Improving cultural competence of healthcare workers in First Nations communities: a narrative review of implemented educational interventions in 2015–20

Keywords: Aboriginal, access to care, cross-cultural issues, cultural competence, cultural safety, First Nations, Indigenous, narrative review.

Internationally health disparities and marginalisation, including barriers to health care, for First Nations people impacted by ongoing colonisation is well documented (Pulver et al. 2015; United Nations Department of Economic and Social Affairs 2015; Anderson et al. 2016; Australian Institute of Health and Welfare 2020). First Nations people, in countries such as Australia, Canada, New Zealand and the USA, have particular needs for culturally competent health care because of historical and intergenerational trauma (Pulver et al. 2015).

Cultural competence is a broad concept, which includes strategies to improve access to health services and health outcomes for diverse peoples (Clifford et al. 2015). It is defined as the ability to understand and interact effectively with people from other cultures. It is often promoted as a strategy to address health inequities, although evidence linking cultural competence to patient outcomes is scarce and of relative low quality (Horvat et al. 2014).

A range of frameworks exist for health worker training in First Nations’ cultural education, including cultural awareness, cultural competence, transcultural care, cultural safety, cultural security and cultural respect (Downing et al. 2011). They differ in their relative focus on individual versus system change, and on a focus for health workers to understand their own culture versus that of another. In Australia, the term ‘cultural responsiveness’ is recommended by the organisation, Indigenous Allied Health Australia, referring to strengths-based, action-orientated approaches that enable Aboriginal and Torres Strait Islander people to experience cultural safety (Indigenous Allied Health Australia 2019).

First Nations cultural training for staff has been recognised as essential by government, numerous healthcare organisations, tertiary education facilities and extended training programs. In Australia, these organisations include, for example, the Federal Government, state governments and medical organisations (National Aboriginal and Torres Strait Islander Health Standing Committee 2016; Northern Territory Health 2016; Indigenous Allied Health Australia 2019; The Royal Australian College of General Practitioners 2020). In jurisdictions with a high proportion of First Nations people, such as the Northern Territory of Australia, where approximately 30% of the population is Aboriginal or Torres Strait Islander peoples and 70% of health system users are Aboriginal or Torres Strait Islander peoples (Li et al. 2011), healthcare workers are a priority for cultural training and education.

A review of undergraduate allied health, medical and nursing student cultural training highlighted the variety of approaches to cultural training, including face-to-face delivery along with blended learning combining a placement in an Indigenous setting, stand-alone placements and digital learning (Francis-Cracknell et al. 2019). The evidence has consistently demonstrated that work placements in Aboriginal health increased understanding and awareness of Aboriginal culture, promoted deeper understanding of the complexities of the determinants of Aboriginal health, increased awareness of everyday racism toward Aboriginal Australians, and enhanced student desire to work in Aboriginal health (McDonald et al. 2018). Undergraduate training should be a necessary minimal level of preparation for the workforce, but varies by discipline and location, and effective and ongoing professional education is also needed.

A number of recent systematic reviews of the effectiveness of First Nations cultural training for health service or patient outcomes have been conducted (Downing et al. 2011; Clifford et al. 2015), with some looking at specific health areas such as dental or diabetes care (Forsyth et al. 2017; Tremblay et al. 2020). These reviews have found relatively few papers where First Nations cultural training was implemented or evaluated well. Most concluded that although there is a lack of strong evidence of effectiveness, positive outcomes are apparent in terms of positive changes to health professionals’ knowledge, attitudes and confidence providing culturally safe care to First Nations patients, assessing patient satisfaction, and improving access to health care (Clifford et al. 2015).

This review is important because with a considerable investment by government and organisations into cultural training and education, current evidence of its effectiveness is needed. The most comprehensive reviews were last published in 2015, allowing for new evaluation research to be published since that time. This study sought to identify new evidence of effectiveness of cultural training for healthcare workers, using quality evaluations that included pre- and post-education program measures, to allow changes in outcomes to be demonstrated.

Consulting with a qualified librarian, we confirmed access to the same databases used by Clifford et al. (2015), as we sought to replicate this approach. These were MEDLINE, The Cochrane Library – Reviews and Trials, Scopus, CINAHL, Sociological Abstracts, PAIS Index, PsycINFO, Campbell Library, with the Informit databases incorporating AITSIS – Indigenous Studies Bibliography/ATSIHealth – Aboriginal and Torres Strait Islander Health Bibliography/APAIS-ATSIS/, FAMILY – Australian Family and Society Abstracts Database/Indigenous Peoples Collection.

Grey literature sources manually searched included MedNar – North Grey Literature Collection. An Australian search included Indigenous HealthlnfoNet (https://healthinfonet.ecu.edu.au/); Closing the Gap Clearinghouse (https://aifs.gov.au/projects/closing-gap-clearinghouse); NSW Ministry of Health, Aboriginal health (https://www.health.nsw.gov.au/aboriginal/pages/default.aspx). A Canadian search included The National Collaborating Centre for Indigenous Health (https://www.nccih.ca/en/); and National Aboriginal Health Organization (https://www.naho.ca/). A New Zealand search included Maori Health (https://www.health.govt.nz/our-work/populations/maori-health). A United States search included American Indian Health (https://www.ncai.org/policy-issues/education-health-human-services/health-care). The search terms used are listed in Table 1.

Table 1.  Search terms used.

The abstracts of studies published since 2015 up to May 2021 (n = 2115) were manually examined by the first two authors from July to October 2021, and any disagreements about study inclusion were resolved through discussion. After removal of duplicates (n = 360) and removal of ineligible studies, 93 full-text articles were reviewed (Fig. 1). Studies were included if they evaluated a structured educational intervention strategy designed to improve cultural competence in healthcare professionals for First Nations peoples of Australia, New Zealand, USA or Canada. Studies were excluded if they focused on non-English or culturally diverse populations (because the focus of this analysis was on First Nations peoples), or the evaluation did not have at least a post-intervention component or did not adequately report outcomes of the evaluation. Studies were also excluded if they described a service delivery model without an explicit cultural awareness/safety component, even if they integrated First Nations cultural competence principles into the delivery of health care. Further, we excluded most studies focused on undergraduate student populations because the students were not yet health professionals and are a distinct population in their own right and did not include follow-up evaluations (e.g. Delbridge et al. 2017; Svarc et al. 2018). Five papers (four as part of an on-going research program) collected follow-up outcome data and were included (Hunt et al. 2015; Thackrah et al. 2015a, 2015b, 2020; Thackrah and Thompson 2018). Due to the heterogeneity between the studies, we performed a systematic review with narrative synthesis. A narrative or traditional literature review is a comprehensive, critical and objective analysis of thecurrent knowledge on a topic (Jahan et al. 2016) that relies primarily on the use of words and text to summarise and explain the findings of the synthesis.

Fig. 1.  PRISMA flowchart summarising the search and selection of studies.

As described in Table 2, data were extracted from the included studies using criteria related to the intervention type and components, the study population and setting, sample size, study design, outcomes measured and intervention effectiveness. To enable comparisons with Clifford et al. (2015), the methodological quality of studies was assessed using criteria from the Dictionary for the Effective Public Health Practise Project Quality Assessment Tool for Quantitative Studies by rating them as weak, moderate or strong by CR and LL for selection bias, study design, confounders, data collection and withdrawal and dropouts (Table 3) (Jackson 2007).

Table 2.  Articles included in the review.

Table 3.  Quality assessment of included papers.

Ethics approval was not required as all data are from publicly available publications.

After full-text review, 13 articles were included in the study (Table 1). Most studies were from Australia (n = 10) with two from Canada and one from the USA. The cultural education intervention included undergraduate tertiary education (Hunt et al. 2015; Thackrah et al. 2015a; Withall et al. 2021), cultural immersive experiences (Thackrah et al. 2015a, 2017, 2020), and professional development workshops, some over several weeks (Liaw et al. 2015; Renault 2015; Durey et al. 2017; Crowshoe et al. 2018; Lewis et al. 2018; Freene et al. 2021).

Positive outcomes of the cultural education interventions were improved attitudes and knowledge (Hunt et al. 2015; Thackrah et al. 2015a, 2017, 2020; Crowshoe et al. 2018); better self-rated confidence in culturally safe practices (Durey et al. 2017); enhanced perceptions of social policies implemented to ‘improve’ Aboriginal people, and self-reported changes in health professionals’ behaviours and skills (Freene et al. 2021); higher levels of cultural strategic thinking (cultural quotient) (Liaw et al. 2015) and cultural competence scores (Renault 2015).

Overall, where reported, participants of cultural education programs enjoyed the experience of participating (Lewis et al. 2018). Only one study examined the impact of the intervention on patient outcomes and found slightly better health risk factor recording (Liaw et al. 2016).

One study reported initial increases in student and staff knowledge and attitudes towards Australian First Nations peoples, but this declined over time (Thackrah et al. 2015a). Another study found that undergraduate cultural training was difficult to incorporate into their professional practice (Withall et al. 2021). Few studies had a long follow-up period. The quality of the papers was generally weak or moderate, with no studies using a control group, most using convenience samples, and few following up participants after the intervention period (Table 2). The study by Liaw et al. (2015) was the strongest methodologically, followed by Durey et al. (2017) and Thackrah and Thompson (2018).

The cultural education programs included in this narrative review demonstrate short-term improvements in healthcare worker knowledge, attitudes and confidence working with First nations peoples. The learning experience was generally very positive. Only one of the studies included here examined the impact of cultural education programs on patient outcomes (Liaw et al. 2015) and this is the area where more attention is needed. Overall, the papers included in the review were strong on the importance of cultural education, but used weak methodology to demonstrate impacts. This is consistent with previous research (Bainbridge et al. 2015; Clifford et al. 2015).

The majority of papers were from Australia, which is in contrast with a previous review that reported the majority of papers from the USA, New Zealand and Canada (Clifford et al. 2015). It is possible that there is an increase in attention to cultural safety in Australia, where it perhaps has been relatively neglected for many years. A program of research in Western Australia has also influenced the present study findings with several related papers following up the effects of cultural training commencing during undergraduate education (Thackrah et al. 2015a, 2017, 2020; Thackrah and Thompson 2018).

A previous review (Bainbridge et al. 2015) identified 20 relevant papers, with five types of interventions and approaches to improve culturally competent healthcare delivery to First Nations populations. These were: reforming health service and systems; greater access to health care; greater cultural competence of the health workforce; training health and medical students; and developing culturally tailored health interventions. The effectiveness of these interventions was variable. This present narrative review focused on cultural education, but comparison with the earlier review demonstrates that little has changed in how training is received, accepted or valued over time.

Changing any health service delivery practice is complex, and this applies equally to changes to improve cultural safety for First Nations peoples. Initial and basic training is fundamental, but needs to be followed up with ongoing professional development, systems and policies that reinforce new practices, and requires systematic leadership to champion change (Freeman et al. 2019; Allen et al. 2020).

Several studies reporting primary healthcare service delivery models support what has been found in this review. They were not included in the review because they did not explicitly engage in cultural awareness or safety education; however, these programs revealed impressive outcomes in several areas – multidisciplinary work, community participation, cultural respect and accessibility strategies, preventive and promotive work, and advocacy and intersectoral collaboration on social determinants of health (Durey et al. 2016; Freeman et al. 2016; Goss et al. 2017; Kildea et al. 2018; Sabbioni et al. 2018; Freeman et al. 2019). These models of care interweave evidence-based western treatment, traditional native healing and rural cultural facilitation (Goss et al. 2017), and apply the principles of First Nations cultural competence in the delivery of health services and demonstrate positive health outcomes (e.g. Freeman et al. 2019).

Focusing on the short-term impacts of cultural education limit the ability to link cultural competence education to patient outcomes. Given the potential impact of primary healthcare services with cultural competence integrated at many levels, there needs to be a to shift from attending a training day or a course to a much more comprehensive approach, including practical applications of cultural safety in everyday practise.

A strength of this study is the recency of the literature reviewed, using similar methodology as previous work, and focusing specifically on the impact of cultural education of healthcare workers. This restriction of scope is also a limitation. By focusing on outcomes, we have not examined factors that could contribute to attaining these outcomes, or examined other impacts that were not measured (Allen et al. 2020 2022). Other limitations include the low number of papers included in this narrative review, which limits the ability to make conclusions about the effectiveness of cultural education.

There is a strong rationale for cultural education of healthcare workers; however, there remains limited evidence for impact of cultural education alone on patient outcomes. Cultural education training by itself may not be adequate to deliver better patient outcomes.

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The project was supported by a 2020 Flinders Foundation Health Seed Grant.

Not applicable.

CR, CR, AW, BR and MB conceived of the study. CR and LL reviewed all the papers. CR drafted the manuscript and all authors contributed to the writing, editing of the manuscript, and approved the final version. All the authors except for ChR and AW are First Nations people. LL and ChR designed and conducted the review. All other authors contributed to the interpretation of the findings and the writing of the manuscript.