Article
Culturally competent healthcare systems: A systematic review

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Abstract

Overview

Culturally competent healthcare systems—those that provide culturally and linguistically appropriate services—have the potential to reduce racial and ethnic health disparities. When clients do not understand what their healthcare providers are telling them, and providers either do not speak the client’s language or are insensitive to cultural differences, the quality of health care can be compromised. We reviewed five interventions to improve cultural competence in healthcare systems—programs to recruit and retain staff members who reflect the cultural diversity of the community served, use of interpreter services or bilingual providers for clients with limited English proficiency, cultural competency training for healthcare providers, use of linguistically and culturally appropriate health education materials, and culturally specific healthcare settings. We could not determine the effectiveness of any of these interventions, because there were either too few comparative studies, or studies did not examine the outcome measures evaluated in this review: client satisfaction with care, improvements in health status, and inappropriate racial or ethnic differences in use of health services or in received and recommended treatment.

Introduction

The need for culturally competent health care in the United States is great: racial and ethnic minorities are burdened with higher rates of disease, disability, and death, and tend to receive a lower quality of health care than nonminorities, even when access-related factors, such as insurance status and income, are taken into account.1 Health disparities related to socioeconomic disadvantage can be alleviated, in part, by creating and maintaining culturally competent healthcare systems that can at least overcome communication barriers that may preclude appropriate diagnosis, treatment, and follow-up. Cultural competence is an essential ingredient in quality health care (see Defining Cultural Competence in Health Care, below). Providing culturally competent services has the potential to improve health outcomes, increase the efficiency of clinical and support staff, and result in greater client satisfaction with services.2

The surge of immigrants into the United States over the past 3 decades has brought a proliferation of foreign languages and cultures. Residents of the United States speak no less than 329 languages, with 32 million people speaking a language other than English at home.3 In response to this expanding cultural diversity, healthcare systems are paying increased attention to the need for culturally and linguistically appropriate services. Cultural and linguistic competence reflects the ability of healthcare systems to respond effectively to the language and psychosocial needs of clients.4

Section snippets

Defining cultural competence in health care

Cultural and linguistic competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable effective work in cross-cultural situations.5 Culture refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups. Competence implies having the capacity to function effectively as an

Culturally competent healthcare systems

In the social environment and health logic model (described elsewhere in this supplement31) access to “health promotion, disease and injury prevention, and health care” serves as an intermediate indicator along a pathway linking resources in the social environment to health outcomes. An important component of access to care for culturally diverse populations is the cultural competence of healthcare systems. This is integral to healthcare quality, because the goal of culturally competent care is

Healthy People 2010 goals and objectives

Cultural and linguistic competence in health care is integral to achieving the overarching goals of Healthy People 201032: increasing quality and years of healthy life and eliminating health disparities.

Access to health care is a leading health indicator. Barriers to access include cultural differences, language barriers, and discrimination. Culturally competent health services improve all focus areas of Healthy People 2010 by reducing barriers to clinical preventive care, primary care,

National standards for culturally and linguistically appropriate services in health care

In March 2001, the Department of Health and Human Services’ Office of Minority Health published national standards for culturally and linguistically appropriate services (CLAS) in health care.4 The CLAS standards (Table 2) were developed to provide a common understanding and consistent definition of culturally and linguistically appropriate healthcare services. Additionally, they were proposed as one means to correct inequities in the provision of health services and to make healthcare systems

Conceptual approach

A description of the general methods used to conduct the systematic reviews for the Guide to Community Preventive Services (the Community Guide) have been described in detail elsewhere.33 The specific methods for conducting reviews of interventions to promote healthy social environments are described in detail in this supplement.31 This section briefly describes the conceptual approach and search strategy for interventions to promote cultural competence in healthcare systems. These

Programs to recruit and retain staff members who reflect the cultural diversity of the community served

Workforce diversity in the healthcare setting is seen as a means of providing relevant and effective services. Workforce diversity programs go beyond hiring practices to include organizational strategies for identifying barriers that prevent employees from fully participating and achieving success. Achieving diversity at all levels of the healthcare organization can influence the way the organization serves the needs of clients of various cultural and linguistic backgrounds. For this review, we

Research issues for improving the cultural competence of healthcare systems

The Task Force found an insufficient number of qualifying evaluation studies to allow conclusions about the effectiveness of interventions to improve the cultural competence of healthcare systems, highlighting the need for more, and better, research in this area. Research is needed to assess intervention effectiveness in changing the structure and process of healthcare delivery. This research must examine meaningful health outcomes and focus on what works best, where, and for whom.

Summary: findings of the task force

The effectiveness of five interventions to improve the cultural competence of healthcare systems could not be determined in this systematic review, because of a lack of both quantity and quality of available studies. We found no comparative studies evaluating (1) programs to recruit and retain staff members who reflect the cultural diversity of the community served or (2) the use of culturally specific healthcare settings; only one qualifying study each (with fair quality of execution)

Acknowledgements

We thank the following individuals for their contributions to this review: Joe St. Charles, Community Guide Research Fellow; Onnalee Henneberry, Research Librarian; Kate W. Harris, Editor; and Peter Briss for technical support.

Our Consultation Team: Regina M. Benjamin, MD, MBA, Bayou La Batre Rural Health Clinic, Bayou La Batre, Alabama; David Chavis, PhD, Association for the Study and Development of Community, Gaithersburg, Maryland; Shelly Cooper-Ashford, Center for Multicultural Health,

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    The names and affiliations of the Task Force members are listed at the front of this supplement and at www.thecommunityguide.org

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