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We sought to synthesize the findings of studies evaluating interventions to improve the cultural competence of health professionals.
This was a systematic literature review and analysis.
We performed electronic and hand searches from 1980 through June 2003 to identify studies that evaluated interventions designed to improve the cultural competence of health professionals. We abstracted and synthesized data from studies that had both a before- and an after-intervention evaluation or had a control group for comparison and graded the strength of the evidence as excellent, good, fair, or poor using predetermined criteria.
We sought evidence of the effectiveness and costs of cultural competence training of health professionals.
Thirty-four studies were included in our review. There is excellent evidence that cultural competence training improves the knowledge of health professionals (17 of 19 studies demonstrated a beneficial effect), and good evidence that cultural competence training improves the attitudes and skills of health professionals (21 of 25 studies evaluating attitudes demonstrated a beneficial effect and 14 of 14 studies evaluating skills demonstrated a beneficial effect). There is good evidence that cultural competence training impacts patient satisfaction (3 of 3 studies demonstrated a beneficial effect), poor evidence that cultural competence training impacts patient adherence (although the one study designed to do this demonstrated a beneficial effect), and no studies that have evaluated patient health status outcomes. There is poor evidence to determine the costs of cultural competence training (5 studies included incomplete estimates of costs).
Cultural competence training shows promise as a strategy for improving the knowledge, attitudes, and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. Future research should focus on these outcomes and should determine which teaching methods and content are most effective.
Racial and ethnic disparities in the quality of health care have been extensively documented,1 and it has been suggested that cultural competence on the part of health care providers and organizations may be one mechanism to reduce racial and ethnic disparities in care.2 Cultural competence has been defined as “the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences”3 by recognizing the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account.4
In anticipation of the promise of cultural competence training, the Office of Minority Health has put forth standards for cultural competence that include training of health care providers,5 and the Accreditation Council on Graduate Medical Education (ACGME) has required that physicians-in-training demonstrate sensitivity and responsiveness to a patient’s culture as part of its professionalism competency.6 Despite the promise of cultural competency training, there has been little systematic evaluation of its potential impact.
The purpose of this study was to conduct a systematic review of the literature of interventions designed to improve the cultural competence of health care providers. Our specific aims were to determine (1) what strategies have been shown to improve the cultural competence of healthcare providers and (2) what the costs of these strategies are.
We conducted a systematic review of the literature to address the broad question of which strategies to improve the quality of care for racial/ethnic minorities are effective. We chose to conduct a systematic review rather than a meta-analysis because of the anticipated heterogeneity in the literature. To that end, we used formal methods of literature identification, selection of relevant articles, data abstraction, quality assessment, and synthesis of results to review literature on the effectiveness and costs of cultural competence training for healthcare providers.
In February 2003, we searched (1) MEDLINE®, (2) the Cochrane CENTRAL Register of Controlled Trials (Issue 1, 2003), (3) EMBASE, (4) the specialized register of Effective Practice and Organization of Care Cochrane Review Group (EPOC), (5) the Research and Development Resource Base in Continuing Medical Education (RDRB/CME), and (6) the Cumulative Index of Nursing and Allied Health Literature (CINAHL®). We designed search strategies, specific to each database, to maximize sensitivity. Initially, we developed a core strategy for MEDLINE, accessed via PubMed, based on an analysis of the Medical Subject Headings (MeSH) and text words of key articles identified a priori. The PubMed strategy, which used terms such as “cultural sensitivity,” “transcultural,” “cultural diversity,” and “multicultural” as well as “cultural competency,” formed the basis for the strategies developed for the other electronic databases.7
In addition to electronic searching, we identified priority journals that had provided the most citations in the electronic searching, and we scanned their tables of contents from February 1, 2003, through June 15, 2003. We also scanned the reference lists of key review articles and all articles eligible for our report. The results of the searches were downloaded and imported into ProCite, a reference management software program. This database was used to store citations, track search results and sources, and track the abstract and article review process.
The following criteria were used to exclude articles from further consideration: published prior to 1980, not in English, did not include human data, contained no original data, a meeting abstract only (no full article for review), not relevant to minority health, no intervention, intervention not targeted to healthcare providers or organizations, no evaluation of the intervention, inconclusive evaluation of the intervention (intervention evaluated only with a post-test), or article did not apply to any of the study questions.
We printed the title and abstract of all citations identified through the literature search, and 2 team members independently reviewed the title and abstract for eligibility. Because reviewer agreement was anticipated to be low (calculated kappa was 0.41 on a random sample of abstracts), we designed our process such that no abstract would be excluded based on the opinion of only one reviewer. When reviewers agreed that a decision regarding eligibility could not be made because of insufficient information, the full article was retrieved for review. When reviewers disagreed on eligibility, citations were returned for adjudication by reviewers until they reached agreement. Reviewers were asked to err on the side of inclusion.
We developed standardized review forms to (1) confirm eligibility for full article review, (2) assess study characteristics, and (3) extract the relevant data to address the study questions. The forms were developed through an iterative process that included review of forms used for previous systematic reviews, discussions among team members and experts, and pilot testing.
For each eligible study, we abstracted data regarding the targeted providers and setting, curricular content (using a previously published framework that included general cultural concepts, specific cultural content, language, racism, access issues, doctor-patient interactions, socioeconomic status and gender/sexuality),8 teaching methods, evaluation methods, and outcomes. We classified outcomes as either provider outcomes (knowledge, attitudes/beliefs, or skills/ behaviors) or patient outcomes (satisfaction, adherence, and health status). We also designed several questions to assess methodological strengths and weaknesses of studies, specifically including study design and objectivity of outcome assessment. Objective outcome assessments included written tests and standardized instruments, whereas outcome assessments that were not considered objective included open-ended interviews and learner self-assessment.
We conducted independent and serial reviews of the quality assessment forms from 10 articles to calculate the agreement between reviewers. Each quality assessment form contained 21 questions with 3–4 possible choices. We found a mean kappa (across the 21 items) of 0.81 for the independent review process and 0.87 for the serial review process. These values are similar and in the range that most experts would consider excellent agreement.9 We used a serial review process to conserve time and resources. A primary reviewer completed the quality assessment and data abstraction forms and a second reviewer, after reading the article, checked each item on the form for completeness and accuracy. Differences between primary and secondary reviewers were resolved by adjudication and, when necessary, consultation and consensus with the entire team of reviewers.
We created summary tables of evidence from these studies and then examined the relation between various intervention characteristics and outcomes across studies. In particular, we examined the outcomes of interventions according to several features of the interventions that we determined would be of interest to educators and policy makers: intervention length (for those at the extremes of ≤ 1 day and ≥ 1 week), curricular content (those that taught general concepts of culture, those that focused on specific cultures, and those that did both), and curricular method (those that used experiential learning, which was defined as either cultural immersion, clinical experience or interviewing members of another culture, and those that did not use any of those methods).
Once all articles were reviewed and data were synthesized, the strength of the evidence supporting each outcome type was graded into 4 categories (grades A through D) based on its quality, quantity, and consistency. We developed the evidence grading scheme based on proposed criteria.10 For quality, we used 2 criteria: study design and the presence of objective assessment. To meet the quality criteria for grade A, there must have been at least one randomized controlled trial and at least 75% of the studies must have used an objective assessment method. To meet grade B, there must have been at least one controlled trial (not necessarily randomized) AND at least 50% of studies must have had objective assessment. To meet grade C or D, there did not need to be any controlled trials and < 50% of studies could have had objective assessment.
For quantity of studies, there had to be at least 4 studies to meet criteria for grade A, 3 studies to meet criteria for grade B, 2 studies to meet criteria for grade C, or at least 1 study to meet criteria for grade D. For consistency, the results of the studies had to be consistent (either beneficial or harmful results in same direction across almost all studies) to meet criteria for grade A, reasonably consistent to meet criteria for grade B (most study results in the same direction), and inconsistent to meet criteria for grade C. If there were too few studies to judge the consistency of results, the strength of evidence supporting the question was given a grade of D. The grading of the evidence was discussed at team meetings (particularly to determine the consistency) and consensus was reached on each criterion. The evidence received a final “grade” that reflected the lowest rank on any of the 4 criteria (2 for quality and 1 each for quantity and consistency).
A total of 34 articles met eligibility criteria.11–44 Figure 1 describes the literature review and search process. The eligible articles are summarized in Table 1 and described in detail in Table 2. Studies on cultural competence training are increasing in frequency. Most have used a pre/post evaluation design, have occurred in the United States, and have targeted physicians and/or nurses. A variety of curricular methods and content has been evaluated, although no 2 studies have evaluated exactly the same curriculum.
Figure 2 shows the number of studies showing beneficial, partial/mixed, harmful, or no effects by type of outcome. A summary of outcomes of these studies is provided in Table 3 and detailed in Appendix A.
Most studies (17/19) demonstrated a beneficial effect on provider knowledge. Eleven of these studies tested the provider’s knowledge about general cultural concepts (such as the impact of culture on the patient–provider encounter21 or the ways in which provider ignorance can adversely impact patients13) whereas 7 evaluated culture-specific knowledge (such as knowledge of disease burdens across particular populations12,14 and traditional cultural practices24,29). One article did not specify. There was no obvious pattern regarding which type of knowledge was impacted more by cultural competence training. Overall, there is excellent evidence to suggest that cultural competence training impacts the knowledge of healthcare providers (evidence grade A).
Of the 25 studies that evaluated the effect of cultural competence training on provider attitudes, 21 demonstrated a beneficial effect, whereas 1 study showed no effect, and 3 studies showed a partial/mixed effect. The most common attitude outcome measured was cultural self-efficacy measured using the Bernal and Freeman cultural self-efficacy scale,27,28,37 which evaluates learner confidence in knowledge and skills related to African American, Asian, Latino, and Native-American patients. Other studies measured attitudes toward community health issues17 and interest in learning about patient and family backgrounds.40 Overall, there is good evidence to suggest that cultural competence training impacts the attitudes of healthcare providers (evidence grade B). Although the quantity of evidence was sufficient and the results were consistent, the quality of the body of literature did not meet criteria for evidence grade A because less than 75% of studies used an objective assessment of learner attitudes.
Of the 14 studies that evaluated the effect of cultural competence training on the provider skills, all demonstrated a beneficial effect. For example, in one study, participants were given 16 1-hour sessions in which they practiced communication skills with community volunteers and were subsequently shown to be significantly more competent in interviewing a non-English-speaking person as rated in videos by a blinded psychologist.16 Other behaviors that were observed included an increase in nurses’ involvement in community-based cancer education programs,32 an increase in learners’ self-reported social interactions with peers of different races/ethnicity,36 and an improvement in the learners’ ability to conduct a behavioral analysis and treatment plan.41 Overall, there is good evidence to suggest that cultural competence training impacts the skills/behaviors of healthcare providers (evidence grade B). Although the quantity of evidence was sufficient and the results were consistent, the quality of the body of literature did not meet criteria for evidence grade A because there was no randomized controlled trial and fewer than 75% of studies used an objective outcome assessment.
Only 3 studies evaluated patient outcomes: 1 targeting physicians,20 1 targeting mental health counselors,44 and 1 targeting a mixed group of providers.40 All 3 studies reported favorable patient satisfaction measures,20,40,44 and 1 demonstrated an improvement in adherence to follow-up among patients assigned to intervention group providers.44
With regard to the methods used to bring about such improvements in patient outcomes, 1 study trained 4 mental health counselors about the attitudes that low-income African American women bring to counseling (4 hours)44 and found that, in comparison with the control group, counselors were rated more highly in the domains of expertness, trustworthiness, empathy and unconditional regard. Another study trained 9 physicians to speak the Spanish language (20 hours)20 and found, after the intervention, that patients were more likely to agree that the physician was concerned, respectful, and listened. A third study implemented a state-mandated 3-day training program focused on team training, recipient recovery principles, clinical issues and cultural competence for all staff who have contact with recipients of inpatient mental healthcare40 and found that, after the intervention, there were improvements in patients’ sense that the staff would see them as individuals. Overall, there is good evidence that cultural competence training impacts patient satisfaction (evidence grade B) and poor evidence that cultural competence training impacts patient adherence or health outcomes (evidence grade D).
Outcomes associated with specific features of the interventions are presented in Table 4. Both shorter- and longer-duration interventions appear effective, as do both methods using experiential learning and those not using experiential learning. Interventions teaching general cultural concepts, those teaching about specific cultures, and those that teach both are all associated with positive outcomes.
Of the 34 articles, there were only 4 articles that addressed the costs of cultural competence training.14,17,19,20 Three of the 4 articles14,17,19 described the costs of interventions that involved international travel. Two programs provided US$2000 (in 200019 and in 1995–199617) for each student to travel from the United States to South America, Asia, or Africa for either 619 or 817 weeks. In each of these programs, the students provided the remaining costs. Another program estimated that an 8-day trip from the United States to Mexico cost US$1200 total in 1994, of which the students contributed 60% on average, and scholarship assistance for the remainder was available through private donations.14
There are limited data regarding the costs of classroom instruction or other types of instruction. One study estimated the cost of 20 total hours of Spanish language instruction for 9 physicians to be US$2000 in 2000, not including the opportunity costs for physician time (approximately 20 hours total for each physician).20 In another program, there were also 60 hours of classroom instruction (20 hours of Spanish language instruction and 40 hours of cultural competence training focused on Hispanic populations) provided for 19 students at an estimated local cost of US$3000 in 1994, of which each student contributed US$80.14 Finally, one program involved matching 26 students to 26 local ethnically diverse families, asked the students to visit the family 6 times, and paid each family US$400 in 1996– 2000.17 Overall, there is poor data (only one study provided comprehensive data) to determine the costs of cultural competence training (evidence grade D).
Cultural competence training is being reported with increasing frequency in the literature and is gaining the attention of health care administrators and educators. Many different curricular methods and content areas have been evaluated. There is excellent or good evidence that cultural competence training impacts intermediate outcomes such as the knowledge, attitudes, and skills of health professionals. Good evidence also exists that cultural competence training impacts patient satisfaction and insufficient evidence that training impacts patient adherence (although the one study designed to do this demonstrated a positive impact). No studies have evaluated patient health outcomes.
It has been suggested that all cultural competence interventions should target the knowledge, attitudes, and skills of health professionals, so measurement of these intermediate outcomes are appropriate, and results are encouraging.1 Intermediate outcomes might ultimately impact patient outcomes considering that health care providers who are more knowledgeable about their patients’ backgrounds, who have more positive attitudes towards their patients, and who have the skills to communicate and apply a patient-centered approach are likely to provide better care to their patients.45 The Institute of Medicine report, Unequal Treatment, suggests that the mechanism involved in the link between improved communication and improved patient health status may be through improved patient satisfaction and adherence.1 The same mechanism may be operating with improved provider cultural competence, but it is additionally possible that culturally competent health professionals may actually be more skillful in obtaining histories and therefore in making diagnoses.
Concerns have existed about whether specific cultural information taught in curricula using a knowledge-based, categorical approach might promote stereotyping of patients.1,4 Although our study found that curricula teaching about specific cultures were associated with positive outcomes in general, one of the studies in our review demonstrated that, following an intervention that taught specific cultural information, students were more likely to believe that Aboriginal people were all alike.12 Given this finding, and other evidence demonstrating that providers exhibit bias and stereotyping behavior in their interactions with ethnic minority patients,46,47 this phenomenon should be evaluated with further studies. Only 2 of the 34 studies in our review included mention of concepts of racism, bias or discrimination in their content, which, in theory, might reduce the likelihood of this effect. Another strategy to avoid stereotyping, recommended by medical educators, is a patient-centered approach that emphasizes general concepts of culture in addition to providing specific cultural information.4
Although this systematic review determined that cultural competence training impacts provider knowledge, attitudes and skills, it is difficult to conclude from the literature which types of training interventions are most effective on which types of outcomes due to the heterogeneity and intermingling of curricular content and methods. There were no 2 studies that evaluated the exact same educational experience, and there were no studies that compared different types of training methods or content. However, almost all studies reported a positive effect, suggesting that employing any intervention may be effective. In particular, our review suggests that both longer and shorter duration interventions, experiential as well as nonexperiential, and curricula focusing on general concepts of culture and specific cultural information (alone and separately) are all associated with positive outcomes. This should be of great interest to medical educators and policy makers, and suggests it might be reasonable to compare interventions of varying length and content in a randomized controlled fashion.
We found that there was little uniformity across studies in measurement of outcomes (even within outcome categories), making it difficult to determine which specific types of knowledge, attitudes, or skills are impacted by cultural competence training. For example, some studies tested students on specific cultural information whereas other studies tested students on general cultural concepts, but no 2 studies reported using the same knowledge assessment tool. Although several studies used standardized measures of cultural self-efficacy, a wide range of attitudes was measured by the studies. Finally, there was also variation in skills measured, which ranged from developing a behavioral treatment plan to socializing with peers across race/ethnicity and would likely have very different and perhaps uncertain effects on clinical care. Future studies ought to link specific provider skills (for example, communication skills to address cultural barriers to adherence) to the relevant patient outcomes of interest (for example, adherence to recommended treatments).
Organizations and providers may have limited resources to conduct educational programs to improve cultural competence. There is insufficient evidence to determine the cost of cultural competence training because only 5 articles included data on costs and because the cost information contained in these 5 articles was too limited to allow for a comprehensive estimate. However, one of the studies that was able to demonstrate an improvement in patient satisfaction also included information about cost, and so perhaps the best evidence is found in that study, where it was estimated to cost $2000 (not including the cost of physician time) to train 9 emergency department physicians in the Spanish language.20 It is also worth noting that both shorter and longer interventions were effective, suggesting that future studies should evaluate the added benefit of additional investments of time.
The limitations of the existing literature provide a template for future research on cultural competence. First, further research would be aided greatly by a uniform conceptual model for provider cultural competence and by a standardized, validated instrument to measure cultural competence. This would allow for comparisons between studies in the future. Second, given the heterogeneity of curricular interventions, it would be helpful to have studies that compare interventions varied by either curricular content or training methods (ie, those that focused on general versus specific concepts of culture, those that use experiential learning compared with classrooms, and so on). Third, and probably most important, studies should attempt to measure patient outcomes. Finally, researchers should include data about the resources and costs of training, so that those who wish to employ interventions to improve the quality of care for racial/ethnic minorities know the investment that must be made in cultural competence to achieve a given outcome.
The results of our study should be interpreted with several limitations in mind. First, we were only able to review published studies. Therefore, there is the possibility of publication bias; that is, published studies are more likely to show a positive effect of cultural competence training than unpublished work. Indeed, most studies examining knowledge, attitudes, and skills were positive studies. Second, we limited our review to articles published in English and to those articles published after 1980. However, we believed these studies would be most relevant given changes in population demographics and the paradigms of medical education. Third, we developed our own criteria to grade the strength of the evidence; however there are no previously used systems for grading evidence that are designed for educational interventions. We are explicit about the method, though, so others could apply different standards if they choose. Finally, our review focused on interventions aimed at the education of health care providers, rather than on all possible organizational strategies to provide culturally and linguistically appropriate services, as other recent reviews have focused more specifically on organizational cultural competence.48
In conclusion, cultural competence training shows promise as a strategy for improving health care professionals’ knowledge, attitudes, and skills and patients’ ratings of care. We believe that interventions that focus on the avoidance of bias, general concepts of culture, and patient-centeredness are promising strategies that should be prioritized for further study. Further research should also focus on the development of standard instruments to measure cultural competence. Studies evaluating the impact of cultural competence training should compare different methods of teaching cultural competence, use objective and standardized evaluation methods and measure patient outcomes including patient adherence, health status and equity of services across racial and ethnic groups.
This article is based on research conducted by the Johns Hopkins Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (Contract No. 290-02-0018), Rockville, MD. The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the US Department of Health and Human Services.