Making stroke services equitable for minority groups: the potential role of cultural competence
Background: In stroke services, providers are challenged to address the needs of people from ethnic minorities. Aim: This thesis will explore the stroke service needs of people from ethnic minorities, and how stroke services can address them. Part 1; Methods: Two group interviews with South Asian participants were used to inform an interview schedule. Using this schedule, 23 individual interviews were performed with South Asian participants, some of whom had experienced a stroke and some who had not. Part 1; Findings: Participants who had not used stroke services held positive expectations about those services. Participants who had used stroke services were negative about their overall experience. Attitudes and behaviour of service providers were seen as poor, and that they lacked an understanding of culturally specific issues. Participants expressed a need to be treated as an individual, to feel cared for and respected, and suggested that staff receive training to address this. Further research was needed to explore the efficacy of training service providers to be culturally competent. Part 2; Methods: Online databases were systematically searched for interventions evaluating service provider cultural competence training, and papers on theoretical frameworks of cultural competence. Components of theoretical frameworks were compared and evaluated. The training literature was evaluated and synthesised using realist methods. A stakeholder group reviewed the findings and made recommendations for practice. Part 2; Findings: Three overarching components reflected these theoretical frameworks, which were; cultural awareness, knowledge and skills. The success of training interventions, underpinned by these components, varied by the type of outcome measured. Where intervention outcomes were based on service providers’ self-reports they were perceived to be effective; where outcomes were based on service-user ratings they were perceived to be moderately effective, and where outcomes were based on clinical assessments they were perceived to be ineffective. The few studies with service-users rating their experiences indicated that a more detailed awareness of cultural issues coupled with practice improved ratings. Other studies have demonstrated that service-user ratings and outcomes can be improved by individuals, or teams, with effective levels of cultural skills implementing subject-specific health interventions. Underpinning these interventions were the understanding of service-users’ cultural needs, matched with appropriate skill-sets of teams or individuals. A stakeholder review of these findings confirmed that raising cultural awareness is an important first step in improving staff cultural competence. In addition, translating training into practice and matching the expectations of minority group stroke service-users, requires on-going support at an organisational and leadership level, with which confidence can develop through mentorship and shaping. Conclusion: The available evidence has shown how to provide cultural awareness knowledge and skills training, but not how to translate this into practical cultural competence. This thesis explores further exiting evidence to draw out components and mechanisms that seem to truly deliver cultural competence. Based on a systematic literature search and a realist review, this thesis proposes a model to suggest how true cultural competence can be achieved.
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