We have synthesized the literature that describes and evaluates interventions that use cultural leverage to narrow disparities in health care. We focused on interventions that emphasized behavioral change of persons in communities and patients in health care organization, access to care, and health care organization innovation. Interventions that emphasized individual behavioral change relied on the expertise of community members to inform their programs. These community members were enlisted to share culturally specific information on health care practices such as breast and cervical cancer screening. Interventions that focused on improving access to health care relied on patient navigators and lay educators to encourage regular screening and to dispel misconceptions about the disease. Finally, those that concentrated on the health care system homed in on the role of health care professionals. The dominant model in this set of interventions emphasized the training of health professionals to effectively deliver culturally specific messages and culturally tailored programs.
Four common themes emerged from this literature review. First, scholarship in this field is still in a nascent stage, although the initial findings from this field are quite promising. One indication of the early stage of this field is the methodological inconsistency of these studies. Six of the studies were descriptive in nature and provided qualitative insights into potential mechanisms, a necessary step in learning how to improve outcomes for communities of color. The remaining 32 studies did formally evaluate processes of care or health outcomes. Twenty-three of these 32 studies reported significant improvements in care across a wide range of conditions and preventive strategies. It also should be noted that none of the studies actually addressed the extent to which the cultural aspects of these interventions brought about the improvements in care, apart from the general mechanisms of quality improvement or public health strategies inherent in the interventions. None of the studies was designed to examine the impact of an intervention on health disparities, which would require a comparison between a specific racial or ethnic group and a white control group. Among the communities that were studied, some populations were clearly underrepresented, such as men of color and Asian Americans.
A second observation that emerges from this intervention literature is that nurses and other nonphysician health care providers implemented the majority of these interventions. Those initiated by physicians were generally brief in duration and focused on training physicians in cultural tools or language acquisition. Nurse-led studies, in contrast, often described in detail the extent to which race and ethnicity influence health care delivery. This may simply reflect that nurse-led interventions are common among public health interventions. On the other hand, as frontline health professionals, nurses may be particularly sympathetic to the need to modify the existing health care delivery system or may recognize opportunities to link institutionally based care delivery with community-based organizations. The preponderance of these interventions focused on improving the health care of women, perhaps reflecting the gender distribution of the nursing field (nurses were the providers in most of the studies). Although some studies included men as subjects, only one specifically targeted men.
A third focus among these studies is improving perceptions of self-worth and self-efficacy surrounding health behaviors. This theme appeared particularly prevalent in studies that focused on prevention. In preventing diseases such as diabetes and HIV, lifestyle habits and perceptions of individual value are particularly salient. Self-worth in the context of societal cues also appeared important in the treatment of substance abuse. Several studies investigated the roles of culture in the treatment of substance abuse by modifying the treatment environment and incorporating culturally specific workers, role models, and concepts into the treatment plan. Incorporating culturally specific messages to emphasize positive self-images may allow patients to boost self-efficacy in the settings of substance abuse and disease prevention. In contrast, we found no studies focused on improving care or outcomes using a strategy of self-efficacy for people of color in the setting of acute illness.
Finally, a central component of a number of these interventions was improving connections between patients and health care organizations through the use of cultural strategies. The long-term management of health and disease are often contingent on the presence of a relationship that enables the mutual exchange of information and the development of treatment plans to which patients of color can successfully adhere. Interventions using culturally specific patient navigators and community health workers can be used to create relationships on the basis of cultural commonalities, seen and unseen, to transcend obstacles that commonly impede the delivery of care to patients of color. These are among the most successful strategies that emerged from our literature review.
In general, the literature indicates that the cultural aspects of race and ethnicity provide unique levels for health disparities interventions. Jones (2000)
suggested a framework for understanding the role of racism in health and health care; such a model could inform the structure of interventions like those we review here. Institutional racism, individually mediated racism, and internalized racism are three levels of differential experience based on race that can affect health and health care. Jones defined institutional racism as differential access by race to the goods, services, and opportunities of society (e.g., health insurance, qualified physicians). Individually mediated racism is divided into two types; prejudice represents differential assumptions about the abilities, motives, and intentions of others on the basis of their race (e.g., assumptions about drug use), and discrimination represents differential actions toward others on the basis of race (e.g., lower referral rates to cardiac catheterization for black women; Schneider et al. 2001
). Finally, internalized racism is defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth. This manifestation of racism is exemplified in the lower frequency of health-seeking behaviors among some communities of color. The three aspects of racism described by Jones may help identify potential targets and strategies for intervention in studies such as those reviewed here (Jones 2000
In addition, “levels of culture,” as described by Hall (1984)
and others, are instructive in understanding how culture can be used for positive leverage in health settings: surface characteristics drawn from traditional dress, music, colors, and so on, are fairly easily incorporated into health materials and programming, whereas deeper dimensions, such as shared underlying values and assumptions, may be harder to incorporate but possibly more effective (Hall 1984
; Kreuter et al. 2003
; Resnicow et al. 1999
). The studies reviewed here describe interventions in which cultural tools can be used in the health care organization and within communities of color to address health disparities by mitigating institutional and internalized levels of racism. We use the term cultural leverage
to describe this strategy for improving the health of communities of color by using their cultural practices, products, philosophies, or environments as vehicles that facilitate behavior change of patients and practitioners. Activating shared norms within racial and ethnic groups, and directing health care delivery in a manner cognizant of cultural practices, could strengthen the linkages between the health care delivery system and the populations it aims to serve and ultimately decrease health disparities.
Several caveats limit our ability to generalize from this literature review. First, although we pursued multiple search engines and databases for our references, only those published in peer-reviewed journals were included. While the peer-review process ensures a level of quality, our review is limited to those published articles. Publication bias in favor of positive results is possible. Furthermore, the vetting and publication of such manuscripts introduce a substantial time lag; we undoubtedly excluded ongoing studies and studies that have been evaluated but not yet reported. In addition, we limited our review to those studies published in the United States. An extension of this work could include intervention studies aimed at addressing minority populations in other countries.
Deep inequities divide the races in the United States, with an impact that extends to health care (Williams and Rucker 2000
). To ameliorate these disparities in health care, it may be insufficient to simply provide equal health care for all, and it may be important to provide health care that is also culturally leveraged. Cultural competence strategies are critical to creating a hospitable setting, but cultural leverage strategies may contribute further to activating individuals within communities of color for behavioral change, facilitating health care connections to communities of color, and creating a safe, nurturing health care environment in which health can flourish.
Several important policy recommendations arise from our review. First, health care organizations and public health entities should continue to actively engage communities of color in developing solutions to the problem of health disparities. We found that some of the most innovative approaches to cultural leverage were borne from active community involvement. It is in engaging a specific community in the creation of an intervention that relationships are fostered and health care bridges can materialize. Cooperation at this early stage of an intervention increases the likelihood of identifying cultural leverage strategies most likely to be effective, and it ensures the incorporation of both seen and unseen cultural nuances. Equally important, early community involvement ensures more than superficial support from the community. This approach entails actively crafting an ongoing relationship with community members via both health care interactions and related social and cultural activities.
Second, multidisciplinary interventions incorporating doctors, nurses, and community health workers should be encouraged. Physician-focused disparity education has often emphasized cultural competence training and demonstrated modest improvements in knowledge and attitudes (Beach et al. 2005
). While cultural competence is an important part of the solution to reducing disparities, our review found that culturally leveraged nursing and community health worker interventions improved processes of care and outcomes. Third, while the literature is limited, there are compelling conceptual reasons why culturally leveraged interventions are likely to add incremental benefit to generic quality improvement interventions such as enhanced patient registries and information systems, audit and feedback of performance measures to physicians, and the implementation of practice guidelines and flow sheets. For example, culturally leveraged interventions often are more likely to mobilize community strengths as well as address some of the root perceptual, attitudinal, and logistical barriers to chronic care self-management, a particularly challenging area for generic interventions.
While cultural leverage is a promising concept for reducing health care disparities, there are several important unanswered questions about cultural leverage that may influence health care policies. Instead of debating the merit of a generic versus culturally leveraged intervention, the most important question may be what combination of interventions and ways of integrating culture into generic quality improvement are most likely to improve quality of care and outcomes. The distinction between culturally leveraged interventions and generic interventions is somewhat artificial, since there is a continuum of interventions incorporating culture. For example, a lay health worker intervention involving community outreach, tailored health messaging, and improved access to the health care system may be at one end, whereas a culturally leveraged telephone nurse case management system of patients with heart failure that involves a patient registry and tracking clinical performance measures is more a mixture of culturally specific and generic approaches. A key question is what types of interventions provide the most value and are most cost effective. Moreover, the most appropriate solutions probably depend on the specific circumstances of a health care organization or set of providers. For example, a health care organization that does not have the ability to identify and track its patients with diabetes would need to develop that capability first before embarking on a culturally tailored nurse case management system. Overall, the more widespread use of cultural leverage interventions is likely to improve racial disparities in health care.