Revision 2

Cultural Competence Training Program For African Immigrants

Cultural Competence Training Program For African Immigrants

Cultural competence can be described as the ability of understanding, communicating, and interacting efficiently with people across cultures (Schouler-Ocak et al., 2015). Cultural competence comprises the process of one being aware of their own view of the world based on their cultural practices and traditions, as well as developing positive attitudes towards the difference in cultures of others (Allison et al., 2016). Cultural competence is an important aspect of healthcare because cultural practices directly impact health care practices (Venters et al., 2019). African immigrants often find themselves in situations of cultural dilemmas because of the differences in culture between their original areas of residence and their new ones (Price et al., 2015).

The main problem witnessed on the project site is the lack of cultural competence among health care providers regarding African immigrants. This problem negatively affects the health care experience of African immigrants (Purnell & Fenkl, 2019). Because of the gap in cultural incompetence, there is a huge disparity in the quality of health services received by the African immigrant population as compared to other population groups in United States (Clough et al., 2013). Evidence points to the fact that the African immigrant population has a lower health score and patient outcomes as compared to other groups with less than 18% of those admitted showing improved results over the course of their recovery (World Health Organization, 2020).

Knowledge gaps existing in practice causing cultural incompetence needs to be addressed because it violated the healthcare sector's goal of ensuring fairness and equality in the access to services regardless of ethnic or racial orientation (Allen et al., 2012). As the World Health Organization explains, the health care sector aims at ensuring that everyone can be as healthy as possible, including the African immigrants (World Health Organization, 2020). The lack of cultural competence among health care providers that leads to African immigrants having poor health experiences violates this goal. The solution put forth by this project is the development of a cultural training program for African immigrants. This program is aimed at equipping health care providers with the right knowledge and set of skills to address the health concerns of African immigrants. The development of a cultural competence program is important because it will help in the removal of sociocultural factors that negatively impact the health experiences of African immigrants (Omenka et al., 2020).

Background

The number of African immigrants entering and settling in the United States increases almost every year (Purnell & Fenkl, 2019). This is because African immigrants prefer moving to the United States in search of better living conditions, better employment opportunities, and better health care services (Seck, 2015). However, African immigrants have been brought up in entirely different societies with completely different cultural beliefs and practices (Allen et al., 2012).

The African immigrant group has unique health care needs and most of these needs are related to their cultural practices (Purnell & Fenkl, 2019). Purnell and Fenkl (2019), report that health care providers are not devoted to finding methods of addressing these unique health care needs of African immigrants. Omenka et al. (2020), explain that the lack of cultural competence among health care providers is a crucial contributing factor to the poor health of African immigrants. Without cultural competence training, health care providers cannot effectively tackle the health care concerns of African immigrants (Kamya, 2017).

Problem Statement

The main problem faced at the project site is the lack of cultural competence training among health care providers, specifically regarding African immigrants. The facility is a primary care clinic in Garland, Texas that attends to various groups of people and the African immigrants group is one of them. However, the African immigrant group is different in terms of their health care needs since most of their medical needs are related to their culture (Asare & Sharma, 2012). The staff have not received formal training on addressing the needs of this population, therefore they cannot deliver health services that address the cultural, social, and linguistic needs of the African immigrant group. This results in poor health conditions for African immigrants. There are several resources available that are not being used, and this project addresses to address these gaps.

The Center for Disease Control and Prevention (CDC) reports that the failure of health care providers to administer effective health care services to African immigrants puts the group at an increased risk of getting sick (CDC, 2021). The Center for Disease Control and Prevention (CDC) reports that this has been clear, especially during the COVID-19 period as many African immigrants have suffered from and died of COVID-19 (2021). The proposed solution is the development of a cultural competence training program for the health care providers. This program is aimed at enabling the health care providers to gain the knowledge and techniques they can employ to provide quality health care services to African immigrants.

PICOT Question

In healthcare workers caring for African Immigrant groups (P), how can how can an effective cultural competence training program (I) compared to no training program (C) be developed to improve the resource allocation and referrals for African Immigrants (O) in less than 4 weeks (T).

Literature Review

Search Methods

The search strategy for this project included the use of databases, search terms, and keywords. The databases included MEDLINE (PubMed), Web of Science, Google Scholar, and CINAHL Complete. The keywords used were based on the PICO framework. The participants were "African immigrants", "African incomers", and "African in-migrants". The intervention was "cultural competence", "competence in cultures", "cultural awareness", "intercultural competence", "culturally responsive", "cultural literacy", and "culturally informed". The outcomes were "improved health care", "better health care", "enhanced health", and "raised health care status". Boolean operators were also used to combine search terms. The search terms were combined to broaden or narrow the search results. "OR" and "AND" were the Boolean operators used. The citation list was reviewed to identify any additional studies that were eligible for inclusion. This was to ensure that no relevant studies were excluded. There was focus on the breadth and specificity of the search.

Predetermined criteria for inclusion and exclusion had already been established and all the citations were reviewed against it. Various types of study designs were included, and these include systematic reviews, cross-sectional studies, and case reports and series. All included studies specifically addressed how cultural competence in the healthcare profession would be useful in improving the health outcomes of African immigrants or how deficiency of cultural competence among health care providers contributed to the poor health of African immigrants. The definition of cultural competency along with all its elements was based on the United States National Library of Medicine-National Institutes of Health (National Library of Medicine, 2019). The library defines cultural competency among health care providers as the ability to collaborate effectually with individuals from different cultures to improve their health care experience and outcomes Health (National Library of Medicine, 2019).

The studies included also specifically compared the cultural competency of health care providers to the health outcomes and experiences of African immigrants. All potential settings, such as hospitals, clinics, community settings, and others that were related to the studies, were included. The studies included specifically had their participants as African immigrants and no other group was substituted for the participants. Studies were exempted because of the following. (a) The study population was not only African immigrants, or there was no separate reporting of the results of African immigrants. (b) The study discussed African Americans instead of African immigrants. (c) The study did not have its core focus as cultural competence among health care providers in relation to African immigrants. (d) The intervention targeted the health care system or the health care providers instead of the patients. However, no studies were excluded based on participant age or sex, or article language.

Review Synthesis

Developing the themes was founded on analysis and examination of previous studies that were related to cultural competence issues among African immigrants. The main themes that emerged include effects of cultural incompetence, how language barriers affect cultural competence, and the impact of cultural competence training on health care workers. These themes are the main points of emphasis when developing a cultural competence program for African immigrants. Focusing on these themes will guarantee the success of the cultural competence program for African immigrants.

Review of Study Methods

Most of the literatures reviewed the qualitative literature review methods to supplement the facts in their studies. The qualitative literature review research was conducted in hospital and clinical settings by assessing redacted medical records. The facts gave insights into how cultural competence affected the quality of patient outcomes among the African immigrant population. The case study aimed at identifying the percentages of hospitals and clinics that acknowledge cultural sensitivity and inclusion through cultural competence training.

Literature Themes

Effects of Cultural Incompetence

The main issue observed in the research is the lack of cultural sensitivity and competence within the health care profession regarding African immigrants. This issue has a negative impact on the health care received by African immigrants. Because of the disparity in cultural competence, the health care providers cannot efficiently deliver health services that cater to the cultural, social, and linguistic needs of the African immigrant patients (Purnell & Fenkl, 2019). As a result, the African immigrant group is seen to have an overall health status score that is lower compared to other groups (Seck, 2015). As the World Health Organization defines, the health care sector has a goal of guaranteeing that everyone's wellbeing is catered for as effective as possible, including African immigrants (World Health Organization, 2020). Health is determined by various social factors outside of the traditional healthcare setting (Purnell & Fenkl, 2019).

Some of these social determinants of health are housing quality, access to healthy foods, and education. Seck (2015) explained that African immigrants have unfavorable social determinants of health which contribute to their lack of quality healthcare. This leads to their poor health experiences because of the lack of understanding by health care workers regarding these social determinants of health. Lack of representation of African immigrants both in leadership and training is also responsible for the lack of cultural competence programs for African immigrants (Clough et al., 2013). Another reason for the lack of cultural incompetence regarding African immigrants is the fact that even most health care workers are white and without cultural training, it is hard for them to understand the needs of African immigrants (Seck, 2015). Even though the medical field is showing increased diversity, most people working in healthcare are not familiar with the culture of African immigrants, so they do not know how to handle this group (Purnell & Fenkl, 2019).

Cultural incompetence has had negative outcomes for African immigrant patients, such as serious health complications and even death. Clough et al. (2013) explained that, due to cultural incompetence, African immigrants are two to three times more likely to suffer from various health-related issues compared to other groups, like white people. The cultural incompetence of health care workers makes African immigrants suffer severely and longer from easily preventable diseases. Seck (2015) reports that some of these negative outcomes are because of subconscious prejudices and implicit bias about the African immigrant group . Addressing cultural incompetence and its effects is the first step to the development of a successful cultural training program for African immigrants (Purnell & Fenkl, 2019).

Language Barriers and Cultural Competence

Language is an aspect of culture that affects the quality of treatment in African immigrant groups (Seck, 2015). Language barriers play an important role in miscommunication between patients and medical providers, which negatively affects the quality of healthcare services and patient satisfaction regarding the African immigrant group (Allison et al., 2016). Due to language barriers, health care professionals have an incomplete understanding of the situations of patients, poorly assess patients, prescribe treatment incompletely, or cause delayed treatment or misdiagnoses (Wamwayi & Murray, 2019). As a result of language barrier, African immigrants end up having decreased satisfaction with healthcare services, complications arising from medication, and a reduced level of understanding of their diagnosis even if they have access to health care (Venters et al., 2019).

All these elements lead to the reduction in the quality of healthcare experience of African immigrants. One way of overcoming the language barrier is through using technology to bridge the language gap between healthcare professionals and African immigrants (Venters et al., 2019). Health care professionals can make use of voice recognition technologies such as Google Assistant and Google Translate. These are technologies that allow for two-way interpretation and can help in transcribing and translating dictations such as a doctor's instructions (Wamwayi & Murray, 2019). Another effective way of overcoming the language barrier is the use of online applications, such as Duolingo, which offer new ways of learning different languages. Health care professionals can use these applications which keep things simple and make learning streamlined and easier, to understand elements of the African immigrants' language and enhance their communication (Wamwayi & Murray, 2019).

Another way of overcoming the language barrier is through the use of an interpreter. The medical facilities can have interpreters specifically for African immigrant groups to enhance communication (Venters et al., 2019). The interpreter can be available physically at the medical facility and if this is not possible, technology has made it easier for the use of an interpreter using virtual platforms such as zoom, Google meet, or Skype (Allison et al., 2016). All these techniques and technologies will help in breaking the language barrier and enhancing effective communication between African immigrants and healthcare professionals. In the long run, the quality of health care services in African immigrants will improve, hence enhancing their overall health care experience and satisfaction.

The Impact of Cultural Competence Training On Health Care Workers

Training programs and cultural competence among health care workers have social, health, and business benefits for healthcare organizations and African immigrants (Omenka et al., 2020). Cultural competence training programs would increase mutual respect and understanding between African immigrants and health care providers (Kamya, 2017). It would also ensure the inclusion of all community members and increased participation and involvement of African immigrants in health issues (Kamya, 2017). Being culturally competent would also enable health care workers to have improved patient data collection for African immigrants and reduce the health care disparities in the African immigrant population (Asare & Sharma, 2012).

Cultural competence training programs for health care workers would help in reducing medical errors, the number of treatments, and legal costs, which increase cost savings (Asare & Sharma, 2012). When healthcare workers undergo cultural competence training programs, they will incorporate diverse ideas, perspectives, and strategies when deciding about African immigrants. Barriers that slow the progress of the healthcare experience of African immigrants would also be decreased and the efficiency of these care services will be improved (Omenka et al., 2020). Cultural competence training would also help health care providers to reduce the literacy gap when handling African immigrants (Omenka et al., 2020).

Most African immigrants come from backgrounds of little or no education which makes it hard for them to gain literacy skills to overcome language barriers or to read and understand instructions and conversations with health care professionals (Omenka et al., 2020). Cultural competence training would provide health care professionals with techniques of dealing with African immigrants with low literacy and explain how to offer them the best care quality. Cultural competence training will also enable health care professionals to coordinate with traditional healers among African immigrants and incorporate culture-specific attitudes and values into health promotion activities for this group (Kamya, 2017).

National Guidelines

Various national guidelines provide standards for culturally and linguistically appropriate services in healthcare. These guidelines aim at making health care services more responsive to the individual needs of patients coming from various cultural backgrounds (U.S. Department of Health and Human Services, 2001). These guidelines include ensuring the provision of health care services in a manner that is compatible with patient cultural health beliefs, practices, and preferred language (U.S. Department of Health and Human Services, 2001). Health organizations are required to establish strategies of recruiting, keeping, and promoting organizational staff and leadership that represent demographic characteristics of the area of service (U.S. Department of Health and Human Services, 2001).

Health care organizations ensure that staff at all levels undergo education and training for culturally and linguistically appropriate delivery of service. Language help services inclusive of bilingual staff and interpreter services at no cost to the patients with limited English proficiency must be offered by health care organizations (U.S. Department of Health and Human Services, 2001). Patients should be informed of the right to receive language help services for their preferred languages. Easy-to-understand materials relating to patients should be made available by healthcare organizations and the development, implementation, and promotion of a written strategic plan outlining clear goals and policies for providing culturally and linguistically appropriate services must be in place (U.S. Department of Health and Human Services, 2001). Internal audits, patient satisfaction assessments, and outcome-based evaluations should be done on integrating culturally and linguistically related measures about the organizations' conduct. Health records should have slots for collecting the patient's race, ethnicity, and language, and this should be integrated into the management information system of the organization management (U.S. Department of Health and Human Services, 2002).

An updated demographic cultural profile of the community should be maintained by the organization and collaborative, participatory partnerships with communities should be developed by the health care organizations regarding the designing and implementation of cultural and linguistic related activities (U.S. Department of Health and Human Services, 2002). Conflict and grievances resolution processes should be culturally and linguistically sensitive, also cross-cultural conflicts and complaints should be resolved appropriately by health care organizations (U.S. Department of Health and Human Services, 2002). Health organizations should make available to the public information about progress and successful innovations in implementing the culturally and linguistically appropriate services standards (U.S. Department of Health and Human Services, 2001).

Aims of the Quality Improvement Project

The quality improvement project is aimed at designing a cultural competence training program that will enable health care professionals to understand African immigrants' expression of health needs. The project is aimed at breaking down barriers that get in the way of African immigrant patients receiving the care they need. It is also aimed at ensuring improved understanding between African immigrant patients and their health care providers. The project is aimed at structuring a cultural competence training program that will accommodate the growing diversity of the United States population demands regarding the African immigrant group and expanding the ability of healthcare professionals to address the needs of this group. Generally, this quality improvement project is aimed at developing a cultural competence training program that will train health care providers on how to incorporate different ideas, perspectives and strategies as they make health decisions about African immigrants which would improve the overall health care experience of this group.

Objectives

The objectives of this project are:

1. To create a cultural competence training program that will help in promoting cross-cultural awareness and competence skills needed for health care professionals to be culturally competent regarding African immigrants.

2. To create an African Immigrant Cultural Competence Toolkit that will be used by care providers to assess and enhance cultural competence in the organization (even after the completion of this project).

3. To create a Resources Toolkit that will be given to African immigrant patients visiting the primary care clinic.

Conceptual Model: Madeleine Leininger's Cultural Care Theory

The theoretical underpinning or conceptual framework for this project will be provided by Madeleine Leininger's Cultural Care Theory. Leininger's theory focuses on the definition of what pertains to transcultural nursing and how nurses comprehend the beliefs and practices of diverse cultural groups (Leininger, 1988). This theory is the most appropriate for this DNP project since it aims at explaining how nurses can provide culturally congruent care through taking actions that are mainly designed to suit the individual's, group's, or institution's cultural values, lifeways, and beliefs (Leininger, 1988). The goal of the Cultural Care Theory is to enable improved health outcomes for individuals of different cultural backgrounds (Leininger, 1988).

Historical Development of the Theory

In the late 1950s, Madeleine Leininger envisioned how the world was increasingly becoming integrated and human beings were interacting on a global scale (Leininger, 1988). Leininger decided that she would go beyond anthropology and emphasize groups of people from diverse parts of the world in expressing her thoughts from a nursing perspective (Leininger, 1988). Leininger had always believed that care is the most essential component of nursing, even before establishing the field of transcultural nursing (Leininger, 1988). Her study of the Gadsup people in Papua New Guinea in the early 1960s was the first transcultural nursing research, and she preceded to establish the initial formal doctoral programs and courses in transcultural nursing in 1965 at the University of the Colorado School of Nursing (Wehbe-Alamah, 2015). The first book to be published regarding Leininger's Cultural Care Theory was 'Nursing and Anthropology: Two Worlds to Blend', which was just published in 1970 (Wehbe-Alamah, 2015). A third and an updated edition of 'Transcultural Nursing: Concepts, Theories, and Research Practices' was authored by Leininger and McFarland in 2002 (Wehbe-Alamah, 2015).

Through her discussions of the theory, Leininger continued to elaborate on the significant features of culture care diversity within the context of transcultural nursing. Leininger established the Transcultural Nursing Society in 1974 aimed at serving nurses worldwide through teaching them how to reinforce the quality of culturally competent care aimed at improving the health and well-being of people worldwide (Wehbe-Alamah, 2015). Over the years, Leininger's theory has been used in training nurses how to provide culturally specific care, which is aimed at improving the health and well-being of people as well as helping them to face unfavorable human conditions, illnesses, or death, in culturally meaningful ways (Wehbe-Alamah, 2015).

The Major Tenets

In developing the major components of the theory, several factors were taken into account by Leininger. These factors were the elements that guided the development of the major tenets of the theory (Leininger, 1988). Leininger explained that wellness and illness are molded by various factors, inclusive of perception and coping skills (Leininger, 1988). Cultural competence is an essential component of nursing and culture affects diverse segments of human life including illness, health, and the search for relief from distress or diseases (Leininger, 1988). Cultural and religious knowledge is a significant aspect of healthcare and the health concepts that cultural groups hold may impact how they seek modern medical care (Leininger, 1988).

Before discussing the major tenets of the theory, it is important to understand the meaning of certain terms related to the theory as defined by Leininger. Care is assisting others in an effort of improving their human conditions of concern or facing death (Wehbe-Alamah, 2015). Caring is an act of providing care (Wehbe-Alamah, 2015). Culture is the learned, shared, and transmitted norms, beliefs, ways of life, and values of a specific group that guides their decision or lifestyle (Wehbe-Alamah, 2015). Cultural care refers to various elements of culture which are responsible for influencing and enabling people to enhance their human conditions or to face illnesses or death (Wehbe-Alamah, 2015). Cultural care diversity describes the differences in meanings, values, or accepted modes of care between or within diverse groups of people, while culture care universality describes the common and similar meanings of care in the cultures (Wehbe-Alamah, 2015).

Theory Application to the DNP Project

Generally, the major tenets of the theory will be used in guiding the research and documentation of how healthcare providers can develop an understanding, appreciation, and respect for the diversity and individuality of African immigrant patients’ values, beliefs, culture, and spirituality, in the context of illnesses, causes of illnesses, treatment, and outcomes (Wehbe-Alamah, 2015). They will be used in the project to research and document how nurses can develop care that fits the values, beliefs, and lifestyles of African immigrants, and which is based on the patients themselves rather than predetermined criteria (Wehbe-Alamah, 2015). The major tenets of the theory will also be used to identify how nurses can bridge the cultural gap to achieve meaningful and supportive care for African immigrant patients and their families (Wehbe-Alamah, 2015). Based on the concepts of the theory, the project will find out how nurses can self-examine their backgrounds, recognize biases and prejudices as well as assumptions about the African immigrant group.

Cultural care preservation or maintenance will be used to identify how the healthcare providers can develop assistive and facilitative professional actions and decisions that can aid the African immigrants to preserve or retain relevant care values that will help them in maintaining their well-being, recovering from illnesses, or facing handicaps or death (Wehbe-Alamah, 2015).

Cultural care accommodation or negotiation will be used in the project to guide the identification and documentation of the assistive, supportive, enabling, or facilitative professional decisions or actions that may help the healthcare providers in training African immigrants to adapt culturally, for improved and satisfactory health outcomes (Leininger, 1988).

Cultural care repositioning or restructuring will be used in the identification and documentation of techniques that the healthcare providers can use to help African immigrants in reordering, changing, or greatly modifying their lifestyles for newer, better, and different health care patterns while respecting the African immigrants’ cultural values and beliefs (Leininger, 1988).

Implementation Model: The Plan-Do-Study-Act Model

Many health care research and reports recommend the Plan-Do-Study-Act model as an implementation model for quality improvement projects (Donnelly & Kirk, 2015). The model is made up of four repeating phrases that are cyclical in nature. These are Plan, Do, Study, and Act (Donnelly & Kirk, 2015). Plan is about the effort and background work of proposing change (Donnelly & Kirk, 2015). Do is about implementing the proposed change (Donnelly & Kirk, 2015). Study is about conducting analysis and evaluation of the outcomes of the proposed change (Donnelly & Kirk, 2015). Act is about revisiting and redesigning the previously planned change to take into account the lessons which have been obtained at the Do and Study phases (Donnelly & Kirk, 2015). The PDSA model is selected because it will be effective in giving rise to changes in a short period and facilitating continuous quality improvement (Donnelly & Kirk, 2015). This model will be used to test the proposed change during the implementation process (Donnelly & Kirk, 2015). It will be used to the test the change through planning, trying, observing results, and taking action on the lessons learnt (Donnelly & Kirk, 2015). The model will be used during the course of the project to assess how the project implementation can be done in a manner that will lead to the desired improvement (Donnelly & Kirk, 2015). The model will also be used to evaluate how much improvement can be expected from the change and how best the proposed change can work in the real environment of interest (Donnelly & Kirk, 2015).

Setting

The setting of this project is a primary care clinic in Texas. It is an ideal place for conducting this project because it is home to a huge number of African immigrants (Chikanda & Morris, 2021). According to American Immigration Council, African immigrants are ever growing and constitute a diverse group in the United States (Chikanda & Morris, 2021). According to the American Immigration Council, Texas is one of the locations with the largest number of African immigrants with other areas being California, New York, Virginia, and Maryland (Chikanda & Morris, 2021). This means that because the project addresses cultural competence concerning African immigrants, it will be beneficial both currently and in the future. The practice location is made up of 10 healthcare providers, including a nurse, family nurse practitioner, office administrator, and medical assistants.

The system used as the solution for electronic health records is EPIC. EPIC provides the primary care clinic with a standard range of primary EHR functions and modules can be added depending on specialty (Milinovich & Kattan, 2018). The primary care clinic uses the EPIC system for appointment management, patient history, scheduling, e-prescription, and clinical workflow. The EPIC system will act as a significant source of data during data collection for the project because it contains all the necessary information about the patients who visit the clinic.

Population of Interest

The population of interest for this project will be in terms of direct and indirect population. The health care providers will form the direct population of interest. These health care providers will be the focus of this cultural competence program for African immigrants and they include nurse, family nurse practitioner, office administrator, and medical assistants. The inclusion criteria will focus on health care providers attending to the health concerns of the African immigrant patients. Anyone else who works at the clinic (either temporarily or permanently) but who is not involved in the provision of care for African immigrant patients will be excluded . This means that all other workers who are not involved in the treatment of African immigrants visiting the clinic for primary care services will be excluded from the project.

The African immigrant population visiting the clinic for primary care services will form the indirect population of interest. The inclusion criteria for this population will be any adults who identify as African immigrants and who visit the clinic for primary care services. The exclusion criteria will be any other patients besides African immigrants visiting the clinic for primary health services. This excludes patients from other ethnicities visiting the clinic for primary care services.

Stakeholders

The significant stakeholders in this project are the clinic owner, the medical director, and the health care providers. The owner of the clinic is a significant stakeholder since she is responsible for overseeing the daily operations of the facility (Kirchner et al., 2012). The owner of the clinic also provides administrative support and oversees the hiring, firing, and training of staff members (Kirchner et al., 2012). The owner of the clinic is also responsible for liaising with patients and health care providers, as well as coordinating plans for patient care (Kirchner et al., 2012). The site administrator is significant because he or she is responsible for ensuring that the running of the activities in the clinic is top notch and as expected. He or she also ensures that quality medical care is provided to the community being served by the clinic (Kirchner et al., 2012). The medical director is significant because they are in charge of the daily operations of the clinic and documentation of the patients seen (Kirchner et al., 2012).

Obtaining permission was vital for the sake of the project and it was granted by the owner of the clinic, the site administrator, and the medical director. Obtaining permission helps in ensuring that the activities of the project at the site will be conducted with adherence to both ethical and legal guidelines and considerations (Milinovich & Kattan, 2018). No affiliation agreements were necessary for this project.

Interventions Comment by Elumalai, Calaiselvy - SRDH: Review begins here Comment by Jessica Grimm: Overall, your plan does not seem to match between sections. I think we need to meet. When the plan does not match throughout, this is a high risk of failure. It seems you may be unclear of what you are doing, or it is not coming through in your writing. Please email Dr. Elumalai so we can meet.

The first intervention is the creation of a cultural competence training program that will be attended to by health care providers. This cultural competence training program will include information regarding how healthcare professionals can be culturally competent when handling African immigrant groups. The cultural competence training program will focus on skills and knowledge that value diversity and which enable health care professionals to comprehend and respond to cultural differences regarding the African immigrant groups. The cultural competence program will also include elements for increasing awareness of health care providers and organization’s cultural norms. The cultural competence training program will include provision of facts about the culture of the African immigrant patients as well as the various possible complex interventions such as intercultural communication skills, exploring potential barriers to care, and establishment of policies that are closely related to the needs of the African immigrant patients. The creation of a cultural competence training program is listed as the first intervention because it will also be carried out as the first intervention and the differences between the time prior to the creation of this cultural competence program and the time after will also be addressed. Comment by Elumalai, Calaiselvy - SRDH: Go chronologically here. Prior to the educational session, you will administer the pretest. Will this be done the same day as the educational session or before that? This should occur in week one of the implementation phase. Then discuss how you will present the educational session. How many educational sessions will you provide to cover all the staff? Then you will administer the post test. Will it immediately follow the educational session or will you administer weeks later?

The second intervention will be the creation, administration, and implementation of an African Immigrant Cultural Competence Toolkit (AICCT). This African Immigrant Cultural Competence Toolkit (AICCT) will include information regarding all the issues concerning the African immigrants visiting the health care facility as well as how to respond and react to them. The African Immigrant Cultural Competence Toolkit (AICCT) will be a summary of all the information regarding how healthcare providers can address the health care concerns of African immigrants in an effective manner while observing the cultural differences between the care providers and the African immigrant patients. African Immigrant Cultural Competence Toolkit (AICCT) will be designed in such a way that it can be used by health care providers both during the project and even after the completion of the project. By using the African Immigrant Cultural Competence Toolkit (AICCT), care providers will be able to assess and enhance cultural competence in the organization concerning African immigrant patients. The African Immigrant Cultural Competence Toolkit (AICCT) will be a significant intervention for this quality improvement project because it is aimed at enhancing continuous change both in the present and the future. The African Immigrant Cultural Competence Toolkit (AICCT) will contain information that will act as a benchmark when being used by health care facility’s care providers as they offer health care services to African immigrants. The comprehensiveness of this African Immigrant Cultural Competence Toolkit (AICCT) is necessary and it will be aimed at eliminating all the identified factors that have been discussed above to be causing ineffectiveness when attending to the health care needs and concerns of the African immigrant patients group. Comment by Elumalai, Calaiselvy - SRDH: Please clarify. When does this occur? Comment by Elumalai, Calaiselvy - SRDH: Plan for interventions discussed are realistic with consideration to the timeline of the project. (The full timeline doesn’t need to be included in the paper but your general plan for intervention should be.)

The other intervention will be the creation, administration, and implementation of a resources toolkit for African immigrant patients. This toolkits will include information regarding resources, the organizations dealing with the resources, physical and online addresses, telephone numbers, and available days of the week. The information will originally be created in English but will also be replicated in various other languages based on their prevalence in the state and around the environment of the health care organization. Examples of these resources will include financial assistance organizations for African immigrants, educational assistance organizations for African immigrants, health care organizations, and religious and cultural organizations for the African immigrants. By use of this African immigrant resources toolkit that will be given to African immigrant patients visiting the primary care clinic, the expected goal is that it will be easier for African immigrants to find help not only in matters related to health care but also in other areas of their lives as well. This is because various issues such as their financial background, educational background, and cultural background may impact their health care experience significantly (Allison et al., 2016). Comment by Elumalai, Calaiselvy - SRDH: What is the timeframe for these interventions? Comment by Jessica Grimm: Agree this needs to be clarified. Try to be more concise in your writing and be clear about when you will use each tool in your intervention timeline. I think you can teach the staff how to use what they need all in the first week, then follow up on what was done in the remaining weeks.

Tools

Described below are the various tools that will be necessary for achieving the objectives and carrying out the interventions of the quality improvement project.

African Immigrant Cultural Competence Toolkit (AICCT)

The first tool will be the African Immigrant Cultural Competence Toolkit (AICCT). This tool will be self developed based on available evidence based literature regarding African immigrants and their healthcare experiences in the United states in general and in California as a state. Although self developed, expert consultation through stakeholders and the project team will be sought for the purposes of validating the tool. Comment by Jessica Grimm: I think this is too much. I would recommend making a quick-guide or a guideline. A one page document that is easy to use. Anything more will be too hard to operationalize for providers.

African Immigrant Resources Toolkit

The other tool will be the African Immigrant Resources Toolkit. This tool will also be designed and developed in a way that supports the objectives and interventions of the QI project. The tool will be self developed and expert consultation through stakeholders and the project team will be sought for validation. The tool will be developed while considering evidence based literature regarding the most significant resources needed by African immigrants as well as the best way of providing them. The tool will be designed in a way that is aimed at improving the health care experience of African immigrants and together with the African Immigrant Cultural Competence Toolkit, it is aimed at achieving the overall objective of the QI project. Comment by Elumalai, Calaiselvy - SRDH: This section is confusing and repetitive, revision is needed Comment by Jessica Grimm: I think this should just be a list of resources for the main needs identified. It should be a short one-page document.

Inventory For Assessing The Process Of Cultural Competence Among Health Care Professionals Revised (IAPCC-R) Comment by Jessica Grimm: This wasn’t part of your plan before. If you want to do this- we can talk about it. Do you think it applies to your project? It looks like you have to pay to use it. Have you sought permission? If you do use it, please include all of this information here and give actual reliability/validity data.

The other tool is the Inventory For Assessing The Process Of Cultural Competence Among Health Care Professionals Revised (IAPCC-R). This tool is created for my measuring the level of cultural competence among healthcare professionals and will be used in the assessment of the level of cultural competence among health care professionals in the health care setting (Allison et al., 2016). The tool is an already established tool and it has been validated by previous studies. While using the established tool, there will be need to seek permission for using the tool from Dr. Josepha Campinha-Bacote.

Educational Presentation

Educational presentation will be another tool used for completing the objectives of the project. This tool has already been validated by numerous evidence based studies conducted previously. No permission is needed for using this tool. Comment by Jessica Grimm: Please discuss that you developed the presentation and that it will be reviewed and approved by the project site and team.

Chart Audit Tool

A Chart Audit Tool is a tool that health care providers will use for checking their individual performance, determining how they are doing, and identifying areas where there is need for improvement (Allison et al., 2016). Expert consultation through stakeholders and the project team will be sought for the validation of the tool. Also, no permission is needed for using the chart audit tool. Comment by Elumalai, Calaiselvy - SRDH: Who does the audit? Comment by Jessica Grimm: Agree. What are you auditing? You can audit if the patient facing handout was given to the patient.

Appendices

(Appendix A)

Permission to complete project at the site

(Appendix B )African Immigrant Cultural Competence Toolkit (AICCT).

(Appendix C)

African Immigrants Resources Toolkit (AIRT).

AFRICAN IMMIGRANT RESOURCES TOOLKIT (AIRT)

(This toolkit contains the various resources available for African immigrants in Texas)

(Appendix D)

Inventory For Assessing The Process Of Cultural Competence Among Health Care (Appendix) Professionals Revised (IAPCC-R)

(Appendix E)

Educational Presentation.

(Appendix F)

Chat Audit Tool.

References

Adekeye, O. A., Adesuyi, B. F., & Takon, J. G. (2018). Barriers to healthcare among African immigrants in Georgia, USA. Journal of immigrant and minority health, 20(1), 188-193.

Allen, K. M., Jackson, I., & Knight, M. G. (2012). Complicating culturally relevant pedagogy: Unpacking African immigrants' cultural identities. International Journal of Multicultural Education, 14(2).

Allison, K. W., Echemendia, R. J., Crawford, I., & Robinson, W. L. (2016). Predicting cultural competence: Implications for practice and training. Professional Psychology: Research and Practice, 27(4), 386.

Asare, M., & Sharma, M. (2012). ROLE OF HEALTH BELIEF MODEL ON SEXUAL COMMUNICATION AMONG AFRICAN IMMIGRANTS. American Journal of Health Studies, 27(2).

Betancourt, J. R., & Green, A. R. (2010). Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Academic Medicine, 85(4), 583- 585.