Framework for culturally competent research
Cultural competence in the healthcare context is an “ongoing capacity of healthcare systems, organizations, and professionals to provide for diverse patient populations high-quality care that is safe, patient and family centred, evidence-based, and equitable” (Reference 1). Healthcare providers are required “to work effectively in cross-cultural situations” (Reference 2). An awareness of the need for cultural competence in healthcare is demonstrated by a growing body of related literature (Reference 3). In an era of evidence-based practice, it therefore translates that trials informing practice should also adopt culturally competent methods.
Cultural competence in the context of research is trial design and conduct that recognises the cultural diversity of its target population (Reference 4). Gibbs et al. report a framework comprising nine criteria that collectively constitute culturally competent research. The nine criteria span the processes of engaging with the target population to inform study design through to recruitment, analysis and dissemination all being in partnership with the target population (References 3 and 5). The rationale for this approach is to maximise relevance, acceptability, feasibility and utility of the research to the target population plus garner support for future implementation of the research into practice.
The nine criteria are ranked on the ‘cultural competence continuum’ which describes varying magnitudes of cultural competence (Reference 2). Cultural blindness describes methodological approaches underpinned by the belief that neither colour nor culture influence behaviour and that all people are the same. Cultural pre-competence describes approaches recognising that the dominant race or culture of a country is not universally applicable but fails to fully attend to cultural differences. For example, a research study may recruit professional members of the research team to represent the target ethnic minorities. However, professionals may have little familiarity with cross-cultural attitudes and beliefs due to their training being in the frame of reference of the dominant society. A non-professional from the target population offers better representation of beliefs and attitudes and could be described as a culturally competent method (Reference 2).
Methods
Definitions for each of the nine Gibbs et al. criteria for culturally competent research were adapted by the research team to reflect the language of healthcare trials. For example, the original language was dominated by qualitative research methodology which we broadened to encompass quantitative methodological approaches. There was originally a criterion that combined analysis with evaluation; this has been split into two separate criteria to recognise how datasets from a large number of participants in a quantitative study require handling. The resulting framework comprising ten criteria has been successfully applied to evaluate the cultural competence of medication adherence trials with people with HIV (Reference 6).
Forming partnerships
Did the researchers work through gatekeepers to establish relationships with the target population*?
This criterion requires researchers to identify gatekeepers who will facilitate them in reaching the full breadth of their target population. Researchers must then work with their gatekeepers to develop trust with and achieve two-way communication with their target population.
*Your target population is those for whom the intervention is intended to benefit in terms of health and/or wellbeing.
Defining research questions
Was the intervention identified and initiated in consultation with the target population?
To identify potential research questions, researchers must consult with patients and carers. Engaging in discussions with these groups will enable researchers to define their research questions.
Identifying the target population and data sources
Did the research team frame data collection to facilitate the target population?
The research team must frame their data collection so that it is applicable to their target population. For instance, if the target population is a charity which focusses on one group, leaflets can be used to recruit participants / collect data. If the target population is a wider community setting then advertising through radio, churches etc.
Appointing staff
Does the research team include representation of the target population?
The research team itself should include representation from people for whom the intervention is of benefit and/or carers or relatives who have a relationship with those in the target population.
Recruitment sample
Was the consent process tailored for the target population including awareness of within cultural variations?
The process should recognise the needs and preferences of the target population. For example:
- Making recruitment materials available in the native languages of the target population.
- Permitting audio recorded verbal consent processes for populations where a significant proportion may have a lower level of literacy or may be suspicious of signing written documentation.
Data collection
Was the data collection process tailored for the target population?
The process should recognise the needs and preferences of the target population. For example:
- Having an interpreter.
- Providing the option of family group interview instead of an individual interview to account for cultural differences in social dynamics.
- Reflection on whether choice of interviewer responsible for data collection is appropriate for the target population e.g. recognises cultural differences in gender dynamics.
Development of intervention
Were the target population involved in the development/customisation of the intervention?
The intervention should be designed in collaboration with members of the target population and their carers and relatives. Representatives of the target population can use their lived experience to help researchers develop and customise elements of the intervention so that they are suitable and accessible for other members of the target population.
Analysis
Were research team members representing the target population involved in the analysis and interpretation of data?
Interpreting qualitative and/or quantitative findings.
Evaluation
Was there feedback from participants to confirm interpretation of the results?
After data interpretation is complete, feedback should be sought, from participants, to confirm that the results have been correctly interpreted by the research team. The medium of choice should be dictated by the target population and may include a combination of media such as an online survey or group meeting.
Reporting/disseminating findings
Did dissemination allow the target population to discuss trial findings and generate solutions?
Dissemination of trial findings should facilitate discussion with patients and carers and encourage them to help generate solutions. For instance, post trial event held in community centres, churches or charities or organisations relevant to the patient population.
Funding
The study was funded by University of East Anglia Seedcorn 2017.
Meet the study team
Professor Debi Bhattacharya
Professor of Behavioural Medicine
d.bhattacharya@le.ac.uk
Professor Andrew Renzaho
Professor of Humanitarian Development Studies
Andre.Renzaho@westernsydney.edu.au
Bethany Atkins
Senior Research Associate
ba226@le.ac.uk
References
- Weech-Maldonado R, Elliott MN, Pradhan R, Schiller C, Dreachslin J, Hays RD. Moving towards culturally competent health systems: organizational and market factors. Soc Sci Med. 2012;75(5):815-22.
- Cross TL. Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. 1989.
- Gibbs L, Waters E, Renzaho A, Kulkens M. Moving towards increased cultural competency in public health research. 2008.
- Betancourt JR, Green AR, Carrillo JE, Owusu Ananeh-Firempong I. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public health reports. 2016.
- Riggs E, Gussy M, Gibbs L, van Gemert C, Waters E, Priest N, et al. Assessing the cultural competence of oral health research conducted with migrant children. Community Dent Oral Epidemiol. 2014;42(1):43-52.
- Wali N, Renzaho A, Wang X, Atkins B, Bhattacharya D. Do interventions to improve adherence to antiretroviral therapy recognise diversity? A systematic review. AIDS Care. 2021;33(11):1379-93.