The impact of cultural concordance between health professionals and patients: a narrative review

Significant ethnic health inequities exist in New Zealand. Māori and Pacific peoples experience a life expectancy gap compared to other ethnic groups of 6.6 years and 6.1 years, respectively.¹ Multiple complex factors drive Indigenous and ethnic health inequities including colonisation, historical and contemporary power imbalances, differential exposure to the social determinants of health^2,3 and inequities in access to and quality of healthcare. Independent of arguments related to higher health needs, Māori also have Indigenous rights to equitable access to education and to good health outcomes. The New Zealand government has obligations to achieve equity for Māori, reaffirmed by Te Tiriti o Waitangi and the United Nations Declaration on the Rights of Indigenous Peoples.

The health sector plays a causal role in ethnic health inequities. For example, Māori receive less access to, and poorer care throughout, the full spectrum of health services from preventative to tertiary care.^4–6 Māori are more likely to experience racism from health professionals,⁵ receive less preventive care such as immunisations,⁷ antenatal care⁸ and cancer screening,⁹ report unmet need for primary care and medicines,⁵ and are less likely to receive appropriate monitoring for chronic conditions.⁸

The cultural safety and cultural competence of health workers¹⁰ is an important contributing factor, and this is harder to achieve when there is cultural mismatch or discordance between patients and providers. A previous systematic review into Indigenous health inequities identified miscommunication, discrimination, culturally insensitive care and mistrust in the health system as important contributing factors.¹¹ A 2024 New Zealand–led systematic review into cardiovascular care for Māori and Pacific peoples also found that cultural appropriateness and safety were important factors identified by a number of qualitative studies, with patient–provider ethnicity matching important for Māori and Pacific peoples.⁶ Despite this, Māori and Pacific patients in New Zealand are unlikely to receive ethnically concordant care. In 2023, Māori made up 17.3% of the population yet only 8.5% of the overall health workforce.¹² Pacific peoples made up 4.9% of the health workforce, compared to 8.9% of the New Zealand population.¹² Māori and Pacific students remain under-represented in New Zealand universities’ health professional programmes.¹³ Increasing the Māori and Pacific health workforce is a key action identified in the government’s 2024 New Zealand Health Workforce Plan to achieve a culturally competent and equitable health “workforce that reflects community need”.¹⁴

This narrative review examines how cultural concordance contributes to health inequities. We synthesise international evidence on the impacts of cultural/ethnic concordance between patients and clinicians on health outcomes. Cultural concordance denotes a shared identity (e.g., ethnicity, language, Indigenous affiliation) or shared cultural understanding between patient and clinician.¹⁵ “Cultural concordance” is used in this paper synonymously with terms used in other research/jurisdictions, including racial concordance and ethnic concordance. Potential mechanisms linking cultural concordance to better outcomes include:

• Trust and cultural safety—promoting better disclosure, higher care utilisation and engagement.
• Improved communication—enabling clearer explanations and shared decision-making.
• Reduced bias/stereotyping—enhancing clinical decision-making and quality of care.

If cultural concordance improves patient engagement, clinical decision-making and treatment, it could play a significant role in improving health outcomes and reducing health inequities for Indigenous peoples and marginalised ethnic groups.

Methods

We searched Scopus, Embase and PubMed databases (August 2025 to September 2025). The query combined health outcome terms (“health”, “wellbeing”, “health outcomes”, “patient outcomes”, “treatment outcomes”, “healthcare experience”, “patient experience”) with concordance terms (“cultural concordance”, “ethnic concordance”, “ethnic matching”, “racial concordance”, “racial matching”). Searches were first limited to review articles, then to original research published since 2015. No additional limits were applied. We did not include grey literature in this review, as we were focussed on peer-reviewed academic literature. Reference lists of relevant review articles were manually screened. Studies focussing exclusively on gender or language concordance were excluded, but studies that examined gender/language concordance in addition to cultural/ethnic concordance were retained.

Results

Database searching yielded 99 systematic reviews, and after abstract screening and removing duplicates a total of 11 systematic reviews and meta-analyses were included for full analysis. The original research papers of five individual studies included in these systematic reviews were also analysed in full. A further nine original studies published in 2025 identified through the database search, which offered a particular focus on health outcomes, were also analysed, as these were too recent to be included in any of the published systematic reviews. A summary table of the 25 systematic reviews, meta-analyses and research studies identified from the database referenced in this paper can be found in Table 1.

The studies analysed investigated the relationship between cultural concordance and a range of outcomes, which can be categorised into the following four areas:

1.      Communication and patient experience

2.      Healthcare utilisation and engagement

3.      Clinical decision-making

4.      Health outcomes

1. Communication and patient experience

There is a strong body of evidence, including from meta-analyses, that cultural concordance improves communication, cultural safety and patient satisfaction.^16–19

A 2018 systematic review of racial concordance literature in the United States of America (USA) found that racial discordance almost always predicted poorer communication (11 of 12 studies) in the communication domains of: satisfaction, information-giving, partnership building, participatory decision-making, visit length and supportiveness/respectfulness of conversations.¹⁹ A meta-analysis of 154 studies relating to mental health¹⁷ found that patients preferred, and rated more positively, a mental health provider of their own race/ethnicity, and this impact was statistically significant. As discussed later, this review also noted that these average findings do not convey the more marked differences found for some sub-groups. A meta-analysis of the effect of racial concordance for Black patients in addiction treatment found that while overall concordance was not associated with treatment access or engagement, it was associated with positive outcomes including increased perceived provider empathy.¹⁶

Not all reviews found a consistent association.^18,20 For example, a 2024 systematic review of 33 studies¹⁸ found that for most patients, cultural concordance with their physician did not result in higher-quality communication; however, patient–provider concordance may improve trust and overall experience in healthcare. One observational study found a small negative association between racial and gender concordance with communication quality.²¹

2. Healthcare utilisation and engagement

There is evidence, including from meta-analyses, that cultural concordance is associated with improved treatment engagement, adherence, retention and preventive service uptake,^22–25 although not all studies have found a relationship.²⁰

Medication adherence

A 2025 systematic review of the impact of racial concordance on medication adherence concluded that concordance was associated with higher adherence rates for non-white patients.²⁵ Of the five studies that met their review criteria, four studies found that patient–provider race concordance was associated with higher adherence rates. Three studies included in the review documented significant findings for Black patients only. One study found significant associations between patient–provider concordance and adherence across Black, Hispanic, Asian, Hawaiian and Pacific groups, for aspirin, cardiovascular medications and smoking cessation.²⁶

Another USA study of 129 adults²⁷ found racial concordance was not associated with any significant impact on medication adherence or blood pressure control after 1 month, but the small sample size is a limiting factor. Another USA study of 597 Black adult patients in primary care suggests a more nuanced relationship between concordance and medication adherence.²⁸ While there was no impact of racial concordance on medication adherence directly, racial concordance did relate to a significant effect modification of the association between communication quality and medication adherence. They found that when Black patients had Black doctors, medication adherence remained the same regardless of how the patient rated the doctor’s communication style. However, when Black patients had white doctors, there was a significant decrease in adherence if the patient rated the communication style as non-collaborative.

Treatment engagement

A 2002 meta-analysis pooling effects across seven studies investigating ethnic concordance in psychotherapy²⁴ found that clients who were matched with therapists of the same ethnicity were significantly less likely to drop out of therapy and attended more psychotherapy sessions than clients without concordant therapists. However, a 2005 meta-analysis of 10 studies (only three of which were included in the 2002 analysis) found no overall benefit of client–clinician racial matching for African American and Caucasian American mental health clients, in terms of treatment retention or post-treatment functioning.²⁹

A longitudinal analysis of leukaemia patients in the USA³⁰ found that concordance between patients and their oncologist was associated with better adherence to treatment after 5 years. Racial concordance alone was associated with a small, but statistically insignificant, increase in adherence; gender concordance alone was associated with a small but significant increase and combined race and gender concordance was associated with a larger statistically significant increase in treatment adherence. These findings further suggest that multiple dimensions of concordance are important and synergistic.

Again, there is evidence that cultural concordance may have greater impacts for particular sub-groups. For example, one review found that a therapist–patient ethnic match decreased the likelihood of young people’s mental health therapy dropout differently for different ethnic groups, especially for adolescents.²²

Uptake of preventative interventions

An analysis of health utilisation data for Asian American sub-groups in the USA²³ found that patient–provider concordance is associated with statistically significant increases in seeking preventive care, seeking care for a new problem and for an ongoing problem, relative to Asian American patients with non–Asian American providers. They also found the association was not equal across all Asian sub-groups. A similar observational study of USA national survey and utilisation data found no statistically significant impact of racial concordance on uptake of mammography, colorectal screening or immunisation.²¹

The fact that patient–provider cultural concordance for non-white patients is generally low complicates the research, because it means the sample sizes are insufficient in most studies to assess the impact. For example, a 2025 analysis of over 20,000 patients investigating the impact of gender or cultural concordance on the uptake of preventative interventions found that while gender concordance was positively associated with increased uptake, no significant impact of racial concordance was found.³¹ The authors note that racial concordance for the non-white patients in this sample was very low (<25%) which limited their analyses.

3. Clinical decision-making

Some studies have specifically examined whether cultural concordance makes a difference to clinical decision-making.

A retrospective analysis of orthopaedic surgeons’ recommendations for patients with knee arthritis found that racial concordance was an independent predictor of being recommended for a total knee replacement, after controlling for patient factors and individual surgeon differences.³² Again, this study found the impact of racial concordance was more important for non-white patients. Black patients who received racially concordant care were more likely to be offered surgery compared to those who received racially discordant care (55.1% versus 23.0%, p=0.0001). For non-Hispanic white patients there was no significant difference in surgery offers between patients who received concordant versus discordant care (p=0.18).

Another USA analysis of cardiologists found when there was patient–physician race concordance, patients were 1.93 times more likely to be referred to cardiac rehabilitation (1.35–2.78, p<0.001) and 1.89 times more likely to participate (0.98–3.90, p=0.06).³³

4. Health outcomes

In terms of healthcare outcomes, there is mixed evidence of the impact of cultural concordance, with some positive findings in specific contexts. Compared to the body of research investigating cultural concordance and patient experience or communication, there is a smaller evidence-base looking at treatment outcomes.

In an analysis of 1.8 million hospital births in the USA between 1992 and 2015, Greenwood et al.³⁴ found that physician–patient racial concordance made a robust difference to the survival of Black babies but made no difference to white babies. Under the care of white physicians, Black newborns experienced 430 more deaths/100,000 births than white newborns, but under the care of Black physicians, Black newborns experienced only 173 deaths/100,000 births above white newborns—a 58% reduction in the racial mortality difference. The Greenwood et al. analysis has been criticised for omitting to include the impact of very low birth weight (VLBW) babies, who are disproportionately Black, and independently associated with poor outcomes. Borgas and VerBruggen³⁵ re-ran Greenwood et al.’s analysis to include VLBW in the model and found that the effect of racial concordance on mortality became statistically insignificant after controlling for the impact of VLBW.

Another recent analysis of birth outcomes in the USA³⁶ found that racial concordance was significantly associated with lower caesarean section rates (23.1% versus 33.6%; p=0.04), and this association persisted after adjusting for maternal comorbidities (p=0.003). Also, when outcomes were stratified by patient race, significant differences in caesarean rates were observed for white providers (p=0.02). No significant differences between races were observed for Asian or Black providers.

A USA analysis of surgical outcomes for 1,858 Black and 4,146 Hispanic adults³⁷ found that Hispanic patients treated by racially concordant surgeons had a statistically significant lower 30-day readmission and length of stay than those treated by discordant surgeons. No significant impact was found for Black patients. The sample size of Black patients in this study was much smaller than the sample of Hispanic patients.

Sánchez-Bahíllo et al.³⁸ found that ethnic matching improved the outcome of family therapy with drug-abusing adolescents in some ethnic minorities. A meta-analysis of the effect of racial concordance for Black patients in addiction treatment found that patients with a racially concordant provider were less likely to have legal problems at follow-up.¹⁶

There is some evidence that the impact of cultural concordance on health outcomes may differ for different groups. For example, in their 2011 meta-analysis, Cabral and Smith¹⁷ found mental health treatment outcomes do not substantively differ based on therapist cultural concordance, except in studies involving Black participants, where effect sizes were the highest across all outcomes of interest. Beaugard et al.¹⁶ also found that Black women in addiction treatment with a racially concordant provider were more likely to be abstinent at follow-up, suggesting that the effects of racial concordance may differ by gender and perhaps other intersections as well.

Multiple dimensions of concordance also appear to make a greater impact than single dimensions. For example, Jerant et al.²¹ found that dual race and gender concordance was significantly associated with higher self-rated health status after 2 years and racial concordance alone was associated with higher self-rated health after 1 year. In some studies cultural concordance also involved language concordance, making the impact of cultural concordance alone difficult to assess.^39,40 A 2025 analysis of 8,979 consultations found that Hispanic diabetes patients in California treated by a Mexican physician were 1.62 times more likely to have better diabetes control compared to those treated by non-Mexican physicians, and were 2.69 times more likely to be referred to a kidney specialist.⁴⁰

Discussion

Overall the evidence indicates that cultural concordance between patients and health professionals matters, with evidence of improved patient experience, communication, engagement and adherence, clinical decision-making and some clinical outcomes. This suggests that measures to improve health workforce ethnic diversity are necessary, alongside measures to improve outcomes from culturally discordant care.

The strength of the association and the groups which see the greatest benefit vary between studies, suggesting that the impact of cultural concordance is influenced by a range of other contextual factors. These findings are important for a New Zealand context, because ethnic inequities in factors such as medication adherence⁴¹ and the uptake of preventative services^42,43 make a significant contribution to health inequities.

An important theme from the literature is that the impact from cultural concordance is not the same across all population groups. Depending on the type of disaggregation, studies variously found that cultural concordance had a stronger impact for certain ethnic groups (especially Black patients) and that the impact sometimes varied by gender and age. Cultural concordance seems to make the least difference for white patients (who are currently overwhelmingly more likely to experience concordant care) indicating that concordance may be most important for more marginalised groups, who currently experience the poorest outcomes. Similarly, some studies found that patient outcomes differed by race for patients of white providers but did not differ for non-white providers.

There are several challenges with the evidence base which make it difficult to draw firmer conclusions. The available research investigates heterogenous populations and outcomes, e.g., the use of disparate instruments to measure communication variables. As already mentioned, patient–provider cultural concordance for non-white groups is generally very low, and this means the sample sizes for these groups are often insufficient to properly assess the impact.

There is a strong geographic bias in the literature, with most studies coming from the USA, so the evidence is strongly biased towards that country’s cultural context and approach to categorising racial groups, which is different to New Zealand’s approach of self-identified ethnicity. Very little research comes specifically from New Zealand or from Indigenous populations. A 2008 qualitative New Zealand study found Māori participants frequently expressed a perception that non-Māori health providers were biased against Māori patients, and participants felt that doctors from a similar cultural background to patients would provide better healthcare.⁴⁴ There is a large, well-documented body of research that Māori experience discriminatory treatment by health providers, although very little examines whether this varies by provider ethnicity. Earlier New Zealand research found that non-Māori doctors themselves reported a lower rapport with Māori patients,⁴⁵ blamed Māori for their own condition or lower healthcare access,⁴⁶ as well as believed that Māori were biologically or genetically more predisposed than others to mental illness.⁴⁷

Racial or ethnic categories are imperfect proxies for cultural concordance and can unintentionally biologise a more complex concept.⁴⁸ Factors such as gender, social status and other competencies may have influence but are infrequently assessed.^15,49 Some commonly used ethnic groupings are also highly heterogeneous, e.g., “Asian”. Studies relying on broad ethnic/racial categorisations may not be sensitive enough to measure a true cultural match between patients and providers. Furthermore, cultural concordance alone does not guarantee that health services are culturally safe. In New Zealand, the Waitangi Tribunal review into Māori health inequities⁵⁰ found that the model of care was also critically important. The tribunal emphasised the need for Māori self-determination and mana motuhake in the design, delivery and monitoring of healthcare services, as well as ensuring that all healthcare services are provided in a culturally appropriate way that recognises and supports the expression of Hauora Māori models of care.⁵⁰ Assessing the impact of models of care and governance on health outcomes is beyond the scope of this review, but is highly relevant to achieving equitable health outcomes.

Summary

Cultural concordance appears to influence a range of important measures related to improving health outcomes and health inequities. Findings are inconsistent and show variability by sub-group. However, meta-analyses link concordance with improved communication quality, trust, satisfaction and perceived respect. Cultural concordance is associated with improved healthcare utilisation, medication adherence and uptake of preventative interventions. Cultural concordance is also associated with differences in clinical decision-making and health outcomes, including caesarean section rates, diabetes management, surgical outcomes and addiction treatment.

Evidence quality is a limiting factor, with few studies powered to evaluate health outcomes, in part due to low levels of patient–provider cultural concordance for non-white patients. Cultural concordance appears to have a greater benefit for certain groups, highlighting the importance of examining intersectionality. Multiple dimensions of concordance (e.g., culture, gender, language) seem important and synergistic. Local research evidence is needed to understand how cultural concordance impacts health equity in New Zealand. However, Indigenous and ethnic health equity requires culturally competent and culturally safe health workforces and systems, and cultural concordance is only one aspect of this. Alongside efforts to improve ethnic workforce diversity and increase the possibility of culturally concordant care, actions are also needed to ensure that culturally discordant care results in better health outcomes.

View Table 1.