Truong et al. BMC Health Services Research 2014, 14:99http://www.biomedcentral.com/1472-6963/14/99

RESEARCH ARTICLE Open Access

Interventions to improve cultural competency inhealthcare: a systematic review of reviewsMandy Truong1*, Yin Paradies2 and Naomi Priest1

Abstract

Background: Cultural competency is a recognized and popular approach to improving the provision of healthcare to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities.The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field toform a comprehensive understanding of the current evidence base that can guide future interventions andresearch in the area.

Methods: A systematic review of review articles published between January 2000 and June 2012 was conducted.Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites weresearched. Reviews of cultural competency in health settings only were included. Each review was criticallyappraised by two authors using a study appraisal tool and were given a quality assessment rating of weak,moderate or strong.

Results: Nineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included avariety of health care settings/contexts and a range of study types. There were three main categories of studyoutcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes.The majority of reviews found moderate evidence of improvement in provider outcomes and health care accessand utilization outcomes but weaker evidence for improvements in patient/client outcomes.

Conclusion: This review of reviews indicates that there is some evidence that interventions to improve culturalcompetency can improve patient/client health outcomes. However, a lack of methodological rigor is commonamongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range ofbiases, while objective evidence of intervention effectiveness was rare. Future research should measure bothhealthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorousstudy designs.

Keywords: Cultural competency, Healthcare, Health outcomes, Health disparities, Minority health, Systematic review

BackgroundCultural competency is a broad concept used to describe avariety of interventions that aim to improve the accessibil-ity and effectiveness of health care services for people fromracial/ethnic minorities. It developed largely in response tothe recognition that cultural and linguistic barriers betweenhealthcare providers and patients could affect the qualityof healthcare delivery. The targeted groups were mainly

* Correspondence: mtr@unimelb.edu.au1McCaughey VicHealth Centre for Community Wellbeing, Melbourne Schoolof Population and Global Health, The University of Melbourne, Carlton,AustraliaFull list of author information is available at the end of the article

© 2014 Truong et al.; licensee BioMed CentralCommons Attribution License (http://creativecreproduction in any medium, provided the or

immigrant populations from non-English speaking coun-tries with limited exposure to Western cultural norms [1].Since its introduction in the 1980s, the range of cultural

competency frameworks and models has burgeoned. Manymodels include dimensions of knowledge (e.g., understand-ing the meaning of culture and its importance to health-care delivery), attitudes (e.g., having respect for variationsin cultural norms) and skills (e.g., eliciting patients’explanatory models of illness) [1]. Over time, the scope ofcultural competency expanded beyond the interpersonaldomain of the practitioner-patient/client interaction toinclude organizational and systemic cultural competency.Although the most often cited definition of cultural

Ltd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly credited.

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competency is that of Cross and colleagues [2], thereis no one widely accepted and definitive conceptualcultural competency framework. The literature containsmany analogous terms/concepts (e.g. culturally appropri-ate care, multicultural education) that add to the lack ofclarity in this field.There is an abundance of international literature re-

lated to cultural competency and the importance of itsintegration into all levels of health care. In the UnitedStates, the prominence of cultural competency withinhealth policy and practice is largely attributed to federaland state regulations calling for culturally competentcare (Office of Minority Health, 2001).Existing reviews have examined cultural competency

and related concepts within health care settings such asnursing [3] and mental health [4] as well as withinhealth care systems [5]. Some reviews have focused oneither provider outcomes [6] or patient/client outcomes[7] while others have examined specific health condi-tions such as diabetes [8].These existing reviews highlight a lack of robust evi-

dence pertaining to the relationship between culturalcompetency and improved provider/organizational behav-iors or patient/client health outcomes. There is also a lackof consensus on the most effective ways of improving cul-tural competency [9] and continuing debate as to whetherinterventions to improve cultural competency can lead toa reduction in health disparities caused by racial/ethnicdiscrimination [10]. The aim of this systematic review ofreviews is to gather and synthesize existing reviews ofstudies in the field to form a comprehensive understand-ing of the current evidence base that can guide futureinterventions and research in the area.For this review of reviews, interventions to improve

cultural competency are defined as those that aim to:improve the accessibility and effectiveness of health carefor people from racial/ethnic minorities by increasingawareness, knowledge and skills of health care providersor patients as well as modifying policies and practices oforganizations. These interventions may be focused at thehealth care provider-patient/client level (e.g. interper-sonal interactions) or more broadly at the organizationallevel (e.g. integration cultural competency into policies,plans and processes). Interventions that meet this defin-ition may also be referred to in this paper by other termssuch as culturally appropriate care and multiculturaleducation if these terms are utilized in specific reviews.

MethodsSearch strategyIn November 2011 the following databases and electronicjournal collections were searched from 2000 to 2011:Medline, Cinahl, Eric, PsycINFO, Proquest (Dissertation/Theses), Scopus and the Cochrane Systematic Review

Database. Reference lists were hand-searched for otherreviews. Key websites (i.e. www.diversityrx.org, www.nccc.georgetown.edu, www.minorityhealth.hhs.gov, www.ceh.org.au, www.hrsa.gov, www.nice.org.uk) were also searched.In July 2012 the search was updated to include recentstudies published up to June 2012. See Additional file 1for search terms used.As cultural competency did not achieve popularity

until the late 1990s and government policies mandatingcultural competence did not occur until the early 2000s[11], a search timeframe of 2000–2012 was chosen.

Inclusion and exclusion criteriaA review was considered eligible for inclusion if it metthe following criteria: i) included quantitative, qualitativeor mixed methods studies, ii) was written in English, iii)included studies involving: health care/service providers/practitioners/clinicians, health administrators, supportstaff and patients/clients/health service users, iv) in-cluded studies utilizing any strategies or interventions toimprove cultural competency (e.g. training programs orworkshops or educational courses), v) included studiesinvolving intervention settings or services related to thehealth sector (e.g. hospitals, community health services,educational institutions teaching health related courses),vi) included studies that used one or more outcome mea-sures at an individual level (e.g. survey), organizationallevel (e.g. programs) or system level (e.g. policies).Reviews were excluded if they described cultural compe-

tency in other non-health settings (e.g. education system),were conducted prior to the year 2000, or did not containa methods section that included information on: searchstrategy, number of included studies, and details of studies.

Quality of the review and synthesis of resultsEach review was critically appraised independently by twoauthors using the health-evidence.org tool for reviews [12].This tool consists of ten questions to assess the quality ofthe review using commonly accepted evidence-informedprinciples. Reviews were given a quality assessment ratingof weak, moderate or strong.

Identification of reviewsThe total search identified 6,830 results. Based on theinclusion and exclusion criteria, titles and abstracts werescreened for eligibility by the first author. Full texts wereretrieved for all reviews where inclusion was in doubt.To reduce the potential for bias in the screening process,the second author independently screened 10% of thetotal identified titles and also extracted data for 10% ofthe reviews that met the inclusion criteria. There was nodifference in agreement between reviewers. See Figure 1:PRISMA flow diagram for a flow chart summary of thesearch and inclusion/exclusion process.

Records identified through database searching in Nov 2011(n=5975)

Duplicates excluded (n= 493)

Total papers screened (n=5482)

Titles and abstracts screened (Excluded n= 5458)

Full text articles assessed for eligibility (n=25)

Articles included in qualitative synthesis (n=19)

In July 2012 we re-ran search for period Dec2011-June 2012. (n= 855 additional for screening, n=4 were included)

Full texts articles excluded (n=6) for following reasons:- Did not report number of

included studies and/or provide details of included studies

- Did not report intervention outcomes

- Did not provide details of search methods

Medlinen= 140

PsycINFOn=380

ERIC n=82

Dissertation & thesesn=491

Cinahln=356

Cochrane n=6

Scopusn=4520

Figure 1 PRISMA flow diagram search process – initial search conducted December 2011.

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Data extraction and analysisData extracted from the included reviews was enteredinto an Excel 2011 spreadsheet under the followingheadings: author(s), year of publication, health caresetting/context, definition/concept/framework of culturalcompetence, method of review (e.g. database(s) searched),inclusion/exclusion criteria, number of included papers,types of papers included, study quality assessment, majorfindings, recommendations and quality/critical appraisalof review.Data extracted from the reviews was descriptively ana-

lyzed using Excel 2011. Meta-analysis was not conducteddue to the heterogeneity of the reviews and their includedstudies. Analysis focused on: types of interventions andstudy outcomes.

ResultsOverview of reviewsSearching yielded a total of 6,830 titles, of which 19 metthe inclusion criteria and were extracted for analysis(Table 1) [3-8,13-25]. The main reasons for exclusionwere: articles were commentary or opinion pieces, arti-cles were of primary studies, review articles examinedcultural competency assessment tools and review arti-cles but did not include any studies with interven-tions. Six review articles were excluded for not providing

information on search strategy and details of includedstudies [26-31].The majority of reviews (n = 15) were published

between 2007 and 2012. Reviews focused on a range ofhealth care settings/contexts, including: health profes-sionals, community rehabilitation, nursing and healthsystems. A range of study designs were included in thereviews, including randomized controlled trials, pre andpost designs as well as qualitative studies. Most reviewsprovided a definition of cultural competency or relatedconcept. The number of studies included in each reviewvaried between 5 and 38. Smith et al.’s [19] review con-sisted of two meta-analyses, of which only the secondmeta-analysis (n = 37) met the inclusion criteria. (Thefirst meta-analysis consisted of retrospective surveystudies that did not report outcome measures.) Thirteenreviews assessed the quality of studies using criticalappraisal tools such as the Oxford Centre for EvidenceBased Medicine [13].

Interventions to improve cultural competencyTypes of interventions to improve cultural competencyincluded in the reviews were: training/workshops/pro-grams for health practitioners (e.g. doctors, nurses andcommunity health workers), culturally specific/tailorededucation or programs for patient/clients, interpreter

Table 1 Summary of 19 included reviewsAuthor &year ofpublication

Health context Definition of culturalcompetence

Sources(years of search)

Number ofincludedpapers

Type of papers Outcomes Was studyqualityassessed?

Major findings(review authors’conclusions)

Reviewquality

Andersonet al. 2003

Healthcaresystems

Based on Cross et al.1989 definition: ‘a set ofcongruent behaviors,attitudes and policiesthat come together in asystem, agency, oramong professionalsand enable effectivework in cross-culturallysituations’

Medline, Eric, Soc Abs,SciSearch, DissertationAbs, Soc Sci Abs, MentalHealth Abs, Healthstar.English only.(1965–2001)

6 Interventionstudies

1) Patient satisfaction,health status 2)utilization of healthservices

Yes Could not determinethe effectiveness of anyof these interventions,because there wereeither too few comparativestudies, or studies did notexamine the outcomemeasures evaluated in thisreview: client satisfactionwith care, improvementsin health status, andinappropriate racial orethnic differences in useof health services or inreceived and recommendedtreatment.

Moderate-strong

Beach et al.2005

Healthprofessionals(physicians andnurses). Moststudies locatedin the UnitedStates.

Cultural competencehas been defined as“the ability ofindividuals to establisheffective interpersonaland workingrelationships thatsupersede culturaldifferences” (Cooperet al. 2002) byrecognizing theimportance of socialand cultural influenceson patients, consideringhow these factorsinteract, and devisinginterventions that takethese issues intoaccount (Betancourtet al. 2003).

Medline, Cochrane,Embase, EPOC,RDRB/CME, Cinahl(1980–2003)

34 RCTs, controlled,pre & post

1) Provider outcomes:knowledge, attitudes,skills 2) patientoutcomes: satisfaction,behaviors, health status3) cost effectiveness

No Cultural competencetraining shows promise asa strategy for improvingthe knowledge, attitudes,and skills of healthprofessionals. However,evidence that it improvespatient adherence totherapy, health outcomes,and equity of servicesacross racial and ethnicgroups is lacking. It isdifficult to conclude fromthe literature which typesof training interventionsare most effective onwhich types of outcomes.Also difficult to determinewhich types of knowledge,attitudes & skills areimpacted by training.

Moderate-strong

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Table 1 Summary of 19 included reviews (Continued)

Bhui et al.2007

Mental health.All studieslocated in NorthAmerica.

Aim of the paper is todevelop a meaningof CC

Ingenta, Medline viaOvid, Medline viaPubmed, Medline Plus,Health Outcomes,HealthPromis, HSTAT,DocDat, NationalResearch Register, NLMGate- way, Cam, ReFerand Zetoc. (1985–2004)

9 No RCTs.Qualitative &quantitativepapers

1) Provider outcomes2) evaluations ofimplemented modelsof CC

No There is limited evidenceon the effectiveness of CCtraining and servicedelivery. Few studiespublished their teachingand learning methods.Only three studies usedquantitative outcomes.One of these showed achange in attitudes andskills of staff followingtraining. No studiesinvestigated service userexperiences andoutcomes.

Moderate-strong

Chippset al. 2008

Healthprofessionalsworking incommunity-basedrehabilitationincluding mentalhealth andprimary care. Allstudies locatedin North America.

“The ability toeffectively provideservices cross-culturally”(Diller 1999). Culturalcompetence trainingprograms aim toincrease “culturalawareness, knowledge,and skills leading tochanges in staff(both clinical andadministrative)behavior andpatient-staff interactions”(Brach & Fraserirector2000). Culturalcompetence includesthe capability to identify,understand, and respectvalues and beliefs ofothers (Andersonet al. 2003).

CINAHL, Medline,Pubmed, PsycINFO,SABINET, Cochrane,Google, NEXUS, andunpublished abstracts(1985–2006)

5 RCTs, quasi-experimental,evaluation studies

1) Provider outcomes:cultural knowledge andattitudes, culturalcompetence, 2) patienthealth outcomes:satisfaction, behaviors,health status

Yes Positive outcomes werereported for most trainingprograms. Reviewedstudies generally hadsmall samples and poordesign. 3 of the 5 studiesreported on patient/clientsatisfaction.

Strong

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Table 1 Summary of 19 included reviews (Continued)

Downinget al. 2011

Health careworkers inAustralia

Throughout this review,the term ‘indigenouscultural training’ will beused to describe trainingthat is concerned withassisting health workersto provide health carethat is accessible,meaningful and useful toindigenous/otherminority groups in termsof their social, emotionaland cultural wellbeing aswell as physical health.

CINAHL PLUS, MEDLINE,Wiley InterScience,ATSIHealth andProQuest.

9 Not reported 1) Provider outcomes:knowledge, attitudes,awareness,

No There is scant evidence forthe effectiveness ofindigenous culturaltraining. The only study toassess knowledge andattitudes before and aftertraining with a controlgroup found no effect.Three studies alsodocumented positivepost-training reports butit is unclear if this relatesto any change in practiceas a result of the training.No information was available with which to assesssystemic differencesbetween the programsthat did and did notproduce (perceived)changes.

Moderate

Fisheret al. 2007

Health careprovision tonon-White racialand ethnicgroups in theUnited States.

Cross’ definition forcultural competence.Definition of culturalleverage: a focusedstrategy for improvingthe health of racial andethnic communities byusing their culturalpractices, products,philosophies, orenvironments asvehicles that facilitatebehavior change ofpatients andpractitioners.

Medline, Cochrane,Web of knowledge,The New York Academyof Medicine GreyLiterature Report(1985–2006)

38 (35uniquestudies)

RCTs, pre-post,controlled

1) Patient outcomes:health behaviors 2)access to health caresystem 3) provider:cultural competence

Yes The interventionsreviewed increasedpatients’ knowledge forself-care, decreasedbarriers to access, andimproved providers’cultural competence.Interventions usingcultural leverage showpromise in reducinghealth disparities, butmore research is needed.

Moderate

Forsetlundet al. 2010

Health care forethnic minorities.Most studieslocated in theUnited States.

To collect andsummarise in asystematic andtransparent manner theeffect of interventionsto improve health careservices for ethnicminorities

Cochrane Library,MEDLINE, EMBASE,British Nursing Index, ISISocial Sciences/ScienceCitation Index (SSCI/SCI)and Research andDevelopment ResourceBase (RDRP).

19 Randomizedcontrolled

Quality of health careservices, use of healthcare services, patienthealth or the quality oflife for patients.

Somewhat Educational interventionsand electronic remindersto physicians may in somecontexts improve healthcare and health outcomesfor minority patients. Thequality of the evidencevaried from low to verylow. The quality ofavailable evidence for theother interventions wastoo low to draw reliableconclusions.

Moderate-strong

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Table 1 Summary of 19 included reviews (Continued)

Harunet al. 2012

Cancer care toethnic minoritywomen. Allstudies locatedin the UnitedStates.

Defines “patient-centredcare”: involves integratingpatient preferences andvalues to guide clinicaldecisions andmanagement, and it isthought to facilitateimproved patientsatisfaction,communication withproviders, safety, costsand efficiency in thehealth-care system.

Medline, PsycINFO,EMBASE and Cochrane

7 Randomizedcontrolled,non-randomized,mixed-methodexperimental

Communication withhealth providers,decision-making,treatment adherence,general patientparticipation,treatment knowledge

Yes Of the 37 selected studies,only 18 included validoutcome measures.Employing a combinationof multiple strategies ismore likely to be successfulthan single interventions.The impact of theinterventions onparticipation was varied andeffectiveness may hinge ona variety of factors, such astype of intervention andstudy populationcharacteristics. Given thepaucity of studies, it isdifficult to draw conclusionsabout the effectiveness ofthe different interventionsfor this broad patient group.

Moderate-strong

Hawthorneet al. 2008

Community-based orhospital-basedsettings. Diabeteseducation forethnic minoritygroups. Moststudies locatedin the UnitedStates.

’Culturally appropriate’health education isdefined here aseducation that istailored to the culturalor religious beliefs andlinguistic skills of thecommunity beingapproached, taking intoaccount likely literacyskills (Overland 1993).

The Cochrane Library,MEDLINE, EMBASE,PsycINFO, CINAHL, ERIC,SIGLE and referencelists of article(prior to 2007).

11 RCTs Patient: health status,behaviors, satisfaction,knowledge.

Yes Culturally appropriatediabetes health educationappears to haveshort-term effects onglycaemic control andknowledge of diabetesand healthy lifestyles.None of the studies werelong-term, and so clinicallyimportant long-term outcomes could not bestudied. No studiesincluded an economicanalysis.

Strong

Hendersonet al. 2011

Chronic healthconditions. Moststudies locatedin the UnitedStates.

Culturally safe serviceswere originally definedas those where there isno assault on a person’sidentity caused by thefact that service deliverymethods or processesare alien to the person’sculture (Ramsden 1990).

CINAHL, MEDLINE,Joanna Briggs Institute,Cochrane Library,Lippincott, Williams andWilkins Collection,PubMed, ProQuest,Dissertations andTheses, and GoogleScholar (1999–2009)

24 RCTs andcontrolled trials

1) Utilization of healthservices 2) patientoutcomes: satisfaction,health behaviours,health status 3)provider outcomes:awareness, culturalcompetency

Yes The review supported theuse of trained bi-lingualhealth workers, who areculturally competent, as amajor consideration in thedevelopment of anappropriate health servicemodel for culturally andlinguistically diversecommunities. Four studiesreviewed involved culturalcompetency training forhealthcare providers andall 4 indicated that culturalcompetency training wasbeneficial. Nevertheless,the translation of culturalknowledge into practiceremains problematic.

Moderate

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Table 1 Summary of 19 included reviews (Continued)

Kehoeet al. 2003

Health care forethnic minoritygroups. Moststudies locatedin the UnitedStates.

CC involves the actualintegration of congruentbehaviors, attitudes andpolicies, within thedelivery of health carein cross-culturalsituations. (Office ofMinority Health 2000)

Medline, Cinhahl(1980–2001)

14 RCTs, quasi-experimental

Patient outcomes:health status, healthbehaviors

Yes A small number of studiesdemonstrated significantlyimproved outcomes forpatients with diabetesmellitus, drug addictions,sexually transmitted infections andother health problems, afterreceiving culturally competent orrelevantinterventions. Fewstudies examinedlong-term effects ofinterventions on healthoutcomes.

Moderate

Kokko 2011 Nursing.Participants inthe studies werefrom Australia,Denmark,Finland,Germany,Norway andSweden.

Cultural competence isdefined as a set of skillsand behaviors thatenable a nurse to workeffectively within thecultural context of aclient/patient (Leininger2002, Papadopoulos2006).

MEDLINE andCumulative Index toNursing and AlliedHealth Literature(CINAHL) databases(2000–2009)

7 Qualitative 1) Provider outcomes:cultural knowledge,personal growth,nursing student’spractice, preparednessfor culturalcompetence in nursing

No The results of the presentstudy demonstrate thatparticipating in overseasstudent exchangeprograms increased thenursing students’preparedness to beculturally competent.

Weak-moderate

Lie et al.2011

Health careprofessionals.Most studieslocated in theUnited States.

Not reported MEDLINE/PubMed, ERIC,PsycINFO, CINAHL andWeb of Sciencedatabases (1990–2010)

7 Interventionstudies

Patient outcomes:satisfaction, behaviors,health status

Yes Study quality was low tomoderate. Effect sizeranged from no effect tomoderately beneficial.There is limited researchshowing a positiverelationship betweencultural competencytraining and improvedpatient outcomes.

Strong

Lu et al.2012

Cancer screeninginvolving Asianwomen. Moststudies locatedin the UnitedStates.

Not reported MEDLINE, EMBASE,Cochrane Database ofSystematic Reviews,Cochrane CENTRALRegister of ControlledTrials, CINAHL,CancerLit, DAREDatabase of Reviews ofEffects, PsycINFO, ABIInform, ERIC, SocialSciences Abstracts,Sociological Abstracts,Health TechnologyAssessment Database(University of York),Proquest Dissertationsand Theses, and KUUCKnowledge Utilization

37 Randomizedcontrol trial(including clusterrandomized trial,and randomizedcontrolledcrossover trial),non-equivalentcontrol group, orprospectivecohort.

Breast cancerscreening, cervicalcancer screening, andthose studies targetingboth breast cancer andcervical cancerscreening

Yes Our review found thatintervention studies variedgreatly by studypopulation andgeographic area. Thereforewe could not arrive at aconclusive andgeneralizable conclusionon effectiveness of anyone particular intervention.Only eighteen of theincluded studies reportedeffectiveness based oncompletion ofmammograms or papsmear, either by self-reportand/or verified throughclinical record. While somestudies demonstrated the

Moderate-strong

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Table 1 Summary of 19 included reviews (Continued)

Database (Universityof Laval)

effectiveness of certainintervention programs, thecost effectiveness andlong-term sustainability ofthese programs remainquestionable.

McQuilkin2012

Nursing.Participants inthe studies weremostly from theUnited States

Evidence of awarenessof personal culture,values, beliefs, attitudesand behaviours;demonstrated ability toassess cross-culturalvariations; and toeffectively performrequisite skills needed toassess and communicatewith individuals fromother cultures(Cavillo et. al, 2009).

Health and PsychosocialInstruments, CINAHLPlus with Full Text, ERIC,Health Source: Nursing/Academic Edition,MEDLINE, PsycINFO,EBSCO, COCHRANE,CINAHL, reference listsfrom identified articles.

37 (16interventions)

Case study,expert opinion,comparativedescriptive,quantitative,systematic review

1) Increase elf-awareness their ownvalues, atti es, beliefsand behav thatcompose r culture,2) increase kill inassessmen dcommunic n withpersons fro othercultures, an ) abilityto provide assessment of tr culturaldifferences

Yes Findings demonstratedthat internationalimmersions providedoptimal experiences todevelop culturalcompetence alone, butmore effective whencombined with otherstrategies. Internationalimmersion experiencescan increase student self-awareness, cross-culturalcommunication andassessment skills, andability to assess culturaldifferences. The evaluationmeasures described in theliterature were consistentlystudent self-perceptionrather than observeddevelopment of thestudent’s culturalcompetence.

Moderate

Pearsonet al. 2006

Nursing Definition: “the ability ofsystems to provide careto patients with diversevalues, beliefs andbehaviors, includingtailoring delivery tomeet patients’ social,cultural and linguisticneeds” (Betancourtet al. 2002)

CINAHL, Medline,Current Contents, theDatabase of Abstractsof Reviews ofEffectiveness, TheCochrane Library,PsycINFO, Embase,Sociological Abstracts,Econ lit, ABI/Inform,ERIC and PubMed. Thesearch for unpublishedliterature usedDissertation AbstractsInternational.(prior to 2005)

19 Quantitative,qualitative,reviews

1) Patient ealthstatus, sat ction 2)nurses: 3) anisations4) systems

Yes The results identified anumber of processes thatwould contribute to thedevelopment of a culturallycompetent workforce.Appropriate and competentlinguistic services, andintercultural staff trainingand education, wereidentified as key findings inthis review.

Moderate-strong

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d softudiorstheid st anatiomd 3anans

s: hisfaorg

Table 1 Summary of 19 included reviews (Continued)

Smith et al.2006

Mental healthprofessions. Allstudies werelocated in theUnited States.

Not reported Dissertation Abstracts,ERIC, HealthSTAR,Medline, Mental HealthAbstracts, ProgrammeApplique’ a’ la Selectionet a’ la CompilationAutomatiques de laLitte’rature, PsycINFO,Social Sciences Abstracts,Social SciSearch,Sociological Abstracts viaSocioFile, and SocialWork Abstracts(1973–2002)

Meta-analysis2 n = 37

Outcome studies Meta-analysis 2- provideroutcomes: multiculturalcounseling competence,racial identity, racialprejudice, client-counselor relationship

Yes Multicultural educationinterventions weretypically associated withpositive outcomes across awide variety of participantand study characteristics.Multicultural educationinterventions that wereexplicitly based on theoryand research yieldedoutcomes nearly twice asbeneficial as those thatwere not.

Moderate-strong

Sumlin &Garcia 2012

DiabetesmanagementinvolvingAfrican Americanwomen in theUnited States

Cultural competence,or tailoring, is defined as“the process of creatingculturally sensitiveinterventions, ofteninvolving the adaptationof existing materialsand programs forracial/ethnicsubpopulation”.

PubMed, CumulativeIndex to Nursing andAllied Health Literature,the Cochrane Reviewdatabase, and TheDiabetes Educatorjournal index.

15 RCTs and quasi-experimentaldesigns

Dietary outcomes,weight loss, changesin metabolic control(A1C), lipids, bloodpressure, andcholesterol

No Of the 15 studies, 6showed significantimprovements in foodpractices, and 8 showedsignificant improvementsin glycaemic control as aresult of the interventions.It is not clear whatcomponents of the 15interventions were mosteffective. Most studies didnot report the duration ofthe sessions, therebymaking comparison of“intervention dose”impossible. In addition,variations across thestudies in content andmethods used do notpoint to specificrecommendations forclinicians or educators toadopt or avoid.

Moderate-strong

Whittemore2007

DiabetesmanagementinvolvingHispanicadults in theUnited States.

Not reported CINAHL, Medline,PsycINFO (1990–2006)

11 RCTs, pre-postdesign

Patient outcomes:clinical, behavioraland knowledge

No The majority of studiesin this review reportedsignificant improvementsin select clinical outcomes,behavioral outcomes, ordiabetes- relatedknowledge.

Moderate-strong

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services, peer education, patient navigators and exchangeprograms.Seven of the 19 reviews focused solely on healthcare pro-

vider cultural competency interventions [6,7,13,14,17,19,23]whilst six reviews examined only culturally competency in-terventions aimed at patients/clients [8,18,20-22,24]. Threereviews included studies that examined organizational levelinterventions such as culturally adapting health programsfor patients and employment of bilingual community healthworkers [5,15,16]. One review focused primarily on inter-ventions directed at health care personnel and/or orga-nizations, although interventions targeting both healthpersonnel and patients were also included [25]. Anotherreview looked at the structures and processes that supportthe development of culturally competent practices [3].Evaluated models of cultural competence in mental healthwere reviewed by Bhui et al. [4].

Study outcomesThere were three main categories of study outcomesamongst the reviews: provider-related outcomes, patient/client-related outcomes and outcomes related to healthservice access and utilization. Evaluations of implementedmodels of cultural competency [4] and cost-effectiveness[6] were also examined.

Provider outcomesMeasured provider outcomes focused on knowledge,attitudes and skills related to cultural competency. InBeach et al.’s [6] review, knowledge refers to informationabout general cultural concepts such as the impact ofculture on the patient-provider encounter or culture-specific knowledge such as traditional cultural practices.Attitude outcomes measured by studies included culturalself-efficacy (assessing learner confidence of knowledgeand skills in relation to ethnic minority patients), attitudestowards community health issues, and interest in learningabout patient and family backgrounds [6]. Skills includedcommunication skills or use of treatment plan. In con-trast, Smith et al.’s [19] review used multicultural coun-seling competence as their main outcome measure whileKokko [17] included studies examined nursing students’cultural knowledge, personal growth and nursing practice.

Patient/client outcomesThere were a variety of patient/client outcomes reported,including physiological outcomes such as blood glucose,weight and blood pressure [8] as well as outcomes suchas patient satisfaction and trust [7], knowledge of cancerscreening and knowledge of health conditions [15]. Be-havioral outcomes such as dietary and exercise behaviorswere also examined in three reviews [15,18,21]. Otherreviews looked at primarily patient-focused interventionsto improve breast and cervical cancer screening among

women [24] and to improve participation in cancertreatment processes [22].

Health service access and utilization outcomesOutcomes related to health service access and utilizationincluded use of bilingual community health workers, in-terpreters, and patient navigators. These interventionswere designed to influence individuals’ ability to accessthe resources of health care organizations by bridgingthe cultures of the organizations and those of the targetcommunities [15].Cost-effectiveness of interventions was considered in

three reviews [6,8,24]. Beach et al. [6] noted that only 4of 34 studies included in their review addressed the costsof cultural competence training. No studies in Hawthorneet al.’s [16] review measured the cost effectiveness of theirinterventions, although some included a rough estimate ofcosts. Two studies in Lu et al.’s [24] review reported costinformation. These reviews noted this as an importantlimitation of studies they examined.

Major findings of reviewsProvider related outcomesSix of the eight reviews that examined healthcare providerinterventions found some evidence of improvement inprovider outcomes such as knowledge, skills and attitudesin relation to cultural competency [6,15-17,19,23].

Patient/client related outcomesSeven of the nine reviews that examined patient/client-re-lated outcomes generally found evidence of some impro-vement in health outcomes. Hawthorne et al.’s [8] reviewof culturally appropriate diabetes health education foundshort-term effects (up to one year) on glycemic controland knowledge of diabetes and healthy lifestyles. However,long-term effects (one year or more) were not examinedby any studies. Whittemore [20] also reviewed culturallyappropriate interventions in relation to diabetes, but forHispanic populations only, finding evidence of significantimprovements in selected clinical outcomes, behavioraloutcomes and diabetes-related knowledge in the majorityof studies. Sumlin & Garcia [21] found significant impro-vement in food practices and glycemic control amongstAfrican American women with Type 2 diabetes followinguse of culturally competent food-related interventions.Kehoe et al.’s [18] review also found that culturally rele-vant interventions improved patient/client outcomes forconditions such as diabetes and drug addiction. Lie et al.[7] found a positive relationship between cultural com-petency training and improved patient/client outcomes.Chipps et al.’s [13] review included three studies measur-ing patient/client satisfaction, with only one of these threestudies finding increased satisfaction of clients with theircounselors. Reviews by Harun et al. [22] and Lu et al. [24]

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found mixed results, and hence were unable to drawgeneralizable conclusions in relation to patient participa-tion in treatment and cancer screening, respectively.

Outcomes related to access and utilization of health servicesFour of five reviews that included studies related tohealth service outcomes found some evidence of im-provement. Fisher et al. [15] reviewed a range of inter-ventions to narrow racial disparities in primary andtertiary health care settings, grouped into three categor-ies: patient behavioral change, access to care, and healthcare organization innovation. They found that interven-tions using culturally specific patient navigators andcommunity health workers were among the most suc-cessful. Henderson et al. [16] reviewed a range of cultur-ally appropriate interventions to manage chronic diseaseamong racial/ethnic minorities, also finding support forthe use of trained bilingual health workers to promotegreater uptake of disease prevention strategies. From ahealthcare systems perspective, Anderson et al. [5] founda lack of both quantity and quality of studies focused onimproving cultural competency. Pearson et al. [3] foundthat appropriate and competent linguistic services andintercultural staff training and education were key indeveloping effective culturally competent practices innursing. Forsetlund et al. [25] found that education in-terventions and electronic reminders to physicians mayimprove health care and health outcomes for minoritypatients. However, the quality of evidence for these inter-ventions was graded as low to very low.

Other outcomesBhui et al.’s [4] review included studies that evaluatedimplemented models of cultural competence; essentiallyorganizational approaches. They concluded that cultur-ally competent care and services at the organizationallevel is addressed in different ways depending on thelocal context, for example managed care and insurancebased service models in the United States may not totranslatable in settings where services are dependent ongovernment funds.

Quality of studies within reviewsThe majority of reviews noted methodological limita-tions of studies. This limited conclusive statementsabout the effectiveness of interventions to increase cul-tural competency. The main methodological criticismsof the studies by the reviews were: small samples [13],poor methodological rigor [7,13,15], no or few long-termstudies [8,18], no economic analysis of interventions[6,8], reliance on self-report measures [19], lack of detailabout interventions [7,19], lack of patient outcome mea-sures [4-6,15] and lack of objective provider measuresrelated to change in practice [14,17].

Some reviews reported the quality/strength of evidencesupporting the outcomes measured [5-8,15,25]. Forexample, Beach et al. [6] graded the strength of evidencefor each outcome type based on its quality, quantity, andconsistency (grades A – D). In their review, evidence ofimpacts on provider knowledge were graded A comparedwith provider attitudes which were graded B.

Recommendations of reviewsTwelve of the nineteen reviews concluded that furtherresearch (e.g. more rigorous trials and evaluations) wasrequired to determine the effectiveness of interventions toimprove cultural competency for providers and patients/clients. The reviews found that many of the studies weredifficult to compare as different frameworks of culturalcompetency were used and studies often lacked a stan-dardized and validated instrument to measure culturalcompetence [6]. Most reviews concluded that training hadpositive impacts on provider outcomes. However, it wasdifficult to determine exactly what types of training inter-ventions were most effective in relation to particularoutcomes [6,13,19]. A need for research into long-termoutcomes [8,18] was identified along with the need toconsider other factors that facilitate cultural compe-tency, such as links with community organizations[3,15]. It was also recommended that cost-effectiveness beassessed [8,24].

Limitations of reviewsSome of the reviews focused on one type of interventionsuch as diabetes education for patient outcomes [8] orhealth provider cultural competency training [14]; onetype of study outcome such as patient outcomes [7]; onetype of study design such as randomized controlled trials[25]; or a particular study population such as Hispanics[20], Asian women [24] or nurses [17]. Although it maybe more feasible for a review to focus on a particulargroup of health providers or type of health care setting,it limits generalizability and applicability of the findings.Many studies were heterogeneous in outcome and inter-ventions, making statistical synthesis and analysis difficult[13]. According to Smith et al. [19], their meta-analysiswas limited by: studies with single-group pre-to post-testassessments (e.g. [32,33]), studies rarely reporting disag-gregated data, and predominantly self-report measures(e.g. [34,35]).It is also difficult to determine the extent to which

knowledge and skills learnt from training/programs aretranslated into practice and how they impact on patient/client outcomes [5,17]. Provider outcomes determinedby self-report are subject to multiple threats to internalvalidity [36] and hence limit the conclusions made regar-ding impact on provider practice [19] and ultimately onpatient outcomes.

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The literature includes a diverse range of populations(e.g. African American, Hispanic/Latino, and Asian), healthcare settings (e.g. community centers, hospitals and aca-demic medical centers) and interventions (e.g. culturallytailored programs for particular racial/ethnic groupsand provider training). However, the majority of stud-ies were based in the United States. Two reviews limitedtheir included studies to only those conducted in theUnited States [15,21].

Heterogeneity of reviews and studiesMeta-analysis was not conducted in this review ofreviews due to the heterogeneity of the reviews and theirincluded studies. Intervention effects were also difficult todetermine as only some reviews described outcomes interms of statistical significance and effect sizes [5,6,8,13,19].Some reviews noted that studies rarely provided sufficientinformation on the curriculum or format, or details of theproviders involved (e.g. age, race, gender, prior training)making it difficult to conclude from studies which types oftraining interventions were most effective for whichgroups and in producing which particular outcomes [6,7].

Critical appraisal of reviewsAll reviews were critically appraised by two authorsusing the health-evidence.org tool for reviews [12] andcompanion tool dictionary [37]. This process was relianton the author’s prior knowledge and experience of thetopic, research principles and study design methods.There were minor disagreements between authors andconsensus was reached through discussion. Reviews werepredominantly of moderate-strong quality (overall assess-ment of review quality is included in Table 1).

Design of reviewsAll reviews had a clearly focused question in relation tothe population, intervention and outcomes. Appropriateinclusion criteria to select primary studies were used bythe majority of reviews. The majority of reviews describedcomprehensive search strategies, although some wereslightly limited in scope [4,14,15,20]. For example, Kehoeet al. [18]’s search strategy consisted of only two electronicdatabases. The number of years covered by the searchstrategies was 20 years or more by the majority of reviews.Two reviews [16,17] covered 10–11 years, one reviewsearched between 2005–2011 [23], and one review [14]did not provide this information.

Methodological rigor of reviewsThe methodological rigor of studies was identified and de-scribed in thirteen reviews [3,5,7,8,13,15,16,18,19,22-25].The methodological rigor of primary studies using anassessment tool/scale was conducted by all these reviewsexcept for two [18,19]. Nine reviews reported the use of

two or more reviewers to assess each study for metho-dological quality [6-8,13,15-17,22,24]. Most reviews usedappropriate methods for combining and comparing resultsacross studies. However, Pearson et al.’s [3] results werenot well presented.

DiscussionThis systematic review of reviews has identified a numberof key issues and limitations in what is currently knownabout interventions to improve cultural competencywithin healthcare. There was considerable heterogeneityamongst the reviews in relation to interventions used, pa-tient populations, health provider populations, health con-texts/settings as well as processes and outcomes of care.This reflects the complexity of the area and its translationto practice and research. Overall, positive effects werereported by most reviews, particularly in relation to pro-vider outcomes. However, it remains unknown exactlywhat types of interventions are most effective, for whom,in what context, and why.Reviews that compared different types of interventions,

e.g. Henderson et al. [16] and Fisher et al. [15], found thatthe use of culturally trained health workers was the mosteffective. However, rather than being comparable, many ofthe primary studies in these reviews were a mixture ofstudy designs focused on various interventions.The included reviews were generally difficult to com-

pare as different definitions and frameworks of culturalcompetency or related concepts were used. Some reviewsdid not provide a definition [4,7,19,20,24]. The lack ofuniformity in terminology and definition reflect the manyvariations of terms and definitions used in relation to cul-tural competency at present. This is likely a key contribut-ing factor to the lack of consensus on the best ways todevelop, implement and evaluate cultural competencyinterventions. Developing such consensus regarding ter-minology and definitions, with a view to improving evi-dence of effective cultural competency interventions isthus an important area of future work both theoreticallyand empirically.Mixed findings were found by two reviews [22,24]. In

their review of breast and cancer screening among Asianwomen, Lu et al. [24] determined that the effective-ness of interventions to promote screening dependedon factors such as the type of intervention, methodsof program delivery, study setting and ethnic population.Harun et al.’s [22] review of interventions to improveparticipation in treatment found that the impact of theseinterventions was varied amongst the seven includedstudies. Both reviews found that patterns of interventiondesign and results of effectiveness were heterogeneous,therefore it was difficult to generalize the effectivenessof particular interventions for particular patient/clientgroups.

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Organizational contextCross-cultural interactions are likely structured andshaped by the worldviews and past experiences of notonly the staff and clients but also the culture of theorganization, which is embedded in and produced by pol-icy frameworks, organizational arrangements and physicalsettings of the organization [38]. Interventions to improvecultural competency need to consider the individual andorganizational contexts and the interplay between them.Training programs may need to be tailored to particulargroups, for example physicians would need particularknowledge and skills specific to their clinical tasks thatwould be inapplicable for reception staff.It is likely that cultural competency training as a stand-

alone strategy is insufficient to improve patient outcomeswithout concurrent systemic and organizational changes[7,9,39]. Embedding cultural competency in organizationalpolicy documents such as position statements and strategicplans are more likely to result in sustained change withinorganizations. There should be a commitment among theleadership of the organization and embedded key perform-ance indicators supported by allocated resources.There is some evidence of a relationship between the

cultural competence of health practitioners and thecultural competence of organizations [39,40]. Providersmay be influenced by their organization’s commitmentand actions in relation to cultural diversity and vice versa.A study found that providers with attitudes reflectinggreater cultural motivation to learn were more likely towork in clinics with more culturally diverse staff and thoseoffering cultural training and culturally adapted patienteducation materials [40].In recognition that different components of the health

system influence health outcomes, some models of cul-tural competency advocate a multi-level approach [2,41].Although some studies have shown that culturally compe-tent practices among organizations are adopted to varyingdegrees [42,43], more research is needed in this area. Grolet al. [44] found that empirical evidence of the effective-ness and feasibility of most theoretical approaches toproduce change in health care was limited. Dreachslinet al. [45] found a paucity of research on organizationalbehaviour in the healthcare and general managementliterature. A more recent review by Parmelli et al. [46]showed limited available evidence regarding effective strat-egies to change organizational culture in health care. Bar-riers and incentives to organizational change should beconsidered when designing and implementing an inter-vention to increase the likelihood of success and sustainedchange [47,48]. Issues related to organizational readinessfor change and innovation also require considerationbefore implementing organizational cultural competencyinterventions [49]. Understanding the reasons for adop-tion and spread of innovation can assist with addressing

the difficulties of organizational change [50]. Planningand implementation of cultural competency interventionsshould acknowledge the interaction between an interven-tion and the setting. Organizational cultural competenceinvolves an understanding of the strengths and weak-nesses of the health care organization and the uniqueneeds of the people it serves.

Beyond self-assessmentSelf-assessment was the most common approach to asses-sing cultural competency, which is a subjective measuresubject to a range of biases [36]. The assessment toolswere mostly process and survey tools, including patientsatisfaction and provider self-assessment questionnaires aswell as self-administered organizational checklists. Manyof these tools have not been validated [51]. Self-rating atthe individual level may be affected by the respondents’level of cultural awareness and is subject to biases such associal desirability [52]. Broader organizational and sys-temic approaches to cultural competency should considerassessments of cultural competency that include objectivemeasures such as document review [52]. Moving beyondself-assessment is a necessary step towards developing astronger evidence base for the use of cultural competencyrelated interventions to improve patient/client health out-comes. In addition, more research is needed to determinehow well both individual-level and organizational-levelguidelines for cultural competency are followed by thosedirectly involved in service delivery [53].

Broader issues of culture, racism and privilegeAcademics have asked whether cultural competency canbe achieved without focusing on issues related to racismand white privilege [54,55]. Concepts related to racism,bias and discrimination were noted in some reviews[3,5,6,14,15,23], although none were measured as out-comes in studies. Two of the 34 studies in Beach et al.’s(2005) review included mention of these concepts in theireducation content. Factors such as structural inequalitiesand racism may have a greater impact on health disparitiesbetween particular groups than cultural differences [56].Self-reflection and awareness of one’s professional and

personal culture is an important component of culturalcompetency [57]. Of the seven reviews that focused on pro-vider outcomes, four discussed these concepts [13,14,17,23].This is despite these self-reflexive elements being criticalto cultural competency. Cultural awareness alone is inad-equate for addressing the effects of structural and inter-personal racism on health disparities. Cultural awarenesstraining has been criticized for increasing stereotypingand reinforcing essentialist racial identities [58]. Reflexiveantiracism training is a promising alternative to culturalawareness training that reflects upon the sources andimpacts of racism on society whilst avoiding essentialism

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and negative emotional reactions associated with Whiteguilt [59].There is a tendency within healthcare to equate

culture with essentialized notions of race and ethnicity,which can lead to practices that separate culture fromits social, economic and political context [10]. Narrowconceptualizations of culture and identity may limit theeffectiveness of particular approaches, and a focus onspecific cultural information may inadvertently promotestereotyping. Care must also be taken to avoid over-focusing on ‘culture’. Although cultural differences mayworsen the problem of differential access and discrimin-ation, broader factors such as poor education and povertymay play a greater role in the poorer health outcomes ofsome individuals and groups in the community [60]. How-ever income and race/ethnicity as risk factors for healthdisparities can overlap and discrimination is often a driverof socio-economic disparities [61].

LimitationsA limitation of this review is that there may be primarystudies in the field that are not included by existingreviews in the literature as this was a review of reviewsrather than a review of primary studies. There were only22 primary studies cited by more than one review. Thisis likely due to the relatively narrow focus of somereviews e.g., by health condition, minority groups or typeof outcome (i.e. patient or practitioner). Another limitationis that only reviews published in English were included.Given that the timeframe for this review was 2000–2012 itis possible that reviews published prior to 2000 were notincluded. However, cultural competency did not achievepopularity until the late 1990s and government policiesmandating cultural competence did not occur until theearly 2000s [11].The search strategy could have been improved by add-

ing more patient-related terms (e.g. migrant and refugee)and applying a more sensitive search filter for systematicreviews. It is possible that some reviews were excludedas a result, however it is unlikely that the overall findingswould be significantly different as this paper includesreviews from various health care contexts and healthcare provider and patient populations as well as differenttypes of studies and cultural competency interventions.It is difficult to make a general statement about the

strength of the effect of interventions as the reviewsassessed their studies differently. Different critical appraisaltools were used by authors and a majority of reviews notedmethodological limitations of studies in their reviews,which limited their ability to make conclusive statementsabout the effectiveness of interventions. In order to de-termine the strength of the effect, an assessment of allprimary studies of the included reviews using a singlecritical appraisal tool to determine the effectiveness of their

interventions and an assessment of quality and bias of eachindividual study is required. However this is beyond thescope of this paper.

ConclusionThis systematic review of reviews of interventions toimprove cultural competency within healthcare settingshas synthesized all recent reviews in order to improveour understanding of the current evidence base andguide future research in this area. The majority of reviewsfound moderate evidence of improvement in provider out-comes and health care access and utilization outcomes.However, there was weaker evidence for improvements inpatient/client outcomes.This review has highlighted the breadth and complexity

of research in this area as well as the popularity of thisarea as shown by the number of published reviews foundduring the period January 2000-June 2012, and parti-cularly from 2007 onwards. Despite this popularity, it isclear that the evidence base is relatively weak, and therecontinues to be uncertainty in the field. First, there is nouniform definition or framework of cultural competencethat is accepted across the spectrum of health contexts/settings either within or between countries. Many termsare used interchangeably with cultural competency (e.g.cultural safety, cultural awareness, cultural responsiveness).Second, there are many potential outcomes from culturalcompetency interventions, as indicated by the variety ofmeasures utilized in reviews, but very few validated toolsto assess cultural competency in the published literature[51,62]. Third, a lack of methodological rigor is commonamongst the studies included in reviews. Moreover, manyof the studies rely on self-report, which is subject to arange of biases, while objective evidence of interventioneffectiveness was rare.Future reviews should be explicit about their definition

or framework of cultural competency and what constitutesa culturally competent intervention, whether at the indi-vidual-level, organizational-level or systemic-level. Reviewsshould also examine multiple outcomes at all three levelswhere possible due to the multi-dimensional nature ofcultural competency interventions and the complexities intranslating cultural competency into practice. Further de-velopment and assessment of organizational cultural com-petency models and assessment tools is needed [63].Multi-level interventions should consider the different

contexts (e.g. government policy vs. community issues) andcultures (e.g. individual vs. organizational) that can affectthe implementation and success of interventions to im-prove cultural competency. Issues related to organizationalchange and understanding the mechanisms by which healthinnovations are adopted should also be taken into account.There is also need for research to examine the time andresources required to implement interventions in addition

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to identifying the most feasible and effective approaches[6]. This is particularly important for organizational orsystemic approaches where cost-benefit/effectiveness is animportant consideration.

Additional file

Additional file 1: Search terms used in search strategy.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsAll authors developed the idea for the systematic review and contributed tothe concept and design. MT conducted the searching and drafted the tablesand figures. All authors contributed to the writing of the manuscript andread and approved the final manuscript.

AcknowledgementsMT was supported by an Australian Postgraduate Award during thepreparation of this manuscript. NP was supported by an NHMRCpostdoctoral training fellowship (628897) and the Victorian Health PromotionFoundation during the preparation of this manuscript.

Author details1McCaughey VicHealth Centre for Community Wellbeing, Melbourne Schoolof Population and Global Health, The University of Melbourne, Carlton,Australia. 2Centre for Citizenship and Globalization, Faculty of Arts andEducation, Deakin University, Burwood, Australia.

Received: 15 May 2013 Accepted: 21 February 2014Published: 3 March 2014

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doi:10.1186/1472-6963-14-99Cite this article as: Truong et al.: Interventions to improve culturalcompetency in healthcare: a systematic review of reviews. BMC HealthServices Research 2014 14:99.

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