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Introduction: Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research. Methods: A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported. Results: Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level. Discussion and implications: We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities. [ABSTRACT FROM AUTHOR]

Background: Mobile clinics have been used to deliver primary health care to populations that otherwise experience difficulty in accessing services. Indigenous populations in Australia, Canada, New Zealand, and the United States experience greater health inequities than non-Indigenous populations. There is increasing support for Indigenous-governed and culturally accessible primary health care services which meet the needs of Indigenous populations. There is some support for primary health care mobile clinics implemented specifically for Indigenous populations to improve health service accessibility. The purpose of this review is to scope the literature for evidence of mobile primary health care clinics implemented specifically for Indigenous populations in Australia, Canada, New Zealand, and the United States. Methods: This review was undertaken using the Joanna Brigg Institute (JBI) scoping review methodology. Review objectives, inclusion criteria and methods were specified in advance and documented in a published protocol. The search included five academic databases and an extensive search of the grey literature. Results: The search resulted in 1350 unique citations, with 91 of these citations retrieved from the grey literature and targeted organisational websites. Title, abstract and full-text screening was conducted independently by two reviewers, with 123 citations undergoing full text review. Of these, 39 citations discussing 25 mobile clinics, met the inclusion criteria. An additional 14 citations were snowballed from a review of the reference lists of included citations. Of these 25 mobile clinics, the majority were implemented in Australia (n = 14), followed by United States (n = 6) and Canada (n = 5). No primary health mobile clinics specifically for Indigenous people in New Zealand were retrieved. There was a pattern of declining locations serviced by mobile clinics with an increasing population. Furthermore, only 13 mobile clinics had some form of evaluation. Conclusions: This review identifies geographical gaps in the implementation of primary health care mobile clinics for Indigenous populations in Australia, Canada, New Zealand, and the United States. There is a paucity of evaluations supporting the use of mobile clinics for Indigenous populations and a need for organisations implementing mobile clinics specifically for Indigenous populations to share their experiences. Engaging with the perspectives of Indigenous people accessing mobile clinic services is imperative to future evaluations. Registration: The protocol for this review has been peer-reviewed and published in JBI Evidence Synthesis (doi: 10.11124/JBISRIR-D-19-00057). [ABSTRACT FROM AUTHOR]