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Table 1 Summary of 19 included reviews

From: Interventions to improve cultural competency in healthcare: a systematic review of reviews

Author & year of publication Health context Definition of cultural competence Sources (years of search) Number of included papers Type of papers Outcomes Was study quality assessed? Major findings (review authors’ conclusions) Review quality
Anderson et al. 2003 Healthcare systems Based on Cross et al. 1989 definition: ‘a set of congruent behaviors, attitudes and policies that come together in a system, agency, or among professionals and enable effective work in cross-culturally situations’ Medline, Eric, Soc Abs, SciSearch, Dissertation Abs, Soc Sci Abs, Mental Health Abs, Healthstar. English only. (1965–2001) 6 Intervention studies 1) Patient satisfaction, health status 2) utilization of health services Yes Could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment. Moderate-strong
Beach et al. 2005 Health professionals (physicians and nurses). Most studies located in the United States. Cultural competence has been defined as “the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences” (Cooper et al. 2002) by recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account (Betancourt et al. 2003). Medline, Cochrane, Embase, EPOC, RDRB/CME, Cinahl (1980–2003) 34 RCTs, controlled, pre & post 1) Provider outcomes: knowledge, attitudes, skills 2) patient outcomes: satisfaction, behaviors, health status 3) cost effectiveness No Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. It is difficult to conclude from the literature which types of training interventions are most effective on which types of outcomes. Also difficult to determine which types of knowledge, attitudes & skills are impacted by training. Moderate- strong
Bhui et al. 2007 Mental health. All studies located in North America. Aim of the paper is to develop a meaning of CC Ingenta, Medline via Ovid, Medline via Pubmed, Medline Plus, Health Outcomes, HealthPromis, HSTAT, DocDat, National Research Register, NLM Gate- way, Cam, ReFer and Zetoc. (1985–2004) 9 No RCTs. Qualitative & quantitative papers 1) Provider outcomes 2) evaluations of implemented models of CC No There is limited evidence on the effectiveness of CC training and service delivery. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. No studies investigated service user experiences and outcomes. Moderate-strong
Chipps et al. 2008 Health professionals working in community-based rehabilitation including mental health and primary care. All studies located in North America. “The ability to effectively provide services cross-culturally” (Diller 1999). Cultural competence training programs aim to increase “cultural awareness, knowledge, and skills leading to changes in staff (both clinical and administrative) behavior and patient-staff interactions” (Brach & Fraserirector 2000). Cultural competence includes the capability to identify, understand, and respect values and beliefs of others (Anderson et al. 2003). CINAHL, Medline, Pubmed, PsycINFO, SABINET, Cochrane, Google, NEXUS, and unpublished abstracts (1985–2006) 5 RCTs, quasi-experimental, evaluation studies 1) Provider outcomes: cultural knowledge and attitudes, cultural competence, 2) patient health outcomes: satisfaction, behaviors, health status Yes Positive outcomes were reported for most training programs. Reviewed studies generally had small samples and poor design. 3 of the 5 studies reported on patient/client satisfaction. Strong
Downing et al. 2011 Health care workers in Australia Throughout this review, the term ‘indigenous cultural training’ will be used to describe training that is concerned with assisting health workers to provide health care that is accessible, meaningful and useful to indigenous/other minority groups in terms of their social, emotional and cultural wellbeing as well as physical health. CINAHL PLUS, MEDLINE, Wiley InterScience, ATSIHealth and ProQuest. 9 Not reported 1) Provider outcomes: knowledge, attitudes, awareness, No There is scant evidence for the effectiveness of indigenous cultural training. The only study to assess knowledge and attitudes before and after training with a control group found no effect. Three studies also documented positive post-training reports but it is unclear if this relates to any change in practice as a result of the training. No information was available with which to assess systemic differences between the programs that did and did not produce (perceived) changes. Moderate
Fisher et al. 2007 Health care provision to non-White racial and ethnic groups in the United States. Cross’ definition for cultural competence. Definition of cultural leverage: a focused strategy for improving the health of racial and ethnic communities by using their cultural practices, products, philosophies, or environments as vehicles that facilitate behavior change of patients and practitioners. Medline, Cochrane, Web of knowledge, The New York Academy of Medicine Grey Literature Report (1985–2006) 38 (35 unique studies) RCTs, pre-post, controlled 1) Patient outcomes: health behaviors 2) access to health care system 3) provider: cultural competence Yes The interventions reviewed increased patients’ knowledge for self-care, decreased barriers to access, and improved providers’ cultural competence. Interventions using cultural leverage show promise in reducing health disparities, but more research is needed. Moderate
Forsetlund et al. 2010 Health care for ethnic minorities. Most studies located in the United States. To collect and summarise in a systematic and transparent manner the effect of interventions to improve health care services for ethnic minorities Cochrane Library, MEDLINE, EMBASE, British Nursing Index, ISI Social Sciences/Science Citation Index (SSCI/SCI) and Research and Development Resource Base (RDRP). 19 Randomized controlled Quality of health care services, use of health care services, patient health or the quality of life for patients. Somewhat Educational interventions and electronic reminders to physicians may in some contexts improve health care and health outcomes for minority patients. The quality of the evidence varied from low to very low. The quality of available evidence for the other interventions was too low to draw reliable conclusions. Moderate-strong
Harun et al. 2012 Cancer care to ethnic minority women. All studies located in the United States. Defines “patient-centred care”: involves integrating patient preferences and values to guide clinical decisions and management, and it is thought to facilitate improved patient satisfaction, communication with providers, safety, costs and efficiency in the health-care system. Medline, PsycINFO, EMBASE and Cochrane 7 Randomized controlled, non-randomized, mixed-method experimental Communication with health providers, decision-making, treatment adherence, general patient participation, treatment knowledge Yes Of the 37 selected studies, only 18 included valid outcome measures. Employing a combination of multiple strategies is more likely to be successful than single interventions. The impact of the interventions on participation was varied and effectiveness may hinge on a variety of factors, such as type of intervention and study population characteristics. Given the paucity of studies, it is difficult to draw conclusions about the effectiveness of the different interventions for this broad patient group. Moderate-strong
Hawthorne et al. 2008 Community-based or hospital-based settings. Diabetes education for ethnic minority groups. Most studies located in the United States. ’Culturally appropriate’ health education is defined here as education that is tailored to the cultural or religious beliefs and linguistic skills of the community being approached, taking into account likely literacy skills (Overland 1993). The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of article (prior to 2007). 11 RCTs Patient: health status, behaviors, satisfaction, knowledge. Yes Culturally appropriate diabetes health education appears to have short-term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. Strong
Henderson et al. 2011 Chronic health conditions. Most studies located in the United States. Culturally safe services were originally defined as those where there is no assault on a person’s identity caused by the fact that service delivery methods or processes are alien to the person’s culture (Ramsden 1990). CINAHL, MEDLINE, Joanna Briggs Institute, Cochrane Library, Lippincott, Williams and Wilkins Collection, PubMed, ProQuest, Dissertations and Theses, and Google Scholar (1999–2009) 24 RCTs and controlled trials 1) Utilization of health services 2) patient outcomes: satisfaction, health behaviours, health status 3) provider outcomes: awareness, cultural competency Yes The review supported the use of trained bi-lingual health workers, who are culturally competent, as a major consideration in the development of an appropriate health service model for culturally and linguistically diverse communities. Four studies reviewed involved cultural competency training for healthcare providers and all 4 indicated that cultural competency training was beneficial. Nevertheless, the translation of cultural knowledge into practice remains problematic. Moderate
Kehoe et al. 2003 Health care for ethnic minority groups. Most studies located in the United States. CC involves the actual integration of congruent behaviors, attitudes and policies, within the delivery of health care in cross-cultural situations. (Office of Minority Health 2000) Medline, Cinhahl (1980–2001) 14 RCTs, quasi-experimental Patient outcomes: health status, health behaviors Yes A small number of studies demonstrated significantly improved outcomes for patients with diabetes mellitus, drug addictions, sexually transmitted infections and other health problems, after receiving culturally competent or relevant interventions. Few studies examined long-term effects of interventions on health outcomes. Moderate
Kokko 2011 Nursing. Participants in the studies were from Australia, Denmark, Finland, Germany, Norway and Sweden. Cultural competence is defined as a set of skills and behaviors that enable a nurse to work effectively within the cultural context of a client/patient (Leininger 2002, Papadopoulos 2006). MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases (2000–2009) 7 Qualitative 1) Provider outcomes: cultural knowledge, personal growth, nursing student’s practice, preparedness for cultural competence in nursing No The results of the present study demonstrate that participating in overseas student exchange programs increased the nursing students’ preparedness to be culturally competent. Weak-moderate
Lie et al. 2011 Health care professionals. Most studies located in the United States. Not reported MEDLINE/PubMed, ERIC, PsycINFO, CINAHL and Web of Science databases (1990–2010) 7 Intervention studies Patient outcomes: satisfaction, behaviors, health status Yes Study quality was low to moderate. Effect size ranged from no effect to moderately beneficial. There is limited research showing a positive relationship between cultural competency training and improved patient outcomes. Strong
Lu et al. 2012 Cancer screening involving Asian women. Most studies located in the United States. Not reported MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane CENTRAL Register of Controlled Trials, CINAHL, CancerLit, DARE Database of Reviews of Effects, PsycINFO, ABI Inform, ERIC, Social Sciences Abstracts, Sociological Abstracts, Health Technology Assessment Database (University of York), Proquest Dissertations and Theses, and KUUC Knowledge Utilization Database (University of Laval) 37 Randomized control trial (including cluster randomized trial, and randomized controlled crossover trial), non-equivalent control group, or prospective cohort. Breast cancer screening, cervical cancer screening, and those studies targeting both breast cancer and cervical cancer screening Yes Our review found that intervention studies varied greatly by study population and geographic area. Therefore we could not arrive at a conclusive and generalizable conclusion on effectiveness of any one particular intervention. Only eighteen of the included studies reported effectiveness based on completion of mammograms or pap smear, either by self-report and/or verified through clinical record. While some studies demonstrated the effectiveness of certain intervention programs, the cost effectiveness and long-term sustainability of these programs remain questionable. Moderate-strong
McQuilkin 2012 Nursing. Participants in the studies were mostly from the United States Evidence of awareness of personal culture, values, beliefs, attitudes and behaviours; demonstrated ability to assess cross-cultural variations; and to effectively perform requisite skills needed to assess and communicate with individuals from other cultures (Cavillo et. al, 2009). Health and Psychosocial Instruments, CINAHL Plus with Full Text, ERIC, Health Source: Nursing/Academic Edition, MEDLINE, PsycINFO, EBSCO, COCHRANE, CINAHL, reference lists from identified articles. 37 (16 interventions) Case study, expert opinion, comparative descriptive, quantitative, systematic review 1) Increased self-awareness of their own values, attitudes, beliefs and behaviors that compose their culture, 2) increased skill in assessment and communication with persons from other cultures, and 3) ability to provide an assessment of transcultural differences Yes Findings demonstrated that international immersions provided optimal experiences to develop cultural competence alone, but more effective when combined with other strategies. International immersion experiences can increase student self-awareness, cross-cultural communication and assessment skills, and ability to assess cultural differences. The evaluation measures described in the literature were consistently student self-perception rather than observed development of the student’s cultural competence. Moderate
Pearson et al. 2006 Nursing Definition: “the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural and linguistic needs” (Betancourt et al. 2002) CINAHL, Medline, Current Contents, the Database of Abstracts of Reviews of Effectiveness, The Cochrane Library, PsycINFO, Embase, Sociological Abstracts, Econ lit, ABI/Inform, ERIC and PubMed. The search for unpublished literature used Dissertation Abstracts International. (prior to 2005) 19 Quantitative, qualitative, reviews 1) Patients: health status, satisfaction 2) nurses: 3) organisations 4) systems Yes The results identified a number of processes that would contribute to the development of a culturally competent workforce. Appropriate and competent linguistic services, and intercultural staff training and education, were identified as key findings in this review. Moderate -strong
Smith et al. 2006 Mental health professions. All studies were located in the United States. Not reported Dissertation Abstracts, ERIC, HealthSTAR, Medline, Mental Health Abstracts, Programme Applique’ a’ la Selection et a’ la Compilation Automatiques de la Litte’rature, PsycINFO, Social Sciences Abstracts, Social SciSearch, Sociological Abstracts via SocioFile, and Social Work Abstracts (1973–2002) Meta-analysis 2 n = 37 Outcome studies Meta-analysis 2- provider outcomes: multicultural counseling competence, racial identity, racial prejudice, client-counselor relationship Yes Multicultural education interventions were typically associated with positive outcomes across a wide variety of participant and study characteristics. Multicultural education interventions that were explicitly based on theory and research yielded outcomes nearly twice as beneficial as those that were not. Moderate-strong
Sumlin & Garcia 2012 Diabetes management involving African American women in the United States Cultural competence, or tailoring, is defined as “the process of creating culturally sensitive interventions, often involving the adaptation of existing materials and programs for racial/ethnic subpopulation”. PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Review database, and The Diabetes Educator journal index. 15 RCTs and quasi-experimental designs Dietary outcomes, weight loss, changes in metabolic control (A1C), lipids, blood pressure, and cholesterol No Of the 15 studies, 6 showed significant improvements in food practices, and 8 showed significant improvements in glycaemic control as a result of the interventions. It is not clear what components of the 15 interventions were most effective. Most studies did not report the duration of the sessions, thereby making comparison of “intervention dose” impossible. In addition, variations across the studies in content and methods used do not point to specific recommendations for clinicians or educators to adopt or avoid. Moderate-strong
Whittemore 2007 Diabetes management involving Hispanic adults in the United States. Not reported CINAHL, Medline, PsycINFO (1990–2006) 11 RCTs, pre-post design Patient outcomes: clinical, behavioral and knowledge No The majority of studies in this review reported significant improvements in select clinical outcomes, behavioral outcomes, or diabetes- related knowledge. Moderate-strong
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