Mixed findings were found by two reviews [ 22 , 24 ]. In their review of breast and cancer screening among Asian women, Lu et al. Harun et al.
Cross-cultural interactions are likely structured and shaped by the worldviews and past experiences of not only the staff and clients but also the culture of the organization, which is embedded in and produced by policy frameworks, organizational arrangements and physical settings of the organization [ 38 ]. Interventions to improve cultural competency need to consider the individual and organizational contexts and the interplay between them.
Training programs may need to be tailored to particular groups, for example physicians would need particular knowledge and skills specific to their clinical tasks that would be inapplicable for reception staff. It is likely that cultural competency training as a stand-alone strategy is insufficient to improve patient outcomes without concurrent systemic and organizational changes [ 7 , 9 , 39 ].
Embedding cultural competency in organizational policy documents such as position statements and strategic plans are more likely to result in sustained change within organizations. There should be a commitment among the leadership of the organization and embedded key performance indicators supported by allocated resources. There is some evidence of a relationship between the cultural competence of health practitioners and the cultural competence of organizations [ 39 , 40 ].
A study found that providers with attitudes reflecting greater cultural motivation to learn were more likely to work in clinics with more culturally diverse staff and those offering cultural training and culturally adapted patient education materials [ 40 ]. In recognition that different components of the health system influence health outcomes, some models of cultural competency advocate a multi-level approach [ 2 , 41 ].
Although some studies have shown that culturally competent practices among organizations are adopted to varying degrees [ 42 , 43 ], more research is needed in this area. Grol et al.
Dreachslin et al. A more recent review by Parmelli et al. Barriers and incentives to organizational change should be considered when designing and implementing an intervention to increase the likelihood of success and sustained change [ 47 , 48 ]. Issues related to organizational readiness for change and innovation also require consideration before implementing organizational cultural competency interventions [ 49 ].
Understanding the reasons for adoption and spread of innovation can assist with addressing the difficulties of organizational change [ 50 ]. Planning and implementation of cultural competency interventions should acknowledge the interaction between an intervention and the setting. Organizational cultural competence involves an understanding of the strengths and weaknesses of the health care organization and the unique needs of the people it serves. Self-assessment was the most common approach to assessing cultural competency, which is a subjective measure subject to a range of biases [ 36 ].
The assessment tools were mostly process and survey tools, including patient satisfaction and provider self-assessment questionnaires as well as self-administered organizational checklists.
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Many of these tools have not been validated [ 51 ]. Broader organizational and systemic approaches to cultural competency should consider assessments of cultural competency that include objective measures such as document review [ 52 ]. In addition, more research is needed to determine how well both individual-level and organizational-level guidelines for cultural competency are followed by those directly involved in service delivery [ 53 ].
Academics have asked whether cultural competency can be achieved without focusing on issues related to racism and 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 outcomes in studies. Two of the 34 studies in Beach et al. Factors such as structural inequalities and racism may have a greater impact on health disparities between particular groups than cultural differences [ 56 ]. Of the seven reviews that focused on provider outcomes, four discussed these concepts [ 13 , 14 , 17 , 23 ]. This is despite these self-reflexive elements being critical to cultural competency. Cultural awareness alone is inadequate for addressing the effects of structural and interpersonal racism on health disparities.
Cultural awareness training has been criticized for increasing stereotyping and reinforcing essentialist racial identities [ 58 ]. Reflexive antiracism training is a promising alternative to cultural awareness training that reflects upon the sources and impacts of racism on society whilst avoiding essentialism and negative emotional reactions associated with White guilt [ 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 from its social, economic and political context [ 10 ].
Narrow conceptualizations of culture and identity may limit the effectiveness of particular approaches, and a focus on specific cultural information may inadvertently promote stereotyping. Although cultural differences may worsen the problem of differential access and discrimination, broader factors such as poor education and poverty may play a greater role in the poorer health outcomes of some individuals and groups in the community [ 60 ].
A limitation of this review is that there may be primary studies in the field that are not included by existing reviews in the literature as this was a review of reviews rather than a review of primary studies. There were only 22 primary studies cited by more than one review. This is likely due to the relatively narrow focus of some reviews e. Another limitation is that only reviews published in English were included. Given that the timeframe for this review was — it is possible that reviews published prior to were not included. However, cultural competency did not achieve popularity until the late s and government policies mandating cultural competence did not occur until the early s [ 11 ].
The search strategy could have been improved by adding more patient-related terms e. It is possible that some reviews were excluded as a result, however it is unlikely that the overall findings would be significantly different as this paper includes reviews from various health care contexts and health care provider and patient populations as well as different types of studies and cultural competency interventions.
Improving the effectiveness of the child protection system: A review of literature
It is difficult to make a general statement about the strength of the effect of interventions as the reviews assessed their studies differently. Different critical appraisal tools were used by authors and a majority of reviews noted methodological limitations of studies in their reviews, which limited their ability to make conclusive statements about the effectiveness of interventions. In order to determine the strength of the effect, an assessment of all primary studies of the included reviews using a single critical appraisal tool to determine the effectiveness of their interventions and an assessment of quality and bias of each individual study is required.
However this is beyond the scope of this paper. This systematic review of reviews of interventions to improve cultural competency within healthcare settings has synthesized all recent reviews in order to improve our understanding of the current evidence base and guide future research in this area. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes.
This review has highlighted the breadth and complexity of research in this area as well as the popularity of this area as shown by the number of published reviews found during the period January June , and particularly from onwards. Despite this popularity, it is clear that the evidence base is relatively weak, and there continues to be uncertainty in the field.
Many terms are used interchangeably with cultural competency e. Second, there are many potential outcomes from cultural competency interventions, as indicated by the variety of measures utilized in reviews, but very few validated tools to assess cultural competency in the published literature [ 51 , 62 ]. Third, a lack of methodological rigor is common amongst the studies included in reviews.
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Moreover, many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future reviews should be explicit about their definition or framework of cultural competency and what constitutes a culturally competent intervention, whether at the individual-level, organizational-level or systemic-level. Reviews should also examine multiple outcomes at all three levels where possible due to the multi-dimensional nature of cultural competency interventions and the complexities in translating cultural competency into practice.
Further development and assessment of organizational cultural competency models and assessment tools is needed [ 63 ]. Multi-level interventions should consider the different contexts e. Issues related to organizational change and understanding the mechanisms by which health innovations are adopted should also be taken into account. There is also need for research to examine the time and resources required to implement interventions in addition to identifying the most feasible and effective approaches [ 6 ].
All authors developed the idea for the systematic review and contributed to the concept and design.
MT conducted the searching and drafted the tables and figures. All authors contributed to the writing of the manuscript and read and approved the final manuscript. MT was supported by an Australian Postgraduate Award during the preparation of this manuscript. National Center for Biotechnology Information , U.
Published online Mar 3. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Mandy Truong: ua. Received May 15; Accepted Feb This article has been cited by other articles in PMC. Methods A systematic review of review articles published between January and June was conducted.
Culture and Child Protection: Reflexive Responses
Results Nineteen published reviews were identified. Quality of the review and synthesis of results Each review was critically appraised independently by two authors using the health-evidence. Identification of reviews The total search identified 6, results. Open in a separate window.
Hayley Davies: Reflexivity in Research Practice
Figure 1. Table 1 Summary of 19 included reviews. English only.
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Moderate-strong Beach et al. Most studies located in the United States. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of services across racial and ethnic groups is lacking. It is difficult to conclude from the literature which types of training interventions are most effective on which types of outcomes. Moderate- strong Bhui et al.