SERVIZI SANITARI CULTURALMENTE COMPETENTI, EQUI E SENSIBILI ALLE DIFFERENZE. UNO STUDIO MULTILIVELLO NEL CONTESTO ITALIANO

This doctoral thesis proposes an in-depth investigation into the implementation of culturally competent and difference sensitive practices in healthcare service. Evidence of inequities in migrants’ health has demanded for the reorientation of health policies to provide diversity responsive and equitable health services. Cultural competence (CC) and difference sensitivity are defined as strategies to promote equity for “diverse” populations and require interventions at individual, organizational and system levels. Some studies have shown that culturally competent practices among organizations are adopted to varying degrees, but organizations tend to lag in integrating CC into management practices, such as leadership and strategic planning, and in promoting community representation and participation. The research project is informed by a theoretical approach which emphasises connections between macro, meso and micro levels of organisation. It consists of two interrelated qualitative studies conducted in three Italian Regions, each one aiming to achieve specific objectives. The first study focuses on the macro level. It aims to explore how health policies address equity and inequities in migrants’ utilization of health services, and to compare different perspectives on policy-making and implementation at the local level, considering facilitators and barriers. In doing so, we conducted: a) a policy document analysis of the three current regional health plans, b) interviews to 19 key stakeholders (in health systems and civil associations). Results highlight trends and dissimilarities in the conceptualization of diversity sensitive and CC in the examined documents. All acknowledge the importance of reducing health inequalities, but relevant differences are found in the focus paid to organizational commitment practices and the participatory ones. Results emphasize the importance of regional coordination practices for diffusing CC. Also they show areas of improvement in reducing the implementation gap faced by organizations confronted with highly differentiated populations. The second study focuses on the meso-micro level. It aims to explore perspectives on cultural competence, considering how it is integrated in managerial practices and in service provision (everyday ‘frontline’ practice and experience). We conducted a qualitative study based on the case study methodology. Data were collected in 3 health organizations of the three Regions. In each organization, individual and group interviews were conducted with managers or staff who had the lead responsibility for cultural intervention; middle managers and frontline professionals (n = 30). We also performed a document analysis on a sample of relevant organizational documents. Findings show different concepts of organizational strategies of cultural competence to promote equity for migrants’ health, and the role of contextual factors in affecting the organizational implementation. Data show practices to promote access and quality of care. However, further work is needed to embed cultural competence principles and practices at all levels of the organisation and promote participatory practices involving migrants and stakeholders. The study provides a clearer insight into the conditions that foster equitable health services and contributes to understanding barriers and facilitators in supporting diversity responsiveness and health equity for migrants, using a multilevel framework.