A critical review of cultural competence frameworks and models in medical and health professional education: A meta-ethnographic synthesis: BEME Guide No. 79

Figures & data

Figure 1. PRISMA flow diagram for the study selection process. ¹The initial search had two stages of search. The first search was conducted between 1 Jan 1990 to 31 Dec 2020 in WoS (core collection) (n = 726), Medline (within WoS search engine) (n = 158) and CINHAL (n = 129). When searching Medline, duplicates within the WoS (core collection) were excluded. The second search was conducted between 1 Jan 1990 and 31 Dec 2020 in PsycINFO (n = 305) and ERIC (n = 46). ²The search was updated from 1 Jan 2021–30 Sept 2022 in WoS (core collection) (n = 166), Medline (n = 138), CINHAL (n = 5), PsycINFO (n = 168) and ERIC (n = 2).

Table 1. Summary of study characteristics.

Thompson-Robinson et al. (2006) Orr and Unger (2020)

No.	Author (Year)	Context	Discipline	Type of Study	Sample	Data Collection Method	Name of model	Aim of model
1	Airhihenbuwa (1990)	Developing countries	Health Education	Opinion	n/a	n/a	PEN-3 Model	To help health education programs in developing countries to be culturally sensitive and appropriate
2	Bernal (1993)	USA	Nursing	Opinion	n/a	n/a	The Culturally Relevant Community Practice Model	To provide direction for the development of a system that will promote culturally relevant care in community health agencies
3	Campinha-Bacote (1999)	USA	Healthcare	Opinion	n/a	n/a	A model and Instrument for Addressing Cultural Competence in Health Care	To concretely guide nursing actions
4	Brach and Fraser (2000)	USA	Healthcare	Systematic review	n/a	Literature search	Conceptual model 9 cultural competency techniques	To reduce health disparities
5	Purnell (2000)	USA & global	Healthcare	Opinion	n/a	n/a	Purnell Model for Cultural Competence	To provide an organising framework for nurses to use as a cultural assessment tool
6	Kim-Godwin et al. (2001)	USA	Nursing	Mixed methods	13	Literature search, interviews, questionnaire	Culturally Competent Community Care (CCCC)	To predict public health outcomes of culturally competent health care in communities
7	Campinha-Bacote (2002)	USA	Healthcare	Opinion	n/a	n/a	Campinha-Bacote’s Model of Process of Cultural Competence in the delivery of healthcare services	To help healthcare providers to develop and implement culturally responsive health care services
8	Leininger (2002)	USA	Nursing	Opinion	n/a	n/a	The Sunrise Model	To discover and explain diverse and universal culturally based care factors influencing the health, well-being, illness, or death of individuals or groups
9	Betancourt et al. (2003)	USA	Healthcare	Systematic review	n/a	Literature search	Framework for Cultural Competence	To eliminate racial/ethnic disparities in health and health care
10	Hart et al. (2003)	UK	Midwifery	Mixed methods	Not specified	Questionnaire, focus groups, interviews	Inequalities Imagination Model	To incorporate issues of individual and structural agency and a broader definition of disadvantage to develop an 'inequalities imagination’
11	Vaught (2003)	USA	Healthcare	Theoretical	n/a	n/a	A Pragmatic Model for Multicultural Education	To provide moral justification for cross-cultural normative claims in healthcare
12	Giddings (2005)	New Zealand /USA	Nursing	Qualitative	26	Semi-structured interviews	The Model of Social Consciousness	To provide a theoretical framework for understanding how people position themselves in relation to social injustice and social action
13	Gustafson (2005)	Canada	Nursing	Opinion	n/a	n/a	Transcultural Nursing Theory	To focus attention on the concept of culture, the goal of providing culturally competent care and the processes to achieve that outcome
14	Mahoney et al. (2006)	USA	Psychiatry/ Mental health nursing	Opinion	n/a	n/a	A Framework for Cultural Competence in Advance Psychiatric Nursing Practice	To provide a framework for teaching about cultural competence that includes both content and process
15	Thompson-Robinson et al. (2006)	USA & global	Public health	Qualitative	13	Literature search, expert panel reviews	Conceptual Framework for the Provision of Culturally Competent Services in Public Health Settings	To conceptualise culturally competent services in public health settings
16	Willis and Porche (2006)	USA	Nursing	Opinion	n/a	n/a	Marginality-Cultural Competence Integrative Framework (M-CCIF)	To help clinicians and scholars to envision and advance culturally competence scholarship related to marginalized men’s health disparities
17	Conviser and Pounds (2007)	USA	Healthcare	Opinion	n/a	n/a	The Care System Assessment Model	To assess care systems and their components and to identify features of care systems that contribute barriers to care access
18	Schim et al. (2007)	USA & global	Healthcare	Opinion	n/a	n/a	3-D Puzzle Model	To provide culturally congruent care
19	Wikberg and Eriksson (2008)	Finland	Nursing	Literature Review	n/a	Literature search	Model for Intercultural Caring	To help nurses understand complexity of intercultural caring and develop cultural competence
20	Gamst et al. (2009)	USA	Mental health care	Cohort	1153	Self-report questionnaires	Multicultural Assessment Intervention Process Model	To systematically embed cultural issues in mental health service delivery
21	Hernandez et al. (2009)	USA	Mental health care	Systematic review	n/a	Literature search	No name given for model	To give a measurable approach to the pursuit of cultural competence in mental healthcare
22	Seeleman et al. (2009)	Netherlands	Healthcare	Opinion	n/a	n/a	Framework of Cultural Competencies	To provide practical translation of learning objectives into competencies
23	Teal and Street (2009)	USA & global	Healthcare	Opinion	n/a	n/a	Culturally Competent Communication Model	To provide culturally competent patient care with models of effective patient-centred communication
24	Westerholm (2009)	USA	Nursing	Opinion	n/a	n/a	Cultural Learning Model	To help nurses learn how to be with others in a way that enhances and changes their understanding of others and themselves
25	Gertner et al. (2010)	USA	Healthcare	Qualitative: Case study	2 hospitals	Case report of tertiary care hospitals (n = 2), community health provision, physician group (400 members) and health network (1100 members)	Conceptual Cultural Competence Model for Mental Health Services	To support organisational change and promote high-quality, safe, and equitable care through culturally competent care delivery across the entire network
26	Janzen et al. (2010)	Canada	Mental health care	Mixed methods	328	Literature search, interviews (n = 22), focus groups (n = 21), case studies (n = 10), questionnaire (n = 111)	The Emerging Framework	To guide future mental health policy and practice
27	Castillo and Guo (2011)	USA	Healthcare	Opinion	n/a	n/a	Framework for Cultural Competence in Health Care Organizations	To help health care organisations integrate strategies for cultural competence in every area of the organization
28	Tirodkar et al. (2011)	USA	Healthcare	Qualitative	75	Semi-structured interviews	Explanatory Models of Health and Disease Among South Asian Immigrants in Chicago	To identify concepts of health and disease as part of a study on designing culturally-targeted heart disease prevention messages for South Asians
29	Durey et al. (2012)	Australia	Nursing	Systematic review	n/a	Literature search	Model of Organisational Change	To increase Aboriginal participation in health workforce, build capacity in non-Aboriginal health professionals to deliver quality care and facilitate collaboration between Aboriginal and non-Aboriginal people
30	Koskinen et al. (2012)	Europe	Nursing	Opinion	n/a	n/a	Framework for a European Curriculum in Cultural Care	To nurture educational development and networking among member institutions
31	Hammell (2013)	Canada	Occupational therapy	Opinion	n/a	n/a	The Canadian Model of Occupational Performance and Engagement	To depict individuals embedded within physical, institutional, social, and cultural environments that afford occupational possibilities
32	Owiti et al. (2014)	UK	Mental health care	Cohort	94	Evaluation forms and questionnaire	Clinical Consultation Service (CCS) Model	To promote cultural competence of clinicians and directly improve patient experiences and outcomes
33	Soulé (2014)	Global	Healthcare	Qualitative	20	Interviews	Refined Cultural Competency themes and domains	Provide a new theoretical framework based on themes that are core to cultural competence
34	Almutairi et al. (2015)	Saudi Arabia	Nursing	Opinion	n/a	n/a	Almutairi’s Critical Cultural Competence Model	To provide a model that enables healthcare workers to gain critical awareness, knowledge and skills for cultural competence, and critical knowledge about the fluidity of culture and consideration of power dynamics.
35	Moore et al. (2015)	USA	Pediatric care	Qualitative	15	Semi-structured interviews	Family-Centred Care Model	To provide a frame for family-centred care in the context of children
36	Nastasi et al. (2015)	India	Public health / Medicine	Qualitative	n/a	Participant narratives	Local Narrative Intervention Model	To create an evidence-based reconstructed behavioral change model
37	Nguyen and Baptiste (2015)	Canada	Rehabilitation	Opinion	n/a	n/a	No new model presented, applied Acculturation Theory	To apply acculturation theory to rehabilitation practice to enhance patient-centred care
38	Garneau (2016)	Canada	Nursing	Systematic review	n/a	Literature search	Framework for critical reflection in cultural competence	To help nursing students develop a perspective transformation to be open to different practice realities
39	Lor et al. (2016)	Global	Nursing	Systematic review	n/a	Literature search	Model of Person-, Family-, and Culture-Centred Nursing Care	To encourage nursing orientated patient care
40	Michael (2016)	Australia	Nursing in elderly care	Mixed methods	n/a	Literature search, focus groups, client narratives, questionnaire	The Diversity Conceptual Model for Aged Care	To support the aged care sector by incorporating the consideration of diversity (from ethnicity to LGBT+)
41	Olaussen and Renzaho (2016)	Global	Health care	Systematic review	n/a	Literature search	A Cultural Competence Model for MWD (Migrants with disabilities)	To address disability-related challenges to healthcare inequality targeting migrants
42	Ahn (2017)	South Korea	Nursing	Cohort	275	Self-report questionnaires	Adapted Transcultural Nursing Immersion Experience Model	To explain the relationship between cultural competence and influencing factors
43	Carnegie et al. (2017)	Scotland	Healthcare	Qualitative	40	Focus groups (n = 7), paired interviews (n = 4)	Cross-cultural Community Engagement Model	To help practitioners and policymakers raise the profile of HPV across diverse communities
44	Dijkman et al. (2017)	Europe	Healthcare	Qualitative	96	Literature search, interviews, Delphi technique	Competence Framework	To describe the outcomes professionals working with older people are expected to achieve and be able to demonstrate
45	Peterson et al. (2017)	USA	Mental health care	Systematic review	n/a	Literature search	1. Ecological Validity Model; 2. Cultural Adaptation Process Model; 3. Psychotherapy Adaptation and Modification Framework	1. To best serve the needs of Hispanic clients; 2. To guide the cultural adaptation of interventions; 3. To adapt treatments to cultural and linguistically diverse populations
46	Wesp et al. (2018)	USA & global	Nursing	Theoretical	n/a	n/a	An Emancipatory Approach to Cultural Competency	To uphold the nursing value of commitment to social justice
47	Andrews and Boyle (2019)	USA	Nursing	Opinion	n/a	n/a	The Andrews/Boyle Transcultural Interprofessional Practice (TIP) Model	To provide a systematic, logical, orderly, scientific process for delivering safe, culturally congruent and culturally competent care; facilitate delivery of nursing that is consistent with cultural backgrounds of people
48	Di Stefano et al. (2019)	Italy	Healthcare	Systematic review	n/a	Literature search	The Client-orientated Model of Cultural Competence	To link managing cultural diversity with cultural competence in health organisations within the framework of client orientation
49	Handtke et al. (2019)	Germany	Healthcare	Systematic review	n/a	Literature search	Model of Culturally Competent Healthcare Provision	To help design interventions
50	Foronda (2020)	USA	Nursing	Systematic review	n/a	Literature search	Theory of Cultural Humility - Rainbow Model of Cultural Humility	To guide individuals for the practice of cultural humility - key concepts, context, inter-relationships, influences and outcomes
51	López et al. (2020)	USA	Psychiatry	Qualitative	16	Video observation of consultations (n = 35)	The Shifting Cultural Lenses Model	To operationalise culturally competent in-session behaviors
52	Ojo et al. (2020)	England, Slovenia, the Philippines, New Zealand	Nursing	Qualitative	181	Focus group (n = 23)	Cultural Analytical Framework	To understand student nurses’ cultural values and beliefs of dementia
53	Orr and Unger (2020)	Israel	Nursing	Opinion	n/a	n/a	TOLERance Model	To promote structural competency in nursing
54	Shattuck et al. (2020)	USA	Education	Qualitative	187	Interviews (n = 75), focus groups (n = 32)	No new model presented but applied the Structural Competency Framework	To leverage structural competency within school health initiatives that can address the vulnerabilities of sexual and gender minority youth (SGMY)
55	Travers et al. (2020)	USA	Healthcare	Qualitative	464	Structured interviews with the administration of a survey	Adaptation of the Anderson’s Expanded Behavioral Model of health services use to include older adults receiving long-term services and supports	To understand both the relevancy of factors for older adults who currently use LTSS (Long Term Services and Supports) vs. those who intend to use LTSS (as described in Andersen’s original exploration)
56	Yang et al. (2020)	Taiwan	Healthcare	Qualitative: Case study	1 hospital	Literature search, hospital case report (n = 1), interviews	Cultural Sensitivity Cultivation Model	To provide a conceptual framework to help improve service quality and experience for international patients
57	Zahiruddin et al. (2020)	India	Public health	Qualitative	44	Curriculum scan, literature search, focus groups (n = 6)	Framework for cultural competencies for Masters of Public Health programs in India	To promote the inclusion of cultural competencies in MPH curricula to achieve more equitable public health practice
58	Broughten et al. (2021)	USA	Healthcare	Qualitative	11	Steering committee	Framework for Interprofessional Colleaborative Practice, Cultural Fluency and Ecological Approaches to Health	To provide core competences to increase students’ interprofessional practice, cultural fluency and ecological approaches to health, in order to reduce health disparities
59	Wang et al. (2022)	Taiwan	Healthcare	Qualitative	25	Semi-structured interviews	Socio-ecological Model of Factors affecting Culturally Competent Care	To categorise factors associated with healthcare providers’ behaviour and intention to offer culturally competent care to Taiwanese sexual and gender minority older adults

Table 2. Themes and Subthemes Synthesised from First and Second Order Constructs.

Themes	Subthemes	Description
Competences		The actionable cultural competences that can be developed by medical and healthcare professionals
	Adaptation to diversity	Provide a safe environment for patients to discuss their cultural health beliefs and practices; Address the needs of diverse patients through its commitment to serving diverse patients
	Advocacy	Advocate for health with and on behalf of marginalised patients
	Attitudes	Demonstrate openness, respect, non-judgemental and non-egoistic attitudes toward cultural differences
	Awareness	Develop awareness of different cultural backgrounds, diversity and potential biases/assumptions
	Capacity building and empowerment	Recognise and minimise power differences between patients and clinicians; develop individualised care not only for the other but also for the self, have flexibility, make bias explicit, and make cultural competence development an ongoing process
	Collaboration	Have multi- and inter-professional cooperation and community outreach for public health practitioners; Collaborate with all stakeholders, including policymakers, health organisational managers, specialists, communities, patients, family and important others, as well as researchers
	Compassion	Demonstrate compassion for the disadvantaged/vulnerable groups, leading towards commitment to advocacy actions
	Critical thinking	Think beyond individual care (to a much more analytic and creative approach that recognises both the structural and individual factors that determine and define needs in contemporary society)
	Cultural formulation and application skills	Formulate a comprehensive understanding of patients’ culturally laden illness experiences and help-seeking behaviours to allow for a broader assessment of patients and adaptations
	Engagement	Possess the motivation to engage in the process of developing cultural competence by thinking and acting creatively in reducing healthcare inequalities
	Knowledge application	Assess and respond to cultural problems, and potentially plan/develop interventions based on existing cultural knowledge and knowledge of methodology for assessment and interventions
	Organisation and leadership	Build an inclusive environment with a diverse workforce that is representative of its patient population; Aspire to take leadership in addressing cultural barriers both with patients and within the healthcare team
	Professional commitments	Show commitments to ethics, actions for change, lifelong learning, and constant self-evaluation
	Scholarship	Conduct research and analytic activities that advance the relevant knowledge base about culturally competent care, and expand professional expertise in terms of clinicians’ own professional practice for innovating care and support
	Self-assessment and reflection	Reflect on past events with the intent of identifying opportunities for future improvement and learning and transforming one’s frame of reference
	Sensitivity	Be sensitive to differences in patient experiences/responses and social justice issues for vulnerable groups; Have the desire and spend efforts to develop programs and services that respect the cultural diversity of populations
	Skills	Possess skills such as rapport building, relationship building, self-reflection, effective communication, culturally inclusive clinical skills, managing complexity in care, and prioritising social justice
Roles and identities		Professional roles and identities being formed by medical and healthcare professionals as a result of gradually developing, sustaining and internalising the above-mentioned cultural competences
	Humble learner	One who is humbled by the cultural knowledge of others, depth of the cultural knowledge system, and who is constantly seeking opportunities to learn cross-culturally
	Advocate	One who advocates for health with and on behalf of marginalised patients
	Collaborator	One who works in collaboration (not exclusively within healthcare) with family members, and community members
	Communicator	One who communicates to establish rapport and trust, formulates a diagnosis and goal interventions, delivers information, strives for mutual understanding, and facilitates a shared plan for treatment
	Expert	One who has the appropriate cultural knowledge and effective methods for cultural assessment and interventions
	Leader	One who elevates the priority of cultural competence, drives systematic efforts and inspires staff support, and applies cultural competence to organisations and systems
	Organiser	One who organises and manages care and services, focusing on integral connectivity, and continuity of care and support for patients of diverse cultural backgrounds
	Professional	One who is guided by professional regulations/laws and committed to the life-long development of cultural competence at all levels
	Reflective practitioner	One who constantly reflects on their cultural encounters and evaluates their own practices for improvement
	Resource allocator	One who ensures sufficient resources are available to foster cultural competence practice
	Scholar	One who is a lifelong learner that conducts research and assessments and renews the methods being used
Structural competency		Competences beyond the individual level concerning the institutional and systemic structure
	Recruitment & management strategy	Recruit a diverse workforce and establish professional and staff training programs that enhance their cultural competence; Implement strategic and organisational management to ensure health equity
	Formal references in policies	Produce formal statements about organisational values, principles, goals, policies, and visions that can serve as references for the provision of culturally competent care
	Partnership between professionals	Establish connections and network with multidisciplinary team and local community members
	Partnership with community	Collaborate with community partners, such as other public, private, or non-profit organisations that help minority groups
	Physical environment	Build a positive and inclusive work environment for multicultural staff
	Professional development	Dedicate to professional development through activities such as organised/self-directed training, participation in professional organisations, enrolment in training programs, and research
	Research and information gathering	Conduct research activities that improve understanding and practice of the provision of culturally appropriate care
	Structural innovations, interventions, evaluation	Design and create a physical and symbolic multicultural environment that ensures users’ open access to services through the elimination of socio-cultural barriers
	Contextual influence	Understand the social context within which the vulnerable and marginalised groups live
	Systematic barriers	Aspire to remove barriers that might be related to beliefs, values, and assumptions of clinicians and patients, professional standards of practice, organisational structures, and national policies

Figure 2. The ACT Cultural Model.

Table 3. Third order constructs/themes.

Third Order Constructs/Themes	Description
Activate consciousness	The development of individual cultural awareness, acquisition of cultural knowledge and demonstration of cultural sensitivity
Awareness	Develop cultural awareness at intrapersonal, interpersonal and systemic/organisational levels
Knowledge and sensitivity	Acquire the two-dimensional knowledge that includes both cultural knowledge and critical knowledge; Demonstrate sensitivity to cultural differences and similarities between people without assumptions and judgement
Connect relations	The connection and collaboration among all stakeholders to achieve culturally competent care provision
Personal connectivity	Work together with patients, caregivers and their families to make sure the care provision is patient- and family-centred
Community connectivity	Involve and collaborate with community healthcare professionals, healers, and spiritual leaders in carrying out health program planning, implementation, and continuous formal and informal evaluation of the provision of programs
Interprofessional connectivity	Connect with multiple health workers from different professional backgrounds
Transform into true cultural care	The transformation to culturally appropriate care in healthcare and the development of social justice at the systemic level
Empowerment strategies	Utilise strategies whereby individual healthcare professionals enact their agency to go beyond merely recognising cultural differences, to also addressing power imbalance operating within the social, historical and political context
Cultural skills	Master good practices in care provision, interaction, communication, decision making, and policy making, as well as essential skills such as cultural consultation and clinical cultural formulation
Professional commitment	Demonstrate commitment to internalise holistic cultural competence as part of their professional identity

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