Cultural competence education for health professionals
Editorial Group: Cochrane Consumers and Communication Group
Published Online: 5 MAY 2014
Assessed as up-to-date: 10 FEB 2014
Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009405. DOI: 10.1002/14651858.CD009405.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 5 MAY 2014
Cultural competence education for health professionals aims to ensure all people receive equitable, effective health care, particularly those from culturally and linguistically diverse (CALD) backgrounds. It has emerged as a strategy in high-income English-speaking countries in response to evidence of health disparities, structural inequalities, and poorer quality health care and outcomes among people from minority CALD backgrounds. However there is a paucity of evidence to link cultural competence education with patient, professional and organisational outcomes. To assess efficacy, for this review we developed a four-dimensional conceptual framework comprising educational content, pedagogical approach, structure of the intervention, and participant characteristics to provide consistency in describing and assessing interventions. We use the term 'CALD participants' when referring to minority CALD populations as a whole. When referring to participants in included studies we describe them in terms used by study authors.
To assess the effects of cultural competence education interventions for health professionals on patient-related outcomes, health professional outcomes, and healthcare organisation outcomes.
We searched: MEDLINE (OvidSP) (1946 to June 2012); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) (June 2012); EMBASE (OvidSP) (1988 to June 2012); CINAHL (EbscoHOST) (1981 to June 2012); PsycINFO (OvidSP) (1806 to June 2012); Proquest Dissertations and Theses database (1861 to October 2011); ERIC (CSA) (1966 to October 2011); LILACS (1982 to March 2012); and Current Contents (OvidSP) (1993 Week 27 to June 2012).
Searches in MEDLINE, CENTRAL, PsycINFO, EMBASE, Proquest Dissertations and Theses, ERIC and Current Contents were updated in February 2014. Searches in CINAHL were updated in March 2014.
There were no language restrictions.
We included randomised controlled trials (RCTs), cluster RCTs, and controlled clinical trials of educational interventions for health professionals working in health settings that aimed to improve: health outcomes of patients/consumers of minority cultural and linguistic backgrounds; knowledge, skills and attitudes of health professionals in delivering culturally competent care; and healthcare organisation performance in culturally competent care.
Data collection and analysis
We used the conceptual framework as the basis for data extraction. Two review authors independently extracted data on interventions, methods, and outcome measures and mapped them against the framework. Additional information was sought from study authors. We present results in narrative and tabular form.
We included five RCTs involving 337 healthcare professionals and 8400 patients; at least 3463 (41%) were from CALD backgrounds. Trials compared the effects of cultural competence training for health professionals, with no training. Three studies were from the USA, one from Canada and one from The Netherlands. They involved health professionals of diverse backgrounds, although most were not from CALD minorities. Cultural background was determined using a validated scale (one study), self-report (two studies) or not reported (two studies). The design effect from clustering meant an effective minimum sample size of 3164 CALD participants. No meta-analyses were performed. The quality of evidence for each outcome was judged to be low.
Two trials comparing cultural competence training with no training found no evidence of effect for treatment outcomes, including the proportion of patients with diabetes achieving LDL cholesterol control targets (risk difference (RD) -0.02, 95% CI -0.06 to 0.02; 1 study, USA, 2699 "black" patients, moderate quality), or change in weight loss (standardised mean difference (SMD) 0.07, 95% CI -0.41 to 0.55, 1 study, USA, effective sample size (ESS) 68 patients, low quality).
Health behaviour (client concordance with attendance) improved significantly among intervention participants compared with controls (relative risk (RR) 1.53, 95% CI 1.03 to 2.27, 1 study, USA, ESS 28 women, low quality). Involvement in care by "non-Western" patients (described as "mainly Turkish, Moroccan, Cape Verdean and Surinamese patients") with largely "Western" doctors improved in terms of mutual understanding (SMD 0.21, 95% CI 0.00 to 0.42, 1 study, The Netherlands, 109 patients, low quality). Evaluations of care were mixed (three studies). Two studies found no evidence of effect in: proportion of patients reporting satisfaction with consultations (RD 0.14, 95% CI -0.03 to 0.31, 1 study, The Netherlands, 109 patients, low quality); patient scores of physician cultural competency (SMD 0.11 95% CI -0.63 to 0.85, 1 study, USA, ESS 68 "Caucasian" and "non-Causcasian" patients (described as Latino, African American, Asian and other, low quality). Client perceptions of health professionals were significantly higher in the intervention group (SMD 1.60 95% CI 1.05 to 2.15, 1 study, USA, ESS 28 "Black" women, low quality).
No study assessed adverse outcomes.
There was no evidence of effect on clinician awareness of "racial" differences in quality of care among clients at a USA health centre (RR 1.37, 95% CI 0.97 to 1.94. P = 0.07) with no adjustment for clustering. Included studies did not measure other outcomes of interest. Sensitivity analyses using different values for the Intra-cluster coefficient (ICC) did not substantially alter the magnitude or significance of summary effect sizes.
All four domains of the conceptual framework were addressed, suggesting agreement on core components of cultural competence education interventions may be possible.
Cultural competence continues to be developed as a major strategy to address health inequities. Five studies assessed the effects of cultural competence education for health professionals on patient-related outcomes. There was positive, albeit low-quality evidence, showing improvements in the involvement of CALD patients. Findings either showed support for the educational interventions or no evidence of effect. No studies assessed adverse outcomes. The quality of evidence is insufficient to draw generalisable conclusions, largely due to heterogeneity of the interventions in content, scope, design, duration, implementation and outcomes selected.
Further research is required to establish greater methodological rigour and uniformity on core components of education interventions, including how they are described and evaluated. Our conceptual framework provides a basis for establishing consensus to improve reporting and allow assessment across studies and populations. Future studies should measure the patient outcomes used: treatment outcomes; health behaviours; involvement in care and evaluations of care. Studies should also measure the impact of these types of interventions on healthcare organisations, as these are likely to affect uptake and sustainability.
Plain language summary
Cultural competence education for health professionals
This review assessed the effects of cultural competence education for health professionals. Five studies were included involving 337 health professionals (including general practitioners, primary care teams and counsellors) and 8400 patients. Three studies were conducted in the USA, one in Canada and one in The Netherlands. At least 3000 patients were from culturally and linguistically diverse (CALD) backgrounds and some of the health professional groups were also from CALD backgrounds. Due to differences in terminology and their cultural meanings, and the evolving nature of concepts and practices in this area, in this review we use the term 'CALD participants' when referring to minority, CALD populations as a whole. When referring to participants in included studies we describe them in the terms used by the relevant study authors.
The studies differed in how the education was provided and which outcome measures were used. Involvement in care improved in one study in The Netherlands measuring mutual understanding between minority CALD background patients and their doctors. Health behaviour also changed in one small study in the USA, in which women whose counsellors had received education were three times more likely to attend planned counselling sessions. However there was no evidence of an effect on a range of treatment outcomes or evaluations of care. None of the five included studies examined the effect of cultural competence education on healthcare organisations, or assessed adverse outcomes.
The review findings showed some support for cultural competence education for health professionals. These findings are tentative, however, as the quality of the evidence was low and more data are needed. Future research on cultural competence education for health professionals should seek greater consensus on the core components of cultural competence education, how participants are described and the outcomes assessed.
Schulungen in interkultureller Kompetenz für Gesundheitsfachleute
Dieser Review bewertet die Wirkung von Schulungen in interkultureller Kompetenz für Gesundheitsfachleute. Wir schlossen dazu fünf Studien mit 337 Fachpersonen (darunter Allgemeinmediziner, Teams für die medizinische Grundversorgung und Berater) und 8400 Patienten ein. Drei Studien wurden in den USA durchgeführt, eine in Kanada und eine in den Niederlanden. Mindestens 3000 Patienten und auch einige Gruppen von Gesundheitsfachpersonen hatten einen Migrationshintergrund ("culturally and linguistically diverse", CALD). Aufgrund von Unterschieden in der Verwendung und kulturellen Bedeutung bestimmter Begriffe sowie der Weiterentwicklung von Konzepten und Praktiken in diesem Bereich verwenden wir in diesem Review den Begriff „CALD-Teilnehmer“, wenn wir uns auf ethnisch und sprachlich verschiedene Minderheiten als Ganzes beziehen. Sind Teilnehmer in eingeschlossenen Studien gemeint, beschreiben wir sie mit den Begriffen, die auch die Autoren der entsprechenden Studie verwenden.
Die Studien unterschieden sich im Hinblick darauf, wie die Schulungen durchgeführt und welche Endpunkte gemessen wurden. Eine Studie in den Niederlanden untersuchte das gegenseitige Verständnis zwischen Patienten, die einer Minderheit mit CALD-Hintergrund angehören, und ihren Ärzten und zeigte, dass sich die Mitarbeit der Patienten verbesserte. In einer kleinen Studie in den USA veränderte sich auch das Gesundheitsverhalten. Hier erschienen Frauen, deren Berater geschult worden waren, mit dreimal höherer Wahrscheinlichkeit zu den geplanten Beratungssitzungen. Es gab jedoch keine Evidenz für eine Wirkung auf eine Reihe von Behandlungs-Endpunkten oder auf die Bewertung der Versorgung. Keine der fünf eingeschlossenen Studien untersuchte die Wirkung von Schulungen in interkultureller Kompetenz auf die Organisation der Gesundheitsversorgung oder bewertete negative Folgen.
Die Ergebnisse des Reviews unterstützen in gewissem Maße das Konzept von Schulungen in interkultureller Kompetenz für Gesundheitsfachleute. Jedoch handelt es sich dabei um vorläufige Ergebnisse, da die Qualität der Evidenz gering war und mehr Daten benötigt werden. Zukünftige Forschungsarbeiten zum Thema Schulungen in interkultureller Kompetenz für Gesundheitsfachleute sollten sich darum bemühen, die zentralen Bestandteile solcher Schulungen, die Beschreibung der Teilnehmer und die bewerteten Endpunkte stärker zu vereinheitlichen.
Anmerkungen zur Übersetzung
S. Schmidt-Wussow, Koordination durch Cochrane Schweiz.