Effect of interventions to improve the quality of health services for ethnic minorities
Systematic review
|Updated
Key message
Background
All patients regardless of sex, ethnicity or social status should be provided health services according to their needs. However, both national and international studies suggest that there may be differences in quality of health care on the basis of ethnicity and that this may be due to structural, organizational and clinical barriers.
Mission
On behalf of South-Eastern Norway Regional Health Authority we collected, critically assessed and summarised the effect of interventions to improve the quality of health services for ethnic minorities. We focused on the effect of interventions aimed at health professionals and health organisations.
Main findings
- Different kinds of educational interventions and electronic reminders to health care providers may under certain circumstances have a small effect on health professionals' practice and minority patients' health outcomes. The quality of the evidence varied from very low to low, but findings are supported by other extensive research on this type of initiatives in other contexts.
- The quality of available evidence is insufficient to determine whether the use of remote interpretation compared to traditional interpretation leads to better communication, whether ethnic matching of client and therapist affects the patient's understanding, symptom status or belief in the usefulness of therapeutic strategies and whether supportive interventions in the form of increased staff resources influence health outcomes for minority patients.
Summary
Background
In all western health systems the aim is to provide all patients with health care services according to their needs, regardless of sex, ethnicity, or social status. However, a health service that initially is offered equally to all may be reduced in quality due to language problems, different frames of reference, lack of knowledge and understanding among health professionals about the culture and distinctive diseases of the ethnic group the patient belongs to.
With minorities we understand indigenous people, national minorities, and immigrants. In Norway, the national minorities are Jews, Kven (persons of Finnish stock), Roma, Romani people and Forest Finns, while Sami also has status as indigenous people.
In the SAMINOR survey from 2003−2004 Sami and Kven reported poorer health than ethnic Norwegians. Sami felt discriminated against more often than the Kven and Norwegians. Those who felt most discriminated against, were also those who were most likely to feel they had poorer health, women even more so than men. We have not been able to identify relevant Norwegian studies of Jews or Roma people's health.
For immigrants, Statistics Norway has done several surveys. In these surveys a higher proportion of immigrants rated their health as less good than the sample from the entire population, experienced more health problems that affected everyday life, and reported more psychosomatic and mental health problems.
International studies have shown that there are disparities in the quality of health services for ethnic minorities compared to the majority population. Some Norwegian studies of barriers to health care utilisation indicate that there may be similar differences in the Norwegian health care system, although in Norway so far, mostly, differences in health and use of and satisfaction with health care have been investigated. Knowledge about the effect of interventions aimed at improving the quality of health care for minorities can help provide a better basis for developing, planning and designing health care services.
A survey from 2002−2004 in the Sami administrative district fewer Sami speaking reported satisfaction with the health services than Norwegian-speaking (57 versus 79 per cent). We know of no studies of Forest Finns, Kven, Jews, Roma or Romani people's use of or satisfaction with health care.
Studies of immigrants' use of health services indicate that:
- More immigrants visit their GP and are more often hospitalized than the general population,
- Immigrants from some countries use specialist and emergency services more than the entire population does,
- The intake rate to psychiatric treatment probably is not in accordance with immigrants’ self-reported needs,
- Some immigrants need an interpreter at a doctor visit, but that the minority of them receives this in the form of a professional interpreter service,
- Most are happy with the Norwegian health service and experience that they receive the same treatment as a Norwegian person would have received, but that in some immigrant groups, some are not quite satisfied.
Several potential socio-cultural factors may lead to differences in the quality of health care to minorities compared to the general population. They can be categorized as organizational, structural or clinical barriers. The purpose of this study is to systematically review the effect of interventions that aim to reduce such barriers and to improve the quality of health services to minorities.
Method
We searched for randomised controlled trials in several databases. Two researchers screened independently of each other all titles and summaries to select the references that potentially met inclusion criteria. Potentially relevant publications were ordered in full text and considered for inclusion or exclusion. All results in the included studies were assessed for possible risk of systematic bias by two researchers working independently of each other. The quality of the final documentation for each outcome in each comparison was assessed using GRADE.
Results
In total 19 randomised controlled trials were identified and included. Most of the studies had so many ambiguities in their reporting on how the study was carried out that it was difficult to estimate the extent of the risk of systematic bias. For example, it was unclear in several studies how the units in the study were allocated to intervention or control group.
Within the category clinical barriers to equity in health services, we identified eight studies in which the intervention was either education alone or as part of a complex intervention.
Within the category structural barriers, there were six studies that tested the effect of reminders alone or as part of a complex intervention for healthcare professionals in diabetes treatment and prevention of cancer. Two studies compared remote interpretation services with common practice, i.e. traditional use of interpretation services.
Within the category organizational barriers, there were two studies of the effect of ethnic matching of therapist and client, and two studies on supportive interventions to general practices in the form of additional personnel resources.
Discussion
Because all interventions, targeted health personnel, groups of patients, and outcomes were so different, we had to evaluate each individual comparison. This meant that the evidence for the effect of each comparison then consisted of only one study. However, both education and electronic reminder interventions have been tested in many primary studies in a wide range of settings in health care and summarised in systematic reviews. The conclusions of the summary of the effect of these interventions should be considered in light of this previous evidence.
Conclusion
The quality of the available evidence is insufficient in isolation to determine whether education alone or as part of a complex intervention, compared with no education, affects physicians’ cross-cultural competence, minority patients' health outcomes, or physician behaviour. Other comprehensive evidence support, however, that various forms of education either alone or together with other interventions may affect both health personnel practices and patient outcomes. Electronic reminders to physicians may in certain contexts have a small effect on health professionals’ practice and health outcomes for minority patients. The quality of the available evidence is insufficient to determine whether the use of remote interpretation affects patient satisfaction and leads to better communication, whether ethnic matching of client and therapist affects patients’ understanding, symptom status, or belief in the usefulness of therapeutic strategies, or whether supportive interventions in the form of increased staff resources influence health outcomes for minority patients.
There is need for more research on general quality improving interventions such as those we identified in this review. Moreover, there is need for more research on the potentially ethnic disparities in diagnosing, treating and following-up of patients from minority groups in Norway. If it should prove to be unfounded differences between minorities and the majority population in health care services, studies should be initiated to map the particular barriers, and interventions tailored to these barriers should be designed. Any interventions that are initiated should be rigorously evaluated and further developments should be monitored over time for assessing trends.