Background
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Examine the definitions of culture, cultural difference and cultural competence adopted by the included studies;
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Examine the intervention strategies utilised by studies;
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Report on the measurement approaches taken to evaluate interventions;
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Examine the reported outcomes of included studies.
Methods
Results
Definitions of culture, cultural difference and cultural competence
Intervention strategies
Publication | Aim | Intervention Strategies | Outcomes | |||||||||||||||||
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Cultural Competency training | Professional Development | Delivery mode | Practitioner cultural competency outcomes | Healthcare/health outcomes | Other outcomes | |||||||||||||||
First Author year | Increased cultural competency | General | Specific | Minimal detail | Other training | Mentoring/Supervision | Multiple sites | Single sites | Knowledge | Attitudes/Beliefs | Skills | Behaviour | Confidence | Patient satisfaction | Patient trust | Practitioner satisfaction | Health outcomes | Research productivity | Training completion rates | Improved readiness to provide cc care |
Aboriginal Workforce (2015) [50] | ✓ | x | ✓ | ✓ | x | x | ✓ | x | x | x | x | x | x | x | x | x | x | x | ✓ | x |
Abbott (2014) [39] | ~ | x | x | x | x | ✓ | ~ | x | ~ | x | ✓ | ✓ | ✓ | x | x | x | x | x | x | x |
Brathwaite (2006) | ✓ | ✓ | x | x | x | x | x | ✓ | ✓ | x | ~ | x | x | x | x | ✓ | x | x | x | x |
Chapman (2014) [38] | ✓ | x | ✓ | ✓ | x | x | x | ✓ | ✓ | ✓ | x | x | x | x | x | x | x | x | x | x |
Dingwall (2015) [42] | ~ | x | x | x | ✓ | x | ✓ | x | ✓ | x | ✓ | x | ✓ | x | x | x | x | x | x | x |
Hinton (2012) [41] | ~ | x | x | x | ✓ | x | x | ✓ | ✓ | x | ~ | x | ✓ | x | x | ✓ | x | x | x | x |
Khanna (2009) [46] | ✓ | ✓ | x | x | x | x | ✓ | x | ✓ | x | ✓ | x | x | x | x | x | x | x | x | x |
Kutob (2009) [47] | ✓ | ✓ | ~ | x | x | x | ✓ | x | ✓ | x | ✓ | x | x | x | x | x | x | x | x | x |
Liaw (2015) [52] | ✓ | x | ~ | ~ | ✓ | ✓ | ✓ | x | ~ | ✓ | ✓ | ✓ | x | x | x | ✓ | x | x | x | ✓ |
Lopez-viets (2009) | ~ | x | x | x | x | ✓ | x | ✓ | x | x | x | ✓ | x | x | x | x | x | ✓ | x | x |
McElmurry (2009) [45] | ✓ | x | ✓ | ~ | ✓ | x | ✓ | x | ✓ | ✓ | ✓ | ~ | x | x | x | ~ | ✓ | x | x | x |
McGuire (2012) [44] | ✓ | x | ✓ | x | x | x | ✓ | x | ✓ | x | x | x | x | x | x | x | x | x | x | x |
McRae (2008) [51] | ✓ | x | ✓ | ✓ | ✓ | x | ✓ | x | ✓ | ✓ | ✓ | x | ✓ | x | x | ✓ | x | x | x | x |
Salman (2007) [48] | ✓ | ✓ | x | ✓ | ✓ | x | ✓ | x | ~ | ✓ | x | x | ✓ | x | x | ~ | x | x | x | x |
Thom (2006) [49] | ✓ | ✓ | x | x | x | x | ✓ | x | x | x | ~ | ✓ | x | ✓ | ✓ | ~ | ✓ | x | x | x |
Wu (2006) [43] | ✓ | x | ✓ | ~ | x | ~ | x | ✓ | x | x | x | x | x | ✓ | x | ~ | x | x | x | x |
Cultural competence training
Publication | Training approach |
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Cross-cultural approaches | |
Brathwaite (2006) [40] | The cultural competency training components of cultural awareness; cultural knowledge; cultural skill; cultural encounter and; cultural desire were addressed by teaching basic process of providing culturally competent care such as a) acknowledging intracultural diversity and the breadth and complexity of culture as something possessed by all; b) conducting cultural assessments of service users; c) learning from patients about their culture d) recognizing the processes of acculturation and cultural diversity within individuals; e) developing agreed upon treatment plans; and f) accommodating non-harmful health beliefs and practices which may differ from practitioners personal and professional culture. |
Khanna (2009) [46] | The training program covered broad cultural competency topics such: as defining cultural and linguistic competency; understanding racial and ethnic health disparities; exploring the relationship between culture and health beliefs; and the importance of cultural competency in effective patient/provider communication. Following training, participants were expected to be able to: define culture and describe the spectrum of diversity; understand the differences between ethnicity, race and culture; recognize and define the concepts of intercultural and intracultural diversity; understand the difference between cultural generalizations and stereotypes; define and understand cultural competency; explain the concept of the cultural competency continuum, and; describe the use of explanatory models and their importance in the patient-practitioner interaction. |
Kutob (2009) [47] | Learning objectives included things such as: distinguishing between the terms culture, ethnicity and race; utilizing the Ask, Share, Compare, Negotiate (ASCN) model with patients; describing evidence based information on health disparities as well as health beliefs and behaviours of Mexican American patients; managing potential barriers to blood sugar control for people with type 2 diabetes, and; the appropriate ordering of routine prevention services for diabetes patients. Participants were assessed for things such as their cultural self-awareness, their ability to be open and nonjudgmental, their avoidance of stereotyping, and ability to elicit patients’ explanatory model among others. |
Salman (2007) [48] | Cultural workshop focused on understanding the components of cultural competence and its relevance to healthcare delivery. |
Thom (2006) [49] | The competencies addressed were knowledge (such as knowledge of cultural identification and levels of agreement with respect to mainstream health beliefs), “communication skills (including listening, explaining, acknowledging, providing recommendations, and working effectively with interpreters); and cultural brokering (including negotiating a treatment plan with patient and family, understanding community resources available to patients, and working with then healthcare system to meet the needs of culturally diverse patients)”. |
Categorical/Multicultural approaches | |
Aboriginal Workforce (2015) [50] | Included an eLearning component providing knowledge on Aboriginal history, culture and people, and exploring key challenges to providing culturally appropriate care to Aboriginal people and communities and a face-to-face workshop component including both generic content (aimed at bridging what is learnt in the eLearning component) and local content (exploring the local communities being served). |
Chapman (2014) [38] | Aimed to provide health practitioners with a comprehensive understanding of aspects of Aboriginal culture and ideology. |
McElmurry (2009) [45] | Cultural workshops addressed Latino patients’ expectations of care and experiences with health services, the impacts of cultural beliefs and language barriers on issues in diagnosis, treatment, and popular herbal remedies frequently utilised in Latino cultures. In addition to cultural workshops, this intervention offered an intensive Spanish language course, or an integrated immersion program including Spanish language classes, cultural workshops, community-based clinical experiences and home-stays. |
McGuire (2012) [44] | A training program focused on factors which may affect patient-practitioner communication and care such as: barriers in accessing health care in the U.S.; differences in health care systems in Latin America and the U.S.; expectations of Latino patients seeking care; social and cultural constructs of health and illness in Latino cultures, and; common health beliefs and practices such as the use of complementary medicine. |
McRae (2008) [51] | Cultural awareness training workshop regarding working with Aboriginal Australians. |
Wu (2006) [43] | Brief training introduced Latino cultural values and home remedies important to history taking, taught residents a few Spanish expressions to help establish rapport with Spanish-speaking patients, and discussed techniques for optimizing the use of interpreters in improving communication. |
Professional development interventions
Publication | Other Training | Mentoring/Supervision |
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Abbott (2014) [39] | An intervention to explore (general practitioner) GP Supervisors and Medical Educators attention to cultural competency when providing supervision to Medical Registrars. Participants viewed a simulated consultation between an Aboriginal patient and GP Registrar highlighting inadequacies in communication and cultural awareness and documented teaching points to prioritize in supervision in response to the video consultation. | |
Dingwall (2015) [42] | Evaluated the effects of training in a culturally adapted Indigenous e-mental health application on Indigenous and non- Indigenous service providers’ awareness, perceived knowledge and confidence in using the app with Indigenous clients. | |
Hinton (2012) [41] | Evaluated the effects of an Indigenous specific “Yarning about Mental Health” training for the Australian Drug and Alcohol workforce providing culturally appropriate strategies and tools for understanding mental health, promoting wellbeing, and delivering brief, evidence-based interventions. | |
Liaw (2015) [52] | Participating medical practices partook in a cultural respect workshop which provided orientation to the ‘Ways of Thinking Ways of Doing’ clinical re-design program designed to improve the cultural competency of General Practices. | Participating practices received support from a cultural mentor to guide the clinical re-design process. |
Viets (2009) [53] | A university-based, culturally centred mentorship program which aimed to train and mentor junior faculty and graduate students from underrepresented backgrounds to conduct addictions-related research projects for Native American, Latino and rural communities and to develop culturally supported interventions (CSI) or adapted empirically supported interventions (ESI) for these communities. | |
McRae (2008) [51] | Pharmacists received training in culturally appropriate teaching strategies then delivered a culturally appropriate program designed to educate Aboriginal Health Workers about cardiovascular medicines management for Aboriginal people. | |
Salman (2007) [48] | Alongside general cultural competency training, this intervention included training in ethno-geriatric care. | |
Wu (2006) [43] | Individual cultural education sessions were provided to residents where language or cultural issues that emerged during specific clinical encounters were reviewed with the cultural educator. |
Delivery mode
Publication | Intervention setting and target group | Delivery mode |
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Aboriginal Workforce (2015) [50] | All health staff in a state based health system, encompassing primary and secondary health settings. | State-wide intervention delivered through a 2-h eLearning component and 6-h face-to-face workshop. |
Abbott (2014) [39] | Training event for GP Supervisors (n = 71) and Medical Educators (n = 4). | Intervention delivered through two non-mandatory GP Supervisor training days involving practitioners from various practice sites. |
Brathwaite (2006) [40] | Public Health Nurses (n = 75) employed at a Public Health Department. | The cultural competence program ran two-hour workshops over five consecutive weeks, with one booster session at 1 month. The intervention was delivered through one organisational site. |
Chapman (2014) [38] | Emergency Department staff including nursing, clerical and allied health staff (n = 44) from in a hospital setting. | Three 2-h workshops delivered over 6 weeks to staff at one site. |
Dingwall (2015) [42] | Training completed over one-year by health staff of diverse professions (n = 138) attending one of ten training courses held in various locations. | Multiple health professionals working across the state. |
Hinton (2012) [41] | Training held for the Alcohol and Other Drug (AOD) workforce (n = 59), including AOD workers and counsellors, mental health and allied health workers. | Four 1-day training workshops held over a period of 2 years for members of two AOD workforce network agencies. |
Khanna (2009) [46] | Healthcare providers and administrators (n = 60). | 4 h long cultural competency training delivered to healthcare professionals working across two large regional medical groups. |
Kutob (2009) [47] | Family Medicine Residents (n = 122). | A 1-h internet-based cultural competency course trialled on a national sample. |
Liaw (2015) [52] | GP clinics (n = 10) and their staff. | Half-day cultural respect workshop, toolkit and cultural mentor to support a clinic re-design process implemented across numerous GP clinics in one region. |
Lopez-Viets (2009) | Ethnic minority junior faculty members at a University (n = 9). | A four-year culturally centred mentorship program delivered in one University. |
McElmurry (2009) [45] | Health care professionals and students (n = 386) across 5 ambulatory care sites. | A 3-year demonstration project offering training to health staff across a large regional health service network involving 5 healthcare sites. A six-session cultural workshop series and intensive Spanish language classes were offered as either an 8-week class series or 1–3-week integrated immersion program. |
McGuire (2012) [45] | Health professionals (n = 63). | Education DVD delivered to healthcare professionals state-wide through conferences, community meetings and clinic training. A life nationwide webcast and satellite conference was also offered, and the training was accessible online. 26 states were represented in the webcast. |
McRae (2008) [51] | Pharmacists (n = 12) and Aboriginal Health Workers (AHW) (n = 47). | Pharmacists and AHW’s based across 10 localities throughout a large regional area. Pharmacists attended an education weekend which included a 4-h cultural awareness session. The health worker education program occurred over 4 sessions ranging from 30 min to 1.5 h. |
Salman (2007) [48] | Nursing staff (n = 202) in hospital settings. | Training was provided to nurses working across two major tertiary hospitals. |
Thom (2006) [49] | Primary care physicians (n = 53) across diverse health care practice settings. | Intervention was implemented across four diverse health care practice sites. Three modules could be delivered as one half-day training or 3 separate sessions of 1–1.5 h. |
Wu (2006) [43] | Medical residents delivering care to Spanish speaking parents (n = 250) in one large teaching hospital. | 30-min group cultural workshop and two individual cultural mentoring sessions delivered to medical residents in one practice setting. |
Study quality
Intervention outcomes
Study Design and Measures | Outcomes | |
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Abbott (2014) [39] | Content analysis to determine the type and detail of the planned feedback, field notes from workshop discussions and participant evaluations to gain insight into participant confidence in cross cultural supervision. | 72% registrars referred to culture or to the patient’s Aboriginality; few (8%) documented plans to utilise national initiatives to support health care access for Aboriginal patients. A lack of supervisor confidence in providing guidance on cross-cultural consultation with Aboriginal patients was identified. |
Aboriginal Workforce (2015) [50] | Data analysis of training completions to measure the percentage of health staff who completed training components; staff and participant interviews; and, web-based survey of Chief Executives. | Average of 35% of New South Wales (NSW) Health staff completed online training, with significant variation in completion of face-to-face component across Local Health Districts (LHD). Program implementation was found to be slower than anticipated. |
Brathwaite (2006) [40] | Multiple time-series design to measure nurse cultural knowledge as measured by the Cultural Knowledge Scale (CKS). | Quantitative and qualitative data showed in an increase in participants cultural knowledge following the program. |
Chapman (2014) [38] | Pre and post questionnaire to measure the cultural awareness (perceptions and attitudes) of staff. | Changes in staff perceptions, but not attitudes which remained neutral. A decrease in ambivalence. |
Dingwall (2015) [42] | Pre and post questionnaire to measure participant knowledge and confidence in delivering e-mental health to Indigenous people. | Significantly improved perceived knowledge and confidence in using e-mental health tools with Indigenous clients after training. |
Hinton (2012) [41] | Pre-post questionnaire to measure participant knowledge and skills. | Significant improvement in knowledge of the warning signs and treatment of mental illness and levels of confidence to assess, treat and communicate with Indigenous mental health clients. |
Khanna (2009) [46] | Retrospective post- then pre- evaluation utilising a non-validated Cultural Competency Assessment (CCA) tool to measure changes in knowledge and skills related to the care of patients from diverse cultural and ethnic backgrounds. | Statistically significant change in participants self-reported knowledge and skills in providing culturally competent care. |
Kutob (2009) [47] | RCT measuring changes in scores on the Cultural Competence Assessment Tool (CCAT), a self-assessment tool developed for the study. | Total CCAT scores significantly increased for experimental group participants (83.55 before the course to 192.09 after the course), but did not change for the control group. |
Liaw (2015) [52] | Pragmatic pre- and post- evaluation using a practice site audit of cultural respect, health checks and risk factor management for Aboriginal patients in general practice. A Cultural Quotient (CQ) questionnaire was used to measure staff cultural strategic thinking, motivation and behaviour. | Practices improved their readiness to provide culturally appropriate care to Aboriginal patients; an increase in Aboriginal patients post intervention (p < 0.05).; and increase in cultural quotient score 74.8–89.8 (p < 0.05); and individual practice staff improved their cultural strategic thinking. |
Lopez-Viets (2009) | Pre- and during intervention evaluation in measures of research productivity, including number of grant applications and awards, publications and professional presentations of mentees. | There was considerable increase in total mentee research productivity: a 200% increase in grant applications and awards, a 336% increase in publications, and a 144% increase in professional presentations. |
McElmurry (2009) [45] | Qualitative written evaluations and pre- and post- program focus groups to measure participants experiences/perceptions, and haemoglobin A1c (HbA1c) levels in patients. | Self-reported increased appreciation of cultural interpretations of health, increased knowledge and consideration of Latino health beliefs and practices, improved ability to interact with patients, and greater respect and appreciation for patients cultural views. Improvements in blood glucose control as measured by a drop in HbA1c. |
McGuire (2012) [44] | Pre-post self-report survey measuring practitioner knowledge and confidence. | Significant (p < 0.001) improvements in knowledge and confidence. |
McRae (2008) [51] | Repeated measures three-phase questionnaire and semi-structured, face-to-face, in-depth interview post-program to evaluate pharmacists confidence. A brief survey to measure acceptability of program to AHWs and an audit of attendance. | Significant improvements in confidence with Indigenous health issues and educating AHWs (p = 0.002); access to resources to deliver education (p = 0.005). Education program delivered to 80% of AHW’s in the region with positive reports of participant satisfaction. |
Salman (2007) [48] | Pre-post questionnaire to measure practitioner self-reported cultural awareness and competence. | No effect sizes reported. Increases in proportion of participants rated as culturally aware and competent. |
Thom (2006) [49] | Randomised Control Trial (RCT) measuring Patient-Reported Physician Cultural Competence (PRPCC) score, patient satisfaction with and trust in physician, and patient health outcomes of weight, blood pressure and glycosylated haemoglobin. | No significant improvement on any outcome measure for either intervention group. Lack of impact of physician training on health care provision. |
Wu (2006) [43] | Comparative study with historical control measuring parent reported satisfaction with interpreter and healthcare experience. | Use of an in-person interpreter significantly increased Latino parents satisfaction (p < 0.001) versus phone interpreter, but a program using an interpreter to educate residents in cultural and language issues increased parents’ satisfaction more. |