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Objective: To explore caregiver perspectives of their children's journey through the specialist paediatric service, the Aboriginal Ambulatory Care Coordination Program (AACC), and non-AACC services at the Perth Children's Hospital., Methods: Eighteen semi-structured interviews with families of Aboriginal children were completed. Indigenous research methodology and a phenomenological approach guided data collection and analysis., Results: Four key themes were identified from interviews: hospital admissions, discharge and follow-up outpatient appointments; communication; financial burden; and cultural issues. Our findings suggest Aboriginal children and their caregivers using the AACC program had more positive and culturally secure experiences than those using non-AACC services. However, barriers relating to health providers' understanding of Aboriginal cultural issues and lived experience were commonly discussed, regardless of which service families received., Conclusions: Australian Aboriginal children have an increased use of tertiary hospital care compared to non-Indigenous children. Healthcare programs specifically designed for Aboriginal children and their families can improve their experience of care in hospital. However, improvements in cultural awareness for other hospital staff is still needed. Implications for public health: Dedicated Aboriginal programs in mainstream services can successfully improve cultural care to their clients, which is fundamental to improving service delivery for families., (© 2020 The Authors.)

Objective: Health disparities in lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+), or sexual and gender minority (SGM) people are known. SGM people have higher cancer risk, but lower rates of screenings, resulting in a higher likelihood of late-stage disease. This study evaluates medical students' clinical cultural awareness in cancer care of SGM patients to identify gaps in education., Methods: This was a cross-sectional survey distributed to medical students at a academic center. There were 38 questions on demographics, attitudes, and knowledge of SGM topics. Descriptive statistics were used for demographic information and stratified analyses assessed responses by demographic subgroups., Results: There were 238 responses from 1145 students (response rate = 20.7 %). Of the responders, 91.2 % and 79 % were comfortable treating lesbian, gay, bisexual (LGB) and transgender patients respectively. Only 28.6 % and 21.8 % were confident treating LGB and transgender patients respectively after taking the survey. 91.2 % of students were interested receiving education regarding SGM health needs., Conclusion: While most medical students are comfortable treating LGBTQ+ patients, most are not confident in their knowledge. This difference is most profound in knowledge of transgender patients., Practice Implications: Schools must provide more education in SGM topics to improve student knowledge to produce competent providers., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier B.V.)

Objectives: To determine the level of cultural competence of European critical care nurses., Design: A multi-country survey performed in 2017 as a part of the European project Multicultural Care in European Intensive Care Units., Method: Online survey of critical care nurses in 15 European countries (n = 591) using the Healthcare Provider Cultural Competence Instrument consisting of 49 items divided into five subscales: awareness and sensitivity, behaviour, patient-centred orientation, practice orientation and self-assessment. Descriptive and correlational analyses were performed., Results: Critical care nurses scored highest for 'awareness and sensitivity' (M = 5.09, SD = 0.76), and lowest for 'patient-centred communication' (M = 3.26, SD = 0.94). Nurses from northern and southern Europe scored higher across all subsets of the cultural competence instrument (all subsets, p < 0.001) than nurses from central Europe. Speaking other languages significantly correlated with higher scores in all subscales (all > 0.05) except 'practice orientation'. Previous education on multicultural nursing significantly correlated with higher scores in all subscales (all > 0.01) except patient-centred communication; and visits to other countries was negatively correlated with all subscales (all, p > 0.001) except patient-centred communication., Conclusion: Being exposed to cultural diversity in different ways, like living in a multicultural country, speaking a second language and visiting other countries may influence development of cultural competence. Therefore, programmes which facilitate multicultural clinical practice are strongly recommended in nursing education., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Internationally qualified midwives comprise approximately 13% of the Australian midwifery workforce. Despite their central role in the Australian midwifery system, understanding of their transitional experiences is limited., Aim: To explore the transitional experiences of internationally qualified midwives practising in Australia., Method: A descriptive qualitative study was undertaken, as the second phase of a larger mixed methods study. In this paper we present in-depth insights from 11 internationally qualified midwives practising in Australia. Individual semi-structured interviews were conducted between May-August 2018, digitally recorded and then transcribed. Transcriptions were analysed using a thematic analysis approach., Findings: Participants in this study identified that the different culture of the work environment, differences in midwifery practice, lack of autonomy in their practice and perceived discrimination influenced their transition into Australian midwifery practice. Four themes were identified: 'Differences in midwifery practice', 'Cultural incongruence', 'Discrimination' and 'Mixed emotions'., Discussion: Success during the complex transition process depends on the migrant midwives' ability to build a sense of belonging, and to develop and adopt strategies that assist in dealing with new workplaces and an unfamiliar workforce., Conclusion: A structured transition program prior to commencing practice, as well as an evidence-based workplace mentorship program with a focus on Australian midwifery care and culture, may be effective strategies to facilitate their transition. To promote awareness of multiculturalism within the work environment, this study recommends actively encouraging host staff to further develop perspectives that enable them to create positive relationships with staff from other cultures., (Copyright © 2019 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: Lesbian, gay, bisexual, trans and intersex (LGBTI) people experience health inequalities and barriers to accessing healthcare at a greater rate than the general population. This paper aims to present the Health4LGBTI training course for healthcare workers and the results of its pilot implementation., Methods: Funded by the European Parliament, the training course was developed by a multidisciplinary team including LGBTI organisations as part of the Health4LGBTI Project. 110 healthcare professionals from diverse medical fields attended the pilot training in six European Member States. Knowledge and attitudes were compared on the basis of a pre-post evaluation design utilising an ad hoc questionnaire., Results: Knowledge scores increased after the training, irrespective of age and sexual orientation of participants. Attitudes scores generally improved, particularly in terms of inclusivity and a greater acknowledgement of LGBTI health needs and self-competence., Conclusion: The Health4LGBTI training course is both feasible and effective in training healthcare professionals and support staff to improve cultural competence and thereby promoting inclusive healthcare practice., Practice Implications: The Health4LGBTI training course can be implemented in different healthcare contexts. Piloting of the course provided an opportunity for healthcare professionals and for support staff to improve their knowledge of, and attitudes towards, LGBTI people., Competing Interests: Declaration of Competing Interest None., (Copyright © 2019 The Author(s). Published by Elsevier B.V. All rights reserved.)

Mental Health First Aid is a population health approach that educates people to recognize and respond to mental health challenges. Since 2012, the Mental Health Commission of Canada has worked with six First Nations communities to develop a culturally-relevant version of the program called Mental Health First Aid First Nations (MHFAFN). This paper presents mixed methods, multi-informant data from a national evaluation to assess the extent to which the course was experienced as culturally safe by Indigenous participants, factors that contributed to these experiences, and ways in which cultural relevancy of MHFAFN can be improved. Our evaluation team conducted participant interviews and surveys, as well as facilitator interviews. Nearly all Indigenous participants (94.6%) experienced the course as safe. Participants and facilitators identified a range of factors that promoted cultural safety, including the knowledge and skills of the facilitators and the cultural components of the course. Participants that did not experience safety identified trauma-related factors and facilitation style. The findings suggest that MHFAFN may be situated in a way where shared cultural backgrounds are imperative to the success of the course. Further evaluation of the MHFAFN curriculum, with the goal of continual improvement, may help to further enhance participants' experiences in taking the course., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

American Indian youth substance use is a major public health concern. To date, there has been limited evaluation of American Indian youth substance use prevention programs. Evaluation of prevention programs is necessary to understand the aspects of programming that are effective or not effective. This mixed-methods evaluation focuses on select outcomes of a 3-year culturally-based prevention program located in six American Indian communities in the Rocky Mountain Region. The goals of the prevention program are to reduce binge drinking by 30% and increase community readiness by 1-point over a 5- year period. In the first year of the program, community members worked with program staff to develop an evaluation plan that would measure the following outcomes: lowering substance use, increasing community readiness, and increasing the reach of prevention messaging through culturally based prevention. The primary research questions this outcome evaluation sought to answer were as follows: 1) Are there differences in American Indian youth who participate in culturally-based prevention activities compared with American Indian youth who do not participate in these activities? 2) Was the prevention program effective in increasing community readiness over a 3-year period? 3) Did community involvement in prevention activities increase overtime? Results from this evaluation indicate that substance use was similar among intervention (n = 200) and non-intervention youth (n = 369). This was somewhat surprising because Intervention youth reported higher levels of social support and community connections than non-intervention group youth. Community readiness decreased -.81 point from 2015 to 2017. The reach of prevention activities increased 365% from 2015 to 2017. We provide lessons learned that may help other communities as they document outcomes related to prevention efforts. Substance use is a multi-faceted problem facing our communities, families, schools, and nation. Innovative, effective, culturally-based prevention programs like the one highlighted in this paper underscore the need for primary prevention strategies., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objective: Patient-clinician communication (PCC) may generate or reduce healthcare disparities. This paper is based on the 2017 International Conference on Communication in Healthcare keynote address and reviews PCC literature as a research area for the National Institute on Minority Health and Health Disparities (NIMHD)., Methods: A narrative review of selected evidence on disparities in PCC experienced by race and ethnic minorities, associations between PCC and poor health outcomes, and patient and clinician factors related to PCC., Results: Factors associated with poor quality PCC on the patient level include being a member of racial/ethnic minority, having limited English proficiency, and low health and digital literacy; on the clinician level, being less culturally competent, lacking communication skills to facilitate shared decision-making, and holding unconscious biases. Recommendations include offering patient- and/or clinician-targeted interventions to guard against unconscious biases and improve PCC, screening patients for health literacy and English proficiency, integrating PCC in performance processes, and leveraging health information technologies to address unconscious biases., Conclusion: EffectivePCC is a pathway to decrease health disparities and promote health equity., Practice Implications: Standardized collection of social determinants of health in the Electronic Health Record is an importantfirst step in promoting more effective PCC., (Published by Elsevier B.V.)

Problem: Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care., Purpose: The purpose of this study was twofold: (1) to explore maternal health care providers' perceptions and experiences of barriers in providing care to Marshallese women, and (2) providers perceived barriers of access to care among Marshallese women. This is the first paper to explore perceived barriers to maternal health care among a Marshallese community from maternal health care providers' perspectives in the United States., Methods: A phenomenological, qualitative design, using a focus group and in-depth interviews with 20 maternal health care providers residing in northwest Arkansas was chosen., Findings: Several perceived barriers were noted, including transportation, lack of health insurance, communication and language, and socio-cultural barriers that described an incongruence between traditional and Western medical models of care. There was an overall discord between the collectivist cultural identity of Marshallese families and the individualistic maternal health care system that merits further research., Discussion: Solutions to these barriers, such as increased cultural competency training for maternal health care providers and the incorporation of community health workers are discussed., (Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.)

Objectives: This paper reports research undertaken to investigate nurses' and parents' experiences of communication about parental emotions in a hospital setting, with a focus on the environmental and cultural context within which the communication occurs., Methods: A focused ethnography was employed as the aims were to understand the context within which nurse-parent interaction takes place, by exploring cultural factors, such as ways of living affecting nursing communication. Data collection occurred in a children's unit of a New Zealand hospital, involving 260h of participant observation field work, informal interviews with parents and nurses, followed by 20 formal interviews with nurses and parents., Results: Nurses are cultural brokers, with the potential to be a link between the insider culture, the hospital and the outside, the parents. Parents look to nurses for cultural brokerage, to help them cross the strong cultural boundaries present in a hospital unit., Conclusion: The context and culture of a hospital unit influences nurse-parent communication. There is a disconnection between parents' emotional needs in hospital and nurses' ability to meet those needs., Practice Implications: Nurses must be supported to provide effective cultural brokerage for parents. Unit managers need to acknowledge that meeting parents' diverse needs is vital., (Copyright © 2017 Elsevier B.V. All rights reserved.)

In this paper, we share the results of a summative evaluation of PEILI, a US-based adult professional development/training program for secondary school Pakistani teachers. The evaluation was guided by the theories of cultural competence (American Psychological Association, 2003; Bamberger, 1999; Wadsworth, 2001) and established frameworks for the evaluation of professional development/training and instructional design (Bennett, 1975; Guskey, 2002; King, 2014; Kirkpatrick, 1967). The explicit and implicit stakeholder assumptions about the connections between program resources, activities, outputs, and outcomes are described. Participant knowledge and skills were measured via scores on a pre/posttest of professional knowledge, and a standards-based performance assessment rubric. In addition to measuring short-term program outcomes, we also sought to incorporate theory-driven thinking into the evaluation design. Hence, we examined participant self-efficacy and access to social capital, two evidenced-based determinants or "levers" that theoretically explain the transformative space between an intervention and its outcomes (Chen, 2012). Data about program determinants were collected and analyzed through a pre/posttest of self-efficacy and social network analysis. Key evaluation findings include participant acquisition of new instructional skills, increased self-efficacy, and the formation of a nascent professional support network. Lessons learned and implications for the design and evaluation of cross-cultural teacher professional development programs are discussed., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: Patient education is an important part of nurses' roles; however the inconsistent quality of communication skills, including those of registered nurses (RNs) from culturally and linguistically diverse (CALD) backgrounds, risk patient safety. Empowerment in patient education has been found to influence patients' self-efficacy and participation in decision-making. Discourse analysis of a whole interaction is used in this paper to trace the consequences of patient education where empowering discourse is displayed by an RN from a CALD background., Methods: Ethnographic techniques of participant observation and audio recordings of naturally occurring interactions between nurses from CALD backgrounds and their patients were conducted and analysed using interactional sociolinguistic (IS) and theme oriented discourse analytic approaches., Results: The interactional consequences of the nurse's empowering approach are readily observable in the data. The RN addresses the patient's education needs through a respectful encounter that illustrates the patient's active involvement., Conclusion: Examining the interactional consequences of empowering discourse demonstrates its effectiveness, and illustrates how empowering behaviour can be integrated into patient education, thus offering an alternative to traditional approaches., Practical Implications: Greater awareness of how to use empowering discourse will offer an alternative and consistent approach that enables nurses to facilitate patient-centred education., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

There has been an ongoing debate regarding the forced use of antipsychotic medications and both the psychiatric and legal professions have reacted strongly to the growing debate. Within the penological context, cases such as Washington v. Harper, Riggins v. Nevada, and Sell v. United States established the framework for determining when antipsychotic medication may be forcibly administered. Medication decisions under the Sell and Riggins cases are to be approved at judicial hearings; whereas, administrative hearings are sufficient for Harper cases. Forensic psychiatrists are also given responsibility in making the legal decision of whether or not to forcibly treat a patient with psychotropic medication against his will. In making this critical decision, a significant factor that is often minimized is the cultural background of the patient. The purpose of this paper is to present cultural factors to be considered in forced medication. Focusing on the culture defense argument, a review of how the legal system has dealt with cultural implications of a case will be presented. This paper will then discuss cultural issues embedded in the assessment, diagnosis, and treatment of psychiatric patients by forensic psychiatrists who are called upon to make the decision of whether or not to force medicate a patient against his will. Lastly, recommendations and a framework for providing a culturally sensitive assessment during the decision to forcibly medicate a patient with psychotropic medication will be offered., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The prevalence rate of depression in primary care is high. Primary care providers serve as the initial point of contact for the majority of patients with depression, yet, approximately 50% of cases remain unrecognized. The under-diagnosis of depression may be further exacerbated in limited English-language proficient (LEP) populations. Language barriers may result in less discussion of patients' mental health needs and fewer referrals to mental health services, particularly given competing priorities of other medical conditions and providers' time pressures. Recent advances in Health Information Technology (HIT) may facilitate novel ways to screen for depression and other mental health disorders in LEP populations. The purpose of this paper is to describe the rationale and protocol of a clustered randomized controlled trial that will test the effectiveness of an HIT intervention that provides a multi-component approach to delivering culturally competent, mental health care in the primary care setting. The HIT intervention has four components: 1) web-based provider training, 2) multimedia electronic screening of depression and PTSD in the patients' primary language, 3) Computer generated risk assessment scores delivered directly to the provider, and 4) clinical decision support. The outcomes of the study include assessing the potential of the HIT intervention to improve screening rates, clinical detection, provider initiation of treatment, and patient outcomes for depression and post-traumatic stress disorder (PTSD) among LEP Cambodian refugees who experienced war atrocities and trauma during the Khmer Rouge. This technology has the potential to be adapted to any LEP population in order to facilitate mental health screening and treatment in the primary care setting., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Unlabelled: Evidence indicates that Aboriginal people are underrepresented among driver licence holders in New South Wales, which has been attributed to licensing barriers for Aboriginal people. The Driving Change program was developed to provide culturally responsive licensing services that engage Aboriginal communities and build local capacity., Aim: This paper outlines the formative evaluation of the program, including logic model construction and exploration of contextual factors., Methods: Purposive sampling was used to identify key informants (n=12) from a consultative committee of key stakeholders and program staff. Semi-structured interviews were transcribed and thematically analysed. Data from interviews informed development of the logic model., Results: Participants demonstrated high level of support for the program and reported that it filled an important gap. The program context revealed systemic barriers to licensing that were correspondingly targeted by specific program outputs in the logic model. Addressing underlying assumptions of the program involved managing local capacity and support to strengthen implementation., Discussion: This formative evaluation highlights the importance of exploring program context as a crucial first step in logic model construction. The consultation process assisted in clarifying program goals and ensuring that the program was responding to underlying systemic factors that contribute to inequitable licensing access for Aboriginal people., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The Tampa Bay Community Cancer Network (TBCCN) was formed as a partnership comprised of committed community based organizations (grassroots, service, health care organizations) and a National Cancer Institute designated cancer center working together to reduce cancer health disparities. Adhering to principles of community-based participatory research, TBCCN's primary aims are to develop and sustain outreach, training, and research programs that aim to reach medically underserved, multicultural and multilingual populations within the Tampa Bay tri-county area. Using a participatory evaluation approach, we recently evaluated the partnerships' priorities for cancer education and outreach; perspectives on the partnerships' adherence to CBPR principles; and suggestions for sustaining TBCCN and its efforts. The purpose of this paper is to describe implementation and outcomes of this participatory evaluation of a community/academic partnership, and to illustrate the application of evaluation findings for partnership capacity-building and sustainability. Our evaluation provides evidence for partners' perceived benefits and realized expectations of the partnership and illustrates the value of ongoing and continued partnership assessment to directly inform program activities and build community capacity and sustainability., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Community education and outreach programs should be evidence-based. This dictum seems at once warranted, welcome, and slightly platitudinous. However, the "evidence-based" movement's more narrow definition of evidence--privileging randomized controlled trials as the "gold standard"--has fomented much debate. Such debate, though insightful, often lacks grounding in actual practice. To address that lack, the purpose of the study presented in this paper was to examine what actually happens, in practice, when people support the implementation of evidence-based programs (EBPs) or engage in related efforts to make non-formal education more "evidence-based." Focusing on three cases--two adolescent sexual health projects (one in the United States and one in Kenya) and one more general youth development organization--I used qualitative methods to address the questions: (1) How is evidence-based program and evidence-based practice work actually practiced? (2) What perspectives and assumptions about what non-formal education is are manifested through that work? and (3) What conflicts and tensions emerge through that work related to those perspectives and assumptions? Informed by theoretical perspectives on the intersection of science, expertise, and democracy, I conclude that the current dominant approach to making non-formal education more evidence-based by way of EBPs is seriously flawed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

An appropriate evaluation methodology is critical in collecting valid data in complex development intervention contexts. This paper explores this issue by putting forward an appropriate evaluation methodology for development interventions in rural China. It draws on the experience of an impact evaluation of a sustainable agricultural biodiversity management project conducted in Hainan, China in 2010. The authors propose that evaluation be culturally responsive and the evaluation design be rooted in the particular cultural context where an evaluation is conducted. The appropriate use of the participatory rural appraisal (PRA) approach and methods helps generate data that are relevant and meaningful for evaluation purposes in rural China., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Depression during pregnancy has been demonstrated to be predictive of low birthweight, prematurity, and postpartum depression. These adverse outcomes potentially have lasting effects on maternal and child well-being. Socio-economically disadvantaged women are twice as likely as middle-class women to meet diagnostic criteria for antenatal major depression (MDD), but have proven difficult to engage and retain in treatment. Collaborative care treatment models for depression have not been evaluated for racially/ethnically diverse, pregnant women on Medicaid receiving care in a public health system. This paper describes the design, methodology, culturally relevant enhancements, and implementation of a randomized controlled trial of depression care management compared to public health Maternity Support Services (MSS)., Methods: Pregnant, public health patients, >18 years with a likely diagnosis of MDD or dysthymia, measured respectively by the Patient Health Questionnaire-9 (PHQ-9) or the Mini-International Neuropsychiatric Interview (MINI), were randomized to the intervention or to public health MSS. The primary outcome was reduction in depression severity from baseline during pregnancy to 18-months post-baseline (one-year postpartum)., Baseline Results: 168 women with likely MDD (96.4%) and/or dysthymia (24.4%) were randomized. Average age was 27.6 years and gestational age was 22.4 weeks; 58.3% racial/ethnic minority; 71.4% unmarried; 22% no high school degree/GED; 65.3% unemployed; 42.1% making <$10,000 annually; 80.4% having recurrent depression; 64.6% PTSD, and 72% unplanned pregnancy., Conclusions: A collaborative care team, including a psychiatrist, psychologist, project manager, and 3 social workers, met weekly, collaborated with the patients' obstetrics providers, and monitored depression severity using an electronic tracking system. Potential sustainability of the intervention within a public health system requires further study., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Much of the early literature on 'cultural competence' focuses on the 'categorical' or 'multicultural' approach, in which providers learn relevant attitudes, values, beliefs, and behaviors of certain cultural groups. In essence, this involves learning key 'dos and don'ts' for each group. Literature and educational materials of this kind focus on broad ethnic, racial, religious, or national groups, such as 'African American', 'Hispanic', or 'Asian'. The problem with this categorical or 'list of traits' approach to clinical cultural competence is that culture is multidimensional and dynamic. Culture comprises multiple variables, affecting all aspects of experience. Cultural processes frequently differ within the same ethnic or social group because of differences in age cohort, gender, political association, class, religion, ethnicity, and even personality. Culture is therefore a very elusive and nebulous concept, like art. The multicultural approach to cultural competence results in stereotypical thinking rather than clinical competence. A newer, cross cultural approach to culturally competent clinical practice focuses on foundational communication skills, awareness of cross-cutting cultural and social issues, and health beliefs that are present in all cultures. We can think of these as universal human beliefs, needs, and traits. This patient centered approach relies on identifying and negotiating different styles of communication, decision-making preferences, roles of family, sexual and gender issues, and issues of mistrust, prejudice, and racism, among other factors. In the current paper, we describe 'cultural' challenges that arise in the care of four patients from disparate cultures, each of whom has advanced colon cancer that is no longer responding to chemotherapy. We then illustrate how to apply principles of patient centered care to these challenges.

This paper focuses on the importance of language in the expression of pain. Variation in definitions of pain is presented, together with a review of the evidence examining the impact language may have on the way pain is expressed linguistically. The implications for conducting research with children who speak different languages are explored. Strategies such as using non-linguistic methods of communication, additional time required for conducting interviews and the inclusion of research team members from the same ethnic or linguistic background are presented., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: To review the literature to determine the attributes of culturally appropriate healthcare to inform the design of chronic disease management (CDM) models for Aboriginal patients in urban general practice., Methods: A comprehensive conceptual framework, drawing on the Access to Care, Pathway to Care, Chronic Care, Level of Connectedness, and Cultural Security, Cultural Competency and Cultural Respect models, was developed to define the search strategy, inclusion criteria and appraisal methods for the literature review. Selected papers were reviewed in detail if they examined a chronic disease intervention for an Aboriginal population and reported on its evaluation, impacts or outcomes., Results: In the 173 papers examined, only 11 programs met the inclusion criteria. All were programs conducted in rural and remote Aboriginal community-controlled health services. Successful chronic disease care and interventions require adequate Aboriginal community engagement, utilising local knowledge, strong leadership, shared responsibilities, sustainable resources and integrated data and systems. These success factors fitted within the conceptual framework developed., Conclusions: Research and development of culturally appropriate CDM models concurrently in both urban and rural settings will enable more rigorous evaluation, leading to stronger evidence for best practice. A partnership of mainstream and Aboriginal-controlled health services is essential to successfully 'close the gap'., Implications: Findings will inform and guide the development, implementation and evaluation of culturally appropriate CDM in mainstream general practice and primary care., (© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia.)

Despite recognition of the central role that service accessibility (and availability) should assume within a system of care, the definition proposed in the feature article of this special issue does not identify specific factors that systems of care must take into account in order to serve diverse children with serious emotional disturbance and their families in a culturally competent manner. This paper provides support for inclusion of the concepts of access and availability in the system of care definition and presents important factors that systems of care must take into account in order to increase access in a culturally competent manner, a core system of care value.

Objective: UK medical schools find it challenging to provide standardised teaching to expanding year intakes. In addition, developing and implementing diversity training can cause difficulties. This paper describes the evaluation of an interactive e-learning programme to raise awareness and understanding of communication difficulties in diversity consultations., Methods: The programme was part of an undergraduate portfolio-based community module. Three hundred and two students were assigned to one of three delivery methods--a large group setting, small groups with a facilitator, and as part of distance learning while on community placement. The evaluation included analysis of their coursework marks, a self-completed evaluation questionnaire, and small group discussions., Results: Two hundred and twenty-three students took part in the evaluation. They were able to apply the concepts they learnt to clinical examples from their own experiences. Type of delivery did not affect coursework marks, but students tended to prefer the e-learning as part of a distance learning package. They offered helpful suggestions to improve its complexity and range., Conclusion: The acceptability and utility of this e-learning module both in face to face teaching and remote placement has been demonstrated, and evaluation by the students has provided valuable information for its further development., Practice Implications: All medical schools should include some diversity training, and further research should concentrate on the effects of this type of learning on longer term outcomes such as attitude and performance tests. Such tools could reduce demands on staff time in facilitation of small groupwork, and their cost effectiveness could be increased by making them available to other medical schools.

Cultural competence and patient centeredness are approaches to improving healthcare quality that have been promoted extensively in recent years. In this paper, we explore the historical evolution of both cultural competence and patient centeredness. In doing so, we demonstrate that early conceptual models of cultural competence and patient centeredness focused on how healthcare providers and patients might interact at the interpersonal level and that later conceptual models were expanded to consider how patients might be treated by the healthcare system as a whole. We then compare conceptual models for both cultural competence and patient centeredness at both the interpersonal and healthcare system levels to demonstrate similarities and differences. We conclude that, although the concepts have had different histories and foci, many of the core features of cultural competence and patient centeredness are the same. Each approach holds promise for improving the quality of healthcare for individual patients, communities and populations.