Table 1 Publications which evaluated or provided measures for systems-level cultural competence interventions
Author, year & publication | Country and population | Health care setting | Type of intervention | Healthcare outcomes | Outcome indicator and/or measure | Study design | Study quality |
|---|---|---|---|---|---|---|---|
Chong, Renhard [36] Paper | Australia Aboriginal and Torres Strait Islander clients | Hospitals | The Improving the Culture of Hospitals Project developed and trialled an evidence based quality improvement ‘toolkit’ to support continuous quality improvement (CQI) for improving cultural sensitivity. Aboriginal staff were trained in the use of CQI technology. A national key stakeholder forum to explore research and implementation. | Hospitals that have improved cultural sensitivity share: relationships with Aboriginal communities and commitment to supporting the Aboriginal workforce. | Cultural sensitivity | Qualitative: Case studies—continuous quality improvement. | Moderate |
Freeman, Edwards [37] Paper | Australia Aboriginal and Torres Strait Islander Australians | An Aboriginal community controlled health care service and a state government-managed primary healthcare service. | Appraisals of the achievement of cultural respect following health- service-level strategies for culturally respectful care. | Implementation enablers: being grounded in a social view of health, advocacy and addressing social determinants; employing Aboriginal staff; creating a welcoming service; supporting access through transport, outreach, and walk-in centres; and integrating cultural protocol. Barriers: communication difficulties; racism and discrimination; and externally developedprograms. Service-level strategies are necessary for achieving cultural respect. | Staff and clients reported on cultural respect strategies, client experiences and barriers to cultural respect. | Two case studies—22 interviews with staff, an audit and survey, four community assessment workshops with 21 clients. | Weak |
Liaw, Hasan [38] Paper | Australia Aboriginal people | General practice and primary care organisations. | A cultural respect workshop provided orientation to the ‘Ways of Thinking Ways of Doing’ clinical re-design program to improve the cultural competency of General Practices. Support from a cultural mentor and a toolkit to guide activities to embed cultural respect into practice. | Identification of Aboriginality of new and existing clients, practice organisational arrangement, chronic disease risk factor recorded, health assessment billed, practitioners’ cultural quotient (cultural strategic thinking, motivation, behaviour). | A generic cultural quotient questionnaire and audit of Aboriginal clients identified, health checks done and clinical risk factors managed. | A pragmatic pre- and post- study using qualitative interviews and quantitative audit and survey. | Weak |
Lieu, Finkelstein [43] Paper | US Non-English speakers and clients with low literacy | Primary health care for Medicaidinsured children with asthma | Aimed to identify practice-site policies and features associated with quality of care for Medicaidinsured children with asthma. | At one-year follow up, clients of practice sites with the highest cultural competence scores were less likely to be underusing preventive asthma medications and had better parent ratings of care. | Health care cultural competence policies and procedures, client selfmanagement, empowerment and communication. | Telephone interviews with parents, surveys of practice sites and computerised databases. | Strong |
Noe, Kaufman et al. [42] Paper | US American Indian and Alaska Native (AI/AN) veterans | Access to appropriate care for AI/AN veterans | What organisational characteristics predict the provision of culturally competent services. | Only 15% services reported that their facilities provided traditional healing services. Mean scores were above the midrange on all organisational readiness to change measures. | Organisational readiness to change. Included items relating to AI/AN veterans’ services and projects. | Adapted Organisational Readiness to Change Assessment survey (needs, leadership, resources, and organisational climate scales). | Weak |
O'Brien, Boddy [39] Paper | NZ (but includes Australian standards) Maori and non- Maori mental health clients | Mental health services and mental health nursing | Health service audit measure using bicultural indicators for clinical records and cultural competence. | Wide variation across services, especially in informed consent, information about legal rights, and culturally safe and recovery-focussed care. | Health service Consumer Notes Clinical Indicators (CNCI) audit tool. | Four phased design: 1) focus groups with expert mental health nurses; 2) Delphi surveys; 3) a pilot study; 4) national audit of mental health services. | Moderate |
O'Brien, Boddy [40] Paper | NZ and Australia Indigenous peoples | Mental health care | Health service audit measure using bicultural indicators for clinical records and cultural competence -Ascertaining the degree to which quality improvement and monitoring systems are enhancing professional practice and client outcomes. | Variation in cultural competence of nursing practice across mental health services. The way in which services were delivered impacted upon clients’ ability to engage in the treatment processes and ultimately in their recovery; clients became more involved in their own care; kin and community became more involved in care. Indicators identified areas of clinical nursing care needing improvements. | Clinical indicators of critical events - Consumer Notes Clinical Indicators (CNCI) audit tool | Audit of mental health services | Moderate |
Reibel and Walker [41] Paper | Australia Aboriginal women | Ante natal services in WA | Client access or utilisation of health service by racial or ethnic group. | Only 9/42 audited services which reported utilisation by Aboriginal women had achieved a model of culturally responsive service delivery (i.e. incorporated Aboriginal specific antenatal protocols/programs, maintained access, employed Aboriginal Health Workers). The indicators established benchmarks for planning culturally appropriate antenatal services. | Access and quality of care of health services (general characteristics, risk assessment, treatment risk reduction and education, access and quality of care); indicators of cultural responsiveness. | Audit. Purposespecific audit tool administered through telephone interviews. | Weak |
Weech-Maldonado, Elliot [5] Paper | Ethnic/racial minority clients | Hospitals | Aimed to assess whether greater cultural competence in hospitals improves client experiences, particularly for ethnic/racial minority clients. | Greater cultural competence was positively associated with doctor communication, overall hospital rating and hospital recommendation. There were greater relative benefits for non-Englishspeaking non-Hispanic whites. | Client experience with care (communication with doctors and nurses, staff responsiveness, pain control, communication about medications, discharge information, cleanliness of hospital, quietness of hospital, recommendations of hospital to friends and family, overall rating) with hospital cultural competence and selfreported client race, ethnicity and language. | Exploratory single timepoint correlation between national Consumer Assessment of Healthcare Providers and Systems (CAHPS) hospital survey scores and Cultural Competence Assessment Tool for Hospitals (CCATH) scores. | Moderate |
Whelan, Weech-Maldonado [44] Paper | US and Australia Diversity management by Senior | Hospitals | Comparative evaluation of how diversity management is enacted in hospitals across two countries. | Both Australian and US hospitals can do much more to implement best practices in diversity management. Australian hospitals scored higher on organisational change indicators; US hospitals on human resource indicators but there was more similarity than difference. Despite 30–40 years of “multicultural health”, neither has achieved best practice. | Diversity management activities (planning, stakeholder satisfaction, diversity training, human resources, health care delivery, organisational change, diversity performance, external and internal influences on racial/ethnic diversity initiatives). | Comparative exploratory study based on single point in time surveys. | Weak |
Whitman and Davis [45] Paper | US Diversifying client population | Cross- 101 general medical and surgical hospitals in Alabama sample of 53 respondents. | Examined the awareness of and preparedness for the diversifying client population through their hospital cultural and linguistic competence practices. | Hospitals are taking initial steps to meet the needs of the diversifying population, but have a long way to go to meet National Standards for culturally and linguistically appropriate services in health care. | Hospital adherence to national standards. | Self-report questionnaires to hospital chief executive officers on the measures and resources that the hospitals currently use to meet cultural and linguistic | Weak |
Wiley [18] Paper | NZ Maori who are disabled | Knowledge and attitudes to cross-cultural disability care. | Consumers, carers, service providers and policy makers’ knowledge and attitudes. | Conflict between Indigenous worldviews framed within a mainstream service; Need for increased coordination and collaboration, workforce development, resources and information development, and community engagement. | Disability care and participation in services. | Semi-structured interview instrument, focus groups. | Weak |
O'Brien, O'Brien [46] Paper | NZ Maori and non-Maori mental health clients | Mental health services and mental health nursing. | Health service audit tool using bicultural indicators for clinical records and cultural competence. | No health care outcomes reported (paper describes development of indicators by expert committee). | Health care delivery | Development of Consumer Notes Clinical Indicators (CNCI) for clinical records and cultural competence and Professional Practice Audit Questionnaire (PPAQ) self-report survey. | |
Siegel, Haugland [47] Paper | US African American, Hispanic, Asian and American Indian | Mental health services | Audit tool to measure the cultural competence of health services. | No health care outcomes reported (paper describes development by expert committee). | Health care delivery | Development of health service benchmarking audit tool and self-report survey. | |
Weech-Maldonado, Dreachslin [48] Paper | US Hospitals | Hospitals in California | Pilot tested an initial draft of the Cultural competency assessment tool for hospitals (CCATH), revised then field tested it with a sample of hospitals. | The CCATH can be used to evaluate hospital performance in cultural competency and identify improvements. Not for profit hospitals had higher CCATH scores than for profit. | The CCATH scales were reliable. | Development of Cultural Competency Assessment Tool of Hospitals (CCATH). |