Cultural competency education for healthcare professionals: an umbrella review

Abstract

Background

Cultural competency is essential for delivering effective and equitable healthcare to increasingly diverse societies. Education and training aim to equip healthcare professionals with the skills and knowledge necessary to provide culturally sensitive care. This umbrella review synthesizes the evidence on cultural competency education for healthcare professionals, focusing on its components, delivery methods, effectiveness, and methodological challenges.

Methods

Following the Joanna Briggs Institute guidelines, a comprehensive search of five databases identified 12 systematic reviews. Data on the educational content, delivery methods, theoretical models, and outcomes were extracted. Methodological quality was assessed using AMSTAR 2.

Results

A total of 12 systematic reviews were included, published between 2005 and 2023. Educational content ranged from general cultural concepts (e.g., communication and sensitivity) to culturally specific practices. Delivery methods included lectures, interactive learning, immersive experiences, and digital tools such as virtual reality. Theoretical frameworks provided structured foundations for interventions. Learner outcomes such as improved cultural knowledge and attitudes were predominantly positive, whereas patient outcomes were evaluated less frequently and showed mixed results. Methodological limitations included unvalidated tools and limited meta-analyses, contributing to limited generalizability of findings.

Conclusions

Cultural competency education effectively improves healthcare professionals' competencies but requires better evaluation of patient-centered outcomes. Addressing these methodological gaps will enhance the evidence based practice, and support the development of feasible, effective strategies for improving education and care quality in diverse healthcare settings.

Trial registration

The protocol for this study was registered with PROSPERO (CRD42024586821).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-08008-7.

Background

Cultural competency in healthcare has emerged as a critical component for delivering effective care which considers individual’s values and preferences in societies characterized by increasing cultural and linguistic diversity [1, 2]. Cultural competency has traditionally emphasized the acquisition of specific knowledge, skills, and attitudes that enable individuals and organizations to function effectively in cross-cultural contexts [3, 4]. Acquiring cultural competency enhances healthcare professionals’ cultural awareness, knowledge, and skills, which not only enables them to provide culturally congruent care but also contributes to improved patient-centered outcomes, including satisfaction, communication, treatment adherence, and clinical outcomes [5–7]. As the discourse on culturally responsive care has evolved, expanded concepts such as cultural humility have gained increasing attention. Cultural humility refers to a lifelong, self-reflective process involving the continuous examination of one’s own cultural assumptions and respectful engagement with others’ cultural identities [8]. This concept extends beyond the knowledge, skills, and attitudes emphasized in cultural competency by incorporating a deeper dimension of self-reflection. While cultural humility can also be fostered through education, it fundamentally relies on individuals’ internal self-reflection and personal engagement. In contrast, cultural competency offers a more structured and foundational approach that can be systematically addressed through education and training. For this reason, cultural competency remains the most essential and operationalizable framework, particularly in the context of healthcare professional development and curricular integration [9, 10].

The conceptual foundation of cultural competency in healthcare can be traced back to Leininger’s theory of culturally congruent care, which emphasized integrating patients’ cultural values into nursing practice [11, 12]. Cross [4] later defined cultural competence as a system-level ability to function effectively in cross-cultural settings, highlighting self-awareness, cultural knowledge, and interpersonal skills. Over time, cultural competency gained prominence in both healthcare research and professional education. Its significance was reinforced in 1994 when the National Institutes of Health (NIH) mandated the inclusion of diverse populations in clinical research, emphasizing the need for culturally sensitive methodologies [13]. This shift was further reflected in healthcare education, where cultural competency increasingly became a core requirement. The American Association of Colleges of Nursing emphasizes the integration of cultural competency into undergraduate nursing curricula [14], while the Liaison Committee on Medical Education requires cultural sensitivity training in U.S. medical schools [15]. Beyond academic settings, healthcare institutions have adopted on-the-job training to help professionals deliver culturally responsive care [7, 16, 17].

Various assessments and educational strategies have been developed to operationalize cultural competency in healthcare. Assessment instruments such as the Inventory for Assessing the Process of Cultural Competence [18], the Clinical Cultural Competence Questionnaire [19], and the Organizational Culture Assessment Instrument [20] have been used to evaluate cultural competency from individual to organizational levels. Educational strategies have been developed cultural immersion which fosters deep understanding through direct engagement with diverse populations [21], blended active and passive learning approaches which provide a balanced and effective way to learn [17], and virtual reality which provides immersive, experiential learning that links theory and practice [22]. Theoretical frameworks such as Campinha-Bacote's Model of Cultural Competence [23], Purnell’s Model for Cultural Competence [24], and Giger and Davidhizar's Transcultural Assessment Model [25] have been used to provide structured and evidence-based foundations for cultural competency education.

Although existing umbrella reviews have examined aspects of cultural competency—such as organizational-level assessment tools [26] and integration strategies for diverse healthcare staff [27]—few have focused on synthesizing educational interventions for healthcare professionals. Given the number of existing reviews, conducting umbrella review is appropriate to provide an overarching synthesis. With these backgrounds, this review aims to summarize the components, outcomes, and methodological features of existing reviews to inform future research and practice. This umbrella review aims to address two key questions: (1) What are the components (e.g., educational content, theoretical models, delivery methods, and intervention features) of cultural competency education for healthcare professionals? (2) What is the effectiveness of cultural competency education, and how have these outcomes been synthesized in existing systematic reviews? By synthesizing the available evidence, this review provides insights into the effectiveness of cultural competency education across various healthcare settings and highlights the methodological challenges that researchers and educators face when implementing and evaluating such interventions.

Methods

The protocol for this study was registered with PROSPERO (CRD42024586821) and the methodology followed the Joanna Briggs Institute (JBI) guidelines for umbrella reviews [28].

Search strategy

A comprehensive literature search was conducted across five databases: Five databases (EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, PubMed, and Web of Science), and grey literature were searched from September 1 to 9, 2024. The search strategy was developed by two reviewers (YL and SS) based on a review of previous literature [29, 30]. A pilot search was conducted in collaboration with a librarian. The final search term using a combination of MeSH and natural language text words has been used: (‘cultural competency' OR 'cultural awareness’ OR ‘cultural diversity’ OR ‘cultural sensitivity’) AND (‘continuing education’ OR ‘education' OR 'training' OR 'teaching' OR 'program' OR 'curriculum’) AND (‘health personnel’ OR 'nurse*' OR 'physician*' OR 'doctor*' OR 'nursing staff' OR 'health care professional' 'health care provider’) AND (‘systematic review’ OR ‘meta-analysis’). Detailed search queries and strategies are provided in the Supplementary 1. Citation management was conducted using EndNote™ [31].

Study selection

Eligible studies met the following criteria: (a) focused on healthcare professionals in health-related fields; (b) included interventions aimed at enhancing the cultural competency of healthcare professionals; (c) examined outcomes related to cultural competency interventions, including patient outcomes (e.g., adherence, satisfaction, trust, clinical outcomes), learner outcomes (e.g., cultural knowledge, cultural attitude, cultural skills, cultural awareness, and other components related to cultural competence), or both; and (d) employed systematic review designs, with or without meta-analysis. Although the primary focus was on healthcare professionals, studies that included mixed populations of healthcare professionals and undergraduate students were also considered eligible to ensure a comprehensive overview of relevant interventions and outcomes. Studies were excluded if they: (a) reviews including only student participants; (b) were not full-text journal articles, such as opinion papers, editorials, dissertations, or conference proceedings; (c) were not peer-reviewed; (d) did not evaluate cultural competency intervention outcomes (e.g., patient outcomes, learner outcomes); and (e) lacked a quality assessment of the reviews. Two reviewers (YL and XF) independently screened the selected studies. Conflicts were resolved through group discussion and consensus with a third reviewer (SS).

Data extraction

Data extraction domains were initially developed by three reviewers (YL, XF, and SS) based on the study goals and objectives, and then iteratively refined while reviewing the included studies until no further major modifications were needed. Two reviewers (YL and XF) then independently extracted the data, and any discrepancies were resolved through discussion and consensus with a third reviewer (SS). The data extraction domains included review characteristics (author, year, participants, review design, number of included reviews, databases searched, and appraisal instruments), intervention details (main theme, educational contents, theoretical model, delivery methods, and intervention duration), and outcomes (learner’s outcomes, patient outcomes, and outcome reporting style). Outcomes were extracted based on the original concept and definitions provided in the included reviews, without reclassification.

Study quality

The AMSTAR 2 tool was employed to assess the quality of systematic reviews [32], with results synthesized and presented narratively. Two independent reviewers (YL and XF) appraised the reviews, resolving disagreements through discussion with a third reviewer (SS). Reviews were rated as high, moderate, low, or critically low based on the number and severity of methodological flaws.

Results

Search results

Figure 1 presents the PRISMA flowchart for umbrella reviews [33]. A total of 2,382 records were identified. After removing duplicates, 2,176 abstracts were screened. Following title and abstract screening, 40 articles were selected for full-text review. During the full-text review, 12 articles met the inclusion criteria and were included in the final analysis. The list of studies excluded following the full-text review is provided in the Supplementary 2.

Fig. 1.

PRISMA flowchart for umbrella reviews

Study characteristics

Table 1 summarizes the key characteristics of the included reviews. The 12 included reviews encompassed a wide range of healthcare professionals, including nurses, physicians, mental health professionals, students, and others. All reviews were systematic in study design, with publication year ranging from 2005 to 2023. The number of studies in each review varied from 5 to 34, with publication years ranging from 1983 to 2022. The predominant study designs were randomized controlled trials (RCTs) (n = 9), followed by quasi-experimental (n = 8), mixed-method approaches (n = 4), qualitative studies (n = 3), and observational studies (n = 2). The most frequently searched databases were PubMed, CINAHL, Cochrane Library, MEDLINE, EMBASE, and PsycINFO. Quality appraisal tools varied across reviews according to their different methodological approaches. Eleven studies used validated quality assessment tools. However, one study evaluated study quality using a self-designed tool [34].

Table 1.

Study characteristics of included reviews

First author (year)	Review design	Participants	Number of included studies (publication year)	Intervention style	Number of database (Database details)	Tool used for quality appraisal
Beach et al. [34] (2005)	SR	Nurses, Physicians	n = 34 (1983–2003)	QES (32) RCT (2)	n = 6 CINAHL, Cochrane Library, Cochrane EPOC, Medline, RDRB/CME	Self-designed evaluation form
Chae et al. [41] (2020)	SR	Nurses, Physicians, Other Health Professional	n = 11 (2001–2007)	QES (6) RCT (5)	n = 8 Cochrane Library, EMBASE, Medline, KoreaMed, KISS, RISS, DBpia	Cochrane Risk of Bias Tool, Risk of Bias assessment tool for Non-randomized studies
Chae et al. [22] (2021)	SR	Nurses, Physicians, Health Professional Students, Other Health Professional	n = 9 (2011–2018)	QES (7) RCT (2)	n = 7 CIHNAL, EMBASE, Medline, PubMed, KISS, RISS, DBpia	Johns Hopkins Nursing Evidence-Based Practice Model
Chipp et al. [35] (2008)	SR	Nurses, Public Health Nurses, Mental Health Professionals, Primary Care Physicians	n = 17 (1991–2006)	Observational (7) QES (3) RCT (2) SR (3)	n = 2 CINAHL, Cochrane Library, Google scholar, PubMed, PsycINFO, Sabinet African Journals	Oxford Centre for Evidence Based Medicine
Filmer et al. [36] (2018)	SR	Nurses, Physicians, Mental Health Professionals, Other Health Professionals	n = 32 (1997–2017)	Mixed method (8) Observational (24) Qualitative (2)	n = 3ERIC, PsycINFO, PubMed	Quality Assessment Tool for Studies with Diverse Designs
Gallagher et al. [37] (2015)	SR and meta-analysis	Nurses, Nursing Students	n = 25 (1999–2012)	QES, RCT (25)	n = 5 PubMed, PsycINFO, ProQuest, Science Direct	Cochrane Risk of Bias Tool
Govere et al. [38] (2016)	SR	Dental Practitioners, Nurse Practitioners, Physicians, Other Healthcare Providers	n = 7 (2002–2013)	QES (5) RCT (2)	n = 5 CINAHL, Cochrane Library, PsycINFO, PubMed, Web of Science	MacMaster Quality Grade
Hardy et al. [16] (2023)	SR	Family Physicians, Nurses, Pharmacists, Speech Language Therapists, Rheumatologists	n = 13 (2014–2022)	Mixed method (9) Quantitative (2) Qualitative (2)	n = 12 ASSIA, BIPNA, Cochrane Library, EMBASE, ERIC, IBSS, Medline, PsycINFO, PubMed, ProQuest, Web of Science	Well Living House quality appraisal scores
Lie et al. [39] (2016)	SR	Home Health Care Workers, Mental Health Professionals, Nurses, Health Professional Students, Physician Assistants, Physicians, Psychology	n = 7 (1991–2010)	QES (3) RCT (4)	n = 5 CINAHL, ERIC, MEDLINE, PsycINFO, Web of Science	Strengthening the Reporting of Observational Studies in Epidemiology, Medical Education Research Study Quality Instrument
Oikarainen et al. [40] (2019)	SR	Nurses, Patient Care Assistants	n = 6 (2001–2015)	QES (5) RCT (1)	n = 4 CINAHL, ERIC, Medic, PubMed	JBI Critical Appraisal Checklist, Cochrane Risk of Bias Tool
Vella et al. [7] (2022)	SR	General Practitioners, Nurse Practitioner, Physicians, Physicians assistants	n = 5 (2010–2021)	Mixed method (3) RCT (2)	n = 4 CINAHL, ERIC, MEDLINE, PsycINFO	Risk of bias tools (RoB 2), ROBINS- I, MIXED METHODS APPRAISAL TOOL (MMAT) 2018
Venkataramu et al. [17] (2021)	SR	Mental Health Professionals, Nurses, Physicians, Psychiatrists, Psychiatry Social Workers, Health Professional Students	n = 14 (2007–2019)	Mixed method (2) Quantitative (5) Qualitative (2) SR (1) Others (4)	n = 1 PubMed	Oxman and Guyatt Index

QES Quasi-experimental studies, SR Systematic review

Intervention features

Table 2 summarizes the key components of cultural competency education, including the main educational theme, educational content, theoretical models, delivery methods, and intervention duration.

Table 2.

Key components of cultural competency education

First author (year)	Main theme	Educational Contents	Theoretical model	Delivery Methods	Intervention Duration
Beach et al. [34] (2005)	Cultural Competency Training of Health Professionals	General Concepts: Basic concepts in cultural competency, Doctor-patient interaction and Language, Information on specific cultures, Cultural diversity and racism	N/A	Lecture-Based Learning: Lectures, Presentation Interactive Learning: Case scenarios, Demonstration, Discussions, Interviewing, Roleplay Immersion: Cultural immersions, Engaging community health activities Digital Resources: Audio/Visual	A single day to 4 years
Chae et al. [41] (2020)	Cultural Competency Training of Health Professionals	General Concepts: Basic concepts in cultural competency (awareness, belief, encounters, desire, knowledge, cultural assessment skills), Communication regarding language, incorporating interpreters, Verbal and nonverbal communication, Motivational interviewing, Negotiation, Information on health disparities, religion, health literacy, environment, cultural difference Culturally Specific Practices: Culturally safe care for infants and prenatal health, Folk medicine, Multicultural healthcare policy, Common service barriers	ASC-N Model (Ask, Share, Compare, Negotiate), Campinha-Bacote's Cultural Competence Model, Giger and Davidhizar Transcultural Assessment Model, Health Belief Model, Kleinman’s Explanatory Model, LEARN Model	Lecture-Based Learning: Lectures, Presentations Interactive Learning: Case studies, Demonstrations, Discussions, Interactive exercises, Role plays, Simulation Reflective Learning: Individual feedback, writing reflection notes Digital Resources: Email, Online writing, Social Network Service activity	4 weeks to 12 months
Chae et al. [22] (2021)	Virtual simulation cultural competence training of Health professionals	General Concepts: Communicating across languages and diverse backgrounds, incorporating interpreters, Information on religious and cultural considerations Culturally Specific Practices: Culturally safe care for maternal health, Professional practice challenges when navigating culturally diverse settings	Campinha-Bacote’s Cultural Competence Model CRASH Principle for Cultural Competence Davis' Model of Empathy-Related Constructs Jeffrey’s Cultural Competence and Confidence Model SPIKES Protocol TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)	Digital Resources-Virtual platforms: Virtual Human Interactions, 3D visuals and sensory stimuli in a virtual simulation platform, Live Video Streaming(Real-time interactions with simulated patients via live video) Online Interactive Simulations: Engaging with virtual patients through online platforms using text, video segments, and decision-making tasks eSimulation Modules: Scenarios combining photos, text, audio, and video clips for interactive decision-making Reflective Learning: Debriefing, Online guided reflection, Pre-briefing	Specific duration not explicitly defined
Chipp et al. [35] (2008)	Cultural Competency Training of Health Professionals in Community Based rehabilitation	General Concepts: Information on specific cultural competence	Campinha-Bacote’s Cultural Competence Model, Cultural brokering model	Lecture-Based Learning: Lectures Interactive Learning: Small group work, Workshops Reflective Learning: Feedback on practice Digital Resources: Audio/Visual	Once to 5 weeks
Filmer et al. [36] (2018)	Cross-Cultural Competency Training of Health Professionals	N/A	Campinha-Bacote Cultural competence model, Giger and Davidhizar Transcultural Assessment Model	Lectures and Didactic Methods: Lectures Interactive Learning: Case studies, Discussions, Experimental activities, Meetings, Role-plays, Vignettes, Workshops Reflective Learning: Feedback Digital Resources: Online modules, Video based case study, Video workshop	1 h to 9 months
Gallagher et al. [37] (2015)	Cultural Competency Training for nurses and nursing students	General Concepts: Cultural competency concept (Awareness, Attitude, Knowledge, Skills), Nurse–patient communication	N/A	Lectures and Didactic Methods: Lectures, Presentation Interactive Learning: Discussion, Role-playing, Simulation, Service learning in community-based activities Immersion: Immersion in a different culture Reflective Learning: Reflective Journaling Digital Resources: Online modules, Videos	mean 3.8 months
Govere et al. [38] (2016)	Cultural Competency Training of Health Professionals	General Concepts: Cultural competency concepts, Specific culture’s Language, Verbal-nonverbal communication, Vocal tones, Information on cultural diversity, Age, Disability, Gender, Race, Religion, Sexual orientation	N/A	N/A	4.5 to 36 h
Hardy et al. [16] (2023)	Indigenous cultural safety training for healthcare professionals	General Concepts: Cultural competency concept (Belief, Confidence, Knowledge, Spirituality), Interpersonal communication skills, Information on historical and cultural considerations, Cultural diversity and racism Culturally Specific Practices: Practicing culturally safe care for indigenous communities, Healthcare policy, Traditional medicine, Professional practice issues	Critical Race Theory, Decolonizing Philosophies, Diffusion of Innovation Theory, Educating for Equity Framework, Public Health Framework, Social-Constructivist Framework, Transformative Learning Theory	Lecture-Based Learning: Lectures Interactive Learning: Discussions, Roleplaying, Simulation, Talking, Mentorships Reflective Learning: Personal reflections, Reflective Journaling Digital Resources: E-learning, Online modules, Podcasts	1 h to 10 weeks
Lie et al. [39] (2011)	Cultural Competency Training of Health Professionals	General Concepts: Cultural knowledge, Awareness, Cross-cultural communication, Language, Use of interpreter, Cultural brokering Culturally Specific Practices: Medical history-taking, providing a safe therapeutic environment	LEARN Model, Pederson's Triad Model of Cross-Cultural Counseling	Lecture-Based Learning: Lectures Interactive Learning: Counseling, Group discussion, Interactive experimental modules, Role-playing, Team building Immersion: Community engagement activities, Spanish immersion program Reflective Learning: Performance feedback	4 h to 3 months
Oikarainen et al. [40] (2019)	Cultural competence educational interventions for nurses	General Concepts: Cultural competency concept (Knowledge, Awareness, Sensitivity, Skills, desire, encounter), Cross-cultural communication, Communication barriers, Verbal and nonverbal communication Information on cultural diversity, Cultural heritage, Professional background, Cultural acceptance, Racism Culturally Specific Practices: Cultural traditional care, culturally congruent care plan, Ethnopharmacology	Campinha-Bacote’s Model of Cultural Competence, Edward T. Hall’s Cross-Cultural Communication Theory, Giger and Davidhizar Transcultural Assessment Model, Leininger’s Theory of Culture Care Diversity and Universality, Lewin’s three stage theory of change, The Purnell Model for Cultural Competence	Lecture-Based Learning: Lectures Interactive Learning: Case studies, Demonstration, Discussions, Group discussions, Role-playing, Simulations Reflective Learning: Debriefing, Reflective exercises Digital Resources: Games, Web modules	1 time to 5 weeks
Vella et al. [7] (2022)	Cultural competence training for health professionals	General Concepts: Cultural competency concept (Knowledge, Belief), Cross-cultural communication, Interpersonal communication, Language, Use of interpreter, Verbal-nonverbal communication, Active listening, Information on cultural diversity, Ethnicity, Racial biases, Socio-cultural factors Culturally Specific Practices: Decision making, Traditional medicine, Cultural respect into routine practice	Cultural Intelligence (CQ) Framework, International Partnership Communication Framework, Model for Managing Chronic Disease (MMCD), Purnell Model for Cultural Competence, Trans-theoretical domains and cultural intelligence frameworks	Lecture-Based Learning: Lectures, Presentation Interactive Learning: Case studies, Focus group discussion, Counseling, Scenario, Workshops Immersion: Community engagement activities, Cultural mentorship Reflective Learning: Group reflection, Education feedback Digital Resources: Email learning, Video consultation	5 weeks to 24 months
Venkataramu et al. [17] (2021)	Cultural competence training for mental health professionals	General Concepts: Communication skills across cultural interviewing techniques, DSM-5 Cultural formulation interview, Cultural consultation model	N/A	Lecture-Based Learning: Conference, Lectures, Examination Interactive Learning: Behavioral simulation, Consultation, Vignette, Discussion, Role-playing Digital Resources: Films, Video demonstration	N/A

Main theme

Of the twelve systematic reviews, ten [7, 17, 34–41] explored cultural competency education, one [22] explored virtual simulation cultural competency education, and one [16] explored indigenous cultural competency education.

Educational content

Of the twelve systematic reviews, eleven [7, 16, 17, 22, 34, 35, 37–41] provided a summary of the educational content. Educational content was categorized into general cultural concepts and culturally specific practices.

Eleven studies [7, 16, 17, 22, 34, 35, 37–41] addressed general cultural concepts, focusing on foundational domains such as knowledge, skills, communication, attitudes, awareness, desire, interactions, and sensitivity. Communication was a prevalent focus, including using proper language, incorporating translators, addressing verbal, nonverbal, and interpersonal communication, and cultural brokering [7, 16, 17, 22, 34, 35, 37–41]. Other topics encompassed broader cultural and societal dimensions, such as cultural diversity, systemic racism, religious and spiritual considerations, health disparities, health literacy, sexual orientation, disability, historical context, and sociocultural determinants of health [7, 16, 22, 34, 38–41]. Six studies included culturally specific practices. These practices emphasize approaches tailored to the unique needs and contexts of specific cultural groups involved in care delivery. Culturally specific practices in education include culturally safe maternal care, integration of traditional care and medicine, development of culturally contextualized care plans, culturally ethical practices, and legal implications, barriers, and challenges in cultural practice [7, 16, 22, 39–41].

Theoretical models

Eight studies [7, 16, 22, 35, 36, 39–41] reviewed whether the intervention incorporated a theoretical framework into their education foundation. The most frequently utilized theoretical frameworks were Campinha-Bacote’s Cultural Competence Model [23], Giger and Davidhizar’s Transcultural Assessment Model [25], Rosenstock’s Health Belief Model [42], and Jeffrey’s Cultural Competence and Confidence Model [43].

Delivery methods

Of the twelve systematic reviews, eleven provided a summary of educational delivery methods categorized as lecture-based learning, interactive learning, reflective learning, immersion, and digital resources. Lecture-based and interactive learning are the most commonly used educational methods. Lecture-based learning encompasses didactic methods such as classroom lectures, conferences, presentations, and formal examinations [7, 16, 17, 34–37, 39–41]. Interactive learning encompasses active engagement and experiential techniques including case studies, collaborative group activities, discussions, demonstrations, interviews, simulations, role-playing, workshops, and scenario-based vignettes [7, 16, 17, 34–37, 39–41]. Reflective learning content was incorporated into nine studies, including debriefing, journaling, individual or group feedback, reflective exercises, and group reflection [7, 16, 22, 35–37, 39–41]. Digital resources included in ten studies featured online platforms such as social networking services, online modules, games, email, and virtual platforms, as well as multimedia tools including videos, visuals, audio, films, and podcasts [7, 16, 17, 22, 34–37, 40, 41]. Chae et al. [22] reviewed virtual simulations for nursing education employing multiple virtual methods, such as real-time interactions with simulated patients, role-playing, and decision-making tasks to enhance cultural competency. Immersion was included in five studies, which placed participants in environments that fully engaged them with the subject matter or culture they are studying and offer hands-on exposure [7, 22, 34, 37, 39].

Intervention duration

The duration of the cultural competency interventions varied significantly across the reviewed studies. Intervention periods ranged from brief single-day sessions to sessions extending over several years. The shortest intervention lasted only one hour [36], while the longest spanned up to four years [34].

Measurements and outcomes of cultural competency education

Measurements

All the included reviews used measurement tools to evaluate the effectiveness of cultural competency education interventions. Various validated and self-designed tools were employed. For measuring learner outcomes in the cultural competency domain, the most frequently used validated tools included the IAPCC developed by Campinha-Bacote [35, 37, 38, 40], the Jeffreys' Transcultural Self-Efficacy Tool [22, 34, 41], the Clinical Cultural Competence Training Questionnaire (CCCTQ) developed by Krajic [40, 41], and the Barrett-Lennard Relationship Inventory (BLRI) developed by Barrett-Lennard [34, 39]. For measuring patient outcomes, commonly used measurement tools included patient satisfaction surveys [7, 16, 34–36, 39, 41], patient adherence rates [34, 35], and clinical outcome measures [7, 35, 36, 39, 41]. The list of tools/measurements used can be found in the Supplementary 3.

Outcomes

Table 3 summarizes the positive effect of cultural competency education and the study synthesis methods in the original systematic reviews. The numbers in the table represent the number of positive effect studies among the total number of studies in the original systematic review. Out of the twelve systematic reviews, eleven reviews assessed learner outcomes [7, 16, 17, 22, 34–38, 40, 41], and seven reviews assessed patient outcomes [7, 16, 34–36, 39, 41]. Among these, nine reviews employed narrative synthesis to report the effectiveness, whereas one additionally conducted a meta-analysis [37]. Notably, two systematic reviews provided comparative analyses of intervention features. Beach et al. [34] narratively compared learner patient outcomes by professions, intervention lengths, contents, and methods. Gallagher et al. [37] conducted a meta-analysis to determine the effect size of cultural competency education by considering factors such as measurement tools, settings, participant types, peer review status, and funding status.

Table 3.

Summary of reported positive effect of cultural competency education and study synthesis methods in the original systematic review

Author	Overall cultural competency	Cultural Knowledge	Cultural Attitude	Cultural Skills	Cultural Awareness	Cultural Communication	Cultural Behavior	Cultural Desire	Self-efficacy	Patient outcome	Patient outcome measurement contents	Outcome synthesis design
	(Number of studies reporting positive outcome effecta/All studies reporting outcome)
Beach et al. [34] (2005)	N/A	(17/19)	(21/25)	(14/14)	N/A	N/A	N/A	N/A	N/A	(3/3)	Satisfaction, Adherence, Health status	Narrative synthesis Comparative analysis by intervention features (health professionals’ type, intervention duration, contents, methods)
Chae et al. [41] (2020)	(9/10)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	(2/2)	(1/3)	Satisfaction, Trust, Clinical outcomes	Narrative synthesis
Chae et al. [22] (2021)	(3/4)	(2/2)	(2/3)	N/A	(1/1)	(1/1)	(1/1)	(1/1)	(1/1)	N/A	N/A	Narrative synthesis
Chipp et al. [35] (2008)	(1/2)	(2/3)	(2/3)	N/A	N/A	N/A	N/A	N/A	N/A	(1/4)	Satisfaction, Adherence	Narrative synthesis
Filmer et al. [36] (2018)	N/A	(14/17)	(4/5)	(11/14)	(6/8)	(0/2)	(1/4)	(2/2)	(3/3)	(N/A/1)	Satisfaction, Trust	Narrative synthesis
Gallagher et al. [37] (2015)	(21/25)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Narrative synthesis Meta-analysis Comparative analysis by intervention features (measurements type, settings, participant type, peer reviewed, funded)
Govere et al. [38] (2016)	(4/5)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	Narrative synthesis
Hardy et al. [16] (2023)	N/A	(5/5)	(0/1)	(5/5)	(1/1)	N/A	(1/1)	N/A	N/A	(0/4)	N/A	Narrative synthesis
Lie et al. [39] (2011)	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	(2/7)	Perceptions, Satisfaction, Trust, Clinical outcomes	Narrative synthesis
Oikarainen et al. [40] (2019)	(3/3)	(2/3)	N/A	(1/1)	(1/2)	N/A	(1/1)	(2/2)	N/A	N/A	N/A	Narrative synthesis
Vella et al. [7] (2022)	N/A	(2/2)	N/A	(2/2)	(1/1)	(2/2)	N/A	N/A	N/A	(2/4)	N/A	Narrative synthesis
Venkataramu et al. [17] (2021)	(N/A/4)	(N/A/3)	(N/A/1)	(N/A/3)	N/A	(N/A/2)	(N/A/1)	N/A	N/A	N/A	N/A	Narrative synthesis

^aPositive effect was defined as a statistically significant or reported improvement after the cultural competency education

Learner outcomes showed predominantly positive results across all studies. The most frequently evaluated domain was overall cultural competency [17, 22, 35, 37, 38, 40, 41]. Specific domains such as cultural knowledge, attitudes, skills, awareness, communication, behavior, and desire, as well as self-efficacy were assessed [7, 16, 17, 22, 34–36, 40, 41]. In contrast, patient outcomes showed fewer positive results, with two reported predominantly positive outcomes (greater than 50%) [7, 34], four found less than half of their outcomes to be positive [16, 35, 39, 41]. Specific patient outcomes included adherence, satisfaction, trust in healthcare professionals, and clinical outcomes.

Methodological quality

The outcomes of the evidence assessment using the AMSTAR 2 are presented in Table 4. Of the 12 reviews, four were rated as high quality, three as moderate, and five as low. None of the studies were graded as critically low according to the AMSTAR 2 guidelines. All systematic reviews adhered to key methodological standards, including clear explanations of study design, transparent study identification and selection processes, assessed risk of bias using appropriate methods, and disclosed of potential conflicts of interest. For the one review that conducted a meta-analysis, appropriate methods were employed, including the assessment of small-study bias and the potential impact of risk of bias on the results [37]. Reviews with methodological limitations lacked a predefined review protocol [17, 22, 34, 35, 37–41], did not duplicate the data extraction process [17, 35], did not provide detailed reasons for excluding studies [34, 35, 37, 40]. Only one review explained the details of their funding sources [37].

Table 4.

Methodological quality assessment using AMSTAR 2

Author Item	Beach et al. [34]	Chae et al. [41]	Chae et al. [22]	Chipp et al. [35]	Filmer et al. [36]	Gallagher et al. [37]	Govere et al. [38]	Hardy et al. [16]	Lie et al. [39]	Oikarainen et al. [40]	Vella et al. [7]	Venkataramu et al. [17]
Q1. PICO components	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q2. Protocol	N	N	N	N	Y	N	N	Y	N	N	Y	N
Q3. Study design explanation	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q4. Comprehensive search strategy	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q5. Duplicate study selection	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q6. Duplicate data extraction	Y	Y	Y	N	Y	Y	PY	Y	Y	Y	Y	N
Q7. Details of excluded studies	N	Y	Y	N	Y	N	PY	PY	Y	N	PY	Y
Q8. Description of included studies	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q9. Risk of Bias assessment	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q10. Funding sources	N	N	N	N	N	Y	N	N	N	N	N	N
Q11. Appropriate methods of meta-analysis	NM	NM	NM	NM	NM	Y	NM	NM	NM	NM	NM	NM
Q12. Assess potential impact of risk of bias on the results	NM	NM	NM	NM	NM	Y	NM	NM	NM	NM	NM	NM
Q13. Account for risk of bias when interpreting/discussing	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q14. Satisfactory explanation for, and discussion of, any heterogeneity	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Q15. Publication bias (small study bias) assessed	NM	NM	NM	NM	NM	Y	NM	NM	NM	NM	NM	NM
Q16. Potential sources of conflict of interest	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y	Y
Score	Low	Moderate	Moderate	Low	High	Low	High	High	Moderate	Low	High	low

Y Yes, N No, PY Partial yes, NM Non-meta-analysis

Discussion

This umbrella review provides a critical synthesis of cultural competency education for healthcare professionals and offers valuable insights into its components, delivery methods, effectiveness, and methodological challenges. The findings showed diverse educational content and delivery methods as well as promising outcomes for healthcare professionals, while also identifying significant areas for improvement.

Systematic reviews of cultural competency have identified diverse educational content and delivery methods. Educational content ranged from fundamental cultural competency domains to culturally specific practices tailored to the needs of diverse patient populations. Theoretical models or frameworks, such as Campinha–Bacote’s model of cultural competence [23], Giger and Davidian’s transcultural assessment model [25], and Jeffrey’s cultural competence and confidence model [43], were frequently used to guide the design and evaluation of cultural competency education. Delivery methods ranged from traditional lectures to immersive and interactive approaches, with innovative technologies such as video, audio, and virtual reality for engaging in realistic simulation experiences. This comprehensiveness of educational content aligns with the findings of other umbrella reviews on healthcare education. For example, umbrella reviews of simulation learning in nursing education have explored its content, framework, and pedagogy [44], whereas empathy-focused communication training in healthcare settings has examined educational content, delivery methods, and mechanisms [45].

Our review confirms the effectiveness of cultural competency education in enhancing the cultural competency of healthcare professionals. However, evaluation of patient-centered outcomes remains limited, with only a few studies reporting significant improvements [7, 34], primarily confined to patients’ self-perceptions [34, 35, 39, 41]. This finding aligns with prior systematic reviews in health professions education, which highlight a lack of focus on patient-centered outcomes. A meta-analysis on virtual patient simulations in health professions education reported that none of the 51 included studies identified patient outcomes [46], while a review of e-learning interventions found that only one out of sixteen included studies assessed patient outcomes [47]. A key purpose of training healthcare professionals is to improve patient outcomes. Evaluating changes in patient-reported outcomes using validated instruments, behavior indicators such as treatment adherence, or quantitative clinical indicators extracted from electronic health records is essential to understanding the impact of education in real-world settings [39, 48, 49]. Despite the challenges posed by the multifactorial nature of clinical environments and the variability in clinical outcome definitions, such evaluations must be undertaken in future research.

Several methodological challenges were identified. The frequent use of unvalidated measurement tools compromised the reliability of reported outcomes and contributed to heterogeneity across studies. Another major limitation was the lack of meta-analyses in most systematic reviews. While RCTs were included in many reviews, insufficient synthesis of their findings has limited the statistical power and the ability to draw generalized conclusions. Previous umbrella review on simulation-based nursing education emphasized the value of meta-analyses in identifying effective intervention features [50]. Furthermore, outcome evaluation remains limited. Two systematic reviews in this umbrella review conducted comparative analyses to examine the influence of factors such as intervention duration, provider type, and content [34, 37]. Further research should employ robust designs to clarify which factors drive the effectiveness of cultural competency education.

This umbrella review has several limitations. First, reliance on existing systematic reviews makes the findings dependent on their quality and scope. To address this, we excluded reviews without quality assessments of primary studies. Second, although the Corrected Covered Area (CCA) was 1.78%, indicating a low level of redundancy [51], the potential for overlapping primary studies across reviews cannot be entirely excluded. To mitigate this, we listed all included primary studies for transparency (Supplementary 4). Finally, to align with our focus on healthcare professionals, we excluded reviews focused solely on students.

Conclusion

This umbrella review highlights the effectiveness of cultural competency education in enhancing healthcare professionals’ cultural knowledge, skills, attitudes, and behaviors while identifying significant gaps in reporting patient outcomes. Educational content, delivery methods, and theoretical frameworks that support structured and evidence-based approaches. However, the frequent use of unvalidated tools and lack of meta-analyses limit the reliability and generalizability of findings. Future research should address these methodological challenges and expand evaluations to include comprehensive patient-centered outcomes. These findings also highlight the need to develop practical and effective educational strategies that support policymakers and educational planners in integrating cultural competency into on-the-job training curricula and continuing professional development programs in healthcare.

Abbreviations

NIH

National Institutes of Health

JBI

Joanna Briggs Institute

RCTs

Randomized Controlled Trials

CCCTQ

Clinical Cultural Competence Training Questionnaire

BLRI

Barrett-Lennard Relationship Inventory

Authors’ contributions

YL: Conceptualization, Data curation, Formal analysis, Methodology, Software, Visualization, Writing – original draft. SS: Conceptualization, Investigation, Project administration, Resources, Supervision, Validation, Writing – original draft, Writing – review and editing. XF: Data curation, Formal analysis, Methodology. All authors reviewed the manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.