Provider Cultural Competence Research Articles

Engagement in Home Visiting Services during the Transition from Pregnancy to Postpartum: A Prospective Mixed Methods Pilot Study

This pilot study used a prospective mixed methods approach to examine predictors of retention in services during the transition from pregnancy to postpartum. Home visiting programs that serve pregnant women are an important means of improving child and maternal well-being. Providing services to women during the transition from pregnancy to postpartum is particularly important, because children under the age of 1 are at high risk for mortality. Morever, mothers face amplified levels of stress during the postpartum period. Unfortunately, home visiting programs in the United States that support pregnant and postpartum women suffer from high rates of attrition. General research on home visiting engagement suggests that the client-provider relationship is an important factor in predicting client engagement in services; however, few studies have examined factors related to maternal engagement during the transition from pregnancy to postpartum. Measures administered during pregnancy for 39 pregnant women were used to predict attrition up to 15 months postpartum. Semi-structured interviews were conducted at 3 months postpartum with 33 of the original 39 women to qualitatively assess factors related to engagement in services during the transition from pregnancy to postpartum. Both quantitative and qualitative analyses indicated that clients’ perceptions of the client-provider relationship was a critical factor in maintaining mothers’ engagement in services. Both types of analyses indicated that perceived provider reliability was related to mothers’ engagement in services. Quantitative analyses also found that perceived provider cultural competence predicted engagement in services. Other findings from qualitative analyses indicated that mothers’ perception of the home visitor as trustworthy/supportive, personable/having good communication skills, knowledgeable, and collaborative/flexible, were factors that mothers noted when discussing engagement in services. These results advance the literature on engagement in home visiting services by overcoming some of the limitations of previous literature and may have implications for home visitor training.

Students’ Perceptions of Provider Cultural Competence and Communication with Providers: Predictors of University Health Center Patient Satisfaction

As student populations become more diverse, understanding university health center (UHC) providers’ cultural competence is important for providing students with quality care. Student satisfaction with UHC provider care is influenced by a number of factors, including interpersonal communication between patients and providers. The emphasis on culture, however, suggests that providers’ cultural competence should also be an important factor. Guided by communication accommodation theory, this study examined the relationships between patients’ willingness to communicate with providers, communication apprehension with providers, and perceptions of providers’ cultural competence and if they predicted patient satisfaction with UHC care. Results suggest that willingness to communicate, communication apprehension, and some elements of perceived provider cultural competence were significantly related. Willingness to communicate, communication apprehension, and patient-centeredness were predictors of patient satisfaction. These findings have implications for how UHCs can focus on culturally competent care while meeting the healthcare needs of students.

840-P: Lower Health-Care Utilization among Diverse Adolescents and Young Adults (AYA) Who Receive Culturally Discordant Care

Background: AYA with T1D encounter many challenges in managing their diabetes, such as uncontrolled glycemic levels, higher probability of complications, and poor clinic attendance. AYA minorities often encounter health care disparities that could be addressed with culturally competent care, which considers the patient’s diverse background and sociocultural factors like communication, language, and beliefs that may influence health behaviors. Objective: To assess patient-reported provider cultural competence and health care utilization among diverse AYA population with T1D. Methods: Patients were recruited during routine diabetes outpatient care visits and asked to complete questionnaires on sociodemographic variables, health care utilization, and clinical experiences and cultural competence as assessed by the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Results: One-hundred forty three AYA (58.7% Male; 45.5% Latinx, 22.4% non-Latinx white) participated, with an average HbA1c of 9.8% in Latinx and 8.6% in non-Latinx whites. Participants who reported some negative experience with provider cultural competence were marginally lower health care utilizers. Specifically, these AYA went to the ER for diabetes-related problems less frequently (p=0.07), had fewer urgent care visits (p=0.08), went to urgent care for hypoglycemia issues less frequently (p=0.08), and attended fewer diabetes care visits (p=0.07). They also went to urgent care for reasons unrelated to diabetes less frequently (p=0.11) and spent fewer days in the hospital when admitted (p=0.13), but these results were not significant. Conclusions: AYA who experience culturally discordant care may utilize health care less frequently. It is unclear if AYA receiving discordant care need less healthcare support, or if their experiences lead to avoidance of needed care. Our results are hypothesis-generating and further investigation is needed. Disclosure J.J. Flores Garcia: None. J. Raymond: Other Relationship; Self; Insulet Corporation. S. Agarwal: None. A. Torres Sanchez: None. M.W. Reid: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust

Exploring Provider Cultural Competence and Patient Mood in an Outpatient Apheresis Unit.

Introduction: Health care and culture are important to patient care. Theoretical frameworks, service delivery, and self-awareness are important to the provider/patient. Provider care varies, and studies are needed to understand the current interactions between providers, patients, and culture. Methodology: This was a prospective, descriptive correlational pilot study. Providers and patients completed a baseline assessment of culture, as well as a Brief Mood Introspection Scale at each visit at the patient's standard of care visit (i.e., visit as part of clinical procedures). Results: The providers and baseline assessment of culture showed higher than average cultural awareness. All four mood subscales show no statistically significant differences in patient or providers' mood. There were no significant differences in mood when considering differences and similarities between gender, race, and ethnicity. Discussion: There was no difference in patient or provider mood in this study when based on the differences or similarities in gender, race, and ethnicity.

The Boston Medical Center Experience: An Achievable Model for the Delivery of Transgender Medical Care at an Academic Medical Center.

Despite increasing appreciation for the medical needs of transgender individuals, the organization of transgender medical care remains suboptimal. Transgender individuals report difficulty in finding providers who have adequate expertise in caring for transgender patients, a lack of provider cultural competence, health system barriers, and discrimination in healthcare settings. At Boston Medical Center (BMC), we sought to address these gaps within an existing academic medical center. In February 2016, BMC established a Center for Transgender Medicine and Surgery (CTMS) to provide a single address for patients to obtain transgender-specific services across a spectrum of healthcare needs. With the establishment of a CTMS at BMC, we were able to leverage broad transgender medical coverage across multiple specialties within an existing academic medical framework. Furthermore, the development of the CTMS resulted in our identification of multiple gaps in transgender healthcare which we could target. Large gaps in care for our institution included genital surgery, perisurgical support, adolescent care, and care coordination. Notably, most of our interventions used existing resources. We propose that this is a replicable model that should be adopted by other academic medical institutions.

Student Perceptions of Providers’ Cultural Competence, Attitudes Towards Providers, and Patient Satisfaction at a University Health Center: International and U.S. Student Differences

The present study surveyed international and domestic U.S. students about their perceptions of university health care providers’ cultural competence, their own attitudes toward university health center providers, and overall satisfaction with university health center providers. Results demonstrated generally positive attitudes and satisfaction, but more negative perceptions of provider cultural competence were identified especially when students perceived problems with providers’ language competence and interest in learning about patients’ backgrounds. International students reported more positive attitudes concerning providers’ cultural competence than U.S. students. Implications of the findings are discussed, along with limitations of the study and suggestions for future research.

Mental health provider cultural competence in the provision of services to Arabs

ABSTRACTFactors contributing to racial/ethnic disparities (among Arabs) in mental health services include a lack of provider cultural competence. A cultural competence measure toward Arabs was developed and administered to providers in Northern Virginia, in order to assess psychometric properties. Factor analyses revealed a unidimensional construct of cultural competence toward Arabs. Additionally, higher levels of cultural competence were significantly related to higher readiness for change, and, specific to Arabs, more previous knowledge and familiarity, and utilization of books for knowledge. A model inclusive of these factors explained 19% of the variance in mean scores. Implications for research, practice, and training are discussed.

Associations Among Depressive Symptoms, Wellness, Patient Involvement, Provider Cultural Competency, and Treatment Nonadherence: A Pilot Study Among Community Patients Seen at a University Medical Center.

Treatment nonadherence is a pernicious problem associated with increasing rates of chronic diseases, escalating healthcare costs, and rising mortality in some patients. Although researchers have suggested numerous factors related to treatment nonadherence, several understudied aspects warrant attention, such as primary-care settings, provider cultural competence, and patient involvement. Adding to the research base, the present pilot study examined 88 primarily Black American and White American community patients from a large university medical center in the southern part of the United States. The study explored two research questions: (a) To what extent are there associations among depressive symptoms, wellness, patient involvement, cultural competency, and treatment nonadherence in a racially diverse community patient population? And (b) to what extent do the study exploratory variables and background characteristics predict treatment nonadherence, both separately and jointly? Depressive symptoms, the patient's perception of a provider's cultural competence, and marital/partnered status were found to be statistically significantly associated with treatment nonadherence, but not entirely in the directions expected.

Community-based participatory research: an innovative approach for improving perioperative care of underserved children.

Pediatric disparities disproportionately affect Latino youth undergoing surgery and their families. As such, there is a critical need for culturally relevant frameworks that can advance perioperative intervention approaches in this population and reduce these disparities. In the following article, we first describe the methodological process of community-based participatory research (CBPR) and next report the results of the CBPR process that was conducted in this population. An interdisciplinary group of investigators, Latina mothers, and various other stakeholders met for a series of CBPR-based structured meetings. Qualitative data collection and analyses of the CBPR process were guided by principles of grounded theory that employs inductive techniques and constant comparison analyses until reaching saturation of data. Barriers identified in the process can be grouped within the following domains: child-related factors, family-related factors, health care provider factors, and hospital system factors. Family system factors category (coded references=136) had the highest number of coded references; this category was found to be best described by the value of familismo or familism, including a duty to help family members when in need. The health care provider category (coded references=42) was ranked second by frequency. Within this category, two major themes surfaced: health care provider cultural competence and overestimating health literacy. All barriers identified will be next incorporated in an innovative behavioral intervention that is currently being developed. We conclude that the model of CBPR can be used within the context of perioperative care of children and their families.

Influence of stigma and homophobia on mental health and on the uptake of HIV/sexually transmissible infection services for Cameroonian men who have sex with men.

Background Men who have sex with men (MSM) in Cameroon consistently face significant stigma and discrimination. The urban HIV prevalence in MSM is estimated at 35%. This study investigates the effect of stigma, discrimination and alienation on Cameroonian MSM's engagement of the HIV treatment cascade. Qualitative interviews were semi-structured using a guide. Participants in Douala, Ngaoundere, Bamenda, Bertoua and Yaoundé were asked to describe the MSM social and structural context, MSM knowledge of existing HIV-related services in public and MSM-focussed non-governmental organisation (NGO) clinics. Using a codebook, coded text was extracted from 40 transcripts with Microsoft Word Macros. These texts were analysed for recurring themes that were developed into results. There were three main themes that emerged. First, among those MSM participants seeking HIV services, many commonly reported experiences of discrimination and physical violence outside the healthcare setting. Second, a few respondents used services provided by the Ministry of Health and local NGOs. However, most participants observed limited clinical and cultural competency of public clinic staff. Third, MSM declared that lack of social support and healthcare access caused them much stress. Several individuals recounted their alienation greatly discouraged them from seeking HIV prevention, treatment and care services. Community-level and public healthcare-related stigma impacts the mental wellbeing of Cameroonian MSM. Alienation among MSM also represents a common obstacle to the uptake of MSM-oriented HIV/AIDS services. Improving provider cultural and clinical competency among Cameroonian health care workers combined with a broader stigma-reduction intervention for Cameroonian healthcare may increase the uptake of HIV prevention, treatment and care among MSM.

Development and psychometric assessment of the healthcare provider cultural competence instrument.

This study presents the measurement properties of 5 scales used in the Healthcare Provider Cultural Competence Instrument (HPCCI). The HPCCI measures a health care provider’s cultural competence along 5 primary dimensions: (1) awareness/sensitivity, (2) behaviors, (3) patient-centered communication, (4) practice orientation, and (5) self-assessment. Exploratory factor analysis demonstrated that the 5 scales were distinct, and within each scale items loaded as expected. Reliability statistics indicated a high level of internal consistency within each scale. The results indicate that the HPCCI effectively measures the cultural competence of health care providers and can provide useful professional feedback for practitioners and organizations seeking to increase a practitioner’s cultural competence.

Disparities in Access to Health Care Among Middle-Aged and Older Adults with Disabilities

Disability is increasing among middle-aged adults and, reversing earlier trends, increasing among older adults as well. Disability is experienced disproportionately by Black and lower socioeconomic status (SES) individuals. We used Medical Expenditure Panel Survey data to examine health care disparities in access to health care for middle-aged (31 to 64 years of age) and older (65+ years of age) adults with disabilities by race and ethnicity, education, and income (n = 13,174). Using logistic regression, we examined three measures of potential (e.g., usual source of care), and three measures of realized (e.g., counseling related to smoking) access. Middle-aged and older minority individuals with disabilities had lower relative risks of having usual sources of care and higher relative risks of having suboptimal usual sources of care (e.g., a place rather than a person) than White adults with disabilities. There were SES effects observed for middle-aged adults with disabilities across most measures that were, for certain measures, more pronounced than SES effects among older adults with disabilities. These findings are important, since health resources (e.g., a usual source of care) may mediate relations among disability, morbidity, and mortality. Policy actions that may mitigate the disparities we observed include financial incentives to support access to an optimal usual source of care and mechanisms to foster behavioral interventions related to smoking and exercise. Ensuring that these actions address the specific concerns of individuals with disabilities, such as physical accessibility and provider cultural competency, is essential.

A Snapshot of Patients’ Perceptions of Oncology Providers’ Cultural Competence

In this paper, we describe an anonymous cross-sectional survey with a sample of 100 racially diverse adult oncology patients using a newly developed patient-reported measure of providers' cultural competence, the Physicians' Cultural Competence for Patient Satisfaction Scale (PCCPS) [1, 2], which was developed using a US midwestern sample of primary care patients. Our primary aims were to examine the reliability of the PCCPS in a more racially diverse urban oncology clinical setting and to identify salient domains of oncology provider cultural competence based on patient-reported satisfaction with direct clinical encounters. Results suggest that patient-reported satisfaction was significantly associated with one of the four domains measured by the PCCPS, physician's patient-centered cultural competence (r = 0.40, p = 0.01), and female patients were more satisfied (t (91) = 5.23, p = 0.02). The PCCPS demonstrated good reliability in an urban diverse cancer patient population. Results help to inform the development of clinical tools that can improve oncology providers' cultural competency.

Associations among depressive symptoms, well-being, patient involvement, provider cultural competency, and treatment nonadherence: An exploratory study among university student-patients

Many students on US university campuses are underserved and undertreated for common mental health and medical conditions. The limited extent to which university students seek psychological and medical care when they need it has long been a problem. Among those who do seek care, treatment adherence appears to be an issue as well. However, few studies have examined factors that may be related to treatment nonadherence in university student-patients. The present survey study examined often-understudied constructs (i.e. patient involvement, treatment nonadherence, and provider cultural competency) in 243 university student-patients. Specifically, using a correlational research design, we examined the relations among depressive symptoms, well-being, patient involvement, cultural competency, and treatment nonadherence. Using multiple linear regression analysis, we also explored the extent to which the exploratory variables predicted treatment nonadherence separately and jointly. The current study revealed two important findings. First, all four factors – depressive symptoms, well-being, patient involvement, and cultural competency – were related to nonadherence to treatment. Second, depressive symptoms and patient involvement explained unique variance in nonadherence to treatment. The findings suggest that increased awareness of and attention to depressive symptoms and patient involvement may have important relevance for engendering healthy campuses and for reducing nonadherence in student-patients. Implications and directions for future research are proffered.

Linking Cultural Competence to Functional Life Outcomes in Mental Health Care Settings

Minorities in the United States have well-documented health disparities. Cultural barriers and biases by health care providers may contribute to lower quality of services which may contribute to these disparities. However, evidence linking cultural competency and health outcomes is lacking. This study, part of an ongoing quality improvement effort, tested the mediation hypothesis that patients’ perception of provider cultural competency indirectly influences patients’ health outcomes through process of care. Data were from patient satisfaction surveys collected in seven mental health clinics (n=94 minority patients). Consistent with our hypothesis, patients’ perception of clinicians’ cultural competency was indirectly associated with patients’ self-reported improvements in social interactions, improvements in performance at work or school, and improvements in managing life problems through the patients’ experience of respect, trust, and communication with the clinician. These findings indicate that process of care characteristics during the clinical encounter influence patients’ perceptions of clinicians’ cultural competency and affect functional outcomes.

The Appeal and Problems of a Cultural Competence Approach to Reducing Racial Disparities

E liminating racial disparities in health care is a high priority goal for health care organizations. Disparities have been observed across a wide range of treatments and health conditions, from treatment of pain due to bone fracture to the treatment of HIV/AIDS. Inequalities between whites and blacks have been documented most frequently, but other non-white groups are disadvantaged as well. Research suggests that access to treatment and provider recommendations tend to account for the inequality. Seeking to eliminate racial disparities, many researchers and administrators have turned to cultural competence programs. Cultural competence in health care began with efforts to improve immigrant patients’ utilization and adherence by educating providers about immigrants’ cultures and how to effectively use interpreters. Subsequently, cultural competence programs were deployed to improve care for native-born minority patients as well. The approach is now widespread: the Affordable Care Act mentions cultural competence; several states require cultural competence training for medical students; and it is common in continuing medical education. The ubiquity of cultural competence programs suggests a widespread commitment to reducing racial inequality. In this issue of JGIM, Saha and colleagues contribute to this effort by presenting an empirical assessment of the effect of self-reported cultural competence on patient outcomes. In cultural competence terms, Saha et al. present important findings based on high quality clinical and survey data and methods. In this editorial, I will describe both their contribution, as well as my view that the foundation for cultural competence’s popularity is also the source of its fundamental problems. Saha and his colleagues seek to remedy a significant problem in the cultural competence field. As they note, there have been few empirical studies demonstrating that cultural competence improves the quality of interpersonal or technical care provided to minority race patients. Saha et al. tackle this problem by evaluating whether health care providers who rate their cultural competence higher have patients with better HIV management and whether there is a stronger positive effect among minority race patients. In order to assess providers’ cultural competence, Saha and colleagues had to first define the construct. Starting from the notion that cultural misunderstanding is a primary source of racial disparities, cultural competence programs began with efforts to reduce racial disparities by teaching about the “cultures” of non-white racial and ethnic groups. Quickly, criticism arose that this approach reinforces stereotypes about racial and ethnic minorities, suggests that racial groups have homogenous cultures, and fails to recognize how white racism and other systems of inequality affect care. Subsequently, most academic publications advised that to be cultural competent, providers should inquire about—and respect—patients’ individual health beliefs and attitudes rather focus on “cultural traits” of racial groups. Saha et al. review the literature and develop a survey instrument based on the current conception of cultural competence. Their instrument primarily assesses providers’ openness to patients’ experiences and perspectives, with some attention to knowledge of inequality. With this measure, they find that for minority race patients, there is a positive effect of provider cultural competence. These findings suggest that better cultural competence among providers will reduce disparities. Yet, we must proceed cautiously before making that conclusion. While Saha and colleagues’ findings contribute to the cultural competence literature, it is unclear that their research will be used to reduce racial disparities in health care. To understand the potential obstacles to reaching that goal, we must examine the cultural competence field in terms of contemporary racial ideology. Doing so reveals what may be an intractable conflict between the appeal of cultural competence and its real potential to reduce racial disparities. Before describing my perception of the conflict, we must define racial ideology. Generally, ideology is the broad set of beliefs that people in a society use to organize their thinking about the social world. Racial ideology helps people make sense of racial categories and inequality by Published online February 13, 2013

African-Americans' perceptions of health care provider cultural competence that promote HIV medical self-care and antiretroviral medication adherence

Most studies of cultural competence in healthcare examine healthcare providers' definitions of cultural competence practices. This study is unique in that it examines the relationship between African-American patients' perceptions of the cultural competence of their HIV healthcare providers and the adherence of these patients to medical self-care and antiretroviral therapy (ART). This cross-sectional, exploratory, descriptive study was conducted at the Ruth Rothstein CORE Center in Chicago, Illinois. The sample consisted of 202 HIV-positive African-Americans who completed surveys during clinic visits. Multiple measures were used, including the Patient Assessments of Cultural Competency survey instrument developed by the Department of Health and Human Services Agency for Healthcare Research and Quality. Medical self-care was measured using the advice and instructions scale and the self-care symptom management for people living with HIV/AIDS categorical scale. ART adherence was measured using the Adherence Behaviors Self-Report and Adherence Self-Report scales. The data revealed many significant correlations between variables. The more patients believed that providers should integrate culture in HIV treatment; the better their reported health (F1,138=0.151, P=0.05) and the more they followed their provider's advice and instructions (medical self-care; F1,138=0.029, P=0.05). Participants who trusted their providers engaged in more medical self-care (F1,138=0.280, P=0.01). More shared treatment decisions were reported among participants who had higher levels of education (F1,127=0.337, P=0.05). Findings of this study indicate the need for increased attention to the role of cultural competence in HIV/AIDS care. Understanding patient perceptions of provider cultural competence has the potential to improve HIV treatment adherence and health outcomes.

Primary care provider cultural competence and racial disparities in HIV care and outcomes.

Health professional organizations have advocated for increasing the "cultural competence" (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care. To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS. Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S. Providers' self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients' receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression. Providers' mean age was 44 years; 56 % were women, and 64 % were white. Patients' mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50-25.7), self-efficacy (3.77, 1.24-11.4), and viral suppression (13.0, 3.43-49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32-1.61; self-efficacy: 1.14, 0.59-2.22; viral suppression: 1.20, 0.60-2.42). Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.

Abstract P16: Cultural Competency to Reduce Stroke Disparities - A Patient Perspective

Background: Increased physician cultural competence has been recommended to reduce racial disparities in stroke and cardiovascular (CV) disease. Culturally appropriate care may be especially important to enhance primary stroke risk reduction for blacks and other high-risk populations. To better understand the extent of culturally competent care, this study explored patient perceptions of their primary care physician (PCP). Methods: A survey derived from the Patient-Reported Provider Cultural Competency (PRPCC) scale assessed history-taking and explanatory behaviors of PCPs, patient satisfaction and trust. The survey was mailed to adults in 25 counties in the stroke belt region (6% margin of error), with a small incentive offered for participation. Results: Responses from 1181 patients were analyzed. Respondents were mostly white (54%) or black (42%) and had a mean age of 56 years. Respondents' PCP was most often a family physician (66%) and either white (72%) or black (19%). Patient-reported omissions in PCP history-taking were common and occurred more frequently than explanatory behaviors. The biggest omissions involved PCP failure to assess (61%) and invite (52%) family participation in health care decision-making. The most common explanatory omission involved never directing patients to community resources (40%). More than 85% of patients felt satisfaction and trust toward their PCP. White patients reported more frequent assessment of traditional healing remedies than black patients. Otherwise there were no differences by patient ethnic group. Trust and satisfaction was similarly high towards black and white physicians, but both history-taking and explanatory behaviors were reported at higher frequencies for black physicians. Conclusions: Many PCPs in the South inadequately assess cultural health determinants and underutilize optimal communication methods. These gaps may have adverse consequences when white physicians care for black patients with CV risk factors, but may not be apparent to either party. Interventions that enhance cultural sensitivity and promote physician skill in effective communication and cross-cultural brokering may strengthen treatment alliances to reduce CV risk and reduce disparities in stroke.

Provider cultural competency, client satisfaction, and engagement in home-based programs to treat child abuse and neglect.

Home-based programs to treat child abuse and neglect suffer from high rates of attrition, limiting their impact. Thus, research is needed to identify factors related to client engagement. Using data (N = 1,305) from a statewide family preservation program, this study investigated the role of program type (i.e., SafeCare(®) [SC] vs. Services as Usual [SAU]) and client perceived provider cultural competence on client satisfaction and engagement with services. Families in SC completed more treatment goals than those in SAU. In addition, provider cultural competence and client satisfaction were higher in SC than in SAU. Higher provider cultural competence was associated with higher goal attainment and satisfaction, and these effects partially mediated the service program differences. The effects of service type and cultural competence on goal attainment and satisfaction varied somewhat by client ethnicity. Findings suggest that clients receiving manualized programs for child maltreatment may be more likely to meet their goals and may perceive such programs to be culturally appropriate and satisfactory.