Effectiveness of Adaptations to Enhance Cultural Competence of Health and Mental Health Services

Purpose: This presentation reports the results of a systematic review and meta-analysis of interventions intended to reduce the effects of bias and facilitate equity across service systems. Although calls to adapt interventions to ensure cultural competence have been numerous, little is known about the effectiveness of these adaptations. This systematic review sought to 1) identify a conceptual framework for cultural competence adaptations and outcomes, 2) conduct an assessment of the quality of evidence supporting distinct adaptations, and 3) develop a model for use in policy and practice to better understand and communicate the effectiveness of various approaches to achieving cultural competence.

Methods: The Cochrane Collaboration guidelines provided a foundation for the planning and execution of this project. Given the intense nature of screening required, the scope of the project was narrowed to include only Randomized Controlled Trials and quasi-experimental studies with parallel cohorts in health and mental health. The search focused on the effectiveness of adaptations to improve cultural competence of services. A team of two information scientists designed the search strategy. Data extraction on accepted articles was assessed for consistency between reviewers by comparing agreement in the content of extracted information until reviewers achieved perfect agreement. Records were abstracted using a categorical system for characterizing the adaptations employed and the outcomes measured. Studies were analyzed and synthesized in accordance with the Cochrane model.

Findings: Following a rigorous search and screening process that began with the identification of 12,662 documents, 30 documents representing 28 studies were retained for analysis. Adaptations involved changes to the structure and process of service delivery, the provision of supplemental services or resources, and adaptations to the intervention content or method of content delivery. Although there was evidence to support the use of cultural adaptations to pre-existing interventions, the degree of effectiveness was moderated by the type of intervention and the outcomes being measured. However, what was consistent across studies was the role that ethnic identity and acculturation played in the effectiveness of culturally tailored interventions. Additionally, all studies that incorporated four or more cultural adaptations had improved outcomes for participants in the culturally adapted group over the standard condition. However, depending on the adaptation, a single change to the intervention could also prove effective. Two of the most effective interventions only made one cultural adaptation to their standard intervention: a change in location and the provision of supplementary services.

Implications: This analysis provides support to the use of cultural adaptations to existing interventions. However, the analysis also found that the bulk of research on adaptations to enhance cultural competence lack the use of control groups, making it impossible to tell if it was the cultural adaptation or the attention brought from the intervention that resulted in the positive outcome. In order to determine if a cultural adaptation is effective, it is necessary to compare it to the same service provided without the adaptation. Much additional research is needed that allows for the isolation of cultural adaptations in research designs to determine their effectiveness.