The effectiveness of cultural competence programs in ethnic minority patient-centered health care--a systematic review of the literature

The effectiveness of cultural competence

programs in ethnic minority patient-

centered health care—a systematic review

of the literature

A. M. N. RENZAHO1,2, P. ROMIOS3, C. CROCK4 AND A. L. SØNDERLUND5

1International Public Health Unit, Department of Epidemiology and Preventive Medicine, Monash University, Level 3, Burnet Building, 89Commercial Rd, Melbourne, 3800 Victoria, Australia, 2Centre for Internal Health, Burnet Institute, Melbourne, 3004 Victoria, Australia,3Health Issues Centre, Melbourne, 3086 Victoria, Australia, 4Australia Institute for Patient and Family-Centred Care, Melbourne, Victoria,USA, and 5Department of Psychology, University of Exeter, EX4 4QJ Devon, UK

Address reprint requests to: Andre M. N. Renzaho, International Public Health Unit, Department of Epidemiology and PreventiveMedicine, Monash University, Level 3, Burnet Building, 89 Commercial Rd, Melbourne, 3800 Victoria, Australia. Tel: +61-3-92-51-77-72;Fax: +61-3-92-44-66-24; E-mail: [email protected]

Accepted for publication 2 December 2012

Abstract

Purpose. To examine the effectiveness of patient-centered care (PCC) models, which incorporate a cultural competence (CC)perspective, in improving health outcomes among culturally and linguistically diverse patients.

Data sources. The search included seven EBSCO-host databases: Academic Search Complete, Academic Search Premier,CINAHL with Full Text, Global Health, MEDLINE with Full Text, PsycINFO PsycARTICLES, PsycEXTRA, Psychologyand Behavioural Sciences Collection and Pubmed, Web of Knowledge and Google Scholar.

Study selection. The review was undertaken following the preferred reporting items for systematic reviews and meta-analyses,and the critical appraisals skill program guidelines, covering the period from January 2000 to July 2011.

Data extraction. Data were extracted from the studies using a piloted form, including fields for study research design, popu-lation under study, setting, sample size, study results and limitations.

Results of data synthesis. The initial search identified 1450 potentially relevant studies. Only 13 met the inclusion criteria. Ofthese, 11 were quantitative studies and 2 were qualitative. The conclusions drawn from the retained studies indicated that CCPCC programs increased practitioners’ knowledge, awareness and cultural sensitivity. No significant findings were identified interms of improved patient health outcomes.

Conclusion. PCC models that incorporate a CC component are increased practitioners’ knowledge about and awareness ofdealing with culturally diverse patients. However, there is a considerable lack of research looking into whether this increase inpractitioner knowledge translates into better practice, and in turn improved patient-related outcomes. More research examiningthis specific relationship is, thus, needed.

Keywords: patient-centered care, cultural competence, intercultural health care, health-care interventions

Introduction

Worldwide immigration has increased throughout the pastcentury and considerably so in the past decade from 150million migrants in 2000 to 214 million in 2010 [1]. Suchchange is reflected in various developed countries and specif-ically in public sectors such as health care, where the work-force and client base are becoming increasingly multifariousin terms of ethnicity and culture [2]. This demographic

transformation is not without its problems, however, asmassive disparities in the health status of the population areevident, negatively affecting primarily ethnic and cultural mi-nority groups [3–6].The successful delivery of health care in a multicultural

setting is often hampered by a host of factors, includingchiefly language and non-verbal communication barriersbetween carer and patient [7, 8], lack of respect and/or aware-ness of cultural traditions and beliefs in the practitioner–client

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relationship [9–11] and interpersonal as well as institutionalstereotyping and prejudice [12–14]. Accordingly, severalhealth-care models have been proposed to shift from a some-what paternalistic health-care model to an approach thatengages the patient in decision making and self-care. Suchmodels include cultural competence (CC) and patient-centeredcare (PCC) models [15, 16].CC has been conceptualized as a ‘a set of congruent beha-

viors, attitudes and policies that come together in a system,agency or among professionals and enable that system, agencyor those professions to work effectively in cross-cultural situa-tions’ [17–19]. It has been hypothesized that lack of awarenessabout cultural differences, together with culturally and linguis-tically diverse (CALD) patients’ lack of knowledge about thehealth system, can lead to two possible unwanted outcomes[16, 20]: (i) compromised patient–provider relationships,making it difficult for both providers and patients to achievethe most appropriate care and (ii) effects on patients’ healthbeliefs, practices and behaviors. As a result, the NationalCenter for Cultural Competence in the USA has suggested aframework for CC [21] emphasizing the need of health-caresystems to• have a defined set of values and principles, policies andstructures that enable them to work effectively andcross-culturally;

• have the capacity to value diversity, conduct self-assessment, manage the difference and institutionaliza-tion of cultural knowledge and adapt to diversity andthe cultural contexts of the communities they serve;

• incorporate the requirements above in all aspects ofpolicy development, administration and practice/servicedelivery.

The health-care models

PCC relies on the recognition that each patient represents adistinctive case with unique requirements and treatmentneeds and, thus, focuses on holistic care provided throughopen carer–patient communication and collaboration [22].Patient empowerment and support also feature prominentlyin this method. As such, PCC principally signifies a moveaway from a ‘one-size-fits-all’ approach in health care to amore tailored treatment plan [22, 23].Several studies attest the relevance of PCC in a range of

health-care settings and the association between the form ofpatient care and health outcomes. For example, Stewart et al.[24] found significant positive correlations between patient-centered communication and patient perception of findingcommon ground (P = 0.01) and in turn linked such positiveperceptions with better recovery (P = 0.0001), less concern(P = 0.02), better emotional health (P= 0.05) and fewer diag-nostic checks and referrals (up to 2 months later). Theseresults were supported by Wanzer et al. [25] who linked patientsatisfaction with communication and physician and nursepractice of PCC (r = 0.73, P = 0.001; r = 0.61, P = 0.001,respectively). Patient satisfaction with care received was alsocorrelated with perceived physician PCC practice (r = 0.67,P= 0.001) and perceived nurse PCC practice (r = 0.68,P= 0.001) [25].

Similar findings highlight the value of PCC in other set-tings, including general preventive health care [26], diabetesmanagement [27], cancer management [28–30], post-cancerfollow-up treatment [31, 32], palliative care [33, 34], mentalhealth [35] and HIV management and treatment [36]. Thus,there is considerable research providing relatively clearsupport for beneficial relationships between the practice ofPCC and patient health, treatment and satisfaction.

PCC and CC

As PCC is designed to take into account the specific circum-stances relevant to each patient—including ethnic and cul-tural variables. The successful delivery of this type ofcollaborative care relies on the ‘CC’ of the health-care pro-vider. That is, for effective PCC, the practitioner must beable to communicate effectively verbally and non-verballyand respect the traditional practices and beliefs of the patient[37]. The significance of CC in health care is exemplified inseveral studies on issues such as physician language ability,cultural knowledge and patient satisfaction. Fernandez et al.[38], for example, found significant positive associationsbetween physician self-rated language ability and successfulelicitation of and responsiveness to patient concerns and pro-blems (OR 4.3; 95% CI, 1.75–10.56). Physician self-ratedunderstanding of patients’ health-related cultural beliefs wasalso significantly linked with patient clarity (OR 3.98; 95%CI, 1.43–11.45), responsiveness (OR 4.56; 95% CI, 1.67–12.46) and understanding of prognosis and condition (OR4.5; 95% CI, 1.73–11.79). Similarly, Mazor et al. [8] foundthat a 10-week medical Spanish course for pediatric emer-gency department physicians was significantly associated withdecreased use of interpreter services in patient care post-intervention (OR 0.34; 95% CI, 0.16–0.71) and increasedpatient satisfaction in terms of perceived physician concern(OR 2.1; 95% CI, 1.0–4.2), respectfulness (OR 3.0; 95%CI,1.4–6.5) and listening/communication (OR 2.9; 95% CI,1.4–5.9). In other examples, the CC of practitioners waspositively correlated with minority patient satisfaction withreceived medical care (r2 = 0.193, P < 0.05) [39] (r = 0.32,P< 0.001) [40] and decreased blood pressure among hyper-tensive patients (r = –0.18; P < 0.05) [40]. These findings arefurther backed up in other research and appear to be rele-vant in a broad range of health-care settings [41–44].As such, CC in health care can best be defined as practi-

tioner flexibility and adaptability in terms of working effective-ly within a variety of cultural and ethnic contexts. Thisincludes linguistic abilities, as well as cultural knowledge,awareness, sensitivity and respect [32]. Considering the in-creasing ethnic and cultural diversity in health-care clientele,CC is, thus, an integral aspect of PCC.

The current review

PCC and CC have been found to be complementary in termsof improving health-care quality and outcomes [15]. Whereaspatient-centeredness aims to improve health-care quality by

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emphasizing the inclusion of the patient’s perspective general-ly in caregiving, CC centers on circumventing cultural barriersbetween the health-care provider and client [45]. As such,both concepts focus on improved health care with an em-phasis on patient-centeredness that in turn begs for acknowl-edgement of patient diversity. On this backdrop, PCC and CCapproaches aim for the development of effective communica-tion and clinical capabilities in health practitioners. For thisreason, PCC and CC have been used interchangeably in theliterature [45]. Nonetheless, there are relatively few PCCmodels that specifically incorporate a CC component andfewer still that have a cultural focus and have been empiricallydeveloped and evaluated [12, 46]. Thus, the aim of the follow-ing systematic review is to examine the effectiveness of PCCmodels that incorporate a CC perspective, in improving healthoutcomes among CALD patients.

Method

Protocol

This review was conducted according to the PreferredReporting Items for Systematic Reviews and Meta-Analysesguidelines that can be accessed at www.prisma-guidelines.org(Fig. 1).

Information sources

A search of the following databases was conducted duringAugust 2011: Academic Search Complete, Academic SearchPremier, CINAHL with Full Text, Global Health, MEDLINEwith Full Text, PsycINFO, PsycARTICLES, PsycEXTRA,Psychology and Behavioural Sciences Collection, Pubmed,Web of Knowledge and Google Scholar.

Search strategy and study selection process

The search terms used were based on MeSH keywords for‘PCC’ and ‘cultural competency’. Searches were conductedon the following terms simultaneously:(i) Cultural competency terms (MeSH terms):

Competency, Cultural; Cultural Competencies;Cultural Competence; Competence, Cultural.

(ii) PCC terms (MeSH terms): Care, Patient-Centered;Patient-Centered Care; Nursing, Patient-Centered;Nursing, Patient Centered; Patient-Centered Nursing;Patient-Centered Nursing; Patient-Focused Care; Care,Patient-Focused; Patient-Focused Care; Medical Home;Home, Medical; Homes, Medical; Medical Homes;

(iii) Other terms (text word): Prejudice, Health care;Racism, Health care; Attitude, Health care.

Reference lists for relevant papers were also manuallysearched for additional citations. Studies were included in thereview based on the following criteria:(i) The study was published in a peer-reviewed scientific

journal.(ii) The full text was available in English.(iii) The population under study comprised health-care

professionals and/or students and/or ethnicminorities.

(iv) The study centered on the development and effective-ness of patient-centered health-care models with aCC focus.

(v) The date of the publication was no earlier than 1January 2000.

Validity assessment

Search results were assessed in three rounds. First, articleswere filtered based on their title. Second, articles were retainedor excluded after reviewing their abstracts. Third, the full-textversions of the remaining articles were obtained and reviewed.The empirical quality of the studies was assessed according tocritical appraisal skill program guidelines (see Table 1).

Data extraction process

Data were extracted from the studies using a piloted form,including fields for study research design, population understudy, setting, sample size, study results and limitations.

Figure 1 Flow chart of study selection.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Table 1 Data extraction strategy

Inclusion criteria Yes No

Is the paper peer reviewed and is the fulltext available?

Proceed↓

Exclude↓

Does the study focus health-care deliveryto ethnic minorities?

Proceed↓

Exclude↓

Does the study involve the developmentand assessment of (an) intercultural PCCmodel(s)?

Proceed↓

Exclude↓

Final decision Include Exclude

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Results

Study selection

A total of 1450 papers were identified in the initial search.The majority of these were rejected based on one or more ofthe following factors: the paper focused on general health-care delivery models without a CC component; the paperdescribed culture-related training programs that were notpart of PCC programs; the paper described CC health-caremodels, but with no empirical evaluation or evidence base;the paper was about work culture rather than ethnic culture;the paper did not cite empirical research (commentaries,book reviews, etc.); or a combination of the above. Overall,13 studies met the inclusion criteria (see Table 1).

Study characteristics and samples

Seven of the studies reviewed were from the USA, four fromCanada and two from the UK (See Table 1). The majority ofthe research was conducted in a professional (clinical/hos-pital) setting (n = 9) [47–55], but student settings were alsoused (n= 5) [49, 56–59]. All participants were adults over 18years of age. The studies predominantly (n= 11) relied onquantitative research designs, including randomized controltrials (RCT), longitudinal design, cross-sectional design anddescriptive correlational design (see Table 1). Qualitative re-search designs were employed in the remaining studies (n=2). Outcome measures comprised patient satisfaction withcare, health outcome or practitioner behavior in four of thestudies [50–52, 54], whereas the remaining nine studies gen-erally used practitioner knowledge and/or awareness of PCCand CC issues as evaluation measures [47–49, 53, 55–59](Table 2).

Summary of findings

Two studies examined patient health outcomes as an evalu-ation measure. Majumdar et al. [51] investigated the effects ofa CC course on 114 nurses and homecare workers. Effectsof the program were also observed for 133 patients.Health-care workers who received the training demonstratedsignificantly higher understanding of multiculturalism than acontrol group (P< 0.0001). Similar findings were evident forcultural awareness (P= 0.0001), understanding of cultural dif-ferences (P = 0.001), cultural beliefs (P = 0.004), adoptinghealth-care literature (P = 0.001), considering patient socialcircumstances (P = 0.011) and regarding culture as importantin successful health-care treatment (P = 0.001). These resultspersisted over time. There were no significant findings interms of patient health outcomes—however, this was pos-sibly due to attrition in the patient participant group [51].Thom et al. [54] assessed the effectiveness of a CC training

curriculum administered to 53 physicians. The trainingprogram comprised cultural knowledge, intercultural commu-nication and cultural brokering (engaging the patient in the de-velopment of a treatment plan in a culturally sensitivefashion). The impact of the intervention was measured in

terms of the CC of the physician as rated by the patient.Secondary measures included patient satisfaction withreceived health care and outcomes. The study yielded no sig-nificant effects across all evaluation variables. Limitations werenoted, however, and related to the brevity of the training cur-riculum (3–5 h), insufficient follow-up assessments and thefact that over 70% of participating physicians were of anotherethnicity than Caucasian and, therefore, possibly already cul-turally capable [54].The remaining eight studies relying on quantitative research

designs examined practitioner training and education pro-grams, with the exception of a single study that looked intoAfrican-American patient satisfaction and perception of phys-ician CC [52]. Here, the effectiveness of the ‘Ask Me 3’ inter-vention was evaluated. The program focused on increasingthe quality of PCC and CC, by encouraging African-Americanpatient involvement in the clinical process [52]. Results indi-cated no improvements in physician CC as rated by thepatient. Significant progress was evident, however, in satisfac-tion for patients who saw their regular physician (P = 0.014).Thus, an interaction effect of physician familiarity and theintervention appeared to increase patient satisfaction with carereceived. Limitations mainly related to a small sample size (n= 64) [52].Brathwaite and Majumdar [47, 48] assessed the effects of

a PCC educational program offered to 76 nurses at aCanadian hospital. The evaluation centered on pre- and post-intervention scores on the Cultural Knowledge Scale.Significant increases in CC over time were evident (P< 0.02)—specifically in relation to cultural knowledge, awareness,confidence and use of lessons learned [47, 48].A study in the USA assessed the Cultural Competence

and Mutual Respect program that was delivered over 3 yearsto 1974 health-care students [57]. Evaluation was based onpre- to post-scores of the Inventory for Assessing theProcess of Cultural Competence-Revised scale (ranging from25 to 100 points), and significant improvements in studentCC were evident with males increasing by 4.1 points (P <0.001) and females by 3.8 points (P< 0.001) [57].Comparable findings were established in four other studies.

[49, 53, 56, 59] One study [58] assessing the impact of a CCPCC educational program on university students found nosignificant improvements in CC post-intervention. This was,however, probably due to limitations of the measurementscales used and the brevity of the intervention period [58].Finally, two qualitative studies were included in the review.

Kirmayer et al. [50] evaluated a program implemented as a cul-tural consultation service for mental health practitioners andprimary care clinicians. Assessment of the service occurredthrough practitioner observation, reason for consultation,examining cultural formulations and recommendations as wellas consultation outcome in terms of clinician satisfaction [50].Patients comprised immigrants, refugees and asylum seekers(n = 102). The most common reasons for consultation withthe service were difficulties with diagnosis (58%) and treat-ment planning (45%) as well as requests for assistance withspecific ethnic groups or clients (25%) [50]. It was furtherevident that the main themes in terms of practitioner cultural

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Table 2 PCC models with a CC scope—from 2000 to present

Author (year) Location Experimentaldesign

Sample (n) Integrated cultural caremodel

Outcome measures Results and limitations

Brathwaite[48] Canada Longitudinal pre- topost-interventionstudy

Registered nurses (76) Brief CC training course. Scores on the CKS. Results showed that the course was effective inincreasing participants’ levels of CC (P< 0.000).Limitations relate to the small sample size and thelack of patient health outcome effects.

Brathwaite andMajumdar [47]

Canada Longitudinal pre- topost-interventionstudy

Registered nurses (76) Five-week CC trainingcourse.

Scores on the CKS. Nurses’ CKS scores increased significantly (Wilks’Lambda P < 0.01). Limitations relate to smallsample size, generalizability and lack of patienthealth outcome effects.

Crandall et al. [56] USA Longitudinal pre- topost-interventionstudy

Second-year medicalstudents (12)

Adaptation andintegration of culturalawareness, sensitivityand knowledge inmedical practice.

Multi-national AssessmentQuestionnaire pre- topost-intervention scores.

A positive impact was apparent pre- topost-intervention. Further research to establishwhether effect decays or persists. Lack ofassessment of patient health outcome effects.

Ghallager-Thompsonet al. [49]

USA Longitudinal pre- topost-interventionstudy

Health-careprofessionals andstudents (340)

The Alzheimer’sHispanic Outreach,Resource and AccessProject.

Participant knowledge ofCC and related attitude andclinical behavior.

Significant improvements in the measured variableswere evident post-intervention (P< 0.05–0.005).

Kirmayer et al. [50] Canada Qualitative study Minority mental healthpatients (100)

Cultural consultationservice; integratingdifferent perspectives ofpsychiatry and medicine.

Referring clinicians’satisfaction with patientprogress.

Clinicians reported increased insight into cases,improved treatment, therapeutic alliance,understanding and communication. Limitationsrelate to the small sample size.

Majumdar et al. [51] Canada RCT Health-care providers(114) and patients (133)

Cultural sensitivitytraining for health-careproviders, culturalawareness,communication andunderstanding.

Health-care providerattitude and culturalcompetency and patienthealth outcomes.

The program improved knowledge and attitudes ofhealth-care providers in the experimental group (P= 0.011–0.0001). There were significantimprovement in patient health outcomes andsatisfaction.

Michalopoulou et al.[52]

USA RCT African-Americanpatients (64)

Culturally sensitive GPpractice of Ask Me 3intervention.Encouraging activepatient articipation inclinical process.Communication andinteraction.

Patient-Perceived CulturalCompetency Measure score.

No significant differences were found betweenexperimental and control groups. Individuals seeingtheir regular GP reported significantly higher levelsof satisfaction with care, than patients seeing theirregular GP. Limitations include small sample sizeand a single ethnicity under study.

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Table 2 Continued

Author (year) Location Experimentaldesign

Sample (n) Integrated cultural caremodel

Outcome measures Results and limitations

Musolino et al. [57] USA Longitudinal pre- topost-interventionstudy

IHSS, professionals inmedicine [60],pharmacy, nursing andPT (1974)

Cultural Competencyand Mutual Respecteducation program.

Pre- to post-interventionscores onCampinha-Bacote’sInventory for Assessing theProcess of CulturalCompetence-Revised.

Overall progress toward CC was observed pre- topost-intervention (P< 0.001). Cultural proficiencywas not attained in IHSS, however. Furtherresearch needs to look into how the program canbe delivered more effectively and its specific effecton health outcomes.

Reicherter et al. [58] USA Case control study/pre-, post-test.

PT students (26) CC educational program. Yang Social Interactionsurvey [46] scores andWilcoxon Rank Sum Testscores pre- topost-intervention.

There were no overall improvements in studentknowledge and attitudes pre- to post-interventions.Limitations relate to small sample size and lack ofexamination of patient health outcomes effects.

Smith [53] USA Two grouplongitudinal pre- topost-interventionstudy

Registered nurses (94) CC curriculum. CSES scores andknowledge base scores.

Scores on the CSES and knowledge base weresignificantly better for intervention group (P=0.015). Limitations relate to the sample size and thelack of assessment of patient health outcomeeffects.

Tang et al. [59] USA Cross-sectional pre-to post-interventionstudy

Medical students (167) Socio-cultural MedicineProgram

Student attitudes tosocio-cultural medicine.

Significant improvements were notedpost-intervention in terms of general attitude,understanding of cultural issues in health care,importance of culture in doctor–patient relationshipand patient health behavior (P < 0.01–0.001).

Thom et al. [54] USA RCT Primary care physicians(53) and patients (429)

CC curriculum forresident and practicingphysicians.

Patient-Reported PhysicianCultural Competence score;secondary outcomes werechanges in patient healthstatus and satisfaction.

There was no discernable impact of theintervention on patient health and attitude.Limitations relate to the brevity of the intervention.

Webb and Sergison[55]

UK Qualitative study Health-careprofessionals andstudents, social servicesprofessional andeducation professionals(140)

CC and antiracismtraining.

Self-reported cultural andracism awareness,knowledge and changedbehavior.

CC and antiracism training were well received byprofessionals. It was a positive experience fortrainees and perceived to be relevant to theirpractice. Appropriate and non-threatening trainingin CC change attitudes, behaviors and practice,including promoting good practice incommunication across linguistic and culturaldifferences. Limitations relate to lack ofmeasurement of patient satisfaction and healthoutcomes.

CKS, Cultural Knowledge Scale; IHSS, interdisciplinary health science students; PT, physical therapy; CSES, Cultural Self-Efficacy Scale.

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formulation and awareness were largely related to communica-tion issues and ignorance of traditions, different family struc-tures, identity conceptions and religious issues. [50].Clinicians indicated favorable reviews of the consultation

service and reported overall greater CC [50]. In a similarstudy, Webb and Sergison [55] examined the effectiveness ofthe CC PCC training course, Equal Rights Equal Access. Ofthe respondents, 75% (n = 36) believed that the course hadbeen effective in teaching CC and in particular communicationand use of interpreter services [55]. Other notable themeswere related to increased self-reported clinician awareness ofthe specific needs of ethnic minorities, embracing diversity intheir clientele and alertness to own stereotypical views andgeneralizations [55].

Discussion

This review examined the effectiveness of PCC models thatincorporate a CC perspective, in improving health outcomesamong CALD patients. There were 13 studies that met theinclusion criteria for this review. Overall, we found evidencesupporting the effectiveness of CC PCC training in increas-ing knowledge levels, self-reported practice and patient satis-faction. However, whereas increases in cultural knowledgeand awareness were evident, no studies reported any signifi-cant findings in terms of patient health outcomes. In fact,only two studies used this variable as an outcome measure[51, 54], and both of these studies were hampered by partici-pant attrition or small sample sizes and short interventionperiods. Importantly, the fact that most of the research onCC PCC programs measured effectiveness in terms of practi-tioner knowledge and not patient health represents a majorshortcoming to the current research on this topic, as patienthealth outcome is one of, if not the most important indicatorof effectiveness of any care model. Thus, the current resultsin this regard are limited, and more research is required toproperly assess the impact of the reviewed interventions onpatient health.

Limitations

As mentioned above, a major limitation to the researchreviewed pertains to the lack of patient health outcome mea-sures in the majority of studies. Only two studies includedsuch an evaluation variable, and both generated non-significant impacts—most likely due to low participantnumbers and participant attrition. Future research shouldinclude evaluation of the practical effects of CC in PCC pro-grams in terms of patient health outcomes. Another limitationcomprises the fact that the review did not include studies pub-lished in languages other than English, thus limiting an inter-national viewpoint. The current review was unable to includenon-English language studies due to lack of funds to meetcosts related to translation services. Finally, the difference inresearch design across studies—and the consequent difficultyin synthesizing and comparing the results of the research—also represents an important limitation.

Conclusion

The objective of this systematic review centered on the effect-iveness of PCC models that incorporate a CC perspective, inimproving health outcomes among CALD patients. Of theinitial 1450 studies identified in the first search round, 13 metthe final inclusion criteria and were included in the review.The majority of the research demonstrated effectiveness ofPCC models in terms of clinician/practitioner cultural knowl-edge, awareness and sensitivity. Only two articles examinedeffects of the intervention programs on patient health out-comes, with both studies reporting non-significant results onthese variables. As such, although the programs may increasepractitioner knowledge and awareness, there is no evidencethat this translates to improved patient health. More researchis, thus, required to properly examine the impact, if any, of CCPCC models on health outcomes.

Funding

This study was funded by the Australian Commission ofSafety and Quality in Health Care.

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Documents

The effectiveness of cultural competence programs in ethnic minority patient-centered health care--a systematic review of the literature