Product Details

Author Information

Corresponding Author
MIchael Stephens
University of Arkansas for Medical Sciences
1125 North College Ave
Fayetteville, AR 72703
United States
p: 479-713-8683
rstephens2@uams.edu

Authors (listed in order of authorship):
Sarah Moore
University of Arkansas for Medical Sciences

Williamina Bing
University of Arkansas for Medical Sciences

Pearl McElfish
University of Arkansas for Medical Sciences

Michael Stephens
University of Arkansas for Medical Sciences

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health

What specific topics does your product address?

Community health , Cultural competency , Health behavior, Health disparities, Minority health, Race & health, Social determinants of health

Does your product focus on a specific population(s)?

Native Hawaiian or other Pacific Islander

What methodological approaches were used in the development of your product, or are discussed in your product?

Community needs assessment, Community-based participatory research , Focus group , Qualitative research, Interview

What resource type(s) best describe(s) your product?

Lecture/presentation

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Marshallese Population in Northwest Arkansas: Cultural Competency Training for Medical Staff and Health Care Providers. The training is a one hour module delivered through a PowerPoint presentation that addresses the topic of providing culturally competent care to Marshallese patients. This training module establishes the framework and rationale for providing culturally competent care, discusses some of the cultural factors within the Marshallese population that may affect health behaviors and decision making, and suggests skills that health care providers and health care workers should develop to improve interactions with their Marshallese patients. This presentation is intended to contribute to the participant’s knowledge and reinforce application of the principles of cultural competency to enable them to effectively serve and address health disparities within the growing Marshallese patient population. The target audience for this presentation is persons working in the health care environment. This includes any person who may interact directly or indirectly with Marshallese patients from the initial encounter through the final interaction, regardless of the communication mechanism – postal mail, telephone, email, text, social media, or in person.

2. What are the goals of the product?

Specific goals associated with an increase in culturally competent care to Marshallese patients in Northwest Arkansas include:
1. Describe the background and history of the Marshallese population in the US and in Northwest Arkansas and illustrate the importance of having knowledge about the Marshallese population in one’s own community
2. Identify cultural characteristics of the Marshallese population that may influence health behaviors
3. Recognize common health beliefs within the Marshallese communities
4. Identify health risk factors commonly found in the Marshallese population
5. Utilize cross-cultural communication skills to appropriately address the health concerns of Marshallese patients

3. Who are the intended audiences or expected users of the product?

The intended or expected audience of this product are persons in the health care environment that may encounter Marshallese patients through any nonverbal or verbal communication modality. This includes all employees whether involved in direct patient care or other roles in the health care environment.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

There are no special instructions required for successful implementation of this product.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

The United States (US) continues to grow more diverse,1 with approximately 14% of the US population foreign born.2 By 2044, the US will become a majority-minority nation.1 Minority communities experience numerous sociocultural barriers related to access to quality health care,3,4 language,5,6 access to health insurance,7 lack of culturally competent care,8-12 and implicit racial/ethnic bias among healthcare providers.7,13-15 Implicit biases exists outside of conscious awareness and are therefore difficult to acknowledge and remedy.16,17 The Institute of Medicine found strong evidence of racial bias in the health care system.18 Implicit bias can undermine the patient-provider relationship, exacerbating poor health outcomes of racial/ethnic minorities.13 In response, cultural competency curricula can be developed to reduce health care providers’ contributions to inequality.8-12,19,20 The cultural competency training program discussed took place in northwest Arkansas, which has had significant population growth and has become more racially, ethnically diverse. The most dramatic population change in northwest Arkansas has been among Hispanic and Pacific Islander populations, with ~150% and ~300% growth, respectively.21-24 Most of the Pacific Islander population in northwest Arkansas are Marshallese.25,26 Northwest Arkansas is home to the largest population of Marshallese in the continental US.27

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Colby S, Ortman J. Projections of the size and composition of the U.S. population: 2014 to 2060 population estimates and projections. Washington, DC: United States Census Bureau;2015.

2. Pew Research Center. Modern immigration wave brings 59 million to U.S., driving population growth and change through 2065: Views of immigration's impact on U.S. society mixed. Washington, DC: Pew Research Center;2015.

3. Fuller-Rowell TE, Evans GW, Ong AD. Poverty and health: the mediating role of perceived discrimination. Psychol Sci. 2012;23(7):734-739.

4. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med. 2000;50(6):813-828.

5. Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health Care. 2007;19(2):60-67.

6. Linsky A, McIntosh N, Cabral H, Kazis LE. Patient-provider language concordance and colorectal cancer screening. J Gen Intern Med. 2011;26(2):142-147.

7. Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):e60-76.

8. Mazor SS, Hampers LC, Chande VT, Krug SE. Teaching Spanish to pediatric emergency physicians: effects on patient satisfaction. Arch Pediatr Adolesc Med. 2002;156(7):693-695.

9. Majumdar B, Browne G, Roberts J, Carpio B. Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. J Nurs Scholarsh. 2004;36(2):161-166.

10. McElmurry BJ, McCreary LL, Park CG, et al. Implementation, outcomes, and lessons learned from a collaborative primary health care program to improve diabetes care among urban Latino populations. Health Promot Pract. 2009;10(2):293-302.

11. Sequist TD, Fitzmaurice GM, Marshall R, et al. Cultural competency training and performance reports to improve diabetes care for black patients: a cluster randomized, controlled trial. Ann Intern Med. 2010;152(1):40-46.

12. Truong M, Paradies Y, Priest N. Interventions to improve cultural competency in healthcare: a systematic review of reviews. BMC Health Serv Res. 2014;14:99.

13. Dominguez TP. Race, racism, and racial disparities in adverse birth outcomes. Clin Obstet Gynecol. 2008;51(2):360-370.

14. Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008;46(7):678-685.

15. van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748-1756.

16. Dovidio JF, Gaertner SL. Aversive racism and selection decisions: 1989 and 1999. Psychol Sci. 2000;11(4):315-319.

17. Nosek B, Greenwald A, Banaji M. The implicit association test at age 7: A methodological and conceptual review. In: Bargh JA, ed. Social psychology and the unconscious: The automaticity of higher mental processes. New York, NY: Psychology Press; 2007:265-292.

18. Smedley B, Stith A, Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academy Press; 2003.

19. Govere L, Govere EM. How Effective is Cultural Competence Training of Healthcare Providers on Improving Patient Satisfaction of Minority Groups? A Systematic Review of Literature. Worldviews Evid Based Nurs. 2016.

20. Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH, 3rd. Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med. 2011;26(3):317-325.

21. United States Census Bureau. Profile of general demographic characteristics: 2000, Benton County, Arkansas. Washington, DC: United States Census Bureau; 2000.

22. United States Census Bureau. Profile of general demographic characteristics: 2000, Washington County, Arkansas. Washington, DC: United States Census Bureau; 2000.

23. United States Census Bureau. Profile of general population and housing characteristics: 2010, Benton County, Arkansas. Washington, DC: United States Census Bureau; 2010.

24. United States Census Bureau. Profile of general population and housing characteristics: 2010, Washington County, Arkansas. Washington, DC: United States Census Bureau; 2010.

25. McElfish P, Hallgren E, Yamada S. Effect of US health policies on health care access for Marshallese migrants. Am J Public Health. 2015;105(4):637-643.

26. United States Government Accountability Office. Compacts of Free Association: Improvements Needed to Assess and Address Growing Migration. Washington, DC: United States Government Accountability Office;2011. GAO-12-64.

27. Hixson L, Hepler B, Kim M. The Native Hawaiian and Other Pacific Islander population 2010. Washington, DC: United States Census Bureau;2012.

28. McElfish P, Kohler P, Smith C, et al. Community-driven research agenda to reduce health disparities. Clin Transl Sci. 2015;8(6):690-695.

29. United States Department of Health & Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Rockville, MD: United States Department of Health & Human Services;2012.

30. United States Department of Health & Human Services, Office of Disease Prevention and Health Promotion. The Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020. Phase I Report: Recommendations for the Framework and Format of Healthy People 2020. Washington, DC: United States Department of Health & Human Services; 2008.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

A primary goal of Healthy People 2020 is to, “achieve health equity, eliminate disparities, and improve the health of all groups". Health disparities are an important focus in public health, as seen by the Department of Health and Human Services (DHHS) Action Plan to Reduce Racial and Ethnic Health Disparities, the CDC Health Disparities and Inequalities Report, and the NIH Strategic Research Plan and Budget to Address and Ultimately Eliminate Health Disparities. University of Arkansas for Medical Sciences Northwest (UAMS), Office of Community Health and Research (OCHR) efforts to better understand health disparities for the Marshallese population of Northwest Arkansas conducted a multi-level needs assessment. The Coalition Partners have been working together for more than 10 years to address community health disparities throughout Northwest Arkansas. In 2012, we began a concerted effort to better understand the health inequalities of the Marshallese and Hispanic communities, starting with improving our understanding of their histories and cultures. To do this, we invited community members from the priority communities to share their stories and perspectives. During that time, we also compiled and reviewed secondary data from the census, school, adult and youth Behavior Risk Factor Surveillance System (BRFSS), Arkansas Department of Health Vital Record, and previous needs assessments conducted by partners in 2004 and 2010. We then conducted more structured qualitative interviews with community members from the priority populations. During these interviews we used structured, yet open-ended questions, so that we could better understand the most pressing needs of the communities as identified by members of these two priority populations. Then, in 2013 we conducted a mixed-methods needs assessment (based on the BRFSS) of the priority populations (3,000 surveyed with both quantitative and qualitative questions). Simultaneously, we conducted a gaps analysis of services and an environmental scan of policies and systems related to the needs identified by community members. Based on the information gained, we conducted qualitative focus groups with lay community members from priority populations to collaboratively interpret and better understand the context of the data and possible solutions. We then held planning sessions to collaboratively review data with community members and worked with community members to set the priorities for action.

The Marshallese community in Northwest Arkansas identified three priority health concerns: 1) high rates of type 2 diabetes; 2) lack of access to healthy foods; 3) lack of access to culturally and linguistically appropriate health care. The third concern voiced by this community is particularly noteworthy considering establishment of The National Standards of Culturally and Linguistically Appropriate Services in Health Care (CLAS standards), which were the result of a multi-year effort by “a broad range of stakeholders, including hospitals, community-based clinics, managed care organizations, home health agencies, and other types of health care organizations; physicians, nurses, and other providers; professional associations; State and Federal agencies and other policymakers; purchasers of health care; accreditation and credentialing agencies; educators; and patient advocates, advocacy groups, and consumers”. CLAS standards were created to, “improve access to care, quality of care, and, ultimately, health outcomes,” for the increasingly diverse population in the US. Utilizing the CLAS standards as a guide, UAMS OCHR staff created the proposed cultural competency training module for health care workers and providers.CLAS standards provided the foundation for the development of this Marshallese-focused cultural competency training for health care providers.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

As discussed above, the UAMS OCHR utilized a community-based participatory approach to develop the training. In order to develop effective and useful training, OCHR staff worked with the Arkansas Coalition of Marshallese (ACOM), the Workers’ Justice Center, Marshallese faith-based leaders, and key stakeholders in the Marshallese community to develop curriculum and content with the goal of providing health care workers with relevant, real-life examples and solutions to improve care to this population. OCHR staff also consulted with area health care workers during product development to understand common challenges, cultural concerns, and appropriate structure for implementation in health care settings. Additionally, to increase the value of the training for health care workers, OCHR staff worked with the UAMS Office of Continuing Medical Education (OCME) to have the module certified for continuing education credits for physicians, pharmacists, nurses, and certified health education specialists. This process involved the identification of areas of professional practice/behavior that needed improvement and identification of practice gaps in regards to knowledge, competence, or performance. Once practice gaps and educational needs were identified, OCHR staff outlined the learning objectives for the module, and collaboratively created and revised the training module with input from our community partners. We then collaborated to create a post-training evaluation designed to assess the effectiveness of the trainings while also identifying additional learning needs of health care workers as related to culturally appropriate care for Marshallese patients. The UAMS office of distance learning was consulted to provide this module via the UAMS Learning on Demand (LOD) website with the aim of meeting health care worker's needs for cultural competency training regardless of time constraints. Specific learning objectives for this module are as follows: 1) describe the background and history of the Marshallese population in the U.S. and in Northwest Arkansas; 2) identify cultural characteristics of the Marshallese population that may influence health behaviors; 3) recognize common health beliefs within the Marshallese community; 4) identify the health risk factors commonly found in the Marshallese population; 5) utilize cross-cultural communication skills to appropriately address the health concerns of Marshallese patients.
Sarah Moore, RN, MS, CHES was the project manager leading development of this product. Ms. Moore has direct experience working in, and is familiar with, the typical practices of health care settings as well as barriers to providing culturally competent care. Her educational experience in community health promotion has provided skill in adult health education development and delivery. Ms. Moore worked with Jellesen Rubon-Chutaro (Pacific Islander/Marshallese cultural expert), Williamina Bing (Pacific Islander/Marshallese cultural expert with extensive experience working in public health) and Dr. Nia Aitaoto (community based participatory researcher, extensive knowledge of health education issues among the Marshallese, and Marshallese cultural expert) in the research and development of this product. Ms. Moore performed research on the topic of cultural competency and the application of this concept in the health care environment before beginning the development process and frequently during development. In addition to using their extensive knowledge and experience, the panel of experts consulted their communities regarding cultural challenges in the health care environment in Northwest Arkansas.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

The evaluation is being published in a journal article under review. A summary of the evaluation is provided below. To date, more than 600 live trainings have been conducted, across 15 different organizations to more than 300 professionals. Results from the post training evaluation revealed that 92% participants noted an increase in learning of new knowledge, competence, and performance. More than 1200 open ended responses from the 600 indiviudal and organizations participants were reviewed and coded. Three qualitative themes emerged. Responses from indiviual and organzational participants were compared and found to be consistent. Both indiviudal and organzational participants reported learning a great deal about cultural differences, as well as an increased awareness and appreciation of the cultural differences of their patient population. Participants also reported behavioral changes in several human resources, and participants indicated behavioral changes in communication/materials.

10. Please describe why you chose the presentation format you did.

The presentation format was selected to be consistent with the expectations of health care environments. All initial presentations were done in-person with PowerPoint and have been converted to electronic format to allow online on-demand access for those who are unable to attend live sessions.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

A strength of this module is that it addressed specific concerns voiced by both community and health care providers. The live sessions allowed for real-time interaction with the presenter, a Marshallese community member and a licensed health care professional. This ability to provide experience-based responses to health care professionals has been of great value to the participants. A limitation of this module is that the online version does not provide the ability to respond to participant questions. A frequently asked question component is being considered to address this void in the online presentation format. The product was peer-reviewed by health care providers and community stakeholders. Revisions were made based on input received. Every presentation, in person or online, has an evaluation component that is reviewed by the presenters to guide revisions and/or adjustments to the product.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

UAMS OCHR staff utilized a community-based participatory approach to understanding the needs of the population and impetus for this product was the direct result of community participation and feedback during a local health needs assessment. Then we used engaged methods to development the training. In order to develop effective and useful training, OCHR staff worked with the Arkansas Coalition of Marshallese (ACOM), the Worker's Justice Center, area faith-based leaders, and key stakeholders in the Marshallese community to develop curriculum and content that is effective, useful, and focused on providing health care workers with relevant, real-life examples and solutions to improve care to this population. The training and evaluation for this module were submitted to the IRB and received an exemption. The collaborators are in agreement regarding the submission to CES4Health.


• Sarah Moore, MS, RN, CHES, Project Manager. Ms. Moore was the project lead, completed the initial research regarding approaches to teaching cultural competency in a health care setting. She collaborated with OCHR staff cultural and research experts and shared the information she learned with her colleague to guide her through the process of developing the Marshallese-specific module. Ms. Moore is the secondary presenter of this training module.

• Williamina Bing, BS, Project Coordinator. Ms. Bing provided technical input to Ms. Moore regarding content structure and guided curriculum development to ensure cultural relevance. Ms. Bing is the primary presenter of this training module.

• Pearl McElfish, PhD, MBA, MS, Director of the Office of Community Health and Research. Dr. McElfish provided technical insight in utilization of community-based participatory approaches to aid in module development and guided evaluation development for this training.

• Michael Stephens, MS, CHES, Program Director. Mr. Stephens provided guidance for module topics and technical insight for training module development, to include utilization of best practices for visual presentations. Mr. Stephens directed quality assurance for this training module.

• The training and evaluation were submitted to the IRB and received an exemption. The collaborators are in agreement regarding the submission to CES4Health.