Several important policy recommendations arise from our review. First, health care
organizations and public health entities should continue to actively engage communities
of color in developing solutions to the problem of health disparities. We found
that some of the most innovative approaches to cultural leverage were borne from
active community involvement. It is in engaging a specific community in the creation
of an intervention that relationships are fostered and health care bridges can materialize.
Cooperation at this early stage of an intervention increases the likelihood of
identifying cultural leverage strategies most likely to be effective, and it ensures the
incorporation of both seen and unseen cultural nuances. Equally important, early
community involvement ensures more than superficial support from the community.
This approach entails actively crafting an ongoing relationship with community
members via both health care interactions and related social and cultural activities.
Second, multidisciplinary interventions incorporating doctors, nurses, and community
health workers should be encouraged. Physician-focused disparity education
has often emphasized cultural competence training and demonstrated modest
improvements in knowledge and attitudes (Beach et al. 2005). While cultural competence
is an important part of the solution to reducing disparities, our review found
that culturally leveraged nursing and community health worker interventions
improved processes of care and outcomes. Third, while the literature is limited, there
are compelling conceptual reasons why culturally leveraged interventions are likely to
add incremental benefit to generic quality improvement interventions such as enhanced patient registries and information systems, audit and feedback of performance measures
to physicians, and the implementation of practice guidelines and flow sheets. For
example, culturally leveraged interventions often are more likely to mobilize community
strengths as well as address some of the root perceptual, attitudinal, and
logistical barriers to chronic care self-management, a particularly challenging area
for generic interventions.
While cultural leverage is a promising concept for reducing health care disparities,
there are several important unanswered questions about cultural leverage that
may influence health care policies. Instead of debating the merit of a generic versus
culturally leveraged intervention, the most important question may be what combination
of interventions and ways of integrating culture into generic quality improvement
are most likely to improve quality of care and outcomes. The distinction
between culturally leveraged interventions and generic interventions is somewhat
artificial, since there is a continuum of interventions incorporating culture. For
example, a lay health worker intervention involving community outreach, tailored
health messaging, and improved access to the health care system may be at one end,
whereas a culturally leveraged telephone nurse case management system of patients
with heart failure that involves a patient registry and tracking clinical performance
measures is more a mixture of culturally specific and generic approaches. A key
question is what types of interventions provide the most value and are most cost
effective. Moreover, the most appropriate solutions probably depend on the specific
circumstances of a health care organization or set of providers. For example, a health
care organization that does not have the ability to identify and track its patients with
diabetes would need to develop that capability first before embarking on a culturally
tailored nurse case management system. Overall, the more widespread use of cultural
leverage interventions is likely to improve racial disparities in health care