Cultural Competence: A
Systematic Review of Healthcare
Provider Education Interventions
Mary Catherine Beach, MD, MPH
Eboni G. Price, MD
Tiffany L. Gary, PhD
Karen A. Robinson, MSc
Aysegul Gozu, MD
Carole Smarth, MD
Ana Palacio, MD, MPH
Mollie W. Jenckes, MHS, RN
Carolyn Feuerstein, BA
Eric B. Bass, MD, MPH
Neil R. Powe, MD, MPH, MBA
Lisa A. Cooper, MD, MPH
The Johns Hopkins Evidence-based Practice Center, Baltimore, MD
Funded by the Agency for Healthcare Research and Quality
Cultural Competence of Health
Professionals
• The ability of individuals to establish effective
interpersonal and working relationships that
supersede cultural differences 1
• Suggested to reduce disparities in healthcare
for racial/ ethnic minority patients
• Required by ACGME for professionalism
• Little systematic evaluation of its potential
1
Cooper LA, Roter DL. in Unequal Treatment. Washington, DC: Nat’l Academies Press, 2003
Study Aim
• To determine the effectiveness and costs of
interventions designed to improve cultural
competence of health professionals
Study Design
• Systematic review of all interventions to
reduce disparities or improve healthcare
quality for racial/ethnic minorities
• Electronic Searches
– MEDLINE, the Cochrane CENTRAL Register
of Controlled Clinical Trials, EMBASE, and
specialty databases
• Hand Searches
– Reference lists of all eligible articles
Inclusion Criteria Exclusion Criteria
• Intervention focused on
cultural competence
• Intervention targeted at
health professionals
• Adequate evaluation of
intervention (pre/post
or controlled trial)
• Published prior to
1980
• Not in English
• No original data
• Meeting abstract (no
full article for review)
Review Process
• 2 reviewers reviewed all abstracts and
articles for eligibility
• Differences between reviewers adjudicated
• If article eligible, we
– Graded article quality using previously
validated, standardized forms
– Abstracted data related to targeted providers
and settings, curricular content, teaching
methods, evaluation methods, and outcomes
Synthesis/ Evidence Grading
Overall
Score
Domains
Quantity
Consistency
Quality
Bias
Objective
Assessment
A - Excellent >=3
Consistent
>= 1 RCT
>=75%
studies
B – Good
Reasonably
consistent
>= 1 controlled
trial
>=50%
Inconsistent
No controlled
trials
>=25%
C - Fair
>=2
D - Poor
>=1
<25%
Results: Literature Search and Eligibility
Electronic Databases
4309
Hand Searching
79
Retrieved
4388
Duplicates 679
Abstract Review
3709
Article Review
281
Excluded 3421
Unable to Review 7
Excluded 247
Eligible articles
34
Characteristics of Studies (N=34)
n
Study Design
Pre/Post
Control
Setting
20
U.S.
14 Subjects
Physicians
n
29
18
Publication Years
Objective Evaluation
1980-89
5
Yes
26
1990-1999
19 Intervention Description
>2000
10
Complete
16
Curricular Methods and Content
Methods
Lectures
Discussion
Case Scenarios
Role Play
Small Group
Clinical Experience
Interaction with others
Audio-visual
Cultural Immersion
n
19
17
13
12
11
10
9
9
8
Content
n
Specific Cultures
26
General Concepts 19
Language
10
MD-PT Interactions 8
Access
3
Racism
2
SES
2
Effects of Cultural Competence Training
Benefit
No Effect
Mixed
Harm
25
# of Studies
20
15
10
1
1
17
3
1
21
14
3
5
1
0
Knowledge
Attitudes
Skills
Satisfaction Adherence
Interventions that Improved
Patient Satisfaction/ Adherence
Intervention
Target
Duration
Spanish language
ED physicians 20 hours
Training in attitudes
that low-income AA
women might bring
to counseling
State mandated
training program
including cultural
competence
Mental health
counselors
4 hours
Mental health
clinics
3 days
Summary of Effectiveness
Level of Evidence Outcome
Excellent evidence
Good evidence
Poor evidence
No evidence
Provider knowledge and
attitudes
Provider skills and patient
satisfaction
Patient adherence
Impact on patient health
Which types of training are
most effective
Costs
• Costs of international travel (3 articles)
– all required students to pay part or all of the
costs ~ $1200 - 2000 per student
• Costs of classroom instruction (2 articles)
– 20 hours of Spanish-language classes for 9
physicians = $2000 (2000)
– 60 hours of classroom instruction for 19
students  $3000 (1994)
Conclusions
• Excellent or good evidence that cultural
competence training can improve provider
knowledge, attitudes, and skills and
patient satisfaction
• Poor or no evidence that cultural
competence training can improve patient
adherence or health outcomes
• More comprehensive and rigorous studies
are needed to guide education in cultural
competence
Limitations of Literature
• Each curricular intervention was different;
generalizability across studies difficult
• No standard instruments for measuring
cultural competence
• Few studies
– describe interventions well enough to permit
replication
– measured patient outcomes
– included data on costs
Implications for Future Research
• Use study designs that minimize bias
• Develop/ use reliable instruments to
measure cultural competence
• Assess outcomes objectively and include
patient outcomes
• Replicate existing curricula
• Compare different curricular methods
• Include data on costs