Consumer Perception of Culturally Competent Community Services & Treatment Outcomes

1. Carol Carstens, PhD, Scott Wingenfeld, MPA, Kwok Tam, MSocSci Ohio Department of Mental Health Office of Research & Evaluation First Meeting on Patient Reported Outcomes in Mental Health September 30, 2012 Washington DC Consumer Perception of Culturally Competent Community Services & Treatment Outcomes

2. Objective: 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 Abstract

3. Research Question What is Cultural Competence? Measuring Cultural Competence Measuring Self-Reported Outcomes Adult Consumer Sample Linear Regression Models Limitations & Sources Cited Ohio Department of Mental Health Office of Research & Evaluation Overview

4. Does consumer perception of the service providers’ cultural competence have any association with self-reported treatment outcomes? Ohio Department of Mental Health Office of Research & Evaluation Research Question

5. Culture falls under the umbrella of person-centered care. It provides a framework for understanding human experience. Personal & Group Identity Beliefs & Values Customs & Traditions Language & History Otherness: Minority versus Majority Ohio Department of Mental Health Office of Research & Evaluation Why isCultural Perspective Important?

6. Ignorance • Indifference • Mistrust • Fear • Discrimination • Difference Beliefs & Values Language Communication patterns Ohio Department of Mental Health Office of Research & Evaluation Cross-Cultural Barriers to Treatment

7. 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 Ohio Department of Mental Health Office of Research & Evaluation DSM IV-TR Guidelines

8. 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) Ohio Department of Mental Health Office of Research & Evaluation The Knowledge Base

9. 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 Ohio Department of Mental Health Office of Research & Evaluation Consumer Based Cultural Competence Inventory (CBCCI)

10. 20 items from CBCCI tested & analyzed by ODMH-ORE staff in 2012 Ohio administration Reduced administrative burden Conceptual & statistical considerations • 10 items from CBCC survey adopted to analyze consumer-reported treatment outcomes Factor loadings > .4 Two factor solution explains 59.4% s² Staff level (8 items) Organizational level (2 items) Cronbach’sα = .91 Ohio Department of Mental Health Office of Research & Evaluation For Study Purposes

11. Ohio Department of Mental Health Office of Research & Evaluation

12. Self-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 Ohio Department of Mental Health Office of Research & Evaluation MHSIP Adult Consumer Survey

13. Ohio Department of Mental Health Office of Research & Evaluation MHSIP Client-Reported OutcomesAs a direct result of the services I received:

14. Ohio Department of Mental Health Office of Research & Evaluation MHSIP Client-Reported OutcomesAs a direct result of the services I received:

15. 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 Ohio Department of Mental Health Office of Research & Evaluation Sampling

16. Ohio Department of Mental Health Office of Research & Evaluation Study Subsample • ♀ = 61% ♂ = 39% • 46.8 XAge 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

17. Some 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 No If you answered YES, what is your minority group? (Specify cultural, racial, ethnic, religious and/or sexual identity)______________________ Ohio Department of Mental Health Office of Research & Evaluation CBCC Survey Leading Question

18. 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. Ohio Department of Mental Health Office of Research & Evaluation Minority Status

19. Ohio Department of Mental Health Office of Research & Evaluation 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

20. Ohio Department of Mental Health Office of Research & Evaluation DV: Treatment Outcomes (N = 311; 13 Independent Variables) R² = .422, F = 11.9018,293, p < .000

21. Ohio Department of Mental Health Office of Research & Evaluation DV: Functioning(N = 317; 13 Independent variables) R² = .381, F = 10.2218,299, p < .000

22. Ohio Department of Mental Health Office of Research & Evaluation DV: Social Connectedness(N = 305; 13 independent variables) R² = .325, F = 7.7318,287, p < .000

23. Ohio Department of Mental Health Office of Research & Evaluation 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%

24. Griner, D, & Smith, TB. 2006. Culturally Adapted Mental Health Interventions: A meta-analytic review. Psychotherapy: Theory, Research, Practice, Training43(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. Ohio Department of Mental Health Office of Research & Evaluation Sources Cited