledge amonghealth service providers about what constituteseffective culturally appropriate services.

What this paper adds

• The use of bi-lingual community health workerscan promote greater uptake of disease preventionstrategies by CALD communities.

• The use of bi-lingual culturally competentcommunity health workers can translate intogreater knowledge and awareness about services.

• Health programmes delivered by their ownpeople are deemed to be culturally sensitive andappropriate.

AbstractCulturally and linguistically diverse (CALD) communities

in Australia experience both significant health disparities

and a lack of access to services. Consequently, there have

been calls for culturally appropriate services for people

with chronic disease in CALD populations. This paper

presents a systematic review of the literature on the effec-

tiveness of culturally appropriate interventions to manageor prevent chronic disease in CALD communities.

Evidence was sought from randomized controlled trials and

controlled studies that examined strategies for promoting

cultural competence in health service delivery to CALD

communities. The outcomes examined included changes

in consumer health behaviours, utilisation ⁄ satisfaction

with the service, and the cultural competence of health-

care providers. Of the 202 studies that were identifiedonly 24 met the inclusion criteria. The five categories of

intervention that were identified included: (1) the use of

community-based bi-lingual health workers; (2) providing

cultural competency training for health workers; (3) using

interpreter service for CALD people; (4) using multimedia

and culturally sensitive videos to promote health for

CALD people and (5) establishing community point-

of-care services for CALD people with chronic disease.The review supported the use of trained bi-lingual health

workers, who are culturally competent, as a major consid-

eration in the development of an appropriate health

service model for CALD communities.

Keywords: bi-lingual health worker, chronic disease, cultural

safety, culturally and linguistically diverse population, health

service model, systematic literature review

Introduction

The health of Australia’s culturally and linguistically

diverse (CALD) population is poor in comparison to the

general population. Hospital admissions for CALD peo-

ple are more than double, particularly for chronic and

disabling conditions, such as diabetes, traumatic injury,

heart and kidney disease and respiratory problems

(Gorman et al. 2003). Immigrants to Australia and espe-

cially refugees face numerous challenges which can

affect their health. Despite the high prevalence of healthproblems, health service usage by CALD people tends to

ª 2011 Blackwell Publishing Ltd 225

Health and Social Care in the Community (2011) 19(3), 225–249 doi: 10.1111/j.1365-2524.2010.00972.x

be lower than would be expected (Kelaher et al. 1999,Comino et al. 2001).

The success of health services for CALD communities

is often less than optimal due to lack of knowledge

among providers about what constitutes effective cultur-

ally appropriate services (Comino et al. 2001, Rao et al.2006). It is only through such knowledge that service

providers are able to understand the reasons for poor

service usage among CALD communities. There is litera-ture to support how providing culturally safe services

can improve the quality of health-care for CALD

communities (Cross et al. 1989, Foronda 2008). Culturally

safe services were originally defined as those where

there is no assault on a person’s identity caused by the

fact that service delivery methods or processes are alien

to the person’s culture (Ramsden 1990). For some time, it

has been argued that equity as a concept cannot deliverinclusion for culturally diverse people as it promotes

‘sameness’ (Eckerman et al. 1992), a notion that automati-

cally favours the dominant culture. More recently, ser-

vice models based on the concept of equality have been

distinguished from those based on the principle of uni-

versality (Kayess & French 2003). Equality implies an

assumption that services should create balance across

people which is often achieved by ignoring or rectifyingdifference. This approach is contrasted against one of the

universality, wherein cultural difference is anticipated,

expected, celebrated and accommodated. To provide cul-

turally safe services, it is necessary to embrace the ‘differ-

ence’ that is inherent across cultures and be willing to

understand and accept all aspects of a particular culture.

At the same time, it is important to acknowledge that

communities and individuals within those communitieswill differ enormously irrespective of the threads that

draw them together.

According to Brach & Fraser (2000), culturally safe

and competent services will translate into better health

via the impact they have on: (1) improved communica-

tion channels; (2) increased trust in the health system; (3)

greater knowledge about health and services in CALD

communities and (4) expanded cultural understandingwithin the health system. Services are likely to become

more appropriate through the use of cultural knowledge

and culturally appropriate processes in assessment, diag-

nosis and treatment and delivery of services or treatment

regimes that ‘fit’ the culture and environment. As a

result, services are more likely to be used, resulting in an

increased rate of disease screening and application of

preventative strategies (e.g. self-management) (O’Con-nell et al. 2007). Importantly, over time, this increase

should result in a circular and ever-increasing cycle of

improvement as more CALD communities develop trust

in the health system. By virtue of their increased pres-

ence within the service system, service providers are

more likely to become aware of how to work effectivelywith these populations. Improved access to screening,

services and preventative behaviours will translate into

improved health outcomes for the communities (Brach &

Fraser 2000).

There is little doubt that culturally appropriate and

competent services will enable CALD people to access

health-care without fear of discrimination and with

respect to their health beliefs. However, in the absence ofclear knowledge about the efficacy of current approaches

to culturally competent service delivery, considerable

wastage can occur through investments in service mod-

els that may not have the desired effect. This paper pre-

sents a systematic review of the literature about

culturally safe and competent services to enable

informed decisions to underpin service development.

Methods

A systematic review of the literature was conducted to

identify culturally appropriate interventions to service

delivery for CALD populations and examine the efficacy

of these interventions. The systematic review represents

the highest form of knowledge generation in the hierar-chy of evidence (Pearson et al. 2007). Through the review

process, we were able to systematically search, identify

and summarise the available evidence to determine the

most effective culturally safe methods of improving the

health outcomes, health behaviours and service usage of

CALD people in the community and the strategies for

improving cultural competence in the health-care sys-

tem.Electronic databases including CINAHL, MEDLINE,

Joanna Briggs Institute, Cochrane Library, Lippincott,

Williams and Wilkins Collection, PubMed, ProQuest,

Dissertations and Theses, and Google Scholar were

searched via computer. We searched for articles pub-

lished within a 10 year period (1999–2009). Data were

extracted simultaneously from all the above mentioned

databases over a period of 6 months from June 2009 toDecember 2009.

Terms such as cultural competence, cultural safety,

cultural awareness, cultural model, diverse populations,

racial ⁄ ethnic disparity, underserved populations and

health service delivery, health service interventions,

chronic disease prevention, screening, health promotion

and health seeking behaviours were used. Terms such as

community-based health service, lay health advisors,community health workers, health advocate, promoters,

natural helpers, Indigenous health worker and inter-

preter service were also searched.

Two researchers screened the abstracts identified in

the search for eligibility using the inclusion criteria. Spe-

cifically, studies were selected for further review if they

S. Henderson et al.

226 ª 2011 Blackwell Publishing Ltd

focused on: (1) participants from CALD communities; (2)health interventions that targeted CALD communities

and CALD consumers with chronic conditions or the

cultural competence of health workers; (3) outcome mea-

sures including utilisation of health services by CALD

consumers, satisfaction with health services by

CALD consumers, positive health behaviours among

CALD consumers and positive physiological status (e.g.

lowered blood pressure). Studies were excluded if theywere unclear in their definition of cultural competence,

included insufficient data, lacked detail of study meth-

ods and participants, did not involve an intervention or

did not provide outcome data.

Data analysis

Twenty-four articles out of 202 that met the inclusion cri-

teria were extracted for analysis by two researchers. If

there were differences in opinion between the research-

ers, consensus was sought through discussion. The arti-

cles were graded for quality of evidence using the

‘Guide to Community Preventative Services’ (Briss et al.2000) as outlined in Table 1. The highest quality ratingswere assigned to articles that applied comparison groups

and prospective measurement (e.g. randomized con-

trolled trials). Moderate quality ratings were assigned to

articles that applied retrospective designs or pre-post

designs without a comparison group. The lowest level of

acceptable quality was assigned to articles that included

only a single cohort assessed at a single point in time.

The articles were then categorised into interventiontypes and the strength of evidence for each type of inter-

vention was determined using the Beach et al. (2005)

grading system (Table 2). In this system, the highest level

of evidence (Grade A) was assigned to the intervention-

outcome combination with the greatest number of

positive findings obtained by high quality studies. Low

grading indicated that only a few studies demonstrated

significant positive findings of a particular type of inter-vention.

Results

The 24 articles (Table 3) were grouped into five interven-

tion categories including: (1) the use of bi-lingual com-

munity health workers (16 studies); (2) the provision ofcultural competency training for health-care providers (4

studies); (3) the use of interpreter service for CALD peo-

ple (1 study); (4) the use of multimedia and culturally

sensitive videos to promote health for CALD people (2

studies) and (5) the establishment of community point-

of-care testing service for CALD people with chronic dis-

ease (1 study).

Bi-lingual community health workers

The common interventions were those involving com-

munity health workers (16 articles). Terms used to

describe these community workers included, lay health

advisors, lay health educators, lay tutors, Aboriginalhealth workers, bi-lingual community mentors, peer

educators and promoters. The term community health

worker (CHW) refers to these collective roles that have

been used in this review.

Five studies in this category were graded as being the

highest quality design (i.e. RCTs), which provided the

strongest evidence (Corkery et al. 1997, Krieger et al.1999, Gary et al. 2003, Griffiths et al. 2005, Lujan et al.2007). In these studies, the outcomes of the intervention

were positive and included an increase in screening rate

(Grade A), improved health status (Grade A), improved

health behaviour (Grade B), completion of health pro-

moting programmes (Grade C), improved health knowl-

edge (Grade C) and an improvement in appointment

keeping and follow-up appointments (Grade D).

The interventions differed, but all incorporated deliv-ery by a CHW. For example, in Corkery et al. (1997)

RCT, the impact of a diabetes education programme

with Hispanic-Americans delivered by CHWs showed

that the knowledge and self-care practices of partici-

pants significantly improved following the education

programme. Specifically, glycohemoglobin levels

Table 1 Grading criteria to determine quality of evidence

Quality of

study design Attributes

High Concurrent comparison groups and

prospective measurement of exposure and

outcome

Moderate All retrospective designs or multiple pre- or

post-measurements but no concurrent

comparison group

Low Single pre- and post-measurements and no

concurrent comparison group or exposure

and outcome measured in a single group at

the same point in time

Excluded All other types of articles

From Briss et al. (2000).

Table 2 Grading criteria to determine quantity of evidence

Grade

Number of studies with

same positive outcomes

A 4

B 3

C 2

D 1

From Beach et al. (2005).

The effectiveness to manage or prevent chronic disease in CALD communities


Tab

le3

Sum

mary

of

stu

die

sin

clu

ded

inth

ere

vie

w

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rventio

n

descriptio

nP

ers

onnel

Outc

om

es

(findin

gs)

Alc

ala

yet

al.

(1999)

To

desig

nan

inte

rvention

model

appro

priate

for

Latino

popula

tions

toin

cre

ase

aw

are

ness

about

heart

dis

ease,

rais

eknow

ledge

about

card

iovascula

r

dis

ease

pre

vention

and

pro

mote

heart

-healthy

lifesty

les

Com

munity

inte

rvention

stu

dy

CV

Dn

>300

Latino

male

sand

fem

ale

s

with

low

levels

of

accultu

ration

(Spanis

hbein

g

their

prim

ary

language);

18–54

years

of

age;

low

SE

S

(fam

ilyin

com

e

less

than

$550

a

week)

and

low

educa

tion

level

(12th

gra

de

hig

hest

year

of

schoolin

g)

Fiv

ecounties

inN

ort

h

Caro

lina

N⁄R

Educational

mate

rials

,e.g

.

Latino

Com

munity

Card

iovascula

r

Dis

ease

Pre

ventio

nand

Outr

each

Initia

tive:

Backgro

und

Report

,S

alu

dpara

su

Cora

zon

poste

r,8

easy-

to-r

ead

bili

ngual

bookle

ts,

bili

ngual

recip

ebookl

et,

a

25-m

inute

educationalvid

eo,

‘Cookin

gW

ith

Your

Heart

in

Min

d’in

Spanis

h

Incre

ased

know

ledge

of

risk

facto

rsof

CV

D

especia

llyfo

r

younger

respondents

.

Incre

ased

aw

are

ness

of

ways

topre

vent

CV

D(1

9%

gain

in

know

ledge

about

pre

vention

facto

rs).

No

sig

nifi

cant

change

tocurr

ent

health

behavio

urs

An

incre

ase

in

know

ledge

of

risk

facto

rs,

especia

lly

am

ong

young

people

,w

ith

an

incre

ase

of

19%

in

aw

are

ness

about

pre

ventin

g

card

io-v

ascula

r

dis

ease

.H

ow

ever,

there

was

no

sig

nifi

cant

change

topeople

s’health

behavio

urs

indic

ating

that

oth

er

str

ate

gie

s

need

tobe

used

to

pro

mote

behavio

ur

change

Earp

et

al.

(2002)

To

dete

rmin

eth

e

eff

ectiveness

of

the

Nort

hC

aro

lina

Bre

ast

Cancer

Scr

eenin

g

Pro

gra

mm

e–

a

CH

Wnetw

ork

inte

rvention

inte

nded

to

incre

ase

scre

enin

g

am

ong

rura

l

Afr

ican

Am

erican

wom

en

Com

munity

tria

l

Bre

ast

cancer

Rura

lA

fric

an

Am

erican

wom

en,

50

years

and

old

er

(n=

801)

M=

55.9

years

Fiv

eru

ral

counties

in

easte

rn

Nort

h

Caro

lina

1993–1997

Thre

e

inte

rventions-

In

reach

(help

prim

ary

care

agencie

sim

pro

ve

bre

ast

scre

enin

g

serv

ices),

Outr

each

(min

imis

epra

ctical

barr

iers

)and

Acc

ess

(CH

Ws

who

educa

te,

incre

ase

aw

are

ness

and

pro

vid

esupport

for

scre

enin

g)

170

train

ed

volu

nte

er

CH

Ws

and

4com

munity

outr

each

specia

lists

Incre

ase

in

com

munity-w

ide

mam

mogra

phy

use

–an

overa

ll

6%

poin

tin

cre

ase

incom

munityw

ide

mam

mogra

phy

use.

Low

-incom

e

wom

en

in

inte

rvention

counties

show

ed

an

11%

poin

t

incre

ase

inuse

above

that

obta

ined

by

low

incom

ew

om

en

in

com

parison

counties

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristic

s,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rventio

n

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Gia

rrata

no

et

al.

(2005)

Outr

each

com

munity

educa

tion

pro

gra

m

on

cancer

pre

vention

and

scre

enin

g

guid

elin

es.

Recru

it

wom

en

inth

e

com

munity

for

free

cancer

scre

enin

g

Com

munity

health

inte

rvention

pro

gra

m

Bre

ast

and

cerv

ical

cancer

Medic

ally

unders

erv

ed

multi

cultura

l,

multi

eth

nic

,and

multi

lingualw

om

en

(Mostly

Afr

ican

Am

erican

and

Latino

wom

en),

n=

10

000

over

6years

of

stu

dy

New

Orleans

1997–2002

Fre

e

mam

mogra

ms,

Pap

sm

ears

,and

clin

icalbre

ast

exam

sand

case

follo

w-u

pand

refe

rral

CH

Ws

and

pro

ject

coord

inato

r

Appro

xim

ate

ly

10

000

wom

en

receiv

ed

educa

tion

and

⁄or

clin

ical

serv

ices

)88%

of

the

wom

en

who

could

be

conta

cte

din

1-y

ear

follo

w-u

p

tele

phone

calls

report

ed

pra

cticin

g

month

lybre

ast

self-e

xam

inations

Griffi

net

al.

(1999)

To

dete

rmin

e

part

icip

ant

satisfa

ction

with

The

Nativ

e

Am

erican

Dia

bete

s

Pro

ject

–a

cultura

lly

appro

priate

dia

bete

seduca

tion

pro

gra

mm

e

Com

munity

inte

rvention

stu

dy

Type

2

Dia

bete

s

Nativ

eA

merican

male

sand

fem

ale

s

18

years

and

old

er

with

dia

bete

s,

(n=

151).

M=

59.2

years

8N

ew

Mexic

o

com

munitie

s

N⁄R

Fiv

e-s

essio

n

lifesty

le

educa

tional

pro

gra

m,

deliv

ere

d

ina

gro

up

form

at

or

indiv

idualfo

rmat

8bili

ngualC

HW

sC

onsum

ers

were

satisfied

with

educa

tional

pro

gra

mm

e,

with

96.7

%of

responses

toa

satisfa

ction

quest

ionnaire

positiv

e



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristic

s,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Lam

et

al.

(2003)

To

pro

mote

Vie

tnam

ese-

Am

erican

wom

en’s

cerv

icalcancer

aw

are

ness,

know

ledge,

and

scre

enin

gth

rough

CH

Woutr

each

and

media

educa

tion

Com

munity

inte

rventio

n

stu

dy

Cerv

ical

cancer

Vie

tnam

ese-

Am

erican

wom

en

(n=

400).

Contr

ol

gro

up

receiv

ed

media

educatio

n

only

Santa

Cla

ra

County

,

Calif

orn

ia

5years

The

inte

rventio

n

gro

up

receiv

ed

both

the

CH

W

outr

each

inte

rvention

(org

anis

ed

CH

W

meetings

with

wom

en

toin

cre

ase

their

know

ledge

and

tom

otivate

them

toobta

in

Pap

tests

)and

the

media

inte

rvention

20

CH

Ws

At

post-

inte

rventio

n,

sig

nifi

cantly

more

wom

en

in

inte

rvention

gro

up

unders

tood

that

hum

an

papill

om

avirus

and

sm

okin

gcause

cerv

icalcancer.

The

num

ber

of

wom

en

who

had

obta

ined

aP

ap

test

incre

ased

sig

nifi

cantly

am

ong

wom

en

inboth

gro

ups,

but

substa

ntially

more

inin

terv

ention

gro

up

(fro

m

62.1

–76.9

5,

P<

0.0

001.

Sig

nifi

cantly

more

wom

en

in

inte

rvention

gro

up

said

they

inte

nded

tohave

aP

ap

test

(fro

m65.6

–90.6

and,

P=

0.0

2)

Navarr

o

et

al.

(1998)

To

investig

ate

the

eff

ectiv

eness

of

the

Por

La

Vid

a

modelin

terv

ention

on

cancer

scre

enin

gam

ong

Latinas

Com

munity

inte

rventio

n

stu

dy

Bre

ast

and

cerv

ical

cancer

Latinas

(n=

609)

M=

34

years

Contr

olgro

up

part

icip

ate

din

an

equally

engagin

g

pro

gra

mentitled

‘Com

munity

Liv

ing

Ski

lls’

San

Die

go,

Calif

orn

ia

12

weeks

Educa

tionalgro

up

sess

ions

to

pro

mote

cancer

scre

enin

g

36

CH

Ws

The

inte

rvention

gro

up

show

ed

an

incre

ase

inth

euse

of

the

cancer

scre

enin

gte

sts

in

com

pariso

nto

wom

en

inth

e

com

munity

livin

g

skill

scontr

olgro

up

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Poss

&

Rangel

(1997)

To

dete

rmin

eth

e

eff

ective

ness

of

a

tuberc

ulo

sis

scre

enin

gand

treatm

ent

pro

gra

m

for

mig

rant

farm

work

er

fam

ilies

Com

munity

inte

rventio

n

stu

dy

Tuberc

ulo

sis

Mig

rant

farm

-work

er

fam

ilies

(n=

853)

Oak

Orc

hard

Com

munity

Health

Centr

ein

Bro

ckport

,

New

York

June–A

ugust

in1994

and

1995

Tuberc

ulo

sis

scre

enin

gand

treatm

ent.

Educatio

nusin

g

short

skits,

dem

onstr

ations

and

audie

nce

part

icip

ation

CH

Ws

and

outr

each

sta

ff

The

outr

each

team

pla

ced

PP

Dskin

tests

on

415

mig

rant

farm

work

ers

and

fam

ilies

during

the

1994

season

and

438

during

the

1995

season

Shephard

(2006)

To

dete

rmin

eth

e

levels

of

satisfa

ctio

nw

ith

the

QA

AM

S

HbA

1c

Pro

gra

m

am

ong

thre

ekey

sta

kehold

er

gro

ups

–docto

rs,

PO

CT

opera

tors

and

patients

with

dia

bete

s

Com

munity

inte

rventio

n

stu

dy

Dia

bete

sIn

dig

enous

Austr

alia

ns

with

dia

bete

s(n

=74)

Rura

l

com

munity

inN

ort

hern

Terr

itory

,

Austr

alia

12

month

sP

oin

t-of-

care

testing

(PO

CT

)fo

r

haem

oglo

bin

A1c

(HbA

1c)

and

urine

alb

um

in-c

reatinin

e

ratio

(AC

R)

is

perf

orm

ed

for

dia

bete

s

managem

ent

GP

sD

octo

rsand

patients

with

dia

bete

sagre

ed

that

the

imm

edia

cy

of

PO

CT

results

contr

ibute

d

positiv

ely

to

patient

care

,

impro

ved

the

docto

r–patient

rela

tionship

,and

made

the

patient

more

likely

tobe

both

com

plia

nt

and

self-m

otivate

dto

impro

veth

eir

dia

bete

scontr

ol

Cork

ery

et

al.

(1997)

To

evalu

ate

the

eff

ects

of

a

bic

ultura

lC

HW

on

com

ple

tion

of

dia

bete

seducatio

n

pro

gra

mand

the

impact

of

com

ple

tion

of

the

pro

gra

mon

patient

know

ledge,

self-c

are

behavio

urs

,and

gly

cem

iccontr

ol

RC

TD

iabete

sH

ispanic

-Am

ericans

who

are

new

ly

refe

rred

toth

e

clin

icfo

r

educa

tion.

Ove

r

20

years

-old

(M=

55.9

years

-old

(n=

64).

Contr

olgro

up:

Non-C

HW

inte

rvention

gro

up

Nurs

e

managed

dia

bete

s

managem

ent

clin

icat

a

tert

iary

care

teach

ing

hospitalin

New

York

City

N⁄R

Dia

bete

seducation

pro

gra

m

Bic

ultu

ralC

HW

and

dia

bete

snurs

e

educato

r

Know

ledge

levels

and

sele

cte

d

self-c

are

pra

ctices

sig

nifi

cantly

impro

ved.

Gly

cohem

oglo

bin

levels

impro

ved

from

abaselin

e

levelof

11.7

–9.9

%

at

pro

gra

m

com

ple

tion

(P=

0.0

04)

and

9.5

%at

the

post

pro

gra

mfo

llow

-up

(P<

0.0

01)



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Gary

et

al.

(2003)

To

dete

rmin

eth

e

eff

ects

of

a

com

bin

ed

prim

ary

care

and

com

munity-b

ased

inte

rvention

appro

ach

on

dia

betic

contr

olin

urb

an

Afr

ican

Am

ericans

with

type

2dia

bete

s

RC

TT

ype

2

Dia

bete

s

Urb

an

Afr

ican

Am

ericans,

(n=

186),

M=

59

years

Contr

olgro

up:

Usualcare

only

East

Baltim

ore

,

US

A.

2years

4para

llelarm

s:

(1)

usualcare

only

;

(2)

usualcare

–

nurs

ecase

manager

(NC

M);

(3)

usualcare

–

CH

W;

(4)

usual

care

–N

CM

⁄CH

W

team

NC

Mand

CH

WN

CM

gro

up

and

CH

Wgro

up

had

modest

declin

es

in

HbA

1c

over

2years

com

pare

d

toth

eusualcare

gro

up

(0.3

%and

0.3

%re

spect

ively

).

The

com

bin

ed

NC

M⁄C

HW

gro

up

had

agre

ate

r

declin

ein

HbA

1c

(0.8

%,

P=

0.1

37)

and

als

oshow

ed

impro

vem

ents

in

trig

lycerides

(-35.5

mg

⁄dl;

P=

0.0

41)

and

dia

stolic

blo

od

pre

ssure

(-5.6

mm

Hg;

P=

0.0

42),

com

pare

dto

the

usualcare

gro

up

Griffi

ths

et

al.

(2005)

To

exam

ine

the

impact

of

a

cultura

llyadapte

d

lay–le

dself-

managem

ent

pro

gra

mm

efo

r

Bangla

deshiadults

with

chro

nic

dis

ease

RC

TC

hro

nic

dis

ease

Bangla

desh

iadults

over

20

years

-old

with

dia

bete

s,

card

iovascu

lar

dis

ease

,

respirato

rydis

ease

or

art

hritis,

recru

ited

from

10

localG

P’s

.

(n=

476)

Contr

olgro

up:

Waiti

ng

list

Tow

er

Ham

lets

,

East

London

–

genera

l

pra

ctices

and

com

munity

centr

es

2years

Cultura

llyadapte

d

lay

led

self

managem

ent

pro

gra

m.

Educa

tional

sessio

ns

on

sym

pto

m

managem

ent,

com

munic

ation

with

health

pro

fessio

nals

,

managin

g

medic

ation,

exerc

ise,

and

decis

ion-m

aki

ng

Pairs

of

train

ed

Bangla

deshi

facili

tato

rs

Impro

vem

ent

in

self-

effi

cacy

(diffe

rence

of

0.6

7)

and

self-

managem

ent

behavio

ur

(0.5

3)

and

reduced

HA

DS

depre

ssio

n

score

s(0

.64).

No

change

in

health

care

use

and

com

munic

ation

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rventio

n

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Krieger

et

al.

(1999)

To

pro

vid

e

outr

each

,

enhanced

trackin

g

and

follo

w-u

p

serv

ices

with

the

aim

of

pro

moting

medic

alfo

llow

-up

RC

TH

ypert

en-

sio

n

Pers

ons

whose

ele

vate

dblo

od

pre

ssure

s(b

lood

pre

ssure

gre

ate

r

than

or

equalto

140

⁄90

mm

Hg)

were

dete

cte

d

during

blo

od

pre

ssure

measure

ment

at

com

munity

sites;

18

years

or

old

er;

bla

ck

or

white;

incom

eequalto

or

less

than

200%

of

povert

y(n

=421).

Contr

olgro

up

receiv

ed

usual

refe

rrals

tocare

Low

-incom

e

neig

hbourh

oods

inS

eatt

le

June

1994–

Oct

ober

1996

Inte

rvention

gro

up

receiv

ed

refe

rralto

medic

alcare

and

if

necessary

,

assis

tance

in

locating

apro

vid

er;

an

appoin

tment

made

by

CH

Wor

tele

phone

follo

w-u

pby

CH

W

with

clie

nts

who

pre

ferr

ed

tom

ake

their

ow

n

appoin

tments

to

assure

an

appoin

tment

was

made;

an

appoin

tment

rem

inder

letter;

follo

w-u

pto

dete

rmin

ew

heth

er

the

appoin

tment

was

kept;

anew

appoin

tment

for

each

mis

sed

appoin

tment

(up

to

3);

and

assi

sta

nce

inre

ducin

g

barr

iers

tocare

thro

ugh

refe

rralto

com

munity

transport

ation,

child

care

,or

oth

er

serv

ices

CH

Ws

The

enhanced

inte

rvention

incre

ase

d

follo

w-u

pby

39.4

%

rela

tive

tousual

care

.

Follo

w-u

pvis

its

were

com

ple

ted

by

65.1

%of

part

icip

ants

inth

e

inte

rvention

gro

up,

com

pare

dw

ith

46.7

%of

those

in

the

usualcare

gro

up



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristic

s,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Luja

net

al.

(2007)

To

exam

ine

an

inte

rvention

led

by

CH

Ws

on

the

gly

cem

iccontr

ol,

dia

bete

s

know

ledge,

and

dia

bete

shealth

belie

fsof

Mexi

can

Am

ericans

with

type

2dia

bete

s

RC

TD

iabete

sM

exic

an

Am

ericans

with

type

2

Dia

bete

s.

(n=

150),

M=

58

years

Cath

olic

faith-b

ased

clin

icin

a

majo

rcity

on

the

Texas-

Mexic

o

bord

er

3m

onth

sP

art

icip

ative

gro

up

educa

tion,

tele

phone

conta

ct

and

follo

w-u

p

usin

gin

spirational

faith-b

ased

health

behavio

ur

change

postc

ard

s

CH

Ws

No

sig

nifi

cant

changes

were

note

dat

the

3-m

onth

asse

ssm

ent,

but

the

mean

change

of

the

A1C

levels

,

F(1

148)

=10.2

8,

P<

.001,

and

the

dia

bete

s

know

ledge

score

s,

F(1

148)

=9.0

,

P<

002,

of

the

inte

rvention

gro

up

impro

ved

sig

nifi

cantly

at

6m

onth

s,

adju

sting

for

health

insura

nce

cove

rage.

The

health

belie

f

score

sdecre

ased

inboth

gro

ups

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Maju

mdar

et

al.

(2004)

To

assess

the

eff

ectiv

eness

of

cultura

lsensitiv

ity

train

ing

on

the

know

ledge

and

att

itudes

of

health

-

care

pro

vid

ers

,

and

the

satisfa

ction

and

health

outc

om

es

of

patients

from

diffe

rent

min

ority

gro

ups

with

health

care

pro

vid

ers

who

receiv

ed

train

ing

RC

T114

healthca

re

pro

vid

ers

(nurs

es

and

hom

eca

re

work

ers

)

133

patients

(fro

m

two

com

munity

agencie

sand

one

hospital)

of

most

ly

British

and

Euro

pean

origin

Canada

18

month

sT

rain

ing

incre

ased

health

pro

fessio

nals

’

open-m

indedness

and

cultura

l

aw

are

ness,

impro

ved

unders

tandin

gof

multi

cultura

lism

,

and

abili

tyto

com

munic

ate

with

min

ority

people

.

Aft

er

1year

patients

who

receiv

ed

care

from

train

ed

pro

vid

ers

,

show

ed

impro

vem

ent

in

utilis

ing

socia

l

resourc

es

&

overa

llfu

nctional

capacity

without

an

incre

ase

in

health

-care

expenditure

s

Cultura

ltr

ain

ing

was

associ

ate

d

with

an

incre

ase

in

cultura

law

are

ness

and

open-

min

dedness,

it

als

oim

pro

ved

unders

tandin

gof

multi

cultura

lism

and

pro

vid

ed

bett

er

com

munic

ation

with

patients

from

min

ority

gro

ups.

Import

antly,

patients

who

receiv

ed

serv

ices

from

these

pro

fessio

nals

report

ed

gre

ate

r

use

of

soci

al

resourc

es

without

extr

ahealth

care

expenditure

and

gre

ate

rfu

nctional

capacity

1-y

ear

post-

inte

rvention



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Bird

et

al.

(1998)

Com

munity

outr

each

inte

rvention

to

pro

mote

recognitio

n,

receip

t,and

scre

enin

g-inte

rval

main

tenance

of

clin

icalbre

ast

exam

inations,

mam

mogra

ms

and

Pap

sm

ears

Contr

olle

d

befo

reand

after

Bre

ast

and

cerv

ical

cancer

Low

incom

e

Vie

tnam

ese-

Am

erican

wom

en

(N=

306),

18

years

and

over

San

Fra

ncis

co,

Calif

orn

ia

3years

Educatio

nal

sessio

ns

–56

sessio

ns

on

genera

l

pre

ventio

n,

86

on

cerv

icalcancer

and

90

on

bre

ast

cancer.

Dis

trib

ution

of

educatio

nal

mate

rials

and

pro

motio

nalevents

CH

Ws

Recognitio

nof

scre

enin

gte

sts

incre

ase

d

sig

nifi

cantly.

Clin

icalbre

ast

exam

inations

incre

ase

d

50–85%

;

mam

mogra

phy

incre

ase

d

59–79%

;and

Pap

sm

ear

incre

ased

22–78%

(P=

0.0

01

for

all)

.

Receip

tof

scre

enin

gte

sts

als

oin

cre

ased

sig

nifi

cantly:

Clin

icalbre

ast

exam

inations

incre

ase

d44–70%

(P=

0.0

01);

mam

mogra

phy

incre

ase

d54–69%

(P=

0.0

06)

and

Pap

sm

ear

incre

ase

d46–66%

(P=

0.0

01)

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cteristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Bis

choff

et

al.

(2003)

To

dete

rmin

eth

e

eff

ectiv

eness

of

an

inte

rvention

to

impro

ve

com

munic

ation

skill

sof

physic

ians

who

dealw

ith

patients

who

do

not

speak

the

local

language

Pre

⁄post

test

stu

dy

N=

434

baselin

e,

N=

582

follo

w-u

p

Patients

who

do

not

speak

the

local

language

Medic

al

outp

atie

nt

clin

icof

a

teach

ing

hospitalin

Fre

nch-

speakin

g

Sw

itzerland

2m

onth

sS

mall

incre

ases

in

patients

’

assess

ments

of

com

munic

ation,

i.e.

expla

nations

giv

en

by

physic

ian;

respect

fuln

ess

of

physic

ian;

com

munic

ation;

overa

llpro

cess

of

the

consultation

and

info

rmation

about

futu

recare

.

The

pro

port

ion

of

consultations

with

patients

who

do

not

speak

the

local

language

inw

hic

h

pro

fessio

nal

inte

rpre

ters

were

pre

sent

incre

ased

sig

nifi

cantly

from

46–67%

The

patients

did

not

speak

the

national

language,

and

when

inte

rpre

ters

were

used

consulta

tions

incre

ase

dfr

om

46–67%

.P

atients

als

ore

port

ed

impro

vem

ents

in

com

munic

atio

n

with

docto

rs

leadin

gto

docto

rs

giv

ing

more

rele

vant

info

rmation

about

futu

recare



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cteristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Chevannes

(2002)

To

undert

ake

train

ing

needs

analy

sis

am

ong

a

multi

-pro

fessio

nal

gro

up

for

the

purp

ose

of

impro

vin

gcare

for

eth

nic

min

ority

patients

and

oth

er

serv

ice

users

Pre

⁄post

test

stu

dy

22

multi-

pro

fessio

nal

indiv

iduals

N⁄A

5health

serv

ice

org

anis

atio

ns

locate

din

a

multi-ra

cia

l

city

inU

SA

1m

onth

Health

pro

fessio

nals

gain

ed

abett

er

unders

tandin

gof

the

concepts

of

eth

nic

ityand

race

and

resourc

es

availa

ble

inlo

cal

com

munitie

sas

a

result

of

the

train

ing

(report

ed

changes

in

thin

kin

gabout

eth

nic

min

orities

and

had

sta

rted

to

acquire

gre

ate

r

confidence

to

engage

with

colle

agues

about

diffe

rent

cultura

l

valu

es

and

pra

ctices

and

the

implic

ations

of

these

for

caring)

)25%

of

the

part

icip

ants

had

transfe

rred

som

e

learn

ing

to

pra

ctice,

how

ever,

the

majo

rity

were

not

able

tobring

about

any

change

Alth

ough

train

ing

incre

ased

unders

tandin

gof

eth

nic

ity,

race

and

cultu

ralvalu

es,

only

25%

of

part

icip

ants

were

able

totr

ansfe

r

this

know

ledge

into

their

pra

ctice

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristic

s,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Jenkin

set

al.

(1999)

Media

-led

com

munity

educa

tional

cam

paig

nto

pro

mote

recogniti

on,

inte

ntion,

receip

t

and

curr

ency

of

routine

checku

ps,

clin

icalbre

ast

exam

inations,

mam

mogra

ms

and

Pap

tests

Pre

⁄post

test

stu

dy

Bre

ast

and

cerv

ical

cancer

Vie

tnam

ese-

Am

erican

wom

en.

Pre

test

tele

phone

inte

rvie

ws

were

conducte

dof

451

random

lysele

cte

d

wom

en

inth

e

inte

rvention

are

a

and

482

wom

en

in

the

contr

olare

a,

and

posttest

inte

rvie

ws

with

454

and

422

wom

en

respectively

.

Wom

en

inLos

Angele

sas

contr

ols

Calif

orn

ia2

years

Bookle

tand

poste

rs

inV

ietn

am

ese

language

new

spaper

art

icle

sand

advert

isem

ents

printe

din

Vie

tnam

ese

new

spapers

;

bill

board

s;

advert

isem

ents

and

vid

eos

aired

on

Vie

tnam

ese-

language

tele

vis

ion

sta

tion;

printe

dm

ate

rials

and

vid

eos

pro

vid

ed

to

agencie

sserv

ing

Vie

tnam

ese

com

munity

Sta

tistically

sig

nifi

cant

incre

ase

for

havin

gheard

of

agenera

lchecku

p,

Pap

test

and

clin

icalbre

ast

exam

ination

Aft

er

2years

,th

ey

dem

onstr

ate

da

sta

tist

ically

sig

nifi

cant

incre

ase

inP

ap

sm

ears

,

clin

icalbre

ast

exam

inations,

mam

mogra

ms

and

gre

ate

raw

are

ness

of

aneed

for

a

genera

lcheck

up

inth

ispopula

tion.

How

ever,

again

,

part

icip

ants

were

not

up

todate

in

any

of

the

scre

enin

gre

gim

es,

indic

ating

that

wom

en

needed

furt

her

inte

rventio

n

tochange

behavio

ur



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Settin

g

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Lorig

&

Gonzale

z

(2000)

To

evalu

ate

the

eff

ectiv

eness

of

a

com

munity-b

ased,

peer-

led

dia

bete

s

self-m

anagem

ent

pro

gra

mm

efo

r

Spanis

h-s

peaki

ng

people

Pre

⁄post

test

stu

dy

Dia

bete

sS

panis

hspeakin

g

people

with

type

2

dia

bete

sw

ho

could

com

ple

te

baselin

e,

3-m

onth

,

and

1-y

ear

questionnaires

and

be

able

toattend

the

cours

eat

a

site

near

their

hom

e.

(n=

109),

M=

54.6

years

Com

munity

centr

es,

neig

hbourh

ood

clin

ics

and

churc

hes

in

Santa

Cla

ra

County

,

Calif

orn

ia

3m

onth

sD

iabete

s

self-m

anagem

ent

educa

tional

pro

gra

mm

es

19

CH

Ws

Sig

nifi

cant

(P<

0.0

5)

impro

vem

ents

in

health

behavio

urs

(exerc

ise,

rela

xation,

com

munic

ation

with

physic

ians,

eating

pro

tein

for

bre

akfa

st,

num

ber

of

port

ions

of

vegeta

ble

seate

n,

havin

ga

glu

com

ete

and

frequency

of

monito

ring),

health

sta

tus

(self-

report

ed

health,

role

funct

ion,

fatigue,

dis

com

fort

and

health

dis

tress)

and

trends

tow

ard

s

less

health

care

utilis

ation

Yu

et

al.

(2007)

To

assess

the

eff

ectiv

eness

of

a

CH

Wtr

ain

ing

pro

gra

mfo

rbre

ast

cancer

scre

enin

g

am

ong

Chin

ese–

Englis

hbili

ngual

train

ees

Pre

⁄post

test

stu

dy

Bre

ast

cancer

79

CH

Wtr

ain

ees

South

east

Mic

hig

an,

US

A.

3m

onth

sC

HW

train

ing

pro

gra

mm

e

CH

W

train

ees

The

bre

ast

cancer

scre

enin

gtr

ain

ing

pro

gra

m

sig

nifi

cantly

incre

ased

CH

Ws’

know

ledge

and

self-e

fficacy

(P<

0.0

1,

t-te

st,

two-t

aile

d)

and

CH

Ws

had

a

positiv

eperc

eption

with

regard

toth

e

train

ing

manual

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cte

ristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Sett

ing

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Morisky

et

al.

(2002)

The

Com

munity

Hypert

ensio

n

Inte

rvention

Pro

ject

(CH

IP)

aim

sto

investigate

medic

al,

environm

enta

l,and

psychosocia

l

facto

rsre

late

dto

adhere

nce

to

treatm

ent

for

hypert

ensio

nand

todete

rmin

eth

e

effi

cacy

of

thre

e

inte

rventions

desig

ned

to

impro

vetr

eatm

ent

adhere

nce

ina

hig

h-r

isk,

unders

erv

ed,

eth

nic

ally

div

ers

e

popula

tion

Longitudin

al

stu

dy

Hypert

en-

sio

n

Hig

h-r

isk,

unders

erv

ed,

bla

ck

and

His

panic

adults.

(N=

1367),

M=

53.5

years

.

18

years

and

over.

usualcare

contr

ol

US

A4

years

Part

icip

ants

were

random

ised

to

either

usualcare

or

one

of

thre

e

inte

rventions:

(a)

indiv

idualis

ed

counselli

ng

sessio

ns

with

CH

Ws;

(b)

a

com

pute

rise

d

appoin

tment

trackin

gsyste

m,

or

(c)

hom

e

vis

its

⁄focus

gro

up

dis

cussi

ons

with

CH

Ws

CH

Ws

Part

icip

ants

assig

ned

toth

e

patient

trackin

g

inte

rvention

show

ed

the

most

sig

nifi

cant

impro

vem

ent

in

appoin

tment

keepin

gand

blo

od

pre

ssure

contr

ol

sta

tus

at

6m

onth

s.

The

12-m

onth

follo

w-u

p

assess

ments

indic

ate

dth

at

indiv

idualis

ed

counselli

ng

and

hom

evis

its

resulte

din

sig

nifi

cant,

susta

ined

impro

vem

ents

in

appoin

tment

keepin

gand

blo

od

pre

ssure

contr

ol

sta

tus



Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cterist

ics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Settin

g

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Schim

et

al.

(2006)

To

test

an

educatio

nal

inte

rvention

aim

ed

at

expandin

g

cultura

l

aw

are

ness,

sensiti

vity

and

com

pete

nce

with

a

multid

iscip

linary

team

of

hospic

e

work

ers

Quasi-

experim

enta

l

longitudin

al

cro

ssove

r

stu

dy

130

multi

dis

cip

linary

and

multile

vel

hospic

esta

ff

N⁄A

8hospic

e

agencie

sin

US

A

1h educa

tional

sess

ion

on

cultu

ral

com

pete

ncy

Cultura

l

com

pete

nce

score

sw

ere

sig

nifi

cantly

gre

ate

raft

er

the

educa

tional

inte

rvention

for

part

icip

ants

inboth

gro

ups,

even

with

am

odest

face-t

o-

face

inte

rvention

The

findin

gs

show

ed

that

cultu

ral

com

pete

nce

sig

nifi

cantly

incre

ased

follo

win

g

the

education

inte

rvention

S. Henderson et al.


Tab

le3

Continued

Stu

dy

Stu

dy

aim

sS

tudy

desig

n

Targ

et

dis

ease

Sam

ple

chara

cteristics,

sam

ple

siz

e,

contr

ol

gro

up

(for

RC

Ts)

Settin

g

Dura

tion

of

inte

rvention

Inte

rvention

description

Pers

onnel

Outc

om

es

(findin

gs)

Jaco

bs

et

al.

(2001)

To

dete

rmin

e

wheth

er

pro

fessio

nal

inte

rpre

ter

serv

ices

are

eff

ective

in

incre

asi

ng

the

deliv

ery

of

health-c

are

to

limited-E

nglis

h-

pro

ficie

nt

patients

2-y

ear

retr

ospect

ive

cohort

stu

dy

N⁄R

4380

Port

uguese

and

Spanis

h-

speakin

g

patients

–adults

continuously

enro

lled

ina

sta

ff

modelhealth

main

tenance

org

anis

ation

for

the

2years

of

the

stu

dy.

Contr

ol

gro

up:

10%

com

parison

gro

up

of

all

oth

er

elig

ible

adults

Ala

rge

Health

Managem

ent

Org

anis

atio

n

inN

ew

Engla

nd

2years

Pro

fessio

nal

inte

rpre

ter

serv

ices

Clin

icalserv

ice

use

and

receip

tof

pre

ventive

serv

ices

incre

ased

inboth

gro

ups

from

1–2

years

.

Clin

icalserv

ice

use

incre

ase

d

sig

nifi

cantly

inth

e

inte

rpre

ter

serv

ice

gro

up

com

pare

d

with

the

com

pariso

ngro

up

The

findin

gs

show

ed

that

in

both

gro

ups

the

use

of

clin

icaland

pre

ventive

health

serv

ices

incre

ase

d

from

1–2

years

.

How

ever,

there

was

asig

nifi

cant

incre

ase

inclin

ical

serv

ice

usage

for

the

inte

rpre

ter

gro

up

invis

its

(1.8

0vs.

0.7

0;

P<

01),

pre

scriptions

writt

en

(1.7

6vs.

0.5

3;

P<

01)

and

recta

l

exam

inations

(0.2

6

vs.

0.0

2;

P<

05)

as

com

pare

dw

ith

the

contr

olgro

up

Siet

al.

(2006)

To

exam

ine

the

impact

of

em

plo

ying

Aborigin

alC

HW

s

(AC

HW

s)

on

deliv

ery

of

dia

bete

scare

in

rem

ote

com

munity

health

centr

es

and

toid

entif

ybarr

iers

rela

ted

toA

CH

Ws

involv

em

ent

in

dia

bete

scare

Follo

w-u

p

stu

dy

Dia

bete

sA

borigin

alpeople

with

type

2

dia

bete

s,

(N=

137)

Seven

rem

ote

com

munity

health

centr

es

inth

e

Nort

hern

Terr

itory

,

Austr

alia

3years

Dia

bete

seducation

pro

gra

mm

e

Aborigin

alC

HW

sT

here

was

a

positiv

e

rela

tionship

betw

een

the

num

ber

of

AC

HW

s

per

1000

resid

ents

and

deliv

ery

of

guid

elin

e-

schedule

d

dia

bete

sserv

ices

(but

not

inte

rmedia

tehealth

outc

om

es).

Pre

sence

of

male

AH

Ws

was

associ

ate

dw

ith

hig

her

adhere

nce

toth

eguid

elin

es



improved from 11.7–9.9% (P = 0.004). At post pro-gramme follow up it was 9.5% (P = 0.001). Similarly in

the Griffiths et al.(2005) RCT with Bangladeshi partici-

pants with chronic diseases such as diabetes, cardiovas-

cular disease, respiratory disease and arthritis, an

intervention run by CHWs showed an improvement in

self-efficacy and self-management behaviour. A RCT

was also conducted by Lujan et al. (2007) of CHWs work-

ing with Mexican Americans. The CHWs delivered anintervention on glycemic control, diabetes knowledge,

and diabetes health beliefs to Mexican Americans with

diabetes. The results showed that whilst there were no

significant changes in glycemic control at 3 months post-

intervention, diabetes knowledge scores increased signif-

icantly. Krieger et al. (1999) used CHWs to deliver fol-

low-up services for hypertensive participants in low-

income neighbourhoods in the United States and foundan increase in follow-up appointments. The follow up

attendance was 65.1% in the intervention group com-

pared with 46.7% in the control group. From these five

studies, it can be extrapolated that the use of bi-lingual

CHWs with CALD communities is beneficial in promot-

ing health by increasing self-management of chronic dis-

eases, knowledge about health conditions and adherence

to follow up care.Eleven studies were community intervention studies

(Poss & Rangel 1997, Bird et al. 1998, Navarro et al. 1998,

Griffin et al. 1999, Lorig & Gonzalez 2000, Earp et al. 2002,

Morisky et al. 2002, Lam et al. 2003, Giarratano et al. 2005,

Si et al. 2006, Yu et al. 2007). Two of these studies (Mori-

sky et al. 2002, Si et al. 2006) were graded as yielding high

quality evidence as indicated by the number of positive

outcomes. They were also graded as being the highestquality study designs, which yielded strong evidence.

The other nine studies tended to offer moderate quality

study designs as they did not have concurrent compari-

son groups with one study only focusing on a single

outcome measurement. The target population in these

studies included African, Latino and Vietnamese-

American, Native American, migrant farm worker

families in the United States and Australian Indigenouspeople.

The interventions identified in the 11 community

based studies included breast and cervical cancer screen-

ing (Grade A), strategies to improve appointment keep-

ing and blood pressure control (high quality evidence),

employing Indigenous CHW to promote adherence to

diabetes guidelines (high quality evidence), diabetes

education (Grade A), tuberculosis screening usingCHWs (Grade D) and CHW training programme (Grade

D). Specifically, four studies demonstrated the effective-

ness of an education programme to promote breast and

cervical cancer screening, another four studies demon-

strated the effectiveness of a diabetes education

programme, one study demonstrated the efficacy ofthree interventions to improve appointment keeping and

blood pressure control, one study demonstrated the use

of skits (short plays) to promote tuberculosis screening,

and another study demonstrated the effectiveness of a

training programme for CHWs. Positive outcomes, how-

ever, were achieved in all 11 studies. For example, in a

study by Bird et al. (1998), an educational programme

was delivered by CHWs to promote clinical breast exam-ination, cervical cancer screening through pap smears,

and mammograms among low-income Vietnamese-

American women. The findings showed that there was

an increase from 44–70% in clinical breast examinations

(P = 0.001), mammogram screening increased from 54–

69% (P = 0.006) and pap smears increased from 46–66%

(P = 0.001) indicating that in all three areas, the uptake

of screening tests increased significantly. In the Earp et al.(2002) study, the rate of mammography use increased by

11% compared with 6% for the overall community fol-

lowing a CHW-led intervention. Similarly, Giarratano

et al. (2005) studied 10 000 women who received a

CHW-led education programme on cancer screening

and found that 88% of those who could be contacted

later reported conducting a once a month breast self-

examination. Navarro et al. (1998) used CHW-led educa-tional group sessions to increase cancer screening in

Latino women and found an increase in the uptake of

cancer screening.

The community intervention study conducted by

Lam et al. (2003) used CHWs to increase Vietnamese-

American women’s knowledge and awareness of cervi-

cal cancer and the need for screening. This study showed

an increase in knowledge levels following the interven-tion; in particular, participants reported that they under-

stood the causal agents of cervical cancer to be

papillomavirus and smoking. The rate of pap smears

increased significantly from 62.1–76.95% (P < 0.0001)

and the number of participants who stated that they

intended to have a pap smear also significantly increased

from 65.6–90.6% (P = 0.02).

Morisky et al. (2002) on the other hand, conducted alongitudinal study with high risk African–American and

Hispanic people with respect to adherence to the treat-

ment for hypertension over a 4 year period. The partici-

pants were all long term sufferers of uncontrolled

hypertension with most engaging in high risk behaviours,

such as, not exercising, salting their food, eating fast foods

and frequently consuming alcohol. Participants

(N = 1367) were randomly assigned to their usual care orto one of the three interventions. The interventions

involved: (1) counselling sessions with CHWs; (2) com-

puterised appointment tracking systems and (3) home

visits by CHWs. The counselling session involved a

10 minute interview where CHWs discussed partici-

S. Henderson et al.


pant’s lifestyle and positive changes such as losing weightor ceasing smoking. For the tracking system intervention,

participants were sent appointment reminder cards

and contacted by telephone 10 days before the appoint-

ment. When participants in this group missed an

appointment, they were phoned up to reschedule another

appointment. Participants were randomly assigned to

their usual care or to one of the three interventions. The

findings indicated that participants assigned to the com-puter tracking system showed significant improvement

in appointment keeping and blood pressure control at

6 months. However, the individual counselling and home

visits showed significant improvement in appointment

keeping and blood pressure control after 12 months. This

indicates that counselling and home visits may be a better

intervention for long-term sustainability in blood pres-

sure control. It may be extrapolated from these findingsthat CHWs promoted self-management in amelioration

of risk factors for hypertension by CALD participants is a

significant and positive way.

Another 3 year follow up study (Si et al. 2006) exam-

ined the effectiveness of employing Indigenous CHWs

to deliver diabetes care in seven remote community

health centres in the Northern Territory, Australia. A

stratified sampling strategy was used to ensure partici-pants were drawn from all seven areas. The participants

(N = 137) were Indigenous people with type 2 diabetes.

A locally developed practice guideline for diabetic care

was used. As per the guidelines, services provided were

laboratory examination of blood glucose levels, basic

measurement and vaccinations, clinical examinations,

and counselling. The findings showed a positive relation-

ship between the number of Aboriginal CHWs per 1000residents and the use of guideline-scheduled diabetes

services. Importantly, the use of male Indigenous CHWs

was associated with higher adherence to the diabetes

guidelines, which may suggest the importance of gender

in CHW interventions.

Similarly, Griffin et al. (1999) study showed that a

Native American diabetes education programme run by

bi-lingual CHWs was considered to be culturally appro-priate by Native Americans. Over 96% of participants

reported satisfaction with the programme. This commu-

nity-based intervention study provides further support

for the use of bi-lingual CHWs as a means of educating

CALD communities about the importance of disease

screening and raising levels of self-management and ⁄ or

preventative knowledge.

Moreover, Lorig & Gonzalez (2000) examined theeffectiveness of a community based diabetes education

programme conducted by CHWs to improve health

behaviours among Spanish-speaking people with type 2

diabetes. The findings indicated a significant improve-

ment in exercise, relaxation, dietary habits, monitoring

blood sugar levels, greater communication with doctorsand less use of health-care facilities. However, Yu et al.’s(2007) study examined the effectiveness of a training pro-

gramme on breast cancer screening for bi-lingual

(English–Chinese) CHWs showed that 3 months post-

intervention, the CHWs reported positive perception

with the training programme. Finally, the use of

screening and treatment for tuberculosis increased in

migrant farm workers following a CHW-led educationprogramme using skits, demonstrations and audience

participation (Poss & Rangel 1997).

Cultural competency training for health-care

providers

Four studies involved cultural competency training for

health-care providers. One study was conducted in

Switzerland (Bischoff et al. 2003), one in Canada (Majum-

dar et al. 2004) and two in the United States (Chevannes

2002, Schim et al. 2006). Although these studies targeted

different groups of health professionals the findings all

indicated that cultural competency training was benefi-

cial when providing healthcare to CALD communities.For example, the Bischoff et al. (2003) pre-post study

examined the effectiveness of a 2-month communication

skill training intervention for physicians working in a

teaching hospital outpatient clinic. The patients did not

speak the national language, and when interpreters were

used consultations increased from 46–67%. The patients

also reported improvements in communication with

doctors, leading to doctors giving more relevant informa-tion about future care.

From the providers’ perspectives, a quasi-experimen-

tal longitudinal study conducted by Schim et al. (2006)

tested an educational intervention to expand cultural

awareness, sensitivity and competence among hospice

workers at eight hospice agencies in the United States.

The findings showed that cultural competence signifi-

cantly increased following the education intervention.An RCT conducted in Canada by Majumdar et al. (2004)

showed that cultural training was associated with an

increase in cultural awareness and open-mindedness, it

also improved the understanding of multiculturalism

and provided better communication with patients from

minority groups. Importantly, the patients who received

services from these professionals reported greater use of

social resources without extra healthcare expenditureand greater functional capacity 1-year post-intervention.

Chevannes’s (2002) pre ⁄post study, based on the

training needs of 22 multi-professional people working

in five health organisations in the United States, also

found that training generally improved ethnic minority

patient care. However, Chevanne found that although

training increased understanding of ethnicity, race and



cultural values, only 25% of participants were able totransfer this knowledge into their practice. These four

studies suggest that health professionals and healthcare

workers can benefit from cultural competency training

in that it may enable them to communicate more effec-

tively with CALD communities. Nevertheless, the trans-

lation of cultural knowledge into practice remains

problematic.

Using interpreter services

Only one study on the use of interpreters (Jacobs et al.2001) was included. This moderate quality research

design retrospective cohort study targeted a large health

management organisation in New England over 2 years.This organisation comprised of 14 individual health cen-

tres. The study examined whether full time professional

interpreter services were effective in increasing health-

care usage among Portuguese and Spanish speaking

workers in four of the health centres in this organisation.

Previously, the organisation used an ad hoc interpreter

service made up of family members of patients who

could speak English, Spanish–Portuguese-speaking staffat the clinics and interpreters without training. The

Spanish–Portuguese participants in the study were

enrolled in a health maintenance programme in the

organisation (N = 327). The control comparison group,

also Spanish–Portuguese was 10% of all other eligible

adults working in the same organisation (N = 4053). The

control group was also randomly selected. The interpret-

ers were Spanish and Portuguese-speaking and wereemployed at four out of the 14 health centres in the

study. Moreover, the interpreters were employed full

time and were given 50 h of training in medical vocabu-

lary, provided with an understanding of the ethics of

patient confidentiality, and also acted as a mediator

between the doctor and patient. The interpreters were

available to patients 24 h a day either by telephone from

home or at the clinic. They were also present with thepatients at scheduled appointments, laboratory, radiol-

ogy and pharmacy visits. The control group continued

with previous strategies that were in place for Spanish–

Portuguese speaking patients. The findings showed that

in both groups the use of clinical and preventive health

services increased from 1–2 years. However, there was a

significant increase in clinical service usage for the inter-

preter group in visits (1.80 vs. 0.70; P < 0.01), prescrip-tions written (1.76 vs. 0.53; P < 0.01), and rectal

examinations (0.26 vs. 0.02; P < 0.05) as compared with

the control group. It may be extrapolated that using

interpreter services for CALD communities does

increase health service uptake. However, the lack of

high quality studies in this category limits the conclu-

sions that can be drawn.

Using multimedia and culturally sensitive videos

to promote health

Two studies (Alcalay et al. 1999, Jenkins et al. 1999) eval-

uated the use of culturally sensitive print and video

materials in promoting health in CALD communities.Both concluded that this strategy was beneficial. Alcalay

et al. (1999) designed educational materials (bi-lingual

booklets, bi-lingual recipe booklets and video on healthy

cooking to prevent heart disease) to increase knowledge

and awareness of cardio-vascular disease and healthy

lifestyles of Latino-American people across five States in

the United States. The findings showed that there was an

increase in knowledge of risk factors, especially amongyoung people, with an increase of 19% in awareness

about preventing cardio-vascular disease. However,

there was no significant change to peoples’ health behav-

iours indicating that other strategies need to be used to

promote behaviour change.

In a similar study, Jenkins et al. (1999) used printed

health education materials in Vietnamese language and

screened videos on Vietnamese language television sta-tions to promote breast and cervical cancer screening in

this population in California. After 2 years, they demon-

strated a statistically significant increase in pap smears,

clinical breast examinations, mammograms and greater

awareness of a need for a general check up in this popu-

lation. However, again, participants were not up-to-date

in any of the screening regimes, indicating that women

needed further intervention to change behaviour.

Community point of care testing (POCT)

In 1998, Australia’s National Diabetes Strategy and

Implementation Plan recommended that a trial of POCT

for HbA1c be conducted in Aboriginal Medical Servicesto assist Indigenous people in diabetes management.

The resultant Quality Assurance for Aboriginal Medical

Services (QAAMS) Program for HbA1c POCT com-

menced as a pilot in 45 Aboriginal Medical Services the

following year. Today, the national QAAMS Program

has 65 participating medical services, with the majority

located in rural and remote Australia. The QAAMS pro-

gram which encompasses POCT as a key strategy hasnow become firmly embedded in the practice of Aborigi-

nal diabetes care.

One study (Shephard 2006) evaluated the QAAMS

Program and assessed satisfaction with point-of care test-

ing (POCT) in a medical service in a remote area of North-

ern Australia for Indigenous patients with type 2 diabetes.

In the medical centre, testing for haemoglobin and urine

albumin-creatinine ratio were carried out by POCT opera-tors who were Aboriginal health workers trained to take

blood and to competently assess results. The POCT

S. Henderson et al.


Program was evaluated over a 12 month period. Satisfac-tion was sought from three key stakeholder groups i.e.

doctors, POCT operators and patients with type 2 diabe-

tes. In the findings, both doctors and patients, reported

that the immediacy of POCT had contributed positively to

the identification and management of diabetes, improved

doctor-patient relationship, and facilitated compliance

and self-motivation to control diabetes. At the end of the

12 months there was a statistically significant drop inHbA1c in patients (N = 74) from 9.3–8.6% (P = 0.003)

with an improvement in the percentage of patients con-

trolling their diabetes. POCT operators and patients also

reported greater satisfaction with diabetic services, espe-

cially the delivery of pathology results. This highlights the

benefits of having all tests conducted by Aboriginal health

workers at the medical service where patients attend at

one point in time indicating that the POCT Program is aculturally and clinically effective service for the control

and management of diabetes in Australia.

Discussion

This systematic literature review suggests that the use of

bi-lingual community health workers (CHWs) may pro-mote greater uptake of prevention strategies such as

screening for cancers and health monitoring. The major-

ity of CHW studies in this review focused on increasing

knowledge about disease and treatment, promoting

screening for detecting breast and cervical cancers and

facilitating health monitoring and self-management of

chronic diseases such as type 2 diabetes, cardio-vascular

diseases and high blood pressure. All 16 studies sug-gested that the use of culturally competent bi-lingual

CHWs translated into better health outcomes via the

impact they had on: (1) improved communication

between health-care providers ⁄ workers and CALD

patients ⁄ clients; (2) increased satisfaction with the health

system; (3) greater knowledge and awareness about ser-

vices and health; (4) expanded cultural understanding

between health service providers and CALD people; (5)significant increases in screening rates and (6) increases

in follow-up care and appointment keeping. Most impor-

tantly, participants reported that health education pro-

grammes delivered by their own people were culturally

sensitive and appropriate.

The issue of gender was a consideration for bi-lingual

CHWs (Si et al. 2006), at least among Indigenous people

with diabetes. However, in the Middle Eastern culture,as with the Aboriginal culture, there is clear delineation

with respect to who provides health advice and educa-

tion for male and female health issues. Thus, bi-lingual

CHWs of both genders and careful matching of workers

to client groups will assist with acceptance of health pro-

motion and education in the community.

Although many different terms have been used in theliterature, bi-lingual CHWs are usually always members

of the local community who work outside the health sys-

tem to create a link between populations that have been

traditionally underserved and healthcare services. They

are usually people to whom the community ‘naturally’

turns to for assistance and ⁄ or support (Bishop et al.2002). They have been called ‘natural channels of social

influence’ (Altpeter et al. 1999, p. 496). Their activities aredirected by the local community and usually involve

work in the clinic or general practice, interpretation and

translation, group facilitation, education and programme

development. As a result of their involvement, services

are likely to be seen as more culturally appropriate. Fur-

thermore, they are able to broker the use of cultural

knowledge and culturally appropriate processes in

assessment, diagnosis, treatment and delivery of services(or treatment regimes). Researchers have suggested that

CHWs can help to gain entry into marginalised and iso-

lated CALD communities in a more efficient manner

than any other type of health worker (Bishop et al. 2002).

There is an assumption that their modes of operating

will be more culturally appropriate and they will there-

fore be able to promote healthy behaviour change more

effectively (Eng & Smith 1995). They clearly provide abridge between their own community and the health

system (Bishop et al. 2002). Most importantly, this

approach has been described as one that can build capac-

ity and strengthen the existing community systems (Eng

& Smith 1995).

In another systematic review that focused solely on

community health workers, Lewin et al. (2007) also con-

cluded that the CHW approach promoted greater uptakeof prevention strategies, such as immunisation, screening

and health monitoring. Mixed findings were apparent in

relation to the ability of the model to promote cultural

competency, but this was not the direct intention of most

studies included in the review. Our review has sug-

gested that the promotion of cultural competence may

be a role for CHWs, but further work is needed to ensure

translation of knowledge into practice. Similarly, mixedfindings were evident for health outcomes, but as in our

review, most studies were of insufficient duration to

determine any long-term health improvements. There

was some evidence from our review that CHWs might

be associated with longer-term outcomes than other

methods such as computerised prompts. Lewin et al.(2007) also concluded that in the long-term, intense one-

to-one advocacy ⁄support may be the most effective styleof CHW intervention. The review has also concluded

that broad educational interventions and health promo-

tion materials, even when conducted by CHWs, may be

insufficient to ensure follow-up or behavioural change.

However, CHWs do appear to be an important tool for



increasing the likelihood of engaging with health ser-vices in the first instance, but also in following-up on

healthcare activities over time.

In conclusion, the bi-lingual CHW model can provide

positive healthcare experiences, greater knowledge and

increased preventative service usage in CALD communi-

ties. By virtue of their background and position in the

community, the CHWs can draw on their existing com-

munity linkages in a culturally appropriate way to act asa bridge between the communities and the health system.

They can advocate for improved access, ensure that local

communities are consulted appropriately and support

them in their interpretation and use of health services.

Despite the relatively positive evidence contained in

this review, there is limited research in this area of the

quality required to draw firm conclusions. There is also

a clear indication that the use of bi-lingual CHWs is nota simple undertaking. Little is understood about how

such a model can be implemented effectively. It is impor-

tant to focus on the ways in which bi-lingual CHWs can

be recruited, trained, supported and integrated into the

current health service delivery system to become a sus-

tainable approach to CALD health in the future. There

are multiple points at which further evidence must be

used to guide decisions about using this model of servicedelivery, including, programme content and workforce

development. In the meantime, it would appear that this

type of intervention is particularly well-suited to the

amelioration of culturally based health disparities as it

capitalises on the strengths and processes within existing

community networks.

Acknowledgements

The authors would like to thank Mr Peter Forday

(CEO, MultiLink), Ms Gale Kerr (Director of Access

Inc), Mr Fazil Rostam and District Multicultural

Coordinator of Logan Region for constructive

comment. We would also like to thank the Research

Centre for Community Clinical Practice Innovation,Griffith University for awarding us $5000 to conduct

this systematic review.

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Documents

The effectiveness of culturally appropriate interventions to manage or prevent chronic disease in culturally and linguistically diverse communities: a systematic literature review