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1.1 Cultural Competence Defined

The definition of cultural competence used for the purpose of this book is perhaps the most widely cited and commonly agreed-upon definition of cultural competence, offered by Cross et al. in their seminal monograph Towards a Culturally Competent System of Care [1]. They defined cultural competence as ‘a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or profession to work effectively in cross-cultural situations’ [1]. The definition provided by Cross et al. expands cultural competence beyond individual practitioners to include healthcare institutions and systems, and the policies and structures of these systems, as well as health professionals and staff in all levels of healthcare systems, from providers to managers and administrators [2]. It also does not focus exclusively on cultural factors, but rather more generally on the behaviours, attitudes and policies that enable effective healthcare in cross-cultural situations. The breadth of this definition allows for a fuller, more integrated conceptualisation of cultural competence, which has the scope to include a range of approaches and issues.

However, there is currently no consistent definition of cultural competence across healthcare settings, service delivery systems or countries; the lack of a clear definition is both a product of and contributor to the complexity in cultural competence interventions and evaluations [3]. Cultural competence has been defined in many different ways [4], and significant inconsistencies in its definition across key literature and policy documents are common [5]. Furthermore, many definitions only address certain aspects of cultural competence. For example, they may focus only on one level of healthcare systems in which cultural competence is needed. Alternatively, some definitions include recognition only of factors impacting healthcare which are seen to be ‘cultural’, not accounting for other social factors which are considered by others to be central to cultural competence.

Consistent with its roots in cross-cultural education, many definitions of cultural competence describe it in the context of the healthcare provider. Cultural competence has historically been concerned with the capacity of healthcare professionals to provide competent and appropriate care to people who do not share the same ethnic identity, language, cultural markers or racial categorisation [6]. Individual cultural competence has been described as the state of being capable of functioning effectively in the context of cultural differences [7]. However, there is a lack of consensus on what is required to establish this state of effectiveness. It has been persuasively argued that effective healthcare is impossible without a working knowledge and understanding of a person’s or group’s culture and background [8]. Therefore, many cultural competence approaches aim to increase practitioners’ knowledge of patients’ cultural backgrounds. Cultural competence is considered to start with the development of individuals’ knowledge and skills to allow for effective engagement with people from diverse cultures [9]. Cultural competence approaches also aim to enable practitioners to reflect on their own culture and to identify, respect and act with consideration and humility when relating to people from other cultures [10].

Suh [4] describes various definitions of cultural competence used across medicine, nursing, psychology, social work and education [4]. Each definition reflects similar features considered integral to improved individual cultural competence, including practitioner knowledge, attitudes and values to support cultural competence. Definitions also included aspects such as awareness of diversity and one’s own culture, acceptance of and respect for cultural differences, the ability to provide effective and appropriate care and skills such as effective communication and the ability to conduct a cultural assessment [4]. Yet none of these definitions make reference to other social factors beyond culture which are implicated in cultural competence. Beach et al. [11] provides a definition of cultural competence which accounts for social as well as cultural influences which may be implicated in patient health beliefs, behaviours and healthcare and health inequities. Here, cultural competence is defined as ‘the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences by recognising the importance of social and cultural influences on patients, considering how these factors interact, and devising interventions that take these issues into account’ (p. 356) [11].

However, it has long been recognised that to meet the needs of culturally, ethnically and racially diverse patient groups, acknowledgement of and responses to sociocultural differences at health system, organisational and individual health practitioner levels are required [1]. Several definitions of cultural competence respond to this need. Addressing the importance of cultural competence in health systems and organisations, cultural competence has been defined as the capacity of a health system to improve population health and wellbeing by integrating cultural practices and concepts into service delivery [12]. Capacity for organisational cultural competence is influenced by values and attitudes; cultural sensitivity; communication; policies and procedures; training and staff development; facility characteristics; infrastructure; intervention and treatment models; family and community participation; and monitoring, evaluation and research [13]. Another definition describing a culturally competent healthcare system was provided by Betancourt et al. as ‘one that acknowledges and incorporates—at all levels—the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs’ (p. 294) [14].

1.2 Cultural Competence-Related Terms

Contributing to the difficulty of defining cultural competence is the many related terms used in the literature [15]. A lack of consensus on accepted, standard terminology [3, 16] has resulted in the interchangeable use of diverse expressions with similar definitions [17]. Many other terms such as cultural safety, cultural security and cultural awareness are used synonymously with cultural competence [3]. For example, in Canada and New Zealand, models of cultural safety have dominated. In the USA, cultural competence or transcultural or cross-cultural care has been most commonly used. In Australia, a range of terms, including cultural competence, cultural safety and cultural security, are used in descriptions of healthcare [5]. Furthermore, different terms have been put forward to clarify and better articulate the meaning of cultural competence, including cultural responsiveness, cultural sensitivity and cultural humility. However, despite their similarities, each of these terms emphasises particular nuances in the meaning and aims of cultural competence, further revealing the complexity and lack of consensus in defining the approach [14]. Because of the interchangeable use of terms by different authors, for clarity, the meanings of key terms used in this review are defined in the Glossary.

1.3 The Historical Development of Cultural Competence

Cultural competence evolved from early models of cross-cultural education in the late 1970s and early 1980s. The primary focus was on trying to bridge the cultural differences that existed between healthcare providers and migrant populations who did not share the same language or cultural norms. In an attempt to reduce the negative effects of this cultural divide on patient healthcare utilisation and experiences, a range of approaches to increase healthcare provider cultural competence were initiated, such as cross-cultural education and training [18]. However, during the late 1980s and throughout the 1990s, conceptualisations of cultural competence shifted significantly. These changes are thought to have come from challenges to predominant cultural competence models at the time, which argued that cultural competence needed to go beyond cultural awareness and sensitivity to make tangible changes in the healthcare encounter [2]. Increasing evidence of disparities in healthcare treatment and quality experienced by various racial and ethnic minority groups also started to reveal broader injustices in healthcare systems [1].

The concept of cultural competence was thus expanded to encompass a focus on reducing health inequities and improving healthcare and health outcomes [15]. Through this expansion of focus to include issues of healthcare disparities came changes in the population groups and key issues targeted by cultural competence. Cultural competence intervention efforts came to include other racial and ethnic minorities besides migrant groups [18] and other socially marginalised groups such as queer, lesbian, gay, bisexual, transgender and intersex (QLGBTI) communities [19]. Broader sociocultural issues also became implicated in health and healthcare inequities [18]. This new focus on racial and ethnic healthcare and health disparities meant that cultural competence needed to address issues which went beyond culture and cultural differences [20]. Factors such as provider and healthcare system bias and stereotyping, historical and ongoing experiences of racism and discrimination and social determinants of health have all come to be included within the scope of cultural competency [18]. There has also been increasing recognition that it is very difficult to disentangle ‘social’ factors such as socioeconomic status and social supports or stressors from ‘cultural’ ones [14]. Hence, the term ‘sociocultural’ is sometimes used instead of ‘cultural’ to describe this range of factors. At this time, cultural competence also expanded beyond the level of the patient-practitioner encounter to look at how cultural competence could be integrated across all levels of healthcare systems [1]. So cultural competence has come to include diverse issues and population groups and utilise diverse approaches to implementation. This complexity has meant a lack of consensus across cultural competence definitions, frameworks and interventions.

1.4 What Does Cultural Competence Encompass

In addition to the absence of consensus on a definition of cultural competence, the evolution of the cultural competence field has resulted in a diversity of opinion and lack of clarity around the scope encompassed by cultural competence in healthcare systems. Much of the literature on models and conceptual or theoretical frameworks predominantly examines individual cultural competence at the health provider level [4, 7, 9, 11, 21,22,23,24,25,26,27].

Although frequently focused on healthcare providers, there is a substantial amount of literature which examines and accounts for cultural competence at other levels in healthcare [28]. Cross et al. provide a framework that includes intervention strategies for developing cultural competence at policymaking, administrative, practitioner and consumer levels. Central to this framework is the adaptation of services and various service-level processes such as intake, assessment and treatment, to ensure that services are appropriate for patients [1]. Several key cultural competence literature reviews examine intervention strategies in the form of culturally appropriate or sensitive programs and services, as well as training and education for providers [3, 29, 30]. For example, Brach and Fraserirector outline a range of approaches to improving service provision, such as the use of interpreter services, coordination with traditional healers, use of community health workers and including family/community members in service provision [29]. Providing training on cultural competence to the health workforce was only one of the suggested strategies. The inclusion of such strategies in the repertoire of cultural competence approaches is more consistent with the multilevel approach recognised as core to cultural competence.

1.5 A Multilevel Framework for Cultural Competence in Healthcare

Consistent with the definition provided by Cross et al. [1], we took a systems approach to assessing cultural competence across multiple levels in healthcare. We provide a framework of healthcare levels (see Fig. 1.1) based on the primary targets of the cultural competence interventions reviewed. These include interventions targeting to improve the cultural competence of health profession students during their education and training, interventions to improve the cultural competence of health practitioners, interventions focused on healthcare service delivery through implementing services and programs to improve healthcare cultural competence and interventions targeting whole healthcare organisations and systems. We recognise that any type of division of complex health systems is going to be fraught and incomplete. However, the process of identifying different levels within health systems helps to unpack some of the complexities and more readily enables thorough evaluation through helping to identify appropriate measures of program impact [31].

Fig. 1.1
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Multilevel framework of cultural competence interventions in healthcare

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1.6 The Purpose of This Book

The international cultural competence literature suggests that cultural competence approaches should work for providing healthcare that is responsive to diverse populations and cultural needs and that ameliorates healthcare disparities and health inequity. However, achieving this requires accounting for a range of complex concepts and issues that are frequently not clarified or differentiated. Furthermore, despite the recognition of the need for cultural competence to be integrated across all levels of healthcare systems, there has been a shortage of literature examining cultural competence strategies implemented across different healthcare levels and the outcomes of these.

This book aims to fill these gaps in cultural competence conceptualisation and frameworks by reviewing the available international evidence on cultural competence in healthcare settings in Canada, Australia, New Zealand and the USA (the CANZUS nations) [32]. First, we provide a conceptual model of the justification for the need for cultural competence to help understand the range of concepts and issues central to cultural competence. We then review the intervention literature and identify the scope of strategies that have been implemented across various levels of healthcare systems to improve healthcare cultural competence. We also review the outcomes that have been achieved through these varied interventions. Throughout the review, we examine what indicators have been applied to measure cultural competence and assess the evidence quality of intervention studies. Recommendations on how to improve the evidence base of cultural competence are provided, with a particular focus on how cultural competence interventions can better demonstrate whether they are indeed addressing the identified drivers of cultural competence. Based on these results, we then present an evidence-informed, multilevel framework for the implementation and evaluation of cultural competence interventions. We draw on evidence about what has been done and what has been achieved, along with suggested approaches to measurement, to create a framework to help inform future cultural competence interventions.

1.7 The Objectives of This Book

The objectives of the book are to:

  1. 1.

    Consider the significance of cultural competence, including the use of similar terms.

  2. 2.

    Identify the drivers of cultural competence and suggest an explanatory model for understanding the conceptual landscape of cultural competence.

  3. 3.

    Identify approaches and strategies that are effective in improving cultural competence across multiple levels of healthcare systems.

  4. 4.

    Examine the outcomes of cultural competence strategies and the relationship between cultural competence and patient healthcare and health outcomes.

  5. 5.

    Report on how cultural competence has been measured.

  6. 6.

    Summarise the quality of available evidence.

  7. 7.

    Discuss the implications of these findings for future cultural competence research and practice.

  8. 8.

    Present an evidence-informed framework for cultural competency intervention implementation and evaluation.

1.8 Structure of the Book

1.8.1 Chapter 2: The Drivers of Cultural Competence

Chapter 2 provides an overview and analysis of the key concepts and issues central to cultural competence. Here a model of the drivers of cultural competence is provided. The two main drivers identified are responding to sociocultural difference in healthcare encounters and improving racial and ethnic healthcare disparities. Related concepts and issues which impact on cultural competence and which are addressed in intervention approaches and their evaluations are also described. Some of these concepts and issues as well as the key tensions in the cultural competence literature are discussed in this chapter.

1.8.2 Chapter 3: Methods

The third chapter details the methods used for the systematic search which informed the scoping review reported throughout Chaps. 4–7. This includes the search terms used, the search strategy employed and data extraction and analysis techniques. The limitations of the review are also described.

1.8.3 Cultural Competence: A Multilevel, Systematic Scoping Review

Commitments at multiple levels—systemic/organisational, professional and client care levels—are required to increase cultural competence and create improved healthcare and health outcomes. The following chapters of this book focus on the different types of interventions aimed at improving cultural competency across multiple levels of healthcare. Four main types of cultural competence intervention strategies were identified from evaluation literature: (1) cultural competence education and training for health and medical students, (2) health workforce development to improve cultural competence, (3) programs and services to improve cultural competence in healthcare and (4) health organisations and systems cultural competence interventions. For each of these chapters, we review the measures and measurement issues and assess the study quality of evaluations. We also discuss the implications for interventions on the relevant healthcare level and review the strengths and weaknesses of the evidence base.

1.8.4 Chapter 4: Health Workforce Development Interventions to Improve Cultural Competence

Chapter 4 reviews the documented intervention strategies and outcomes targeting health professionals practising within health systems. The primary interventions identified included cultural competence training and other training and professional development interventions aimed at improving the cultural competence of the health workforce. These health workforce cultural competence interventions reported a range of provider- and patient-related outcomes indicative of improvements in health provider and healthcare cultural competence.

1.8.5 Chapter 5: Cultural Competence Education and Training Interventions for Health and Medical Students

The fifth chapter provides an overview of the documented intervention strategies that have been implemented to improve the cultural competence of health students. Delivered predominantly through universities, the main strategies were the integration of cultural competence into university curriculum, cultural competence training and cultural immersion experiences. The outcomes reported in cultural competence education interventions all related to their impact on student’s cultural competence.

1.8.6 Chapter 6: Programs and Services to Improve Cultural Competence in Healthcare

The sixth chapter is focused on reviewing evaluations of health programs and services which aim to improve the cultural competence of healthcare delivery. A range of different programs targeting diverse population groups and health issues across the four countries were identified. The commonalities in intervention strategies were the use of one or more approaches to community, cultural and language adaptations. Most programs and services utilised a combination of various strategies to improve the cultural competence of healthcare delivery. The reviewed interventions reported a range of healthcare outcomes and improvements in certain health measures for participants.

1.8.7 Chapter 7: Health Organisation and System Cultural Competence Interventions

Chapter 7 reviews interventions on the level of healthcare systems and organisations/agencies. The diverse interventions reviewed in this chapter utilised a range of approaches to increasing healthcare cultural competence. The key strategies were audit and quality improvement approaches and organisational-level policies or strategies. Outcomes reported included various organisational system outcomes, as well as outcomes for the patient-provider encounter.

1.8.8 Chapter 8: Cultural Competence Strengths, Weaknesses and Future Directions

In this chapter, we provide an overall discussion outlining the trends in the evidence across the intervention evaluations on the various levels. We examine where the strengths of the evidence lie (what the most promising cultural competence approaches are) and the major evidence gaps (where is further development in the cultural competence evidence base needed). This chapter particularly focuses on analysing the extent to which the interventions reviewed have addressed the primary drivers of cultural competence identified in Chap. 2. Recommendations are provided for the future direction of cultural competence approaches to increase the capacity of health services to provide effective and quality care for social and culturally diverse population groups.

1.8.9 Chapter 9: Multilevel Cultural Competence Intervention Implementation and Evaluation Framework

Based on the results from the previous five chapters, in this chapter we provide an evidence-informed, preliminary framework to inform a multilevel cultural competence approach. The framework addresses strategies for intervention implementation on the various levels. It also details intervention outcomes and measures to guide intervention evaluations to help build the cultural competence evidence base.