It’s clear that there are huge health disparities, inequalities and worse healthcare and outcomes for those coming from a minority Culturally & Linguistically Diverse (CALD) background.

The role of culture in health has been extensively explored by the recently published Lancet Commission (Napier et al, 2014) who defined cultural competence as:

Awareness of the cultural factors that influence another’s views and attitudes, and an assimilation of that awareness into professional practice.

A new Cochrane systematic review by Horvat and colleagues aims to examine whether cultural competency education (improving the cultural awareness, knowledge and/or skills) for healthcare professionals would lead to better outcomes for patients, professionals or organisations (Horvat et al, 2014).

Methods

The authors conducted a broad search of the literature (via multiple databases) in line with Cochrane standards, only focusing on randomised controlled trials (RCTs). Identified literature was double extracted.

Four primary outcomes were explored:

1. Treatment
2. Health behaviours
3. Involvement
4. Evaluations of care, with adverse events added

Secondary outcomes focused on health professionals knowledge.

Results

• Five RCTs were identified. These varied in design with most using a cluster design, three from the US, one from Canada, and one from The Netherlands
• In total, the review included 337 professionals and 8,400 patients (41% from CALD backgrounds)
• The overall quality of studies was graded as low
• Treatment outcomes were covered by two trials, but no data could be extracted and there was no evidence of effect
• Health behaviours were covered by one trial, which found significant improvement in attendance for one additional counselling session (RR 1.53 (95% CI 1.03 to 2.27)
• Involvement was covered by two trials, but only one was included. Involvement might have improved following education of health care professionals, although the quality of the evidence was regarded as low
• Evaluations of care were covered by three trials, but the authors could not combine the studies
• Adverse events were not reported in any of the studies
• Health professionals knowledge was covered by three trials, but only one provided data. There appeared to be a significant difference, but this showed no evidence of effect once there was adjustment for clustering

Conclusion

The authors concluded:

The review findings showed some support for cultural competence education for health professionals. These findings are tentative, however, as the quality of the evidence was low and more data are needed.

Future research on cultural competence education for health professionals should seek greater consensus on the core components of cultural competence education, how participants are described and the outcomes assessed.

Discussion

Clinically, it seems clear that short training courses are not impacting on patient outcomes. Services need to think more creatively about how they address the needs of those from a minority Culturally & Linguistically Diverse (CALD) background. The Lancet Commission on culture and health has recently recommended 12 areas in need of immediate attention in order to improve healthcare worldwide, this included embedding culture at the centre of healthcare.

What we seem really unclear about is how this can be transferred to a mental health context, which will probably require greater awareness and flexibility in service provision that goes beyond simple training.

Links

Horvat L, Horey D, Romios P, Kis-Rigo J. Cultural competence education for health professionals. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009405. DOI: 10.1002/14651858.CD009405.pub2.

Napier D et al., Culture & Health. The Lancet Commission. Published online October 29th 2014. DOI:10.1016/S0140-6736(08)61345-8