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Cultural competence education for health professionals

  1. Lidia Horvat1,2,*,
  2. Dell Horey3,
  3. Panayiota Romios4,
  4. John Kis-Rigo2

Editorial Group: Cochrane Consumers and Communication Group

Published Online: 5 MAY 2014

Assessed as up-to-date: 10 FEB 2014

DOI: 10.1002/14651858.CD009405.pub2


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.

Author Information

  1. 1

    Department of Health, Sector Performance, Quality and Rural Health Branch, Melbourne, VIC, Australia

  2. 2

    La Trobe University, Cochrane Consumers and Communication Review Group, School of Public Health and Human Biosciences, Bundoora, Vic, Australia

  3. 3

    La Trobe University, Faculty of Health Sciences, Bundoora, VIC, Australia

  4. 4

    Australian Red Cross, Carlton, VIC, Australia

*Lidia Horvat, Sector Performance, Quality and Rural Health Branch, Department of Health, 50 Lonsdale Street, Melbourne, VIC, 3000, Australia. lidia.horvat@health.vic.gov.au.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 5 MAY 2014

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Characteristics of included studies [ordered by study ID]
Harmsen 2005

MethodsStudy design: Cluster RCT; RCT randomisation at GP level with outcome measurements at patient level

Location: The Netherlands

Setting: GP Clinics

Study aims: 1) To decrease inequalities in care provided between "Western" and "non-Western" patients; 2) To assess the effectiveness of an educational intervention on intercultural communication aimed to decrease inequalities in care provided between "Western" and "non-Western" patients

Inclusion/exclusion criteria: GPs with a practice population of at least 25% of patients with a "non-Western" country of origin were invited to participate. Inclusion criteria for patients were a GP consultation on random days in February, May and November 2000. Adolescents aged 13 to 17 years excluded.

Informed consent obtained: Unclear

Ethical approval: Yes. University Ethical Commission of the Erasmus Medical Centre, University Medical Centre in Rotterdam (MEC163.267/1997/122)

Funding source and amount: Theia Foundation of Zilverenkruis Achmea (JvH/agbrf640), ZonMW: Netherlands Organisation for Health Research and Development. Fonds Aachterstandswijken, Districts Huisartsen Vereniging Rotterdam (Besluit FAW:98/09/H-O). Stichting Bevordering van Volkskrach (MK/avg/000–001). Amount not stated.

Statistical methods and their appropriateness: Multilevel multiple regression techniques adjusted for baseline values

Consumer involvement : None reported


ParticipantsHealth professional participants

Type and number: 38 GPs (19 in each group)

Age: Not reported

Gender: 30 males and 8 females

Ethnicity: Process of determining GP ethnicity was not described. 2/38 GPs were reported to have "a non-Dutch (but Western) ethnic background" and "had lived and worked for more than 20 years in The Netherlands".

Professional qualifications: GPs - general physicians

Languages: Not reported

Previous cultural competence GP training: not reported

Method of recruitment: GPs were approached by letter followed by one repeat request by telephone

Patient participants

Type and number: 369 CALD patients described as "non-Western" patients. Total study sample = 986 patients (includes 614 Western patients)

Age: Adolescents aged 13 to 17 excluded. Parents of children up to 12 years interviewed. Non-Western patients included 7 aged 0 to 12 years (1.9%); 107 aged 18 to 29 years (29.2%); 177 aged 30 to 49 years (48.4%); 66 aged 50 to 65 years (18%); 9 aged over 65 years (2.5%)

Gender: Male = 142 (38.8%), Female = 224 (61.2%) (Western M = 223 [36.5%] and F = 388 [63.5%])

Ethnicity: Cultural background was assessed using a validated patient cultural background scale (Harmsen 2005) The "non-Western group" (comprising "mainly Turkish, Moroccan, Cape Verdean and Surinamese patients") and a '.Western' group (comprising "mostly Dutch but also some patients from other Western European, North American, Canadian and Australian origin".

Professional Qualifications: Patients - no statistical tests reported comparing education levels of non-Western and Western patients, however comparison shows significant difference in education levels (χ2= 23.5, P value < 0.001). Non-Western patients were more likely not to have completed primary school (8.0% cf 3.2% of "Western" patients (OR 0.38, 95% CI 0.20 to 0.69)).

Languages: 20.8% of non-Western patients reported to speak no Dutch or to have poor self-perceived proficiency, 32.5% reported average proficiency and 46.7% reported good proficiency

Method of recruitment: Not described but needed to attend for a consultation on random days

Estimated average cluster sizes: 16 for all participants and 10 for CALD participants only


InterventionsEducation intervention: 2.5 day program for GPs with follow-up session after 2 weeks, and 12 min video-taped instruction for their patients in waiting room.

Aim of intervention: To improve intercultural communication between GPs and their patients
Comparison: No intervention


OutcomesPrimary outcome categories

Treatment outcomes: None reported

Health behaviour: None reported

Involvement in care: Mutual understanding between GP and patient [primary outcome]*

Evaluations of care: Patient satisfaction with consultation*; Patient’s feeling that consideration shown; Patient’s perception of quality of care

Secondary outcome categories

Health professionals

Knowledge and understanding: None reported

Consultation processes: None reported

Evaluation of processes and outcomes: None reported

Healthcare organisations

Adverse events: None reported

Quality and safety measures: None reported

Service utilisation: None reported

Health economic outcomes: None reported

Other outcomes: None reported.

*= selected outcome. The rationale for the selection of outcomes for each category is reported in  Table 4.


Conceptual frameworkFocus of the intervention was to improve intercultural communication between GPs and their patients. 

1.  Education content:· Knowledge addressed: culture, cultural competence; models of health and illness; socio-cultural context of health disparities; specific theoretical model.  Unclear if epidemiology; social determinants or constructs of racism and prejudice addressed.

Assessment and application of knowledge to relevant environmental, population, organisational and professional and systemic contexts addressed.

Skills included cultural self-assessment and communication skills; collaboration skills; non-verbal communication skills. Unclear if skills in deconstructing stereotypes or trust and partnership establishment included.

2.  Pedagogical approach: Teaching and learning method: Description for the GP intervention was based on Pinto’s three step method but the patient intervention is not. Key theoretical construct and principles: reported as Kleinman’s theory of exchanging explanatory models.

3.  Structure:

Delivery: Face-to-face

Format: 2.5 day program with follow-up session after 2 weeks

Frequency and duration: Once only

Method of assessment: Unclear

Method of evaluation: Unclear

Organisational support: Unclear

Participation: Voluntary

4.  Participant characteristics:

Target audience: GPs and their patients

Who delivered the intervention: Not reported


NotesContact with author: Yes - additional information regarding education intervention. Only study that included an intervention for patients.

Participant numbers in each group were computed from Figure 1 (Flowchart of levels of response of patient population [p345]) for baseline and the third measurement (T3). At baseline, there were data for 176 participants in the intervention group, which included 35% "non-Western" participants (62) and 175 participants in the control group, including 33% "non-Western" participants (58). At T3 data were reported for 151 participants in the intervention group (41% "non-Western" [62]) and 151 participants in the control group (31% "non-Western" [47]). At T1 there were 120 "non-Western" patients (Intervention = 62 and Control = 58) and at T3 there were 109 "non-Western" patients (I = 62 and C = 47).

The authors reported: "The effect on mutual understanding and perceived quality of care was analysed using multilevel multiple regression techniques adjusted for baseline values.…Differences between the two patient groups were tested by means of regression analysis with adjustment for baseline fraction, weighing cases (physicians) with the total number of patients seen at baseline plus at the measurement concerned." Thus it was judged that the study authors had taken clustering into account in their analyses so subsequent adjustments were not undertaken.

Risk differences at 6 months were taken from  Table 4 (p 348), which reported difference between intervention and control groups as percentage of range adjusted for baseline with 95% CIs. Mutual understanding (involvement in care outcome) was reported as a continuous outcome with a 2% range and 11% difference to give MD 0.21, 95% CI 0.002 to 0.422. This difference was reported as adjusted for baseline differences. Neither confidence intervals nor standard deviations were reported for baseline data.

Patient satisfaction with consultation (evaluation of care outcome) was reported as a dichotomous outcome with RD 0.14 95%CI -0.031 to 0.305. SDs were calculated using RevMan.

Authors' conclusions: "Our intervention on intercultural communication for both GPs and patients was effective in the non-Western patient group, which supports our aim of Western patient group, which supports our aim of decreasing differences in outcomes of care between Western and non-Western patients. Both mutual understanding and perceived quality of care improved."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information given about sequence generation process

Allocation concealment (selection bias)Unclear riskInsufficient information about allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNo blinding of GPs but authors state "Patients were ignorant about the group assignment of their GP". Patients seeing intervention GPs also exposed to a 12-min video-taped instruction prior to doctor visit, which was considered possibly to influence their expectations and assessments.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskInterviewers, experts and research assistants who conducted preliminary data processing were blinded to intervention assignment (p 344).

Incomplete outcome data (attrition bias)
All outcomes
High riskMore than half the non-Western participants dropped out (55% of total failed home interviews).

Selective reporting (reporting bias)Unclear riskInsufficient information to determine

Other biasUnclear riskThere was an imbalance in attrition between the intervention and control groups between T1 and T3. No non-Western patients were lost from the intervention group but the control group reduced from 58 to 47 (16% loss).

Majumdar 2004

MethodsStudy design: RCT randomisation at healthcare provider level

Location: Southern Ontario, Canada

Setting: Two community home care agencies and one hospital

Study aims: 1) To determine the effectiveness of cultural sensitivity training on the knowledge and attitudes of healthcare providers; 2) To assess the satisfaction of patients from different minority groups with healthcare providers who receive this training

Inclusion/exclusion criteria: No criteria reported for providers. Patients were eligible if they received care from the selected healthcare providers (those who did and did not participate in the cultural sensitivity training). Patients with history of cognitive impairment excluded

Informed consent obtained: Yes

Ethical approval: Unclear

Funding source and amount: Not reported

Statistical methods and their appropriateness: Not reported

Consumer involvement (in the design of study and/or intervention; in delivery of intervention; in evaluation of intervention; in interpretation of study findings): Not reported


ParticipantsHealth professional participants

Type and number: 114 healthcare professionals (nurses and homecare workers)

Mean age: 40.09 (SD 11.03) experimental group; 42.57 (SD 10.15) control group

Gender: Not reported

Ethnicity: The majority "identified themselves as Canadians, and had parents of either Canadian or British origin". It is noted that healthcare professionals from minority groups were included in the study but this is not described in detail.

Professional qualifications: Mean education 14.72 (SD 2.85) years experimental group and 14.54 (SD 2.77) years control group

Language(s): Care providers: English (less than 15% for both groups spoke French as their native language)

Previous cultural competence care provider training: not reported

Method of recruitment: Unclear. "All study participants were financially compensated for time spent in training and measurement."

Patient participants

Type and number: 133 patients of two home care agencies and one hospital (the purpose of the study was to assess outcomes "of patients from different minority groups" but these are not described.) Unable to determine number of CALD patients from available data.

Mean age: not reported

Gender: Male = 35%, female = 65% in both groups

Ethnicity: "Both the experimental and control groups identified their ethnicity as 'Canadian', 'British' or 'European'". The study was reported to be conducted in urban area where approximately 25% of population is foreign-born.

Professional qualifications: high school or intermediate level (grades 5 to 8) reported as highest level of education by 77.2% of experimental group and 78.4% of control group.

Language(s): "the first language spoken by both groups was English"

Method of recruitment: Patients volunteered but no further details are provided


InterventionsEducation intervention: 36-hour program targeting nursing and home care providers and their patients.  Used a number of validated tools (6 tools)

Comparison: No intervention

Aim of intervention: To change provider attitudes, patient satisfaction and accessibility to services (implied only)


OutcomesPrimary outcome categories

Treatment outcomes: Client health outcomes (OARS); Physical & Mental Health Assessment

Health behaviour: None reported

Involvement in care: Expenditure of Health Care & Social Services

Evaluation of care: Patient satisfaction [primary outcome] Client Satisfaction Questionnaire

Secondary outcome categories

Health professionals

Knowledge and understanding: Improved understanding cultural attitudes [primary outcome]

Consultation processes: None reported

Evaluation of processes and outcomes: None reported

Healthcare organisations

Adverse events: None reported

Quality and safety measures: None reported

Service utilisation: None reported

Health economic outcomes: None reported

Other outcomes : These were difficult to determine clearly, but reported instruments suggested that the following were included: provider cultural attitudes (open-mindedness vs closed-mindedness). This was measured with Ego Defensiveness, Open-Closed Mindedness and Nurses Attitude Toward Culturally Different Patients Questionnaire. Other instruments used to measure outcomes included: Rokeach Dogmatism Scale and Self-Assessment of Cultural Awareness.


Conceptual frameworkEducation intervention focused on improving cultural sensitivity.

Insufficient information across the domains of our conceptual framework.  Unable to obtain further information. 

1.  Education content: Knowledge addressed: cultural awareness and cultural sensitivity included but other topics not reported.

Assessment and application of knowledge not reported.

Skills in cultural self-assessment and communication included but unclear if deconstructing stereotypes or trust and partnership establishment included. Used a number of validated tools and questionnaires.

2.  Pedagogical approach: not reported

3.  Structure:

Frequency and duration: 36 hour program

Delivery: Unclear

Format: Unclear

Method of assessment: Unclear

Method of evaluation: Unclear

Organisational support: Unclear

Participation: Voluntary

4.  Participant characteristics:

Target audience: nursing and home care providers and their patients

Who delivered the intervention: not reported


NotesContact with author: Yes - but no additional information provided

Useable data relating to the review outcomes could not be extracted from this study

Authors' conclusions: The study showed “the benefits of cultural sensitivity training and indicated the feasibility of promoting awareness among healthcare providers by using culture-sensitive interventions.

Structured cultural sensitivity training programs could potentially help reduce cultural disparities in the healthcare system. The success of this training program is marked by the fact that the changes reported by the providers were not temporary.

This study also indicated that attitudinal change is a long­term process. The changes in providers were associated with improved functional outcomes among their patients."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information given about sequence generation process

Allocation concealment (selection bias)Unclear riskNo information given about allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes
High riskNo blinding of participants, and outcomes judged likely to be influenced by lack of blinding

Blinding of outcome assessment (detection bias)
All outcomes
High riskNo blinding of outcome assessment, and outcome measurement likely to be influenced by lack of blinding

Incomplete outcome data (attrition bias)
All outcomes
High riskHigh rates of attrition across both patient and healthcare professional groups. More patients from control group dropped out of the study and more healthcare professionals dropped out of the intervention group compared to the control group

Selective reporting (reporting bias)High riskNot all pre-specified outcomes were reported but selected items from pre-specified instruments with statistically significant differences were reported

Other biasUnclear riskInsufficient information to determine

Sequist 2010

MethodsStudy design: Cluster RCT - Randomisation at primary care team level

Location: Massachusetts, USA

Setting: 8 Ambulatory Health Centres

Study aim: 1) To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for "black" patients; 2) To assess whether these efforts reduced racial differences between "white" and "black" patients for these 3 measures of diabetes care.

Inclusion/exclusion criteria: Primary care teams within a multispecialty group practice in eastern Massachusetts that had instituted key components of the Chronic Care Model including a common electronic medical record system

Informed consent obtained: Written informed consent obtained from clinicians, and a waiver of informed consent approved for patients

Ethical approval: Yes. The Harvard Pilgrim Health Care and Brigham and Women’s Hospital Human Studies Committees

Funding source and amount: Grant from Robert Wood Johnson Foundation (amount not stated)

Statistical methods and their appropriateness: Intention-to-treat analyses. Used generalized estimating equations to adjust SEs for clustering by primary care team and then fit multivariate ordinal logistic regression models to predict differences in clinician responses
Consumer involvement: In the development of the intervention 1084 diabetic patients responded to a survey to assess their perceived needs for information in a number of domains: right foods choice; weight loss; regular exercise; stress management; and understanding medications


ParticipantsHealth professional participants

Type and number: 124 primary care clinicians in 31 primary care teams (comprising 91 primary care physicians and 33 nurse practitioners [NPs] or Physician Assistants [PAs]) Gender: (reported for clinicians only) Female: Physicians = 60%. NPs or PAs = 94%

Ethnicity: The process for determining health professional ethnicity was not reported, however. clinicians were described as "white" (82%),"Asian" (14%), "black" (2%), and "Hispanic" (2%).

Professional qualifications: Physicians reported to have average of 19.0 years clinical experience and NPs or PAs as 18.7 years experience

Language(s): Not reported

Previous cultural competence training: Unclear

Method of recruitment: Not reported

Patient participants

Type and number: 2699 "black" patients (36%, population used in this review). Total sample = 7557 diabetic patients (4858 "white" patients [64%])

Age: (reported for all patients, "black" and "white" combined) Mean 62.5 years (SD 13.5) intervention group; 62.3 years (13.2) control group and 4858 "white" patients 4858 (64%)

Gender: Not reported

Ethnicity: "Patient race was collected by self-report during the patient registration process" and were described as either "black" or "white" diabetic patients.

Professional qualifications: Education levels described mainly at high school and above

Language(s): Not reported

Estimated average cluster sizes = 944 for all participants and 337 for "black" participants only

Method of recruitment: Used data from patient records. No recruitment


InterventionsEducation intervention: Two-day training program (consecutive) for primary care physicians, nurse practitioners and physician assistants (physicians attended only one day). Delivered by training experienced firm

Comparison: No intervention

Aim of intervention: To help primary care teams meet specified goals of: understanding attitudes of trust and bias; increase their knowledge of health disparities; gain skills to improve delivery of cross-cultural care


OutcomesPrimary outcome categories

Treatment outcomes: Rate of achieving clinical control targets within preceding 12 months for: Haemoglobin level (HbA1c level less than 7.0%); LDL cholesterol level less than 2.59 mmol/L [100 mg/dL])*; Blood pressure less than 130/80 mm Hg) [primary outcomes]

Health behaviour: None reported

Involvement in care: None reported

Evaluation of care: None reported

Secondary outcome categories

Health professionals

Knowledge and understanding: Clinician acknowledgement of racial differences in the quality of diabetes care for "black" clients over 12-month period across health services, within health centre*; among their patients [primary outcome]

Consultation processes: None reported

Evaluation of processes and outcomes: None reported

Healthcare organisations

Adverse events: None reported

Quality and safety measures: None reported

Service utilisation: None reported

Health economic outcomes: None reported

Other outcomes : None reported

*= selected outcome. The rationale for the selection of outcomes for each category is reported in  Table 4.


Conceptual frameworkIntervention can be mapped against most domains of our conceptual framework.

1.  Education content: Knowledge included culture, cultural competence, socio-cultural context of health disparities, epidemiology and social determinants, constructs of racism and prejudice and specific theoretical models such as explanatory models of health and illness; patient centeredness; consumer participation.

Unclear if models of health and illness included.

Assessment and application of knowledge to relevant environmental, population, organisational and professional and systemic contexts addressed.

Skills: Skills building around effective cross-cultural communication and to provide action-oriented tools to address disparities. Included communication skills and trust and partnership establishment. Unclear if skills in cultural self-assessment or deconstructing stereotypes included.

2.  Pedagogical approach: Teaching and learning method described but key theoretical construct and principles unclear. An underlying principle of the educational design was clearly grounding in the actual experience of black patients. The development of educational materials and recommendations tailored to caring for black patients were derived from patient focus groups and surveys. Clinicians were also given stratified patient data throughout the study.

3.  Structure:

Delivery: Face-to-face and off site , included a mix of lectures, group discussions, and community engagement activities

Format: 2 day program for Nurse practitioners and physician assistants (1 day only for physicians)

Frequency and duration: Once only

Method of assessment : Unclear

Evaluation method: Unclear

Organisational support: Links to organisational policies and procedures described. Embedded within professional development program with formal mentoring and peer support processes and professional accreditation points available. Monthly "race-stratified reports" complied and given to physicians, and monthly performance feedback reports provided

Participation: voluntary

4.  Participant characteristics:

Target audience: Primary care physicians, nurse practitioners and physician assistants

Who delivered the intervention: Harvard Pilgrim Health Care Foundation


NotesContact with author: Yes - additional information relating to education intervention

Study authors report adjusting for clustering, but the ICC used was not reported

Authors' conclusions: "We demonstrate that an intensive 12-month program of cultural competency training and race-stratified performance feedback increased primary care clinician awareness of the presence of racial disparities. However, we could not attribute any improvement in important measures of disease control for black diabetic patients to the program."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information given about sequence generation process

Allocation concealment (selection bias)Unclear riskNo information given about allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes
Low riskUnclear if blinding of participants occurred but patient treatment outcomes judged unlikely to be influenced by lack of blinding

Blinding of outcome assessment (detection bias)
All outcomes
Low riskPatient treatment outcomes obtained from medical records. Clinician outcomes self-reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo missing data for patient treatment outcomes. (Possible 20% attrition in clinician numbers)

Selective reporting (reporting bias)Unclear riskInsufficient information to determine

Other biasLow riskSample adjusted for clustering by primary care team but inter-correlation coefficient not reported

Thom 2006

MethodsStudy design: Cluster RCT

Location: California, USA

Settings: 4 locations - Academic Medical Centre-based Family Practice; Community-based Practice; Rural Family Medicine Residency Program; Inner-city Family Medicine Residency Program

Study aims: To develop and evaluate a brief cross-cultural curriculum for resident and practicing physicians based on a model of culturally competent physician behaviors, and to evaluate the training plus feedback compared to feedback alone with respect to changes in patient-reported physician behaviors, patient satisfaction, patient trust in his or her physician, and disease-specific patient health outcomes

Inclusion/exclusion criteria: Physicians worked at one of four sites. Patients of physicians recruited to study were eligible if they had been seen in the past 12 months and had at least one visit for diabetes (ICD 9 code 250) or hypertension (ICD 0 code 401 to 405) that could be identified from computerized billing and encounter records

Informed consent obtained: Unclear but implied

Ethical approval: Yes. Approved by Institutional Review Boards at Stanford University and at the University of California

Funding source: California Endowment, grant #19991083 (amount not stated)

Statistical methods: Baseline characteristics compared using Chi2 test for dichotomous or categorical variables and Student's t-test for continuous variables. Mean changes in patient outcome measures from baseline to end of the study were calculated for each group and compared between groups using multiple analysis of variance (MANOVA) to adjust for differences in patient and physician characteristics and for differences in patient and physician characteristics and levels of each outcome variable at baseline. No adjustment for clustering reported.
Consumer involvement: None reported


ParticipantsHealth professional participants

Type and number: 53 primary care physicians (23 in training & feedback group and 30 in feedback only group)

Age: Mean = 39.2 years

Gender: 24 females in total (45%); including 41% (9) of intervention group (Training & Feedback) and 52% (15) in the control group (Feedback only group) (figures computed from percentages)

Ethnicity: There was no information about how ethnicity was determined. The physician sample was described as comprising 38 "White" or "Caucasian" (the study uses these terms synonymously for physicians) (72%, I:C = 64%: 80%); 8 "Latino" (27%: 7%); 5 "Asian American" (9%: 10%); 1 "African American" (0%: 3%) ; and 2 others (not described further)

Professional qualifications: 33 family physicians in practice (62%) and 20 family medicine residents (38%)

Language(s): 43 another language (in addition to English), 34 spoke Spanish

Previous cultural competence training: Not reported

Method of recruitment: On site directly by one of the study investigators

Patient participants

Type and number: 429 patients with at least one visit for diabetes (ICD 9 code 250) or hypertension (ICD 0 code 401 to 405) were included in the trial. There were 247 in the intervention group (Training and Feedback) including 173 "non-Causcasian" patients and 182 in the control group (feedback only) including 142 "non-Caucasian" patients. The total number of "non-Causcasian" patients = 315 (73%)

Age: Mean = 54.9 years (SD = 11.6) (Training & Feedback group), 62.1 years (SD = 11.4) (Feedback only group)

Gender: Female 48.8% (Training & Feedback group), 63.2% (Feedback only group)

Ethnicity: Assignment of ethnicity is unclearly reported although the study reports that participants in one group were more likely to "self-identify as Latino or Asia". The groups in the study sample were comprised of the following:"Caucasian non-Hispanic" (21.9% feedback only and 30.0% training and feedback), "Latino/Hispanic" (28.9% and 25.3%), "African-American" (20.3% and 23.2%), "Asian" (23.0% and 13.1%) and "Other" (5.9% and 8.4%)

Professional qualifications: Not reported

Language(s): Recruitment letters sent to patients were in English, Spanish, and Chinese

Other: Participating patients were paid $10 for returning the baseline questionnaire, and $5 for each follow-up questionnaire

Estimated average cluster sizes: 107 for all participants and 79 for CALD participants only

Method of recruitment: Patients recruited by mail, with a follow-up phone call if needed after the second mailing. Recruitment letter and screening questionnaire in English, Spanish and Chinese. Participating patients were paid $10 for returning baseline questionnaire and $5 for each follow-up questionnaire


InterventionsEducation intervention: Short education intervention (3 hours) for GPs.

Comparison: No intervention

Aim of intervention: 1) to expand knowledge of ethnic patients (knowledge and belief systems; 2) to enhance communication skills for cultural competency; 3) use of interpreters and cultural brokering


OutcomesOutcomes for CALD participants were not reported separately

Primary outcome categories

Treatment outcomes: Change in patient weight*; systolic blood pressure; glycosylated haemoglobin [primary outcomes]

Health behaviour: None reported

Involvement in care: None reported

Evaluation of care: Patient satisfaction with consultation; patient perception of physician consideration; Patient Reported Physician Cultural Competency (PRPCC) Scale [primary outcome]*

Secondary outcome categories

Health professionals

Knowledge and understanding: None reported

Consultation processes: None reported

Evaluation of processes and outcomes: None reported

Healthcare organisations

Adverse events: None reported

Quality and safety measures: None reported

Service utilisation: None reported

Health economic outcomes: None reported

Other outcomes: Patient trust in the physician

*= selected outcome. The rationale for the selection of outcomes for each category is reported in  Table 4.


Conceptual frameworkExplicitly describes content of education intervention and reports on most domains of conceptual framework.

1.  Education content: Knowledge included culture, cultural competence, models of health and illness, epidemiology; and social determinants and specific theoretical models such as explanatory models of health and illness; patient centeredness; consumer participation. Socio-cultural context of health disparities and constructs of racism and prejudice not reported.

Assessment and application of knowledge to relevant environmental, population, organisational and professional and systemic contexts addressed.

Skills included communication skills; collaboration skills; non-verbal communication skills, deconstructing stereotypes, and trust and partnership establishment.

Unclear if cultural self-assessment included.

2.  Pedagogical approach: Teaching and learning method described but and key theoretical construct and principles unclear. Adapted from a model developed by one of the co authors. Peer education, adult learning principles and application of LEARN mnemonic to the patient interview (Listen, Explain, Acknowledge, Recommend, Negotiate)

3.  Structure:

Delivery: Face-to-face

Format: Offered as either single half-day training session or 3 separate 1 to 1.5 hour sessions

Frequency and duration: Once only

Method of assessment: Unclear

Evaluation method: Post-training evaluation rated on 5-point Likert-scale

Organisational support: Unclear

Participation: Voluntary  

Participant characteristics:

Target audience: GPs

Who delivered the intervention: GP instructors included authors of the paper, two other physicians with expertise in cross-cultural care, and experts in training and use of interpreters


NotesContact with author: Yes - additional information re education intervention

Comparison of changes in outcomes (means and standard deviations) are reported in  Table 5, and participant numbers in each group provided in  Table 4. ( Table 5 is assumed to be mislabelled, reporting the numbers of physicians in each group rather than the number of patient participants).

Outcomes were not reported for the "non-Caucasian" participants separately so all outcomes are for all participants. The average cluster size was assumed to include 107 participants (28 "Caucasian" and 79 "non-Caucasian")

Numbers in the intervention and control groups for the continuous outcomes - change in patient weight (treatment outcome) and Patient Reported Physician Cultural Competency (PRPCC) evaluation of care outcome) were adjusted based on the design effect (DEFF=1+(1-M)ICC, where M is the average cluster size).

We used the estimated ICC of 0.2 (from Harmsen 2005 sample size calculations) as this was the only ICC we identified for this type of intervention. However this ICC is based on an average cluster size of 20. Sensitivity analyses were conducted with ICCs of 0.01, 0.02, and 0.05 using data from a study of ICCs (Campbell 2000).

The sensitivity analyses did not substantially alter the magnitude or significance of the summary effect size for either outcome.

Treatment outcome (Change in patient weight):

1) ICC = 0.2; DEFF = 22.2; ESSIntervention = 11 ESSControl = 8

SMD = 0.06 (95% CI -0.85 to 0.97)

2) ICC = 0.02; DEFF = 3.12; ESSIntervention = 79 ESSControl = 58

SMD = 0.07 (95% CI -0.27 to 0.41)

3) ICC = 0.01; DEFF = 2.06; ESSIntervention = 119 ESSControl = 88

SMD = 0.06 (95% CI -0.25 to 0.38)

4) ICC = 0.05; DEFF = 6.3; ESSIntervention = 39 ESSControl = 29

SMD = 0.07 (95% CI -0.41 to 0.55)

Evaluation of care (Patient Reported Physician Cultural Competency):

1) ICC = 0.2; DEFF = 22.2; ESSIntervention = 11 ESSControl = 8

SMD = 0.11 (95% CI -0.80 to 1.02)

2) ICC = 0.02; DEFF = 3.12; ESSIntervention = 79 ESSControl = 58

SMD = 0.11 (95% CI -0.23 to 0.45)

3) ICC = 0.01; DEFF = 2.06; ESSIntervention = 119 ESSControl = 88

SMD = 0.11 (95% CI -0.16 to 0.39)

4) ICC = 0.05; DEFF = 6.3; ESSIntervention = 39 ESSControl = 29

SMD = 0.10 (95% CI -0.27 to 0.48)

Authors' conclusions: "We did not find any measurable impact of a brief (4.5 hours) training curriculum aimed at improving physician cross-cultural knowledge and skills on any of the outcomes we chose."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNo information given about sequence generation process

Allocation concealment (selection bias)Unclear riskNo information given about allocation concealment.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskNo information given about whether patients were blind to physician allocation but treatment outcomes judged unlikely to be affected by lack of blinding

Blinding of outcome assessment (detection bias)
All outcomes
Low riskNo information given about whether patients or assessors were blind to physician allocation but primary outcomes (treatment outcome and patient reported physician cultural competency) judged unlikely to be affected by lack of blinding

Incomplete outcome data (attrition bias)
All outcomes
High riskOf the 671 patients enrolled in the study 320 completed all surveys (48%). The proportions of respondents from the intervention and control groups are not reported

Selective reporting (reporting bias)Unclear riskInsufficient information available

Other biasHigh riskUnit-of-analysis error. Cluster trial but results reported for individuals with no adjustment for clustering. Adjustments for other possible effects. Significant baseline differences between study populations in intervention and control groups reported for demographic characteristics, diagnoses and outcome assessment. Considerable heterogeneity across participating sites. Unclear if physicians recruited at cluster sites before or after allocation

Wade 1991

MethodsStudy design: Cluster RCT

Location: USA

Setting: College counseling centre in midwest city

Study aims: 1) To examine the effects of brief culture sensitivity training for counselors and the effects of whether counselors were "Black" or "White", on "Black" female clients' perceptions of counselor characteristics and the counseling relationship and clients' satisfaction with counseling; 2) to assess client attrition across three counseling sessions

Inclusion/exclusion criteria: Counselors recommended by counseling faculty. No criteria for counseling clients reported

Informed consent obtained: Unclear. Clients signed consent forms. No participants (counselors nor clients) were told about the purpose of the study

Ethical approval: Unclear

Funding source and amount: Not stated

Statistical methods: Multivariate analyses of variance (MANOVAs), with Hotelling's test of significance, performed on client ratings of counselors and counseling process. Due to considerable attrition, post-hoc analyses were conducted including MANOVAs using client ratings from last counseling session attended. Significant MANOVA results were followed by univariate F tests on each type of client rating from each counseling sessions. No adjustment for clustering reported

Consumer involvement: black female volunteers who either were former welfare recipients or defined themselves as lower-middle-class socio-economic status acted as clients in the training practice sessions. They were paid $5 per hour


ParticipantsHealth professional participants

Type and number: 8 counselors

Age: 30 to 54 years, mean = 35.5 years. No significant differences in age, between groups P < 0.42

Gender: All female

Ethnicity: Process of determining ethnicity not reported. Described as "White" (4) or "Black" (4) (counselors stratified to intervention and control groups in randomisation)

Professional qualifications: All had a Masters degree in counseling, 5 enrolled in doctoral programs and 3 were community-based counselors. Experience ranged from 2 to 12 years with a mean of 5 years. No significant differences in counseling experience between groups P < 0.48

Language(s): Not reported

Previous cultural competence training: Unclear

Method of recruitment: Not described. Counselors were paid $5 fee per session or $10 per client, whichever amount was greater

Patient participants

Type and number: 80 "Black" clients

Age: 19 to 44 years, mean = 37.5 years with significant differences between groups P < 0.026. Clients assigned to treatment group were younger (M = 29.60 years, SD = 7.34) than those assigned to control group (M = 33.18 years, SD = 7.15). Authors judged subjects in the two groups "appeared to be in the same cohort."

Gender: All female

Ethnicity: Process of determining ethnicity not reported. Described as "Black" (80)

Professional qualifications: 70% high school diploma or equivalent, 7.5% completed 1 year of college, 11% completed associate's degree, 4% completed 3 years of college, and 7.5% completed bachelor's degree. No significant differences between number of educational years' experience between groups.

Language(s): Not reported

Other: Clients referred to college counseling centre by social service agencies or self-referred in response to radio and newspaper announcements. Clients received no financial remuneration for participation but customary fees were waived

Cluster sizes:10 "Black" women

Method of recruitment: Referred to college counseling center by social service agencies or self-referred in response to radio and newspaper notices. Participation described as voluntary and that they were allowed to terminate counseling at any time. Fees were waived


InterventionsEducation intervention: Culture sensitivity training for counselors (4 hours)

Comparison: No intervention

Aim of intervention: To teach counselors to: a) attend to client's suspiciousness of social system and how this affects their perceptions of counselors; b) attend to racial and class differences between clients and counselor; c) attend to how client's attitudes and feelings of the experience of being black affect counseling process; d) attend to clients' values and to make explicit their own values during counseling


OutcomesPrimary outcome categories

Treatment outcomes: None reported

Health behaviour: Client concordance with attendance (over three counseling sessions*)

Involvement in care: None reported

Evaluation of care: Client perception of counseling process; Client perception of counselors repeated at end of three counseling interviews (This outcome was comprised of different dimensions that were reported individually. No overall measure was reported so we calculated the effect estimate for each dimension and chose the dimension [Attractiveness] whose effect estimate was ranked n/2 )

Secondary outcome categories

Health professionals

Knowledge and understanding: None reported

Consultation processes: None reported

Evaluation of processes and outcomes: None reported

Healthcare organisations

Adverse events: None reported

Quality and safety measures: None reported

Service utilisation: None reported

Health economic outcomes: None reported

Other outcomes: None reported

*= selected outcome. The rationale for the selection of outcomes for each category is reported in  Table 4.


Conceptual frameworkSmall target group of counselors (8). Unclear across  most domains of our conceptual framework

1.  Education content: Knowledge included culture, cultural competence, models of health and illness, socio-cultural context of health disparities, constructs of racism and prejudice and specific theoretical models such as explanatory models of health and illness; patient centeredness; consumer participation.

Not reported if epidemiology; and social determinants were included

Application of knowledge to relevant environmental, population, organisational and professional and systemic contexts not reported.

Skills included cultural self-assessment, communication skills and establishment of trust and partnerships

2.  Pedagogical approach: Key theoretical construct and principles described but teaching and learning method unclear. Based on Pedersen's model

3.  Structure:

Delivery: Face-to-face

Format: Workshop

Frequency and duration: Once only, 4 hours of training

Method of assessment: Unclear

Evaluation method: Unclear

Organisational support: Unclear

Participation: Voluntary.

4.  Participant characteristics:

Target audience: Counselors

Who delivered the intervention: Not reported


NotesContact with author: No

The risk ratio for the dichotomous outcome, client concordance (health behaviour outcome) was calculated from client attrition data reported in the publication (numbers attending each session for intervention and control groups). Values for the three behavioural dimensions (expertness, trustworthiness and attractiveness) of the continuous outcome client perception of counseling (evaluation of care outcome) were reported at three time points (after each counseling session), but a summary measure for the outcome was not reported. A post-hoc decision was taken to use the change in one dimension of the scale between the first and final time points. The effect estimate for each dimension was calculated and the attractiveness dimension, which had the median effect (n/2), selected.

Numbers in the intervention and control groups were adjusted for the continuous outcome - client perception of counseling (evaluation of care outcome), and events and participants for the dichotomous outcome - client concordance with attendance (health behaviour outcome) based on the computed design effect (DEFF=1+(1-M)ICC, where M is the average cluster size) . We used the estimated ICC of 0.2 (from Harmsen 2005 sample size calculations) as this was the only ICC we identified for this type of intervention. However this ICC is based on an average cluster size of 20. Sensitivity analyses were conducted with ICCs of 0.01, 0.02, and 0.05 using data from a study of ICCs (Campbell 2000). The intervention and control groups both comprised 40 black women.

The sensitivity analyses did not substantially alter the magnitude or significance of the summary effect size for either outcome.

Evaluation of care (Client perception of counseling):

1) ICC = 0.2; DEFF = 2.8; ESSIntervention = 14 ESSControl = 14

SMD = 1.60 (95%CI 0.99 to 2.20)

2) ICC = 0.02; DEFF = 1.18; ESSIntervention = 34 ESSControl = 34

SMD = 1.60 (95%CI 1.05 to 2.15)

3) ICC = 0.01; DEFF = 1.09; ESSIntervention = 37 ESSControl = 37

SMD = 1.60 (95%CI 1.08 to 2.13)

4) ICC = 0.05; DEFF = 1.45; ESSIntervention = 28 ESSControl = 28

SMD = 1.60 (95%CI 0.99 to 2.20)

Health behaviour (Client concordance with attendance):

1) ICC = 0.2; DEFF = 2.8; ESS = 14

RR = 1.53 (95%CI 1.03 to 2.27)

2) ICC = 0.02; DEFF = 1.18; ESS = 34

RR = 1.48 (95%CI 1.11 to 1.96)

3) ICC = 0.01; DEFF = 1.09; ESS = 37

RR = 1.52 (95%CI 1.17 to 1.98)

4) ICC = 0.05; DEFF = 1.45; ESS = 28

RR = 1.53 (95%CI 1.12 to 2.10)

Authors' conclusions: "A major finding of this study is that Black female clients’ perceptions of counselors and the counseling process were affected more by culture sensitivity training of the counselors than by counselor race. Counselors who had received culture sensitivity training were assigned higher ratings on expertness, trustworthiness, attractiveness, unconditional regard, and empathy than were counselors who had not received the additional training. Furthermore, clients assigned to counselors the culture sensitivity training group returned for more follow up sessions and reported greater satisfaction with the counseling process than did clients assigned to counselors in the control group."


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskUsed table of random numbers to assign counselors to intervention and control groups

Allocation concealment (selection bias)Unclear riskInsufficient information about allocation concealment

Blinding of participants and personnel (performance bias)
All outcomes
Low riskCounselors and clients unaware of nature of the study

Blinding of outcome assessment (detection bias)
All outcomes
Low riskNo blinding of outcome assessment but outcome measurement judged to be unlikely to be influenced

Incomplete outcome data (attrition bias)
All outcomes
High riskImbalance in reasons for missing data across groups, and although data was imputed using an appropriate method, there were very high rates of attrition in the control group over the study (> 70%)

Selective reporting (reporting bias)High riskOne outcome - clients' perceptions of the counseling process - was not reported for each group, probably due to the high attrition in the study

Other biasHigh riskThere is no indication that analyses have taken account of clustering

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Afuwape 2010Intervention directed at patients, not health professionals

Berlin 2010Patient outcomes not part of study design

Bhattacharyya 2010Intervention is not related to cultural competence

Bhui 1998Not an RCT

Bloch 2012Patient outcomes not part of study design

Bremner 2011Intervention directed at patients, not health professionals

Butterfloss 2002Not an RCT or cultural competence intervention

Choi 2012Intervention directed at patients, not health professionals

Christensen 1984Not an RCT

Cooper 2009Intervention does not involve training for health professionals

Cooper 2010Intervention does not involve training for health professionals

Cortese-Peske 2013Patient outcomes not part of study design nor assessed

Crenshaw 2011Not an RCT

Fossli Jensen 2000Intervention does not involve cultural competence training for health professionals

Gendron 2013Not an RCT

Greenberg 2013Patient outcomes not part of study design

Greer 2007Not an RCT

Heitzler 2011Patient outcomes not part of study design nor assessed

Jackson 2000Intervention is not directed at health professionals

Javier 2013Not an RCT

Khanna 2009Not an RCT

Kopke 2012Not a cultural competence education intervention

Kutob 2009Outcomes for patients is not part of study design or assessed

Kutob 2013Patient outcomes not part of study design nor assessed

Lasser 2010Intervention is not directed at health professionals

Manfredi 1998Intervention did not include cultural competence education of health professionals

Marra 2010Not an RCT

Martey 1995Not an RCT

Maxie 2006Not an RCT

McCabe 2006Not an RCT

Miranda 2003Intervention did not include cultural competence training for health professionals

Mostow 2010Not an RCT

Naeem 2011Intervention did not include cultural competence training for health professionals

Nagel 2009aIntervention did not include cultural competence training for health professionals

Nagel 2009bNot an RCT

Newland 2008Not an RCT

O'Brien 1977Outcomes for patients is not part of study design or assessed

Omer 2008Not an RCT

Palmer 2011Not an RCT

Park 2013Patient outcomes not part of study design nor assessed

Prescott-Clements 2013Patient outcomes not part of study design nor assessed

Resnick 2009Not a cultural competence education intervention and outcomes for patients is not part of study design or assessed

Roberts-Thomson 2010Not a cultural competence education intervention

Rogers 2000Not an RCT

Schim 2006Outcomes for patients is not part of study design or assessed

Schouten 2005Outcomes for patients is not part of study design or assessed

Sheikmoonesi 2011Not a cultural competence education intervention

Sheridan 1982Not an RCT

Sixta 2007Not a cultural competence education intervention

Sixta 2008Not an RCT

Smith 2001Outcomes for patients is not part of study design or assessed

Thomas 2000Not an RCT

Tozer 2010Not an RCT

Witter 2012Patient outcomes not part of study design nor assessed

Xu 2010Not an RCT

 
Characteristics of ongoing studies [ordered by study ID]
Clark 2010

Trial name or titleNCT01251523: Improving Asthma Outcomes Through Cultural Competence Training for Physicians

MethodsRandomized clinical trial

ParticipantsParents of pediatric subjects (children with asthma)

InterventionsThe randomized clinical trial compares two educational interventions: Physicians Asthma Care Education (PACE) and PACE plus with 90 physicians in Atlanta and the Bronx and their 1192 patients.

OutcomesPrimary outcomes measures include: emergency department visits of parents and children at 3 time points.

Starting dateNovember 2010

Contact informationLara J Thomas, MPH; ljthomas@umich.edu

NotesThis study will evaluate the effects cultural competence training for physicians on health outcomes of children and performance ratings given to physicians by the parents of the child. The estimated completion date for the study was January 2014.

Researcher Anneliese Synnot contacted Lara Thomas in February 2014 and was advised that no data are available yet.

 
Comparison 1. Cultural competence training vs no training

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Treatment outcomes (dichotomous)12699Risk Difference (Random, 95% CI)-0.02 [-0.06, 0.02]

 2 Treatment outcomes (continuous)168Std. Mean Difference (IV, Random, 95% CI)0.07 [-0.41, 0.55]

 3 Health behaviour (dichotomous)128Risk Ratio (M-H, Random, 95% CI)1.53 [1.03, 2.27]

 4 Involvement in care1Std. Mean Difference (Random, 95% CI)0.21 [0.00, 0.42]

 5 Evaluations of care (dichotomous)1Risk Difference (Fixed, 95% CI)0.14 [-0.03, 0.31]

 6 Evaluations of care (continuous)2Std. Mean Difference (IV, Random, 95% CI)Subtotals only

 7 Knowledge & understanding (dichotomous)187Risk Ratio (M-H, Random, 95% CI)1.37 [0.97, 1.94]

 
Summary of findings for the main comparison.

Cultural competence training for health professionals compared with no training

Patient or population: CALD patients and their health professionals (Primary care settings in high income countries)

Intervention: Cultural competence training for health professionals

Comparison: No training

OutcomesImpactNo of Participants
(studies)
Quality of the evidence
(GRADE)

Treatment outcomes

(Different measures)1
No evidence of effect on treatment outcomes in two studies; the proportion who achieved cholesterol control target over 12 months and weight loss over six months were assessed.27672
(2 studies)
⊕⊕⊝⊝
low3

Health behavioursClient concordance with attendance significantly improved for the intervention group across three counselling sessions. Women in intervention group were 1.5 times more likely to attend the third counselling session (RR 1.53, 95% CI 1.03 to 2.27).282

(1 study)
⊕⊕⊕⊝
low4

Involvement in care

(Mutual understanding)5
One study in The Netherlands reported improved mutual understanding between one in five patients (described as "mainly Turkish, Moroccan, Cape Verdean and Surinamese patients") and their largely "Western" GPs (mostly Dutch) (SMD 0.21, 95% CI 0.00 to 0.42).1092
(1 study)
⊕⊕⊝⊝
low6

Evaluations of care

(Different measures)7
Three studies showed mixed outcomes. There was no evidence of effect on evaluations of care between intervention and control group participants in two studies but a third study showed significant improvements in client perceptions of their health professional after cultural competence training.1952
(3 studies)
⊕⊕⊝⊝
low8

Health professionals knowledge & understanding

(Awareness of racial differences)9
No evidence of effect on clinician awareness of racial differences in the quality of diabetes care for "black" clients was found in one study among the proportion of clinicians acknowledging racial disparities in care occurred "very often" or "somewhat often" (RR 1.37, 95% CI 0.97 to 1.94), with no adjustment for clustering.87
(1 study)
⊕⊕⊝⊝
low10

Adverse eventsNone of the included studies measured adverse outcomes.0

GP: General Practitioner; CI: Confidence interval; RD: Risk Difference; SMD: Standardised Mean Difference CALD: Culturally and Linguistically Diverse

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1. Rate of achieving control target of LDL cholesterol < 2.59mmol/L (< 100mg/dL) in previous 12 months and change in patient weight (pounds). Data in both studies collected from patient records.

2. Study population adjusted to take account of design effect of clustering in one study. Assumed ICC of 0.2. Sensitivity analyses using different values for ICC did not substantially alter magnitude or significance of summary effect sizes.

3.Allocation concealment and attrition unclear. One study did not take account of clustering and reported outcomes for all patients not CALD population.

4. Single study with small sample especially after adjustment for the design effect of clustering. Outcome not likely to be affected by lack of blinding.

5. Validated scale to measure mutual understanding by comparing GP and patient assessments of consultation. Responses could range from -1 (total misunderstanding) to +1 (complete mutual understanding). GPs completed the questionnaire immediately after the consultation and patient interviews were conducted 3 to 8 days after a consultation.

6. Single study. Baseline imbalance and high attrition for CALD population. Blinding of assessment unclear.

7. Measures include dichotomous measure of Patient satisfaction with consultation, which was measured in patient interviews at home 3–8 days after GP consultation. There were two continuous measures: Patient reported physician cultural competency, which asks patients about 13 physician behaviours using 5-point scale with score transformed to a 0 to 100 scale, a single dimension (attractiveness) from validated scale with twelve 7-point bipolar items, Client perception of counselors ('attractiveness') .

8. Allocation concealment and attrition were high or unclear. One study did not take account of clustering and reported outcomes for all patients and not the CALD population separately. Sample sizes were small after adjusting for clustering.

9. Clinician awareness of racial differences in care measured with a 5-point Likert scale (very often to very rarely).

10. Single study with small sample size. Allocation concealment unclear. No adjustment for clustering in computation of relative risk.

 
Table 1. Conceptual framework

1.      Educational content2.      Pedagogical approach3.      Structure of the intervention4.      Participant characteristics

a. Types of knowledge

b. Assessment and application

c. Skills
a. Teaching and learning method

b. Theoretical constructs and principles
a. Delivery and format

b. Frequency and timing

c. Assessment and evaluation of intervention

d. Organisational support
a. Delivering the intervention (teacher/ facilitators)

b. Engaging in the intervention (target audience)

 See Description of the intervention for details of the conceptual framework.
 
Table 2. Outcomes by category for included studies

Included studiesHarmsen 2005Majumdar 2004Sequist 2010Thom 2006Wade 1991

Primary outcome categories

Treatment outcomesNone
  • Client health outcomes (OARS)
  • Physical & Mental Health Assessment
#Proportion achieving clinical control targets within preceding 12 months for:

  • Haemoglobin level (HbA1c level less than 7.0%)*
  • LDL cholesterol (level less than 2.59 mmol/L [100 mg/dL])
  • Blood pressure (less than 130/80 mm Hg)
Change in patient:

  • Weight*
  • Systolic blood pressure
  • Glycosylated haemoglobin
None

Health behaviourNoneNoneNoneNoneClient attrition

Involvement in care#Mutual understanding between GP and patient*Expenditure of Healthcare & Social ServicesNoneNoneNone

Evaluation of care
  • Patient satisfaction with consultation*
  • Patient’s feeling that consideration shown
  • Patient’s perception of quality of care
#Patient satisfaction*None
  • Patient satisfaction with consultation
  • Patient perception of physician consideration
  • #Patient reported physician cultural competency*
  • Client perception of counselling process
  • Client perception of counsellors*+

Secondary outcome categories

Health professionals

Knowledge and understanding#Mutual understanding between GP and patient*^#Improved understanding cultural attitudes*#Clinician acknowledgement of racial differences in the quality of diabetes care for black clients over 12-month period:

  • Across health service
  • Within health centre*
  • Among their patients
NoneNone

Consultation processesNoneNoneNoneNoneNone

Evaluation of processes and outcomes NoneNoneNoneNoneNone

Healthcare organisations

Adverse events NoneNoneNoneNoneNone

Quality and safety measuresNoneNoneNoneNoneNone

Service utilisationNoneNoneNoneNoneNone

Health economic outcomesNoneNoneNoneNoneNone

 # indicates a primary outcome in the included study * indicates an outcome selected for this review +This outcome was comprised of different dimensions that were reported individually. No overall measure was reported so we calculated the effect estimate for each dimension and chose the dimension whose effect estimate was ranked n/2.
 
Table 3. Comparison of study aims, settings and CALD descriptions of participants used

Study nameStudy aimsSettingCALD description of health professionalsCALD description of patients

Harmsen 20051) To decrease inequalities in care provided between “Western” and “non-Western” patients

2) To assess the effectiveness of an educational intervention on intercultural communication aimed to decrease inequalities in care provided between “Western” and “non-Western” patients.
GP clinics in The Netherlands2 of 38 GPs had "non-Dutch (but Western) ethnic backgrounds"Assessed validated patient cultural background scale (Harmsen 2006). The "non-Western group" comprised "mainly Turkish, Moroccan, Cape Verdean and Surinamese patients". The "Western” group comprised "mostly Dutch but also some patients from other Western European, North American, Canadian and Australian origin".

Majumdar 20041) To determine the effectiveness of cultural sensitivity training on the knowledge and attitudes of healthcare providers

2) To assess the satisfaction of patients from different minority groups with healthcare providers who receive this training
Two community home care agencies and one hospital in Southern Ontario, Canada.

The study was conducted in an urban area described as where “approximately 25% of population is foreign-born.”
Authors reported that “Providers from both experimental and control groups who completed the T3 follow-up had similar demographics.” Majority "identified themselves as Canadians, and had parents of either Canadian or British origin".

Authors also note that “To achieve a more complete cultural perspective, steps were taken to ensure the inclusion of healthcare providers from minority groups” but do not provide any further detail.
Authors reported that “Demographically, patients in the experimental and control groups were similar” and that "Both the experimental and control groups identified their ethnicity as 'Canadian', 'British' or 'European'. The first language spoken by both groups was English". No further information was reported.

Sequist 20101) To evaluate the effect of cultural competency training and performance feedback for primary care clinicians on diabetes care for “black” patients

2) To assess whether these efforts reduced racial differences between “white” and “black” patients for these 3 measures of diabetes care.
8 ambulatory Health Centres, Massachusetts, USAProcess for determining ethnicity not reported, however clinicians were described as "white" (82%),"Asian" (14%), "black" (2%), and"Hispanic" (2%)."Patient race was collected by self-report during the patient registration process" and participants were described as either "black" or "white" diabetic patients.

Thom 2006To develop and evaluate a brief cross-cultural curriculum for resident and practicing physicians based on a model of culturally competent physician behaviours, and to evaluate the training plus feedback compared to feedback alone with respect to changes in patient-reported physician behaviours, patient satisfaction, patient trust in his or her physician, and disease-specific patient health outcomesFour locations in California, USA:

  • An academic medical centre-based family practice
  • A community-based primary care practice;
  • A rural family medicine residency program
  • An inner-city family medicine residency program
No information about how ethnicity determined. Sample comprised 53 physicians described as comprising 38 "White" or "Caucasian" (both terms used for physicians) (total 72%, comprising 64% of physicians in the intervention group and 80% of the control group); 8 "Latino" (total % not reported; I=27%: C=7%); 5 "Asian American" (I=9%: C=10%); 1 "African American" (I=0%: C=3%); and 2 others (not described further).Process of assignment of ethnicity unclear. Potential participants approached on basis of self-designation in computerised records (as “Hispanic” or “Asian”) or on the basis of their surname.

Participants in one group reported to be more likely to "self-identify as Latino or Asia". Groups in the study described as comprised of the following:

"Caucasian non-Hispanic" (21.9% feedback only and 30.0% training and feedback), "Latino/Hispanic" (28.9% and 25.3%), "African-American" (20.3% and 23.2%), "Asian" (23.0% and 13.1%) and "Other" (5.9% and 8.4%).

Wade 19911) To examine the effects of brief culture sensitivity training for counselors and the effects of whether counselors were black or white, on black female clients' perceptions of counselor characteristics and the counseling relationship and clients' satisfaction with counseling

2) to assess client attrition across three counseling sessions
College counseling centre in midwest city USAProcess of determining ethnicity not reported. Described as "White" (4) or "Black" (4) (counselors were stratified to intervention and control groups in randomisation)Process of determining ethnicity not reported. Described as "Black".

 
Table 4. Summary of intervention across domains of conceptual framework

Study IDHarmsen 2005Majumdar 2004Sequist 2010Thom 2006Wade 1991SUMMARY - all studies

1. EDUCATIONAL CONTENT 

a) Types of knowledge 

Culture/cultural competenceIntercultural communicationCultural sensitivityCultural competencyCultural competencyCultural sensitivityTwo studies used the term cultural sensitivity (Majumdar 2004; Wade 1991).Two used the term cultural competence (Sequist 2010; Thom 2006). One study (Harmsen 2005) explicitly focused on intercultural communication. No study included explicit definitions of terminology used.

Models of health and illnessKleinmans' explanatory modelsNot reportedUnclearReported adaption of Tirado's model of culturally competent physician behaviours specifically knowledge of patients, communication skills and cultural competence [p3].Training session included "overview of issues and concerns culturally distinct individual bring to counseling" [p10]Three of the five studies reported inclusion of a description or understanding of specific models of health and illness as part of the education intervention. Two studies were unclear or did not report. 

Socio-cultural context of health disparitiesGP intervention "aimed to improve sensitivity and knowledge about culturally determined differences in views and behaviour “.Not reportedSpecified goal of increasing knowledge about health disparities (p41)

 
Not reportedOverview of the issues and concerns culturally distinct individual bring to counselling (p.10)Three studies addressed socio-cultural context of health disparities but not in a common manner. Two studies did not report inclusion of this.

Epidemiology and social determinantsUnclearNot reportedCurriculum reviewed potential racial and cultural biases in healthcare, appropriate methods of collecting clinically relevant cultural data [p41]Included epidemiologic data on diabetes and hypertension in different racial/ethnic groups.Not reportedTwo studies included explicit reference to epidemiology and the social determinants of health. Two studies did not report and one was unclear.

 

Constructs of racism and prejudiceUnclearNot reportedThemes from focus groups with black patients, including illustrative quotes and care recommendations, used to develop educational materials [p41]Not reportedParticipants instructed to "attend to racial and class differences between the counselor and the client" in the training practice sessions [p10]Two studies addressed constructs of racism via varied methods. Two studies did not report on this component and one was unclear.

Specific theoretical modelsKleinmans' explanatory models [p343]None reportedOne of the stated goals of curriculum was to develop understanding of trust and bias.     

 
Knowledge of patients included "knowledge of patients cultural health beliefs and identification of their level of acculturation with respect to mainstream health beliefs"Pedersen's (1985) triad model of cross-cultural counsellingFour of the five studies reported on the use or inclusion of specific theoretical models as part of the education or training intervention.  One study was unclear.

Other topicsNone reportedCultural awarenessNone reportedModule 2 discussed cultural gap between healthcare professionals and patient's knowledge and belief systems [4]

 
None reportedTwo of the studies included topics in addition to what is specified in our conceptual framework. Thom 2006 reported on the cultural gap between healthcare professionals  and patients knowledge and belief systems, and Majumdar 2004 also reported on cultural awareness.

b) Assessment and application

Application of knowledge to relevant contextsGPs trained in self-chosen strategies to solve gaps in views and culturally defined communication

style.[344]
Not reportedCurriculum reviewed ways to incorporate information into effective clinical care plans for people with diabetes.  Monthly educational materials included practical recommendations.Module 3 - cultural brokering - included "negotiating a treatment plan with patient and family, understanding community resources available to patients, and working with the healthcare system to meet the needs of culturally diverse patients”. [p4]None reportedThree of the five studies reported on this component, and two studies did not report. Thom 2006 reported most comprehensively.

c) Skills – inter- and intra-personal 

Cultural self-assessmentGPs were allowed to reflect on their own culturally defined norms, views and
communication style
Cultural Self-Awareness Questionnaire and the Dogmatism Scale instrumentsUnclearUnclearTraining included discussion on counsellor self-awareness and the minority client. Participants instructed to make explicit their own values during counselling practice sessions [p10]Three of the five studies reported on cultural self-assessment processes (Harmsen 2005; Majumdar 2004; Wade 1991). It was unclear in two studies.

Communication, collaboration and non-verbal communication skillsGPs and patients received intervention with intention of improving the intercultural communication between them. GPs: intercultural communication.Not reportedSkills building around effective cross-cultural communication and to provide action-oriented tools to address disparities.                     Module 2 “Enhancing Communication Skills for Cultural Competency - included "listening, explaining, acknowledging, providing recommendations, and working effectively with interpreters. Participants taught to recognize and deal with their own defensiveness as counsellors and recover from mistakes made during the process of counselling [p10].Four of the five studies (Harmsen 2005, Sequist 2010; Thom 2006; Wade 1991) reported the inclusion of communication skills in the training /education intervention to improve cross cultural communication. One study did not report this.

Thom 2006 reported a specific  module on “Enhancing Communication Skills for Cultural Competency”.

Deconstructing stereotypesUnclearUnclearUnclearModule 1 objective to "teach techniques for assessing beliefs and practices of individual patients" infers that there would be an understanding and analysis of stereotypes.Training to "articulate the client's problems within a cultural framework" [p10] could infer some element of deconstruction of stereotypes but possibly insufficient time to address this.Two of the five studies inferred a deconstructing stereotypes component (Thom 2006; Wade 1991). Three studies were unclear.

Trust and partnership establishmentUnclearUnclearSpecified goal to meet understanding attitudes of trust and bias. 

 
An objective of Module 2 was to model problematic and improved physician communication [p4], through the LEARN method.Training included skills to anticipate and deal with client resistance. [p10]Three studies of the five (Sequist 2010; Thom 2006; Wade 1991) reported  addressing issues of trust and partnership establishment between patients and healthcare professionals. it was not clear on two studies.

2. PEDAGOGICAL APPROACH

Teaching and learning methodGP intervention based on Pinto’s three step method but patient intervention is not.UnclearUnclear

Some discussion of taking a quality improvement framework.
Peer education, adult learning principles and application of LEARN mnemonic to the patient interview (Listen, Explain, Acknowledge, Recommend, Negotiate).UnclearTwo studies identified explicit  teaching and learning methods (Harmsen 2005; Thom 2006),  and  three studies were unclear.

 

Key theoretical construct and principlesKleinman’s theory of exchanging explanatory models cited.UnclearUnclearAdapted from a model developed by one of the co authors. emphasise goal of cultural versatility the concept of a cultural competency continuum used across all modules.Based on Pedersen's model which is designed to train counsellors to: (a) articulate the client's problems within a cultural framework, (b) anticipate and deal with client resistance, (c) recognize and deal with their own defensiveness as counsellors, and (d) recover from mistakes made during the process
of counselling.
Three studies (Harmsen 2005; Thom 2006; Wade 1991) reported key theoretical constructs and principles that underpinned the training. Two studies were unclear on this component.

 Comments  An underlying principle of the educational design was clearly grounding in the actual experience of black patients. The development of educational materials and recommendations tailored to caring for black patients were derived from patient focus groups and surveys. Clinicians were also given stratified patient data throughout the study.Curriculum was field tested with 18 primary care physicians and was refined based on participant feedback. Thom 2006 reported the curriculum was field tested with 18 primary care physicians and was refined based on participant feedback.  Sequist 2010 reported that an underlying principle of the educational design was clearly grounding the curriculum in the actual experience of black patients. The development of educational materials and recommendations tailored to caring for black patients were also derived from patient focus groups and surveys.

3. STRUCTURE

a) Delivery and format

DeliveryFace-to-face impliedUnclearFace-to-face offsite delivery, including engagement with black diabetic patients to learn of barriers to managing diabetes in the community.Face-to-face implied.Face-to-faceFour of the five studies reported face to face delivery of the education/training intervention (Harmsen 2005; Sequist 2010; Thom 2006; Wade 1991). One study did not state  clearly how the intervention was delivered.

FormatFormat of GP program not described. Patients viewed 12-minute videotaped instruction in waiting room prior to consultation. Available in languages of major ethnic groups (Moroccan-Arabic, Moroccan-Berber, and Turkish).UnclearMix of lectures, group discussions, and community engagement activities

 

 
3 modules corresponding to the 3 areas of cultural competency model. Mix of didactic presentations, group discussion, role-playing with learners, critique, group exercises, use of trigger tapes, and handouts. [p4]Workshop with overview, group discussion and skills training by practice sessions with volunteer black clientsFour of the five studies (Harmsen 2005; Sequist 2010; Thom 2006; Wade 1991), reported a mixture of didactic and experiential learning formats including: lectures, small group discussions; video, role plays and simulation exercises.  One study was not clear.

b) Frequency and timing

Frequency and durationGPs: 2.5 day program of training which included follow-up session after 2 weeks          36 hours of cultural sensitivity training [p163]. No other details provided.Nurse practitioners and physician assistants attended 2 consecutive days. Physicians attended the second day only.  Monthly written education materials provided [p 41].Offered as either single half-day training session or 3 separate 1 to 1.5 hour sessions.4 hour cultural sensitivity training workshopAll studies reported a range of training options and duration from 2.5 days with follow up sessions, half-day workshops (3 to 4 hours) to short training sessions lasting 1 to 1.5 hour hours. Harmsen 2005 reported a 2.5 day program of training which included follow-up session after 2 weeks. Majumdar 2004 reported that the training comprised  of 36 hours  of training but did not report  further details. Sequist 2010 reported that the nurse practitioners and physician assistants attended 2 consecutive days, but that physicians attended the second day only.  Monthly written education materials provided [p41] were also provided.  Thom 2006 reported that the education intervention was offered as either a single half-day training session or 3 separate 1 to 1.5 hour sessions. Wade 1991 reported that the training entailed a 4-hour cultural sensitivity training workshop.

c) Assessment and evaluation

Method of assessmentUnclearUnclearNot reported

 
Unclear

 

 
UnclearThree of the five studies (Harmsen 2005; Majumdar 2004; Wade 1991) were unclear on the method of assessment of the intervention. Sequist 2010 reported that a survey tool was used in the clinical trail setting to assess healthcareprofessional awareness of disparities.  Thom 2006reported the use of  a Patient -Reported Provider Cultural Competency Scale, where learners were asked post raining to rate the usefulness of the training on a 5 point Likert scale.

 

Evaluation method
UnclearUnclearNot reported

 

 
Post-training evaluation on a reported] were rated on 5-point Likert-scale. As above. Only one study used post training evaluation.

d) Organisational support

 

Links to organisational policies and procedures
UnclearUnclearMonthly performance feedback reports provided.UnclearUnclearOnly one study (Sequist 2010) reported that monthly performance feedback reports were provided to participating clinicians that *were stratified by cultural group and focused on achieving desired BP, cholesterol, and A1c outcomes.  These were all aligned with broader organizational goals.

 

Embedded within professional development program
UnclearUnclearUnclear

 
UnclearUnclearOnly one study (Sequist 2010) reported that the intervention was linked to clinician professional development through CME credit which was given to attending physicians.

 

 

Use of mentoring and peer support processes
UnclearUnclearMonthly "race-stratified reports" complied and given to physicians.UnclearUnclearOnly one study (Sequist 2010) reported a mentoring or support process though the provision of comprehensive race-stratified monthly reports.  The reports included:  Clinical performance metrics (A1c, BP, cholesterol control); Medication prescribing patterns (statin medications); Patient experience data collected via patient survey; Patient insight data collected via patient focus groups on topics including role of religion, race, and diet in chronic care management

 

Links to formal professional accreditation points or qualifications
UnclearUnclear* CME credit was given to attending physicians.unclearUnclearOnly one study (Sequist 2010) reported that CME credit was given to attending physicians.

 

 

Participation
Voluntary  - by letter of invitationVoluntaryVoluntary [p 45]VoluntaryVoluntary, but counsellors recommended by counselling facultyAll studies reported that participation in the education/training was voluntary.

4. PARTICIPANT CHARACTERISTICS 

a) Delivering of interventionFacilitator(s) not reported.Facilitator(s) not reported.Facilitated by off-site program, Harvard Pilgrim Healthcare FoundationGP instructors included authors of the paper, two other physicians with expertise in cross-cultural care, and experts in training and use of interpreters." [p4]Facilitator(s) not reported.Two of the five studies reported on who facilitated the education/training interventions.

 

b) Engagement (target audience)GPs and their patients. Adolescents aged 13 to 17 excluded and parents of children up to 12 years interviewed.Nursing and home care providers and their patientsPrimary care physicians, nurse practitioners and physician assistantsGPs and their patients with diabetes or hypertension. Patients were paid $10 for completing baseline questionnaire and $5 for each of the 2 follow-up questionnaires.80 black women and 8 female counsellors (4 black and 4 white)Both health professionals and their patients were directly subjected to an intervention in one study only (Harmsen 2005), although four studies (Harmsen 2005, Majumdar 2004, Thom 2006 and Wade 1991) reported that participants were both health or welfare professionals and their patients/clients. Sequist 2010 described only health professionals as study participants.

 

STUDY SUMMARY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
Education Intervention was a 2.5 day program for GPs: and their patients.  It included a follow-up session after 2 weeks.

Focus of the intervention was to improve intercultural communication between GPs and their patients. 
Education intervention focused on improving cultural sensitivity.  A 36 hour program targeting nursing and home care providers and their patients.  Used a number of validated tools.

Insufficient information across the domains of our conceptual framework.  Awaiting further info.  
Two (consecutive)s day training program  for primary care physicians, nurse practitioners and physician assistants (though physicians attended only one day). Delivered by training experienced firm. Intervention can be mapped against most domains of our conceptual  framework.

Only intervention with  reporting on the organisational support component of domain 3.
Education intervention for GPs and their patients.

One of shortest education interventions.

Only study that explicitly describes the content of the education intervention.

Reporting on most  domains (with most detail) of our conceptual framework.
Small target group of counsellors (8). Unclear across  most domains of our conceptual framework. 

 
Table 5. Rationale for outcome selection

Outcome categoryStudy outcomeStudy IDRationale for selectionData typeAnalysis

Primary outcomes*Sample size adjusted for clustering


Treatment outcomesClient health outcomes (OARS)

Physical & Mental Health Assessment
Majumdar 2004Choice of two outcomes - more information from study authors needed to determine which had lower effect size.UnknownExcluded (no useable data)

Rate of achieving control target of LDL cholesterol < 2.59mmol/L (< 100mg/dL) in previous 12 monthsSequist 2010A primary outcome (one of three) with the median effect size for population of interest ("black" patients).Rate (dichotomous)RD calculated as generic inverse variance using reported sample sizes, difference in reported proportions and derived numbers of those reporting "very often" or "somewhat often". Standard error calculated from reported 95% CI.

Change in patient weight (pounds)Thom 2006Study primary outcome for all study participants. Other primary outcome measures relate to study subgroups and all data are not reported.ContinuousEffect estimates (SMD) were standardised for concordance (to ensure effect estimates indicated benefit to intervention group when greater than zero (change in weight loss multiplied by minus one).*

Health behaviourClient concordanceWade 1991Only outcome in this category reported by study. Reported in terms of client attrition.DichotomousRR calculated to ensure standardisation (i.e. that benefits indicated by values > 1)

Involvement in careMutual understanding between GP and patientHarmsen 2005Only primary outcome in this outcome category reported by study.AgreementSMD calculated with generic inverse variance

Expenditure of Healthcare & Social ServicesMajumdar 2004More information from study author needed.UnknownExcluded (no useable data)

Evaluation of carePatient satisfaction with consultationHarmsen 2005One of three non-primary outcomes in this category reported by study with the median effect size.Rate (dichotomous)RD calculated with generic inverse variance

Patient satisfactionMajumdar 2004Outcome used for sample size calculation.UnknownExcluded (no useable data)

Patient reported physician cultural competencyThom 2006One of three outcomes in this category reported by study, but this was the only primary outcome.ContinuousSMD calculated with generic inverse variance

Client perception of counsellors - attractiveness dimensionWade 1991One of two outcomes reported in this category. Scale measures 3 behavioural dimensions of counsellors: expertness, trustworthiness and attractiveness. Limited data reported for client perception of counselling so we could not apply our criteria for selection as intended. Post hoc decision to use one dimension of scale in review. The study reported results for each dimension of client perception of counsellors. The effect estimate for each dimension was calculated. "Attractiveness" was the dimension with median effect (n/2).ContinuousInverse variance (SMD)*

Healthcare professionals

Knowledge and understandingImproved understanding cultural attitudesMajumdar 2004Primary outcomeUnknownExcluded (no useable data)

Clinician acknowledgement of racial disparities in diabetes careSequist 2010Primary outcome.

Reported at three levels (all health service, with own health centre, and within own practice). Outcome with median effect size chosen (within health centre).
Rate (dichotomous)RD calculated with generic inverse variance

Mutual understanding between GP and patientHarmsen 2005Also categorised as primary outcome in the patient-related outcome category, involvement in care.AgreementExcluded as used for patient-related outcome

Consultation processesNo outcomes reported


Evaluation of processes and outcomes None reported


Healthcare organisations

Adverse events No outcomes reported


Quality and safety measuresNo outcomes reported


Service utilisationNo outcomes reported


Health economic outcomesNo outcomes reported

 
Table 6. Quantitative summary across domains

Study IDHarmsen 2005Majumdar 2004Sequist 2010Thom 2006Wade 1991TOTAL

1. EDUCATION CONTENT:      

a. Types of knowledge

·   Culture/cultural competence5

·   Models of health and illnessNRU3

·   Socio-cultural context of health disparitiesNRNR3

·   Epidemiology and social determinantsUNRNR2

·   Constructs of racism and prejudiceUNRNR2

·   Specific theoretical modelsNR4

·   Other topicsNRNRNR+2

Sub-Total41+54+519/30

60%

b. Assessment and application

·   Application of knowledge to relevant contexts.NR√.NR3

Sub-Total101103/5

60%

c. Skills – inter and intra personal 

·   Cultural self-assessmentUU3

·   Communication, collaboration and non-verbal communication skillsNR4

·   Deconstructing stereotypesUUUNR1

·  Trust and partnership establishmentUU3

Sub-Total2123311/20

55%

DOMAIN TOTAL7288833/55

60%

2. PEDAGOGICAL APPROACH:      

a.   Teaching and learning methodUU3

b.    Key theoretical construct and principlesUU3

Comments   +2

DOMAIN TOTAL201+2+16/10

60%

 3. STRUCTURE:      

a. Delivery and format

·    DeliveryU4

·    FormatU4

b. Frequency and timing

·    Frequency and duration5

c. Assessment and evaluation

·    Method of assessmentUUU2

·    Evaluation methodUU 2

Total3155317/25

68%

d. Organisational Support      

·    Links to organisational policies and proceduresUUUU1

·    Embedded within professional development programUUUU1

·    Use of mentoring and peer support processesUUUU1

·    Links to formal professional accreditation points or qualificationsUUUU1

·    Participation5

Total115119/25

36%

DOMAIN TOTAL42106436/50

72%

4. PARTICIPANTS’ CHARACTERISTICS:      

a. Delivery of interventionNRNRNR2

b. Engagement (target audience)5

DOMAIN TOTAL112217/10

70%

TOTAL number of framework components reported (proportion of framework described by study)14

(56%)
5+

(20%)
21

(84%)
18+

(72%)
14

(56%)
14/25

(58%)