CONSUMER PERCEPTION OF CULTURALLY COMPETENT COMMUNITY SERVICES & TREATMENT OUTCOMES

Carol Carstens, PhD, Scott Wingenfeld, MPA, Kwok Tam, MSocSciOhio Department of Mental Health Office of Research & Evaluation

First Meeting on Patient Reported Outcomes in Mental Health

September 30, 2012 Washington DC

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ABSTRACTObjective: To look at the relationship between patient self-reported experience of care and measures of clinical care.Data Source/Collection: Data were collected in a mail survey of minority consumers (N = 311).Design/Methods: In this cross-sectional study, Likert-type scales were used to collect information on client perception of providers’ cultural competence and self-report measures of functioning, quality of life, and social connectedness. Hierarchical regression was used to examine the relationship between cultural competence and the independent variables.Principal Findings: After controlling for subject-related factors, consumer perception of provider cultural competence was significantly related to self-reported outcome measures.Conclusions: Cultural competence is a specific approach to patient centered care that can improve the outcomes of mental health services.

Ohio Department of Mental Health Office of Research & Evaluation

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OVERVIEW Research Question What is Cultural Competence? Measuring Cultural Competence Measuring Self-Reported Outcomes Adult Consumer Sample Linear Regression Models Limitations & Sources Cited

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RESEARCH QUESTION

Does consumer perception of the service providers’ cultural competence have any association with self-reported treatment outcomes?

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WHY IS CULTURAL PERSPECTIVE IMPORTANT?

Culture falls under the umbrella of person-centered care. It provides a framework for understanding human experience.Personal & Group IdentityBeliefs & ValuesCustoms & TraditionsLanguage & HistoryOtherness: Minority versus Majority

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CROSS-CULTURAL BARRIERS TO TREATMENT Ignorance Indifference Mistrust Fear Discrimination Difference

Beliefs & ValuesLanguageCommunication patterns

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DSM IV-TR GUIDELINES Inquire about cultural identity — race,

ethnicity, gender, sexual orientation, religion, spirituality, disability status & other self-defining characteristics

Explore cultural explanations of the problem

Consider cultural factors in psychosocial environment and level of functioning

Examine cultural elements in the client-provider relationship

Overall cultural assessment goes into diagnosis and individual treatment plan

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THE KNOWLEDGE BASE

Very little research looks at the relationship between

provider’s cultural competence & the patient’s symptoms, functioning or social support (Griner & Smith, 2006)

evaluates cultural competence from the consumer perspective (Cornelius et al, 2004)

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CONSUMER BASED CULTURAL COMPETENCE INVENTORY (CBCCI)Experimental 52-item Inventory developed by L.J. Cornelius & others in Maryland in 2002.

Awareness of patient culture Respectful behaviors Language interpreters Understanding indigenous practices Consumer involvement Acceptance of cultural differences Community outreach Patient-provider-organization interactions

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FOR STUDY PURPOSES 20 items from CBCCI tested & analyzed by ODMH-

ORE staff in 2012 Ohio administrationReduced administrative burden Conceptual & statistical considerations

10 items from CBCC survey adopted to analyze consumer-reported treatment outcomesFactor loadings > .4Two factor solution explains 59.4% s²Staff level (8 items)Organizational level (2 items)Cronbach’s α = .91

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Survey Item #

Question Factor 1

Factor 2

2 The staff listen to me and my family when we talk to them. .706  

3The staff who work directly with me on my mental health needs respect my belief in God, a supreme being, or higher power.

.709  

4 Some of the staff at my agency understand the difference between their culture and mine. .755  

5 Staff understand that people of my racial or ethnic group are not all alike. .739  

7 When I first called or came to the agency, it was easy to talk to the staff. .532  

8 Most of the time, I feel I can trust the staff who work with me. .707  

10Staff understand some of the different ideas that I, my family, and others from my minority group may have about mental illness.

.743  

11Staff are willing to be flexible and provide alternative approaches or services to my cultural/ethnic treatment needs.

.737  

16 The agency waiting room has pictures or reading material that show people from my minority group.   .962

17 The agency’s reading materials and handouts are in other languages as well as English.   .603

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MHSIP ADULT CONSUMER SURVEYSelf-rated Perception of Care

General Satisfaction (3 items)Access to Care (4 items)Quality & Appropriateness (8 items)Participation in Treatment (2 items)

Outcomes (8 items) Functioning (5 items) Social Connectedness (4 items)

http://www.nri-inc.org/projects/SDICC/TA/Ganju.Smith_1.pdf

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MHSIP CLIENT-REPORTED OUTCOMESAS A DIRECT RESULT OF THE SERVICES I RECEIVED:

Domain Items

Outcomes of Services

• I deal more effectively with daily problems

• I am better able to control my life• I am better able to deal with crisis• I get along better with family• I do better in social situations• I do better in school and/or work• My housing situation has improved• My symptoms don’t bother me as

much

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MHSIP CLIENT-REPORTED OUTCOMESAS A DIRECT RESULT OF THE SERVICES I RECEIVED:

Domain Items

Functioning

• I am able to do things that are more meaningful to me

• My symptoms don’t bother as much• I am better able to take care of my needs• I am better able to handle things when they go

wrong• I am better able to do things I want to do

Social Connected-ness

• I am happy with the friendships I have• I have people with whom I can do enjoyable

things• I feel I belong in community• In a crisis, I would have the support I need

from family or friends

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SAMPLING Adult survey: 4,740 randomly selected

adult consumers with serious mental illness (SMI)

Minority subsample: 1,325 consumers selected if race code indicated person of color OR ethnicity code indicated hispanic origin

175 individuals selected where race = White without hispanic qualifier

Total subsample = 37% of adult consumer sample received cultural competence survey

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STUDY SUBSAMPLE ♀ = 61% ♂ = 39%

46.8 X Age Range 17.9 – 88.2 SD = 11.8 91% Medicaid 9% other public coverage 88% long term 12% new in 2011 87% still in treatment

6.5% terminated 7% unknown status

85%

9%6% Race

BlackWhiteOther

Hispanic = 7%

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46%29%

19% 7% DiagnosesPsychotic DOMaj DeprBipolar DO

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CBCC SURVEY LEADING QUESTIONSome people belong to minority groups because their race, country of origin, history, language, religion, or sexual orientation is different than most people. Do you consider yourself a cultural, racial, ethnic, religious, or sexual minority group member?

Yes NoIf you answered YES, what is your minority group? (Specify cultural, racial, ethnic, religious and/or sexual identity)______________________

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MINORITY STATUS About 37% of the sample who were

people of color or hispanic ethnicity said No to the question about minority status. The US is becoming more racially and

ethnically diverse. Many people in the sample do not appear

to see themselves as “other” or set apart from mainstream society because of race or ethnicity.

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13 INDEPENDENT VARIABLESENTERED INTO REGRESSION MODELS

Age Race Gender Ethnicity Geographic Profile Diagnosis Service Longevity Service Continuity

Perception of Care General Satisfaction Access Quality &

Appropriateness Participation in

Treatment* Cultural Competence

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DV: TREATMENT OUTCOMES (N = 311; 13 INDEPENDENT VARIABLES)

Significant Variables β t pBipolar DO -.108 -2.157 .032Major Depression -.176 -3.487 .001Small City Geo Type .177 3.853 .000Participation in Tx .277 4.080 .000Cultural Competence .187 2.970 .003

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R² = .422, F = 11.9018,293, p < .000

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DV: FUNCTIONING(N = 317; 13 INDEPENDENT VARIABLES)

Significant Variables β t pBipolar DO -.212 -2.365 .019Major Depression -.220 -4.261 .001Small City Geo Type .146 3.093 .000Participation in Tx .242 3.462 .001Cultural Competence .183 2.834 .005

Ohio Department of Mental Health Office of Research & Evaluation

R² = .381, F = 10.2218,299, p < .000

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DV: SOCIAL CONNECTEDNESS(N = 305; 13 INDEPENDENT VARIABLES)

Significant Variables β t pMajor Depression -.143 -2.587 .010Small City Geo Type .127 3.530 .012Access .235 2.110 .036Participation in Tx .222 2.988 .003Cultural Competence .427 6.217 .000

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R² = .325, F = 7.7318,287, p < .000

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LIMITATIONS Cultural

Competence: Confounded Construct Minority status Race & Ethnicity Group vs Individual

identity Scale Development:

Limited psychometric testing on CBCC

Dependent Vars: Post-hoc outcome

measures Diversity of Service

Population Unknown: Sample

religious/spiritual identification = 8%

Sample GLBT identification = 2%

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SOURCES CITED Griner, D, & Smith, TB. 2006. Culturally Adapted

Mental Health Interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training 43(4): 531-548.

Cornelius LJ, Booker NC, Arthur TE, Reeves I & Morgan O. 2004. The Validity and Reliability Testing of a Consumer-Based Cultural Competency Inventory. Research on Social Work Practice 14(3): 201-209.

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Ohio Department of Mental Health Office of Research & Evaluation