SYSTEMATIC REVIEW Open Access
Organisational systems’ approaches toimproving cultural competence inhealthcare: a systematic scoping review ofthe literatureJanya McCalman1,2* , Crystal Jongen1,2 and Roxanne Bainbridge1,2
Abstract
Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groupson a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare.Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remainson competency strategies aimed at health promotion initiatives, workforce development and student education.This paper aims to bridge the gap in available evidence about systems approaches to cultural competence bysystematically mapping key concepts, types of evidence, and gaps in research.
Methods: A literature search was completed as part of a larger systematic search of evaluations and measures ofcultural competence interventions in health care in Canada, the United States, Australia and New Zealand.Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describingmeasurements. Thematic analysis was used to identify key implementation principles, intervention strategies andoutcomes reported.
Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementingsystems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key typesof intervention strategies to embed cultural competence within health systems were: audit and quality improvementapproaches and service-level policies or strategies. Outcomes were found for organisational systems, theclient/practitioner encounter, health, and at national policy level.
Discussion and implications: We could not determine the overall effectiveness of systems-level interventionsto reform health systems because interventions were context-specific, there were too few comparative studiesand studies did not use the same outcome measures. However, examined together, the intervention andmeasurement principles, strategies and outcomes provide a preliminary framework for implementation andevaluation of systems-level interventions to improve cultural competence. Identified gaps in the literatureincluded a need for cost and effectiveness studies of systems approaches and explication of the effects ofcultural competence on client experience. Further research is needed to explore the extent to which culturalcompetence improves health outcomes and reduces ethnic and racially-based healthcare disparities.
Keywords: Cultural competency, Indigenous, Ethnic minorities, Health disparities, Health systems, Health services
* Correspondence: [email protected] of Health, Medicine and Applied Sciences, Central QueenslandUniversity, Cnr Shields and Abbott Streets, Cairns 4870, QLD, Australia2Centre for Indigenous Health Equity Research, Central QueenslandUniversity, Cnr Shields and Abbott Streets, Cairns 4870, QLD, Australia
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
McCalman et al. International Journal for Equity in Health (2017) 16:78 DOI 10.1186/s12939-017-0571-5
IntroductionHealthcare organisations serve clients from diverse Indi-genous and other ethnic and racial groups on a dailybasis, and require appropriate client-centred systemsand services in order to provide optimal healthcare. Yetthere is extensive research evidence demonstrating thatracial and ethnic minorities do not receive equaltreatment when accessing healthcare services [1]. Dis-parities can result from discriminatory treatment byhealthcare practitioners [2], and can also be amelio-rated by the actions of healthcare organisations. Cul-tural competence has been identified as one strategyto address racial and ethnic health disparities inhealthcare by providing services that meet clients’ cul-tural, social, and communication needs [3–5].The concept of cultural competence was first identi-
fied in the late 1980s to address the effects of culturaland linguistic barriers in the interpersonal encounterbetween healthcare practitioners and clients on healthservice access and delivery [6]. It was considered thatindividual health practitioners needed to be capableof functioning effectively in cross- cultural contexts[7], and, that this required them to develop awarenessof cultural differences [6]. Recognising the importantrole of organisations, the scope of cultural compe-tence expanded beyond the interpersonal domain ofcross-cultural care to address multiple levels includinghealth systems [6].Cultural competence was defined in the late 1980s
as a “set of congruent behaviours, attitudes and pol-icies that come together in a healthcare system,agency or among professionals that enable that sys-tem, agency or professions to work effectively incross- cultural situations” [8]. The responsibility forcultural competence was therefore considered not justto concentrate in single healthcare services, but toalso require broader system- wide policies [9]. It wasargued that a systems approach to cultural compe-tence is required, because: “The bottom line is thatclinicians and caregivers cannot on their own driveand follow practices that lead to culturally and lin-guistically appropriate care” [2]. The earlier broaddefinition of cultural competence by Cross, Bazron[8] was reiterated in 2008 by the United States (US)National Quality Forum [10] as the “ongoing capacityof healthcare systems, organisations and professionsto provide for diverse client populations high qualitycare that is safe, client and family-centred, evidence-based and equitable”.Systems approaches are increasingly being applied in
the delivery and management of various aspects ofhealthcare [11]. A systems perspective considers health-care organisations as systems comprised of interrelatedand interdependent components: client care; ancillary
services; professional staff; and financial, informational,physical and administrative subsystems [12, 13]. Systemsthinking focusses attention on how components are con-nected to each other within a whole entity, how compo-nents work together to achieve an intended outcome,and thereby how systems can be changed to producebetter outcomes [11]. A systems approach to culturalcompetency integrates practices throughout the organi-sation’s management and clinical sub-systems, thus re-quiring an amalgamation of attitudes, practices, policiesand structures to enable healthcare organisations andprofessionals to work effectively in culturally diversesituations [8]. An organisation becomes more cultur-ally competent by adapting these systems and subsys-tems to the needs of its diverse workforce and clientpopulation [13].In the decades since the first definition of cultural
competence, racial and ethnic diversity has increased inCanada, Australia, New Zealand (NZ) and the US (theCANZUS nations), with Census projections predictingcontinuing diversification [2]. In these nations, Indigen-ous and other ethnic and minority peoples, particularlythose with limited English proficiency, share poorerhealth and life expectancies than the majority popula-tions [1, 3, 14–16]. Hence, the mandate for systems-levelcultural and linguistic competence to reduce disparitiesin healthcare has strengthened.Multi-levelled and multi-strategic systemic responses
have been enacted in the four countries to improve cul-tural competence. At national levels, the governments ofNZ and the US have enacted legislation (NZ Health andDisability Act and US National Standards for Culturallyand Linguistically Appropriate Services (CLAS) in healthand health care which have been legislatively mandatedby at least six states) to improve culturally competentcare, language access services and organisational sup-ports for cultural competence [13, 17–19]. The US Na-tional Quality Framework reiterated its commitment byidentifying six domains for cultural competency: 1) lead-ership; 2) integration into management systems and op-erations; 3) workforce diversity and training; 4)community engagement; 5) client- provider communica-tion; and 6) care delivery and support mechanisms [10].Australia has recently renewed its national framework forcultural respect [20] and in Canada, the broad Multicul-turalism Act is aimed at providing all citizens with equalaccess and opportunities to ensure that needs associatedwith culture are considered in decision-making processes[21]. National professional associations have also devel-oped healthcare practitioner competency standards.At regional and local levels, healthcare organisations,
including hospitals and primary healthcare services areincreasingly recognising cultural competence as an or-ganisational strategy to address the needs of diverse
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 2 of 19
client populations [4]. Healthcare organisations havedeveloped policies; workforce education and trainingprograms; audit, monitoring and quality improvementpractices; and culturally tailored programs and services[6, 15, 22–28]. Despite some healthcare organisationsbeing responsive to the cultural and linguistic needs oftheir client populations, the required financial invest-ments and failure to recognise the potential benefitsmean that some organisations do not implement culturalcompetence interventions [13].Despite such efforts to enact systems-level approaches
to cultural competence, few studies have described orassessed the extent of systems approaches to culturalcompetence [13]. This paper aims to bridge the gap inavailable evidence about systems approaches to culturalcompetence by systematically searching, selecting andsynthesising existing publications to map key concepts,types of evidence, and gaps in research [29]. By so doing,the review will provide healthcare organisations withguidance to implement systematic approaches to culturalcompetence by identifying the mix of strategies thatwork in practice, principles for implementing them, andthe extent to which they can expect improvements in cli-ents’ experiences of healthcare and their health outcomes.As suggested by Dijkers [30], assessments of the quality ofstudies are included to provide confidence that the impli-cations of the review for policy, practice or clients, arebased on high quality research. The research questionwas: What is the current evidence base for the impact ofsystems level approaches to cultural competence?The objectives of the paper are to:
1. Identify systems-level interventions that have beenevaluated in the literature;
2. Report the effects of these interventions inimproving cultural competence;
3. Report on how cultural competence at a systems-level has been measured;
4. Summarise the quality of available evidence.
MethodThe paper is based on the results of a broader systematicscoping review of the literature to identify interventionstrategies and indicators which have been applied to in-crease cultural competency in health care, along withthe outcomes of these interventions [31]. The review ofcultural competence in health care in Australia, NZ,Canada and the US was undertaken first in July 2012and updated in June 2016. The four CANZUS nationswere selected because they share a history of settler col-onisation by Britain, similar legacies of English commonlaw, political governance, language, settlement and cul-ture, and health systems [32].
However, important contextual differences in broadnational healthcare systems and cultural competence ap-proaches affect its implementation.
Search strategyThe search strategy employed for the review comprised aninitial search in 2012, for the period 1 January 2002–31July 2012. The start date was determined by the seminalUS Institute of Medicine report on Unequal Treatment:Confronting Racial and Ethnic disparities in healthcare [1]which highlighted systemic disparities in health care andhealth status for racial and ethnic minority populations.The search was updated in June 2016 for the period 1August 2012–31 December 2015.For each search, a qualified librarian systematically
searched 17 electronic databases and relevant websites(Fig. 1). Peer-reviewed and grey literature (includinggovernment and agency reports) published in Englishwere included. The references of reviews of culturalcompetency in healthcare were hand-searched for add-itional relevant studies.
Inclusion criteriaStudies were included in the broader review [31] if they:
1. Explicitly focussed on cultural competence inrelation to Indigenous and other minority ethnic andracial groups in Australia, Canada, NZ or the US.That is, studies aimed to improve culturalcompetence or included an indicator of culturalcompetence (or like terms). Included studies weredesigned to addresscultural awareness of health staff;Indigenous or ethnic minority peoples’ access tohealth services, procedures, and/or culturally specificprograms; the provision of culturally respectfulservices; Indigenous or ethnic minority workforcedevelopment; and culturally tailored interventions.We did not include studies with a primary focus onracial or ethnic disparities in health, the recruitmentand retention of staff members who reflect thecultural diversity of the community served, nor theidentification of Indigenous peoples or ethnicminorities in health service records.
2. Related to cultural competence in any health careservice (i.e. hospitals, primary health care settings,specialist health areas, private practice andcommunity health settings), and for both health careoutcomes and population health outcomes;
3. Were intervention evaluations or studies ofindicators/measures of cultural competency.Following Sanson-Fisher, Campbell [33], interventionevaluations were defined as studies that evaluatedthe effectiveness of a strategy, service, program orpolicy designed to improve cultural competency.
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 3 of 19
Indicator/measurement studies were defined as stud-ies that described, developed, tested or applied mea-sures/indicators of cultural competence.
Identification, screening and inclusion of publicationsAs shown in the Preferred Reporting Items for System-atic Reviews and Meta-Analyses (PRISMA) diagram [34]in Fig. 2, a total of 1171 publications were identified inthe first search and a further 1543 publications in thesecond search. The titles and abstracts of these 2714publications were imported into the bibliographic cit-ation management software, EndNote X7, duplicates re-moved and their abstracts manually examined to identifyevaluations of strategies to improve cultural competencyin health care or indicators of cultural competency. Oneauthor (RB) screened the first search and a secondauthor (CJ) retrieved and screened titles and abstracts ofthe remaining publications from the second search; thosewhich did not meet inclusion criteria were excluded. Thefull texts of the remaining publications were retrieved andscreened by blinded reviewers (RB, JM). Inconsistencies inreviewer assessments were resolved by consensus.In this paper, we report on the evidence for healthcare
systems approaches to cultural competence. A total of141 publications relevant to this review were included inthe broader review. For the purposes of this review,
studies focussed on healthcare organisational systemsapproaches were mined and extracted from the broaderreview.
Data analysisData that related to the author, year and type of pub-lication; country where developed and population;health care setting; type of intervention/measurement;healthcare outcomes assessed; outcome indicator and/or measure; study design and study quality were ex-tracted (Table 1). The quality of intervention studieswas assessed using the Effective Public Health Prac-tice Project (EPHPP) quality assessment tool forquantitative studies and Critical Appraisal SkillsProgramme (CASP) quality assessment tool for quali-tative studies.Thematic analysis methods [35] were used to identify
key themes across evaluations. A mind map was con-structed to sort the intervention strategies utilised andtheir associated outcomes. Overarching themes werethen reviewed, refined and named [35].
ResultsWe found 15/109 (13.8%) papers that met the inclusioncriteria as evaluating or providing measures for systemsapproaches to cultural competence. Of these, 12 were
Fig. 1 Search strategies
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 4 of 19
intervention studies and three were measurement stud-ies. There was a significant variation in focus, content,mode of delivery and duration of interventions. Therewas also heterogeneity in the outcomes reported acrossthe studies. A summary of the extracted characteristicsof the included studies is provided in Table 1. Measure-ment studies are shaded.
Publication yearThe quantity of publications was somewhat evenlyspread over the time period (2002–2016). Four publica-tions were included from the first 5 years (2002–2006),six from the second (2007–2011) and five from the third4-year period (2012–15).
Country of origin, population and healthcare settingSeven publications were from the US (one of these com-pared results with Australian hospitals); four were fromAustralia; and four from NZ, and one was NZ/Australian.No studies were from Canada. All but one of the US pub-lications focussed on ethnic and racial minority clientsother than Indigenous peoples, or diversity in general; oneon American Indian and Alaskan native clients. The
Australian and NZ publications all focussed on Indi-genous clients. The healthcare settings that were thefocus on the cultural competence intervention/meas-ure were hospitals (n = 5 publications), primaryhealthcare services (n = 4) and specialist mental health(n = 4), antenatal (n = 1) and disability (n = 1) services.
Intervention detailsAlthough expressed using diverse terms (e.g. culturalsensitivity, cultural respect, diversity management), theaim of all 15 papers was to increase cultural competencythrough systems level-approaches. A detailed overviewof intervention components is provided in Table 2. Thesymbol ✔ denotes evidence that the author(s) explicitlyadvanced adoption or support of the element of culturalcompetence, ~ denotes an implicit or inferred referenceconsistent with the intent of that element; and ✗ denotesno evidence for that element.
Principles for implementationThe three most commonly reported principles forimplementing systems-level interventions and mea-sures to improve culture competence were: user
Fig. 2 PRISMA flow diagram
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 5 of 19
Table
1Pu
blications
which
evaluatedor
provided
measuresforsystem
s-levelculturalcom
petenceinterven
tions
Autho
r,year
&pu
blication
Cou
ntry
and
popu
latio
nHealth
care
setting
Type
ofinterven
tion
Health
care
outcom
esOutcomeindicator
and/or
measure
Stud
yde
sign
Stud
yqu
ality
Cho
ng,Ren
hard
[36]
Pape
rAustraliaAbo
riginal
andTorres
Strait
Island
erclients
Hospitals
TheIm
provingtheCulture
ofHospitalsProjectde
velope
dandtrialledan
eviden
cebasedqu
ality
improvem
ent
‘toolkit’to
supp
ortcontinuo
usqu
ality
improvem
ent(CQI)for
improvingculturalsensitivity.
Abo
riginalstaffw
eretrained
intheuseof
CQItechn
olog
y.Anatio
nalkey
stakeholder
forum
toexploreresearch
and
implem
entatio
n.
Hospitalsthat
have
improved
cultu
ralsen
sitivity
share:
relatio
nships
with
Abo
riginal
commun
ities
and
commitm
entto
supp
ortin
gtheAbo
riginalworkforce.
Culturalsen
sitivity
Qualitative:Case
stud
ies—
continuo
usqu
ality
improvem
ent.
Mod
erate
Freeman,Edw
ards
[37]
Pape
rAustraliaAbo
riginal
andTorres
Strait
Island
erAustralians
AnAbo
riginalcommun
itycontrolledhe
alth
care
service
andastatego
vernmen
t-managed
prim
aryhe
althcare
service.
App
raisalsof
the
achievem
entof
cultu
ral
respectfollowinghe
alth-
service-levelstrateg
iesfor
cultu
rally
respectful
care.
Implem
entatio
nen
ablers:
beinggrou
nded
inasocial
view
ofhe
alth,advocacyand
addressin
gsocial
determ
inants;employing
Abo
riginalstaff;creatin
ga
welcomingservice;
supp
ortin
gaccessthroug
htransport,ou
treach,and
walk-
incentres;andintegratingcul-
turalprotocol.Barriers:com-
mun
icationdifficulties;
racism
anddiscrim
ination;
andexternallydevelopedp
ro-
gram
s.Service-levelstrategies
arenecessaryforachieving
culturalrespect.
Staffandclients
repo
rted
oncultu
ral
respectstrategies,
client
expe
riences
and
barriersto
cultu
ral
respect.
Twocase
stud
ies—
22interviewswith
staff,an
auditandsurvey,fou
rcommun
ityassessment
worksho
pswith
21clients.
Weak
Liaw
,Hasan
[38]
Pape
rAustraliaAbo
riginal
peop
leGen
eralpracticeandprim
ary
care
organisatio
ns.
Acultu
ralrespe
ctworksho
pprovided
orientationto
the
‘Waysof
Thinking
Waysof
Doing’clinicalre-designpro-
gram
toim
provethe
cultu
ralcom
petencyof
Gen
-eralPractices.Sup
portfro
ma
cultu
ralm
entorandatoolkit
togu
ideactivities
toem
bed
cultu
ralrespe
ctinto
practice.
Iden
tificationof
Abo
riginality
ofne
wandexistin
gclients,
practiceorganisatio
nal
arrang
emen
t,chronicdisease
riskfactor
recorded
,health
assessmen
tbilled,
practitione
rs’cultural
quotient
(culturalstrateg
icthinking
,motivation,
behaviou
r).
Age
neric
cultu
ral
quotient
questio
nnaire
andauditof
Abo
riginal
clientsiden
tified,
health
checks
done
andclinicalriskfactors
managed
.
Apragmaticpre-
and
post-stud
yusing
qualitativeinterviews
andqu
antitativeaudit
andsurvey.
Weak
Lieu,Finkelstein
[43]
Pape
rUSNon
-Eng
lish
speakersandclients
with
low
literacy
Prim
aryhe
alth
care
for
Med
icaidinsured
children
with
asthma
Aimed
toidentifypractice-site
policiesandfeatures
associ-
ated
with
quality
ofcare
for
Med
icaidinsuredchildren
with
asthma.
Aton
e-year
follow
up,clients
ofpracticesiteswith
the
high
estcultu
ralcom
petence
scores
wereless
likelyto
beun
derusing
preven
tive
asthmamed
ications
andhad
better
parent
ratin
gsof
care.
Health
care
cultural
competencepo
licies
andprocedures,client
selfm
anagem
ent,
empo
wermentand
commun
ication.
Teleph
oneinterviews
with
parents,surveys
ofpracticesitesand
compu
terised
databases.
Strong
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 6 of 19
Table
1Pu
blications
which
evaluatedor
provided
measuresforsystem
s-levelculturalcom
petenceinterven
tions
(Con
tinued)
Noe
,Kaufm
anet
al.[42]Pape
rUSAmerican
Indian
andAlaskaNative(AI/
AN)veterans
Accessto
approp
riate
care
forAI/A
Nveterans
Whatorganisatio
nal
characteristicspred
ictthe
provisionof
cultu
rally
compe
tent
services.
Only15%
services
repo
rted
that
theirfacilitiesprovided
tradition
alhe
alingservices.
Meanscores
wereabovethe
midrang
eon
all
organisatio
nalreadine
ssto
change
measures.
Organisational
readinessto
change
.Includ
editemsrelatin
gto
AI/A
Nveterans’
services
andprojects.
Adapted
Organisational
Readinessto
Chang
eAssessm
entsurvey
(needs,leade
rship,
resources,and
organisatio
nalclim
ate
scales).
Weak
O'Brien,Bo
ddy
[39]
Pape
rNZ(but
includ
esAustralianstandards)
Maoriandno
n-Maori
men
talh
ealth
clients
Men
talh
ealth
services
and
men
talh
ealth
nursing
Health
serviceauditmeasure
usingbicultu
ralind
icatorsfor
clinicalrecordsandcultu
ral
compe
tence.
Widevariatio
nacross
services,especially
ininform
edconsen
t,inform
ationabou
tlegal
rights,andcultu
rally
safe
and
recovery-fo
cussed
care.
Health
service
Con
sumer
Notes
ClinicalIndicators
(CNCI)audittool.
Four
phased
design
:1)
focusgrou
pswith
expe
rtmen
talh
ealth
nurses;2)D
elph
isurveys;3)
apilot
stud
y;4)
natio
nalaud
itof
men
talh
ealth
services.
Mod
erate
O'Brien,Bo
ddy
[40]
Pape
rNZandAustralia
Indige
nous
peop
les
Men
talh
ealth
care
Health
serviceauditmeasure
usingbicultu
ralind
icatorsfor
clinicalrecordsandcultu
ral
compe
tence-Ascertaining
thede
gree
towhich
quality
improvem
entand
mon
itorin
gsystem
sare
enhancingprofession
alpracticeandclient
outcom
es.
Variatio
nin
cultu
ral
compe
tenceof
nursing
practiceacross
men
talh
ealth
services.The
way
inwhich
services
werede
livered
impacted
upon
clients’ability
toen
gage
inthetreatm
ent
processesandultim
atelyin
theirrecovery;clients
becamemoreinvolved
intheirow
ncare;kin
and
commun
itybe
camemore
involved
incare.Ind
icators
iden
tifiedareasof
clinical
nursingcare
need
ing
improvem
ents.
Clinicalindicatorsof
criticalevents-
Con
sumer
Notes
ClinicalIndicators
(CNCI)audittool
Aud
itof
men
talh
ealth
services
Mod
erate
ReibelandWalker
[41]
Pape
rAustraliaAbo
riginal
wom
enAntenatalservicesin
WA
Client
access
orutilisatio
nof
health
serviceby
racialor
ethn
icgrou
p.
Only9/42
auditedservices
which
repo
rted
utilisatio
nby
Abo
riginalwom
enhad
achieved
amod
elof
cultu
rally
respon
sive
service
delivery(i.e.incorporated
Abo
riginalspecificantenatal
protocols/prog
rams,
maintaine
daccess,employed
Abo
riginalHealth
Workers).
Theindicatorsestablishe
dbe
nchm
arks
forplanning
cultu
rally
approp
riate
antenatalservices.
Accessandqu
ality
ofcare
ofhe
alth
services
(gen
eralcharacteristics,
riskassessmen
t,treatm
entrisk
redu
ctionand
education,access
and
quality
ofcare);
indicatorsof
cultu
ral
respon
sivene
ss.
Aud
it.Pu
rposespe
cific
audittool
administered
throug
hteleph
one
interviews.
Weak
Hospitals
Mod
erate
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 7 of 19
Table
1Pu
blications
which
evaluatedor
provided
measuresforsystem
s-levelculturalcom
petenceinterven
tions
(Con
tinued)
Weech-
Maldo
nado
,Elliot
[5]Pape
r
Ethn
ic/racialm
inority
clients
Aim
edto
assess
whe
ther
greatercultu
ralcom
petence
inho
spitalsim
proves
client
expe
riences,p
articularlyfor
ethn
ic/racialm
inority
clients.
Greater
cultu
ralcom
petence
was
positivelyassociated
with
doctor
commun
ication,
overallh
ospitalratingand
hospitalrecom
men
datio
n.Thereweregreaterrelative
bene
fitsforno
n-Englishspe
akingno
n-Hispanicwhites.
Client
expe
riencewith
care
(com
mun
ication
with
doctorsand
nurses,staff
respon
siveness,pain
control,commun
ication
abou
tmedications,
dischargeinform
ation,
cleanlinessof
hospital,
quietnessof
hospital,
recommendatio
nsof
hospitaltofriends
and
family,overallratin
g)with
hospitalcultural
competenceand
selfreportedclient
race,
ethn
icity
andlang
uage.
Exploratorysing
letim
epoint
correlation
betw
eennatio
nal
Con
sumer
Assessm
ent
ofHealth
care
Providers
andSystem
s(CAHPS)
hospitalsurveyscores
andCultural
Com
petence
Assessm
entTool
for
Hospitals(CCATH
)scores.
Whe
lan,Weech-
Maldo
nado
[44]
Pape
r
USandAustralia
Diversity
managem
ent
bySenior
Hospitals
Com
parativeevaluatio
nof
how
diversity
managem
ent
isen
actedin
hospitalsacross
twocoun
tries.
Both
AustralianandUS
hospitalscando
muchmore
toim
plem
entbe
stpractices
indiversity
managem
ent.
Australianho
spitalsscored
high
eron
organisatio
nal
change
indicators;U
Sho
spitalson
human
resource
indicatorsbu
ttherewas
moresimilaritythan
difference.Despite
30–40
yearsof
“multicultural
health”,ne
ither
hasachieved
bestpractice.
Diversitymanagem
ent
activities
(plann
ing,
stakeholdersatisfactio
n,diversity
training
,hu
man
resources,
health
care
delivery,
organisatio
nalchang
e,diversity
perfo
rmance,
externalandinternal
influenceson
racial/
ethn
icdiversity
initiatives).
Com
parative
exploratorystud
ybasedon
sing
lepo
int
intim
esurveys.
Weak
Whitm
anand
Davis[45]
Pape
rUSDiversifyingclient
popu
latio
nCross-101ge
neralm
edical
andsurgicalho
spitalsin
Alabamasampleof
53respon
dents.
Exam
ined
theaw
aren
essof
andprep
ared
ness
forthe
diversifyingclient
popu
latio
nthroug
htheirho
spital
cultu
raland
lingu
istic
compe
tencepractices.
Hospitalsaretaking
initial
step
sto
meetthene
edsof
thediversifyingpo
pulatio
n,bu
thave
along
way
togo
tomeetNationalStand
ards
forcultu
rally
and
lingu
isticallyapprop
riate
services
inhe
alth
care.
Hospitaladh
eren
ceto
natio
nalstand
ards.
Self-repo
rtqu
estio
nnairesto
hospitalchief
executive
officerson
the
measuresand
resourcesthat
the
hospitalscurren
tlyuse
tomeetcultu
raland
lingu
istic
Weak
Wiley[18]
Pape
rNZMaoriwho
are
disabled
Know
ledg
eandattitud
esto
cross-cultu
rald
isability
care.
Con
sumers,carers,service
providersandpo
licymakers’
know
ledg
eandattitud
es.
Con
flict
betw
eenIndige
nous
worldview
sframed
with
ina
mainstream
service;Needfor
increasedcoordinatio
nand
collabo
ratio
n,workforce
developm
ent,resourcesand
inform
ationde
velopm
ent,
Disability
care
and
participationin
services.
Semi-structured
interview
instrumen
t,focusgrou
ps.
Weak
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 8 of 19
Table
1Pu
blications
which
evaluatedor
provided
measuresforsystem
s-levelculturalcom
petenceinterven
tions
(Con
tinued)
andcommun
ityen
gage
men
t.
O'Brien,O'Brien
[46]
Pape
rNZMaoriandno
n-Maorimen
talh
ealth
clients
Men
talh
ealth
services
and
men
talh
ealth
nursing.
Health
serviceaudittool
usingbicultu
ralind
icatorsfor
clinicalrecordsandcultu
ral
compe
tence.
Nohe
alth
care
outcom
esrepo
rted
(paper
describ
esde
velopm
entof
indicatorsby
expe
rtcommittee).
Health
care
delivery
Develop
men
tof
Con
sumer
Notes
ClinicalIndicators
(CNCI)forclinical
recordsandcultu
ral
compe
tenceand
Profession
alPractice
Aud
itQuestionn
aire
(PPA
Q)self-repo
rtsurvey.
Sieg
el,H
augland
[47]
Pape
rUSAfricanAmerican,
Hispanic,Asian
and
American
Indian
Men
talh
ealth
services
Aud
ittool
tomeasure
the
cultu
ralcom
petenceof
health
services.
Nohe
alth
care
outcom
esrepo
rted
(paper
describ
esde
velopm
entby
expe
rtcommittee).
Health
care
delivery
Develop
men
tof
health
servicebe
nchm
arking
audittool
andself-
repo
rtsurvey.
Weech-
Maldo
nado
,Dreachslin
[48]
Pape
r
USHospitals
Hospitalsin
California
Pilottested
aninitialdraftof
theCulturalcom
petency
assessmen
ttool
forho
spitals
(CCATH
),revisedthen
field
tested
itwith
asampleof
hospitals.
TheCCATH
canbe
used
toevaluate
hospital
perfo
rmance
incultu
ral
compe
tencyandiden
tify
improvem
ents.N
otforprofit
hospitalshadhigh
erCCATH
scores
than
forprofit.
TheCCATH
scales
were
reliable.
Develop
men
tof
CulturalC
ompe
tency
Assessm
entTool
ofHospitals(CCATH
).
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 9 of 19
Table
2Characteristicsof
thesystem
slevelinterventions
andmeasuresto
improvecultu
ralcom
petence
Publication
Aim
Implem
entatio
nStrategies
FirstAutho
rYear
Increased
cultu
ral
compe
tency
User
engage
men
tOrganisational
readiness/
commitm
ent
Multip
lesites
ofde
livery
Aud
itandqu
ality
improvem
ent
Organisation-levelp
oliciesor
strategies
Develop
resources,tools
andgu
idelines
Implem
entatio
nof
auditand
mon
itorin
g
Cultural
protocol
orpo
licy
Workforce
diversity/
commun
ication
Workforce
CCtraining
Tailoredservices/
prog
rams
Org.enviro
nmen
t:supp
ort,access,
resource
Cho
ngin
2011
[36]
✓✓
✓✓
✓✓
✓✓
✓✓
✓
Freeman
2014
[37]
✓✓
✓✓
✗✗
✓✓
✗✓
✓
Liaw
2015
[38]
✓✓
~✓
✓✓
✗✓
✓✓
✓
Lieu
2004
[43]
✓✗
✓✓
✗✗
✓✓
✓✗
✓
Noe
2014
[42]
✓✗
✓✓
✗✗
✗✗
~✓
~
O’Brien2004
[39]
✓✓
~✓
✓✓
✓✓
~✓
~
O’Brien2007
[40]
✓✓
~✓
✓✓
✓~
~✓
~
Reibel2010
[41]
✓✓
~✓
✓✓
✓✓
✗✓
✓
Weech-
Maldo
nado
2012b[13]
✓✗
✓✓
✗✗
~✓
✓✓
✓
Whe
lan2008
[44]
✓✗
✓✓
✗✗
✓✓
✗✗
✓
Whitm
an2008
[45]
✓✗
✓✓
✗✗
✓~
~✗
~
Wiley2009
[18]
✓✓
✓✗
✗✓
✓✓
✓✓
O’Brien2003
[46]
✓~
~✓
✓✓
✓~
~✓
✓
Sieg
al2003
[47]
✓✓
~✓
✓✗
✓✓
✓✓
✓
Weech-
Maldo
nado
2012c[48]
✓✓
✓✓
✓✗
✓✓
✓✓
✓
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 10 of 19
Table
2Characteristicsof
thesystem
slevelinterventions
andmeasuresto
improvecultu
ralcom
petence(Con
tinued)
Publication
Strategies
Outcomes
FirstAutho
rYear
Organisation-levelp
oliciesor
strategies
Organisationalsystems
Client/practition
eren
coun
ter
Health
outcom
esNational
outcom
es
Advocacyfor
cultu
ral,econ
omic
&social
Prom
oted
natio
nalC
Cstandards
implem
entn
Increase
quality/
access/
participation
Improved
resources/
toolsforprovidingcc
Iden
tificationof
need
sfor
improvem
ent
Health
care
outcom
esCultural
respect/
commun
ication
Client/
family
satisfaction
Practitione
outcom
es/
satisfaction
Health
outcom
esor
redu
ced
disparity
Inform
ednatio
nal
standards
Cho
ngin
2011
[36]
✗✓
✗✓
✓✗
✓✗
~✗
✓
Freeman
2014
[37]
✓✗
✗✗
✓✗
✓✓
~✗
✗
Liaw
2015
[38]
✗✗
✗✓
✓✓
✓✗
✗✗
✗
Lieu
2004
[43]
✗✓
✓✗
✓✓
~✓
✗✓
✗
Noe
2014
[42]
✗✗
~~
✓✗
~✗
~✗
✗
O’Brien2004
[39]
~✓
✓✓
✓✓
~✓
~✗
~
O’Brien2007
[40]
~✓
✓✓
✓✓
~✓
✓✗
~
Reibel2010
[41]
✗✗
✓✓
✓~
✓~
✗✗
✗
Weech-M
aldo
nado
2012b[13]
✗✓
✓✓
✓✓
✓✓
✗✗
✗
Whe
lan2008
[44]
✗✗
✗✓
✓✗
✗✗
✗✗
✗
Whitm
an2008
[45]
✗✓
✓✗
✓✗
✓✗
✗✗
✗
Wiley2009
[18]
✓✓
✓✗
✓✗
✓✓
✓✗
~
O’Brien2003
[46]
~✓
✓✓
✓✗
~✗
✗✗
Sieg
al2003
[47]
✗✓
✓✓
~✗
~✗
✗✗
Weech-M
aldo
nado
2012c[48]
✗✓
✓✓
~✗
~✗
✗✗
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 11 of 19
engagement (n = 8), organisational readiness or com-mitment (n = 8) and delivery across multiple sites (n =12). Other principles mentioned in publications included:being grounded in a social view of health, employing mi-nority group staff, creating a welcoming service, support-ing access, integrating cultural protocols, self-rating ofservices’ processes of change against the end goal of cul-tural security, using multi-level strategies and carefulcoordination.
User engagementEight of the 12 papers described engagement and collab-oration with affected population groups in the develop-ment and/or implementation of systems level culturalcompetence [18, 19, 36–41]. The frequency with whichpublications reported engagement with users in thedevelopment and delivery of effective cultural compe-tence interventions indicates the importance of user in-volvement in identifying appropriate interventions. Forexample, Chong et al. [36] described a quality improve-ment framework designed collaboratively with Aborigi-nal Australians, and noted that hospitals with improvedcultural sensitivity were those who engaged and had re-lationships with local Aboriginal Australian communitiesand commitment to supporting their Aboriginal work-force. This required senior management to prioritise andsupport this work and ensure that Aboriginal staff weretrained to facilitate the process. Siegal et al. [19] identi-fied the importance of users’ knowledge of culturalneeds as one of 12 domains of US gold standard per-formance indicators that could be integrated withinmental health services to measure the integration of cul-tural competence into daily operations. The emphasis onuser involvement in part, was related to a recognitionthat healthcare users from diverse ethnic and racialbackgrounds often have different worldviews to thoseunderpinning the services of healthcare organisationsand practitioners. For example, Wiley [18] noted conflictbetween worldviews of Maori disability clients which werebased on Maori beliefs and traditions, compared withthose of the mainstream services which were perceived byclients to fail to listen to the client or family. The conse-quence of not involving users was described by Wiley [18]whose evaluation of NZ’s national disability strategy foundthat Maori disability clients deemed the strategy to be lessthan optimally effective because it was adapted frommainstream to the Maori context rather than user-developed.
Organisational readiness and commitmentThe issue of organisational readiness for implementingcultural competence strategies was addressed in eightpublications. For example, from the US, an exploratorystudy by Noe [42] focussed on the issue of the
organisational readiness and capacity of 27 healthcareservices of the Department of Veterans Affairs to adoptand implement native-specific services for American In-dian and Alaska Native (AI/AN) veterans. They used anadapted Organisational Readiness to Change Assessmentsurvey and profiled the availability of AI/AN veteranprograms and interest in and resources for such pro-grams. Other publications considered the commitmentof managers to supporting cultural competence as onekey enabler of implementation [5, 36, 37, 43–45].
Multiple sites of deliveryAll of the included publications considered the imple-mentation of cultural competence across multiple,rather than single healthcare sites. The number ofsites ranged from two primary healthcare services[37] to 66 hospitals [5].
Strategies of systems-level interventionsThe 12 systems-level intervention studies to improvecultural competence could be categorised into two broadtypes of approach: 1) audit and quality improvement ap-proaches conducted across or within health services; and2) evaluations of organisation-level systemic policies orstrategies for cultural competence.
Audit and quality improvement approachesconducted across or within health servicesWe found five intervention publications that reportedon the trialling and/or implementation of audit andquality improvement approaches through targeted strat-egies [36, 38–41]. All five specifically focussed on Indi-genous clients from Australia (3) and NZ (2) and wereimplemented within hospitals, primary healthcare ser-vices, mental health and antenatal services.In these diverse healthcare settings, each study docu-
mented the development or tailoring of audit tools forthe setting. In some studies, audit processes were usedsimply to identify the need for quality improvement. Forexample, persistent and significantly poorer Aboriginalperinatal outcomes motivated Reibel and Walker [41] toaudit the usage frequency and characteristics of culturalresponsiveness of maternal and child health antenatalservices used by Aboriginal women in WesternAustralia. The utility of such studies lay in their identifi-cation of the extent of need for quality improvement.Other studies developed audit tools and tested them intrial sites. From Australia, for example, a case study byChong [36] evaluated the development and piloting ofan evidence based quality improvement framework toimprove cultural sensitivity as it relates to Aboriginalhealth service delivery in five hospitals.One study documenting the full audit and quality im-
provement cycle from NZ described the development
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 12 of 19
and use of culturally and clinically reliable biculturalaudit tools, the 25-item Consumer Notes Clinical Indica-tors (CNCI), to measure the achievement of culturallycompetent mental health nursing practice standardsagainst standards of expected health care [39, 46].Client ethnicity data was collected and linked to these
quality measures. Another pre-post mixed methodsstudy by Liaw [38] also documented the full audit andquality improvement cycle with 10 general practices.The study assessed the identification of Aboriginal cli-ents, completion of health checks and management ofchronic disease risk factors, and training and mentorshipof staff to embed cultural respect in practice [38]. Moni-toring of the frequency and characteristics of expectedhealthcare and client usage was then conducted [38, 39].
Evaluations of service-level policies or strategiesfor cultural competenceWe found six evaluations within or across service-levelpolicies or strategies for cultural competence [5, 18, 37,43–45]. Four were from the US, one compared USand Australian hospitals, one was from Australia andone from NZ. The evaluations of service-level policiesand strategies for cultural competence considered verydiverse populations and healthcare settings. One studyevaluated the effects of organisational cultural compe-tence policies on healthcare and health outcomes[43]. This US study by Lieu [43] examined the cul-tural and linguistic competence policies of five healthplans in three states, and their association with qual-ity of managed care for Medicaid-insured children ofnon-English speakers with asthma.Two studies evaluated the effect of cultural compe-
tence on clients’ experiences of care. Weech- Maldonadoet al. [5] explored whether greater cultural competencein hospitals improved client experiences, particularly forethnic/racial minority clients, by correlating scores fromthe US national Consumer Assessment of HealthcareProviders and Systems Hospital Survey with those fromthe Cultural Competence Assessment Tool for Hospi-tals. Freeman et al. [37] identified cultural respect strat-egies in two primary healthcare case studies. Thestrategies were: being grounded in a social view ofhealth, including advocacy and addressing social deter-minants; employing Aboriginal staff; creating a welcom-ing service; supporting access through transport,outreach, and walk-in centres; and integrating culturalprotocol. They also identified client experiences and bar-riers to cultural respect (communication difficulties; ra-cism and discrimination; and externally developedprograms).Three studies evaluated the extent to which (or how
well) organisational or national cultural competence pol-icies/strategies had been implemented. Whitman and
Davis [45] considered whether the policies and practicesused by Alabama hospitals met the national US NationalCLAS standards. Whelan et al. [44], compared diversitymanagement strategies by senior hospital managers inPennsylvania with those of Sydney hospitals to deter-mine how well they implemented best practice diversitymanagement. The diversity management activities evalu-ated included planning, stakeholder satisfaction, diversitytraining, human resources, health care delivery, organ-isational change, diversity performance, and external andinternal influences on racial/ethnic diversity initiatives.From NZ, Wiley [18] suggested a need for improved co-ordination, collaboration, workforce development, infor-mation and resources, and community engagement inthe implementation of the NZ Disability Strategy.
Outcomes of systems-level cultural competenceinterventionsFour types of outcomes of systems-level cultural compe-tence were identified. These were: 1) organisational sys-tems outcomes including improved resources/tools forproviding cultural competence and identification ofneeds for improvement; 2) outcomes related to the cli-ent/practitioner encounter including identification ofcultural respect/communication, client/family satisfac-tion, and practitioner outcomes/satisfaction; 3) health-care and health outcomes; and 4) broader outcomessuch as informing national standards for culturalcompetence.
Organisational healthcare systems outcomesSeven of the 12 intervention papers described outcomesof improved resources/tools for providing cultural com-petence, and all 12 papers identified needs for systemsimprovements in promoting cultural competence. Thepublications that reported audit and quality improve-ment approaches [37–41] considered these approachesto be relevant for establishing benchmarks for healthservice utilisation and quality and to driving system-wide healthcare action against national standards, andreported improved healthcare outcomes. Audits pro-vided a quality mechanism for identifying aspects ofhealth care where improvements in cultural competencewere needed [39, 40] and a commitment by healthcareadministrators to achieving culturally-competent policy,health service delivery and environments [36]. Liaw etal. [38] found encouraging improvements in primaryhealthcare staff members’ scores on cultural competencyscales, and that audits, training and mentoring led to in-creases in Aboriginal health checks and improved man-agement of clinical risk factors.All 12 publications identified areas of further need for
improved implementation of systems approaches to cul-tural competence. For example, Reibel and Walker [41]
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 13 of 19
identified that only nine of the 42 Western Australianantenatal services which reported use by Aboriginalwomen, had provided both culturally secure and con-sistent antenatal care. Few services incorporated Abo-riginal specific antenatal protocols/program, employedAboriginal Health Workers, or were accessed regu-larly by Aboriginal women. The authors suggestedthat the cultural responsiveness indicators used in theaudit established benchmarks as a starting point forfuture service delivery improvement [41]. Freeman etal. [37] concluded that service-level strategies werenecessary to achieving cultural respect and had thepotential to improve Aboriginal and Torres Strait Is-lander health and wellbeing.Similarly, studies based on surveys of healthcare
system administrators also identified needs for sys-tems improvements in promoting cultural compe-tence. For example, Noe et al. [42] determined thatprogram needs, leaders’ practices and communicationpredicted the provision of care that staff consideredmet the needs of AI/AN veterans, but not implemen-tation of native-specific services. Assessment of or-ganisational readiness could assist in developingstrategies for adopting and implementing native-specific programs and services. At a broader scale,Whelan et al. [44]’s comparison of Australian and UShospitals found that both systems can do much moreto implement best practices in diversity management.Australian hospitals scored higher on organisationalchange indicators; US hospitals on human resourceindicators, but there was more similarity than differ-ence. They concluded that despite 30–40 years of“multicultural health”, hospitals in neither country hasachieved best practice. Similarly, the study by Whit-man and Davis [45] of Alabama hospitals found thatalthough these hospitals were taking initial steps toprepare for a diversifying client population, only 13%hospitals met all four of the linguistic CLAS stan-dards, and 19% met none. That is, enforcement of na-tional legislation was inconsistent and legislation initself does not necessarily guarantee health serviceimplementation.
Client/practitioner encounter outcomesStudy outcomes also included the increased involvementof clients and their families in their own healthcare, im-proved relationships in the client/practitioner encounter,and consequently increased health service access andfrequency of visits. For example, Weech-Maldonado etal. [5] found that greater cultural competence was posi-tively associated with some measures of clients’ expe-riences with care (doctor communication, overallhospital rating and hospital recommendation). Therewere greater relative benefits for non-English-speaking
non-Hispanic whites. Freeman [37] found that 22 staffand 21 clients reported positive appraisals of theachievement of cultural respect. While not significant,Reibel and Walker [41] found that Aboriginal womenincreased utilisation to the nine culturally responsiveantenatal services from 3 to 5 visits.
Health outcomesHealth outcomes were also reported. Lieu et al. [43]found that Medicaid-insured children of non-Englishspeakers with asthma clients of managed care practicesites with the highest cultural competence scores wereless likely to be underusing preventive asthma medica-tions based on parent report at follow-up (odds ratio:0.15; 95% confidence interval: 0.06–0.41 for the highestvs lowest categories) and had better parent ratings ofcare. O’Brien et al. [40] found that implementation oftheir NZ audit and quality improvement approach inmental health services enabled measured improvementsin clients’ and families’ involvement in health care andultimately improved recovery. Thus, cultural compe-tence improved the quality of healthcare and producedhealth outcomes.
National outcomesFinally, there were national policy outcomes from cul-tural competence interventions. For example, elementsof the quality improvement toolkit developed for hospi-tals by Chong et al. [36] were included in the AustralianCouncil of Healthcare Standards; this provided a furtherdriver for change. Wiley [18] demonstrated that therewas commitment to achieving a culturally-competentNZ national disability strategy, health service deliveryand workplace environment to benefit Maori peoplewith disabilities. The implementation of the strategyrequired collaboration across sectors, accountabilitystructures and effective evaluation tools, as well ascollaboration between Maori people with disabilitiesand their families, and the disability sector. As statedby Wiley [18], these “provide cautionary lessons thatIndigenous [and other ethnic and racial] peoples andgovernments in other countries can use in the devel-opment of culturally comprehensive… policy.”
How has cultural competence at a systems-level beenmeasured?Many of the intervention studies incorporated measure-ment instruments, but we also found three studies thatspecifically reported the development of quality im-provement and other indicators to measure culturalcompetence at systems levels. Of these, two were fromthe US and focussed on diverse ethnic and racial groups,and one from NZ which described the development ofclinical and cultural competence indicators for mental
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 14 of 19
health service improvements for Maori clients. Therigorous processes of indicator development and testingdescribed demonstrated the considerable resourceswhich have been invested into developing and pilotinginstruments to audit service performance across sectorswithin health [19, 46].A US study by Siegal et al. [47] described the develop-
ment of gold standard indicators that could be inte-grated within mental health services to measure theintegration of cultural competence into daily operations.The US Substance Abuse and Mental Health ServicesAdministration Centre developed, pilot tested and estab-lished the psychometric properties of the measures usingan expert panel to rate the measures according to theirimportance, feasibility, reliability and likely stage of im-plementation. The result was a checklist of 85 perform-ance measures, clustered within 12 domains:commitment of the organisation to cultural competence;integration of cultural competence within organisation;activities related to cultural competence in organisa-tional components; cultural competence advisory com-mittee; knowledge of cultural needs of target population;knowledge of cultural needs of users; linguistic capacity;services; cultural competence training and education; re-cruitment, hiring and retention; outcomes; and con-sumer and family education.Also targeting mental health services, O’Brien et al. [46]
described the development and validation of the NZ cultur-ally and clinically reliable bicultural audit tools to measurethe achievement of their mental health nursing practicestandards (evaluation of their implementation is describedabove). The CNCI audit tool was based on identification of‘critical events’ from nursing notes in consumer’s casenotes. Critical events were ‘non-sentinel rate- based clinicalindicators considered crucial to achievement of practicestandards which if not achieved, identified a need for im-mediate rectification [46]. Of 100 clinical indicator state-ments, 25 valid and reliable indicators were considered tobe crucial to the achievement of the NZ standards. Themeasures were also considered to be relevant to mentalhealth nursing internationally by providing a frame-work for improving practice against standards of ex-pected health care [40].Weech-Maldonado et al. [48] described the develop-
ment of the Cultural Competency Assessment Tool forHospitals (CCATH) to reflect the six US National QualityForum domains and 14 CLAS standards. An initial draftof the tool was then pilot tested to ensure ease of adminis-tration, comprehensibility and clarity, and to minimise re-sponse burden. It was revised, then field tested with fiveCalifornian and Pennsylvanian hospitals. The pilot testingresulted in the redesign and reduction of the survey to 28items based on four overarching domains: culturally com-petent care; human resource management; translation and
interpretation; and leadership, climate and strategies.. The28-item version was then focus tested with hospital stafffrom seven US states and interviews with hospital admin-istrators. Final revisions were then completed. The studyfound that the CCATH scales were reliable, and that theCCATH can be used to evaluate hospital performance incultural competency and identify improvements. Not forprofit hospitals had higher CCATH scores than for profithospitals.
The quality of available evidenceOnly one of the 12 intervention studies was rated ofstrong quality [43]. Four studies were rated of moderatequality, and seven of weak quality, with lack of consist-ently strong methodology across the majority of assessedcriteria. The quality of the three measurement studieswas not assessed.There were no randomised controlled studies. One
was a prospective cohort study, which used multipledata sources [43]; one a pre-post intervention cohortanalytic study [39]. Six provided evidence from con-trolled single timepoint audits or measures of culturalcompetence across multiple healthcare services [5, 39–42, 44, 45]. The remaining three studies used an explora-tory qualitative case study design [18, 36, 37].
LimitationsThe publications reviewed were identified using a rigoroussearch strategy which incorporated electronic databases,websites/clearinghouses and reference lists of reviews de-signed to discover peer and non-peer reviewed publica-tions. Therefore, it is highly likely that the studies in thisreview are representative of published cultural compe-tence research from the US, Canada, NZ and Australia.However, being a non-exhaustive search strategy, it is pos-sible some relevant publications were not found. Add-itionally, due to the breadth and complexity of systems-level cultural competency, this review only included stud-ies which explicitly aimed to improve, or included an indi-cator of cultural competency, possibly excluding studieswhich implicitly aimed to increase cultural competence.Given the complexity of systems-level approaches, studiesmay have used terms (such as diversity management,community engagement, or quality improvement for par-ticular health issues and population groups) which werenot included in our search. To further develop the evi-dence base on systems-based interventions to improvecultural competency and their impacts on relevant out-comes, it is important that studies use consistent termin-ology and explicitly address this in their aims.
DiscussionSystems approaches focus attention on how things worktogether to achieve an intended outcome and on
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 15 of 19
understanding of the ‘whole’ system [11]. By understand-ing how things are connected to each other within awhole entity, systems can be changed to produce betteroutcomes [11]. Derived from the thematic analysis of theinterrelated systems implementation principles, strat-egies, and outcomes identified in this systematic scopingreview, Fig. 3 below provides a preliminary genericframework for systems-level approaches to cultural com-petence; however the framework would require tailoringfor specific country/setting/populations and types ofhealth care services provided.All of the 12 intervention studies explicitly iterated
some core principles for implementing cultural compe-tence across healthcare systems. There was variationacross studies in the explication of important implemen-tation principles. The three highlighted in this reviewwere user engagement in the development and/or imple-mentation of strategies, organisational readiness, and de-livery across multiple sites. Other reviews of the culturalcompetence literature have also reported the value ofuser engagement to ensure congruence of strategies withthe cultural beliefs, values and practices of the affectedpopulation groups [4, 23, 27, 28]. However, studies inthis review provided innovative systematic ways toembed user engagement into healthcare. These includedproviding services that are based on the worldviews/par-adigms and control by the user group (e.g. [18, 37]),audit indicators for user’s consent, choice, mutual goal
setting and review; assessment by cultural advisors; spe-cific cultural preferences and access to these; and sup-port for access to traditional medicine/remedies (e.g.[19, 46]). The finding that some mainstream systemslevel interventions were less users (e.g. [18]), suggeststhat similar to other cultural competence strategies,achieving improvements in systems-level cultural com-petence approaches is dependent on early collaborationwith affected user groups and networks with user-controlled health services.The issue of organisational readiness/commitment has
also been identified in other reviews. It makes sense thatorganisational commitment is required for systems ap-proaches, given the complexity required to coordinateorganisational sub-systems to work together in a coordi-nated way to achieve culturally competent healthcareprovision [49]. Organisational commitment is also re-quired because cultural competence is just one of manyinvestment priorities facing healthcare organisations,and as [50] argued, the available financial incentives forcultural competence remain “not always clear or consist-ent”. Studies have suggested that the business potentialprovided by quality culturally competent care should berecognised in national cultural competence policies orstrategies by linking these with quality care incentivepayments [13, 50]. However, this systematic searchfound no intervention studies of the impact of financialincentives or the cost effectiveness of systems-level
Fig. 3 The implementation principles, strategies and outcomes of systems approaches to cultural competence
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approaches; hence it remains unclear whether systems-level cultural competence is a cost-effective strategy.An interesting review finding was that all intervention
studies of systems approaches were implemented acrossmultiple sites. This may be a result of efforts to scale upinterventions and for maximum reach and outcomes, orsimply due to a quest for stronger research outcomes.Further research is needed within singular health organ-isation and across multiple organisations.The two key types of intervention strategies to embed
cultural competence within health systems identifiedwere: audit and quality improvement approaches; andservice-level policies or strategies for cultural compe-tence. Audit and quality improvement approaches wereimplemented across diverse healthcare settings and rele-vant to improving healthcare practice against nationalbenchmark standards. They resulted in improved rela-tionships with local communities, increased health ser-vice access and frequency of visits, and the increasedinvolvement of clients and their families in their ownhealthcare and ultimately improved recovery followingmental illness [38, 40, 41]. Evaluations of service-levelpolicies and strategies for cultural competence includedcultural protocols or policies such as for interpretor ser-vices and translation of materials; workforce diversityand training; the tailoring of services or programs;providing a conducive organisational environment; advo-cacy; promoting national standards; and increasing ac-cess, participation and quality. Studies found thatcompliance with service level policies resulted inimproved client and family satisfaction and health out-comes such as improved compliance with medication [5,43]. These findings were extended by a promising recentpaper, published post- search, which found that a sys-temic, multifaceted and organisational level culturalcompetency initiative in two hospitals led to overall per-formance improvement, and outperforming of controlhospitals with respect to diversity climate [49].We could not determine the overall effectiveness of
systems-level interventions to reform health systems be-cause interventions were context specific to both thecountry, setting and population, and to the type ofhealth care services concerned. As well, there were ei-ther too few comparative studies, or studies did notexamine the same outcome measures. The preponder-ance of the literature about systems-level cultural com-petence interventions focussed on qualitative processevaluations, which explore the concepts and issues anddescribed the interventions and formative or intermedi-ate outcomes. It is likely that this is because the field isstill in the relatively early stages of development, there-fore there has not been enough elapsed time for follow-up studies and thus we do not know the full impact ofsystems-level cultural competence interventions on
healthcare services or their clients. Further, almost everyincluded study utilised a different measure, suggestingthat measures of cultural competence at systems levelrequire further elucidation. The domains of the mentalhealth performance measures for administrative and ser-vice entities [19] and more recent CCATH for applica-tion in hospitals [48] suggest that important outcomemeasures are: the cultural competence of clinical/healthcare (including consumer representation and care deliv-ery), human resource management (including workforcediversity and training), translation and interpretation ser-vices, and organisational commitment, leadership anddata management and quality improvement systems.The findings of this review suggested that also useful aremeasures of the health outcomes from interventions andbroader research translation to effect national or juris-dictional policies related to cultural competence inhealthcare. Documented measures (e.g. [46–48]) are cur-rently based on the perceptions of healthcare managers/administrators who are likely to have the required infor-mation to complete them [49]; however, given the im-portance of user engagement, there is a strong case forincorporation of patient perspectives in evaluating thecultural competence of healthcare interventions. In thecase of national level policy interventions, the samewould apply to the inclusion of policy makers and publicperspectives. The effectiveness of an intervention wouldbe evaluated based on improvement in outcome mea-sures. While tailoring across healthcare setting is neces-sary, as suggested by Brach and Fraser [50], theconsistent use and reporting of systems-level culturalcompetence measures within each setting type wouldprovide an important tool for comparable quality im-provement efforts to build a strong evidence base.Identified gaps in the literature included a need for
cost-effectiveness studies of systems approaches to im-prove cultural competence, further explication of the ef-fects of cultural competence on client experience, andstudies to further explore the ultimate effect of culturalcompetence on improving health outcomes and redu-cing ethnic and racially-based healthcare disparities.Doing so will require a concerted commitment to ad-equately funding the implementation and monitoring ofsuch initiatives [50, 51].
ImplicationsFew studies have previously examined the impact ofsystems-level approaches to cultural competence [22, 25,49]. While substantial evidence suggests that systems-level cultural competence should work, our finding of only12 intervention studies means that we cannot confidentlydetermine the extent to which systematic approaches tocultural competence are useful for improving clients’ ex-periences of healthcare and their health outcomes. Rather,
McCalman et al. International Journal for Equity in Health (2017) 16:78 Page 17 of 19
there is little guidance for healthcare organisations abouthow to identify what mix of cultural competence strategiesworks in practice; when and how to implement themproperly [22], or whether their investment in culturalcompetence interventions will have the intended effectson client experiences or health outcomes.
AbbreviationsACP Journal club: American College of Physicians Journal Club; AI /AN: American Indian and Alaska Native; AIATSIS: Australian Institute ofAboriginal and Torres Strait Islander Studies; ApaI-ATSIS: Australian Public AffairsInformation Service – Aboriginal and Torres Strait Islander Studies;ATSIHealth: Aboriginal Torres Strait Islander Health; Sahps: ConsumerAssessment of Healthcare Providers and Systems survey; CANZUSnations: Canada, Australia, New Zealand and the United States NZ: NewZealand; CASP: Critical Appraisal Skills Programme quality assessment tool;Step: Cultural Competence Assessment Tool for Hospitals; CINAHL: CumulativeIndex to Nursing and Allied Health Literature; CLAS: Culturally and LinguisticallyAppropriate Services; CNCI: Consumer Notes Clinical Indicators; CochraneDSR: Cochrane Database of Systematic Reviews; CQI: Continuous qualityimprovement; DARE: Database of Abstracts of Reviews of Effects; EBMReviews: Evidence Based Medicine reviews; Afpp: Effective Public HealthPractice Project quality assessment tool; FAMILY-ATSIS: Family Aboriginal TorresStrait Islander Studies; PARENTS: Primary Application Information Service;PPAQ: Professional Practice Audit Questionnaire; PRISM: Preferred ReportingItems for Systematic Reviews and Meta-Analyses; US: United States
AcknowledgementsThanks to Mary Kumjav who completed the initial searches.
FundingNot applicable.
Availability of data and materialsNot applicable – the review is based on published papers.
Authors’ contributionsAll authors were integrally involved in designing the review. All screened thepublications, rated their quality and read and approved the final manuscript.JM drafted the manuscript and CJ and RB critically reviewed it.
Competing interestsThe authors declare that they have no competing interests.
Consent for publicationNot applicable.
Ethics approval and consent to participateNot applicable.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Received: 29 December 2016 Accepted: 2 May 2017
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