Table 1

Descriptive information on study populations, definitions, models of cultural competence, and outcomes


Nature of Evidence

Definitions of CC

Reference population

Models of cultural competence

Ferguson (2003)

Setting of standards for curriculum for cultural diversity in the years 1999 and 2000.

Evaluation of programme of teaching, and of cultural competence: change in attitudes and behaviour

Cultural competence is a dynamic continuum consisting of seven stages: Listen, Elicit, Assess, Recommend, Negotiate (LEARN)

15 New England & New York Medical Schools, USA

137 participants (83 women, 42% family medicine specialists, 52% less than 10 years in practice.

Community Curriculum Model

Module 1: CC and the role of the physician

Module 2: teaching skills of CC

Module3: Moving beyond cultural awareness

Hadwiger (1999)

Cultural competence in critical care nursing practice.

Narrative responses to case scenarios used to develop skills, self reflection, and improved quality of care plans

Process of working with patients from different cultural background than one's own

To reflect on beliefs and assumptions

Negotiate a plan of care without use of stereotypes

Problem solving and writing competencies

Nursing Students in a Midwest Community, USA

Campinha-Bacote Model [30][37]

1. Cultural awareness

2. Cultural Knowledge

3. Cultural Skill

4. Cultural Encounters

One case over 6–8 week period: 4 case scenarios

Siegel et al (2003) †

Performance measures of cultural competency were selected and benchmarked in 21 health care organisations inUS

Delphi exercise: experts asked to rate importance, feasibility and reliability of indicators; these were then reviewed to ensure they addressed CLAS (cultural and linguistically appropriate services) standards set by US Dept. Health and Human Services

The set of congruent behaviors, attitudes, skills, policies and procedures that enable the organization's caregivers to work effectively and efficiently in cross/multicultural situations

Mental Health Care Organizations in the USA

Expert panel of four major ethnic groups in US: African American, Hispanic, Asian Indian, and Asian American

Survey data from 21 mental health organizations

Telephone interviews of services already implementing cultural competency benchmarks.

Key informant interviews with 21 best practice organisations: 15 administrative sites and 8 service entities

Phase 1: develop a framework of key domains and select performance measures of cultural competence: (1) needs assessment; (2) information exchange; (3) services; (4) human resources; (5) policies and plan, (6) linked to outcomes.

Three organisational levels: (1) administrative (state mental health authority or a managed care entity); (2) service delivery entity and (3) individuals involved directly or indirectly with the delivery of care. Phase 2: Measures reduced to a manageable size

Kim-Godwin (2001)

Concept analysis by 13 community nurses and nurse experts

Key domains of cultural competence: 1)Caring 2)Cultural sensitivity, 3)Cultural knowledge 4) cultural skills are'

In 1996 scale tested on 192 senior undergraduate and graduate nursing students in two South Eastern US centres. Community Health Nurses in Idaho.

In 1998, in depth interviews with 13 nurses (8 community health nurses and 5 community nurse experts).

Culturally Competence Community Care

Kondrat et al (1999)

Semi-structured interviews with 64 workers at 4 different mental health agencies/case record analysis of 24 consumers

Sites matched on per capita expenditure, proportion of African American Clients, proportion of minority staff

Sites picked where minorities doing better on community tenure (benchmark agencies) and compared with sites where they were not doing so well

The best practice approach is pragmatic, practice driven, and results oriented.

Community Mental Health Agencies in Ohio, USA

Field observations: Intensive observations of 3 days per week for a period of 2 weeks

Then 2 days per week for a period of 2 weeks

Then 1 day per week, for 12 weeks

Semi-structured interviews: administrators (3 or more), team leaders (2 or more), managers, 6 clients, 6 carers at each of the four sites (snowballing technique)

Document analysis: Case records of 24 consumers (12 African American and 12 Caucasian) for decision nodes in care. " years of entries per client.

Benchmarking Research Model

Kirmayer et al (2003)

Participant observation & analysis of case reports of first 100 referrals

Cultural consultation models suggest a mechanism to address the impact of cultural diversity on mental health problems.

Mental health Service providers, Montreal, Canada

Cultural Consultation Model based on DSM-IV cultural formulation, using cultural consultants and culture brokers. Three options: 1) 1–3 meetings with patient, and brief report, phone calls, case conference to transmit immediate recommendations, subsequent more detailed report; 2) Cultural consultant discusses case with referring consultant without seeing patient directly. Clinical case conference may ensue; 3) Consultant meets with referring community organisations, without directly seeing community members. In a clinical case conference, community organisations express problems in engaging or providing a service for a specific cultural group.

Frusti et al (2003)

Qualitative data: individual (n = 43) senior staff including directors and managers; and focus group interviews with staff, with efforts to include minority groups

Quantitative data from documents from the nursing organisation and organisation as a whole, seeking evidence of diversity competence

Diversity Competence Model assessment: diversity competence is defined as an individual's ability to respect each person's uniqueness. Goals of marketplace success, ability to compete, enhanced overall performance, and increased capability of all staff

Nursing Workforce

Diversity Competency Model:

1) Drivers

2) Linkages

3) Cultures,

4) Measurement,

5) all held together by Commitment

Stork et al (2001)

Case study of five US states To assess implementation of cultural competence provisions in behavioural managed care contracts.

Cultural Competence: "Agencies, programs and services that are responsive to the cultural, racial and ethnic differences of the populations they service" (CASSP, 1984)

Culturally competent professionals are those who have " the ability to serve individuals of diverse backgrounds" [38]

Exploratory study of how five states of average population distribution and resources implement, monitor and enforce contractual obligations for culturally competent provision in Medical managed care.

State managed behavioural organisations Federal regulations about cultural competence derive from Disability Act of 1990, Civil Rights Act that prohibits discrimination.

Interpretation of these rules: translation services, language assistance, quality assurance rules, including grievance procedures, to have capacity and appropriate range of services to serve enrolees, as well as sufficient disciplinary mix, geographic distribution).

Extent of contractual provisions, monitoring, flexibility in provider organisation.

US Department of Health and Human Services (HRSA)

Participant observation/group discussions/documentary analysis

Developed an assessment profile for organisational cultural competence, and evaluated its performance in health care organisations across a range of size, expenditure, populations served, and cultural competency levels

Cultural competence is a critical factor in providing relevant services to nations growing culturally ethnically diverse population

USA Health Care Organizations

Organizational Cultural Competence Assessment Profile: gives structure, process and outcome indicators for each of the OMH domains of organisational cultural competency:

Model Domains: 1)Values and attitudes, 2)Cultural sensitivity, 3) Communication, 4) Policies and Procedures, 5) Training and Staff development, 6) Facility characteristics, 7) Intervention and treatment model, 8) Family and community participation, 9) Monitoring, evaluation and research

† Definitions agreed: Cultural Group. A subgroup that is from the major racial ethnic groups of African American, Hispanic American, Asian American, American Indian, or from a recent immigration or refugee group. Subgroups can be narrowly defined in terms of worldview, values, rituals, and the like; however, subgroups are most often defined by distinct languages, such as Vietnamese among Asian Americans; or distinct locales of origin, such as Dominicans among Hispanic Americans. Not included are cultural subgroups that have retained their cultural identity in mainstream America, but in ways that do not preclude their participation in US's system of health care and social welfare. Not included were cultural groups defined by physical disabilities, sexual orientation, or other characteristics, as their particular concerns were not in the purview of this project. Target Population. The specific part of the general population designated as the population to be served by the administrative or service delivery entity. Population Area. The geographical area designated as the area to be served by the administrative or service delivery entity.

Bhui et al. BMC Health Services Research 2007 7:15   doi:10.1186/1472-6963-7-15

Open Data