organisational systems’ approaches to improving cultural

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

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McCalman et al. International Journal for Equity in Health (2017) 16:78 DOI 10.1186/s12939-017-0571-5

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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 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.


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


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


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


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


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


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


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


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

).


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]

✓✓

✓✓

✓✗

✓✓

✓✓

✓


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]

✗✓

✓✓

~✗

~✗

✗✗


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


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]


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


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


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


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,


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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