Table 1 Description of the six approaches on responsive health care that were included

1. CLAS Standards - National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) [ 9 ]. These standards were developed by the Office of Minority Health, part of the U.S. Department of Health and Human Services. Some of the standards have the status of mandates, meaning that they are Federal requirements for all health care organizations that receive Federal funds; others are purely recommendations. We included the CLAS standards because they were the first one and probably the most comprehensive and influential approach currently in use. In May 2013 the Enhanced CLAS Standards were published [ 11 ]. Although largely similar, there are some differences of emphasis between the original and the Enhanced CLAS Standards:

• The revised CLAS acknowledged that in order to address disparities in health care (for any target group), we need to go beyond cultural issues and deal with other (e.g., social, psychological) issues.

• In the vision on responsive care some slight changes of emphasis could be found, such as a shift from regarding diversity as a ‘group’ characteristic to ‘appreciating the diversity of individuals’. The enhanced CLAS also places more emphasis on the importance of ‘patient- and family centred care’, thus bringing it more into line with the JC Roadmap.

2. Advancing Effective Communication, Cultural Competence, and Patient- and Family Centered Care: A Roadmap for Hospitals (JCR) [ 20 ]. This ‘Roadmap’ has been developed by the Joint Commission (JC), an independent, not-for-profit organization which accredits and certifies health care organizations in the United States. The Roadmap was developed in addition to existing JC requirements “to inspire hospitals to integrate concepts from the fields of communication, cultural competence, and patient- and family-centered care into their organizations.” We included the JC Roadmap because of the global influence of JC and the Joint Commission International (JCI) accreditation program on health care organizations through their accreditation programs (applied in over 50 countries). JC developed its own framework of recommendations in which cultural competence is embedded within effective communication and patient- and family centred care. Please note that 1) other existing JC requirements also include issues related to those issues discussed in the Roadmap, and 2) that the national Joint Commission Standards are different from the Standards of the Joint Commission International.

3. Cultural Responsiveness Framework. Guidelines for Victorian health services (CRF) by the Rural and Regional Health and Aged Care Services, Victorian Government, Department of Health (Australia) [ 21 ]. The CRF was developed to replace the Health Service Cultural Diversity Plans (HSCDPs) which since 2006 have required all Victorian health services to develop and implement policies for ethnic diversity in care. The intention of the CRF is to consolidate multiple requirements for reporting on cultural diversity initiatives within health services. All Victorian health services are required to submit plans and achievements according to the standards and measures in the CRF to the Statewide Quality Branch. We included the CRF because it has been disseminated and made compulsory in a large health care system in Australia.

4. Recommendation of the committee of ministers to member states on mobility, migration and access to health care (COER) of the Council of Europe [ 22 , 23 ]. The Council of Europe is an international organization set up “to achieve a greater unity between its members for the purpose of safeguarding and realizing the ideals and principles which are their common heritage and facilitating their economic and social progress” [ 37 ]. We included the COER because it has been endorsed by the Health Ministers of the 47 member states of the Council of Europe. The document is aimed at ministerial level, therefore it includes recommendations that have consequences for the whole health system. These recommendations focus on the diversity responsiveness in the context of migrants and their children. To make comparisons possible we have only included the recommendations at organizational level in our analysis.

5. Equality Delivery System (EDS) for the NHS [ 24 ]. EDS originates from the Equality and Diversity Council within the British National Health Service (NHS). It is designed to help NHS organizations to comply with the ‘Public Sector Equality Duty’ (PSED) of the Equality Act. This act “requires public bodies to consider all individuals when carrying out their day to day work – in shaping policy, in delivering services and in relation to their own employees” [ 38 ]. EDS is made available to the NHS as an optional tool. It was included because it is a European instrument which has been disseminated in a large health care system.

6. Equity Standards (EQS) of the Task Force on Migrant-Friendly and Culturally Competent Healthcare [ 25 ]. These Standards were developed by a group of mainly European experts set up within WHO’s Health Promoting Hospitals network. The Equity Standards are a self-assessment instrument to enable health care organizations to carry out an ‘equity evaluation’ against a set of standards. The instrument was piloted in 10 European countries, as well as in two non-European ones. The Equity Standards were included because of the broad international context in which they were developed.