Finally, Greenhalgh (2012) critiqued systematic reviews in relation to today’s complex and multifaceted health challenges because they leave many broad questions unanswered. She claimed that Cochrane reviews are boring and sometimes cannot be implemented in practice:
22 Cultural competency in the delivery of health services for Indigenous people The technical process of stripping away all but the bare bones of a focused experimental question removes what practitioners and policymakers most need to engage with: the messy context in which people get ill, seek health care (or not), receive and take treatment (or not), and change their behaviour (or not) (Greenhalgh 2012:371). Although this systematic literature search strikes a sensible balance between the highly technical, rigid, resource intensive but often inaccessible conventional systematic literature review on the one hand and the undisciplined non-transparent approaches on the other, Greenhalgh’s comment suggests that the findings of searches such as this for cultural competency for Indigenous populations need to be carefully tailored to the discrete (messy) contexts in which they might be carried out. Gaps in the evidence There is a need to improve the quality of evaluations of cultural competence interventions targeting health care delivery to Indigenous Australians. The quality of evidence derived from the majority of studies was insufficient to provide a strong basis for specific interventions. This is in line with the findings of a recent review by Paul et al. (2010:566) of the ‘sorry state of the evidence base’ for improving the health of Indigenous populations in Canada, the United States, New Zealand and Australia. They found only 19 out of 665 intervention studies sufficiently met rigorous quality criteria and allowed them to confidently establish the effectiveness of strategies for improving health outcomes. There is an urgent need for future evaluations of interventions targeting improvements in cultural competence to employ more rigorous methods, in particular, stronger study designs and reliable and valid measures of outcome effects. Because the most rigorous study design, a randomised control trial, or even the inclusion of a control group, might not be possible in many settings, interrupted time-series designs may be a feasible option for evaluating interventions that aim to reduce health inequalities. These designs require the ability to reliably and objectively measure study outcomes multiple times before and after intervention. Conclusion Other international jurisdictions have enshrined cultural competence requirements with legislation; they have also allocated responsibility for cultural competence to professional health associations. Policies and programs are most likely to be effective if they comprise multiple components at different levels of health care (across and within health services, by individual practitioners, to client groups and within health training curricula).
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