1 Teaching Cultural Competency: A Review of the Literature Sunita Mutha MD 1,2, Carol Allen MA 1, Cynthia Salinas MD 3, Arnab Mukherjea MPH 4 1 The Network Program, Center for the Health Professions 2 Department of Medicine 3 Department of Family and Community Medicine University of California, San Francisco 4 School of Public Health University of California, Berkeley

2 BACKGROUND  Critical need to eliminate disparities in health care among diverse populations in the U.S.  Reasons for disparities include attitudes and knowledge of health care professionals associated with:  stereotypes and biases  lack of knowledge of cultural issues  ineffective communication skills

3 BACKGROUND  There are calls to improve clinicians’ ability to provide culturally competent care for all populations  There is limited guidance for educators about the structure, content and effectiveness of cultural competency curricula

4 AIM OF REVIEW  To summarize what is currently known about the structure, content and effectiveness of cultural diversity education programs for a spectrum of health professionals at different levels of training.

5 DEFINITION  Cultural competency is “a set of behaviors, attitudes and policies that enable effective work in cross- cultural situations.”  Definition broadened to include knowledge and communication skills that enhance clinicians’ ability to be aware of cultural differences and to provide appropriate care that is congruent with patients’ values, beliefs and expectations.

6 DATA SOURCES  Pub Med search for articles published between 1966 to December 2001  Supplemented with review of references of index articles, as well as relevant reports and websites addressing cultural competency education

7 SELECTION CRITERIA  Inclusion criteria:  Articles written in English  Describing curricula for students, residents or clinicians  In medicine, nursing, dentistry and pharmacy  With quantitative evaluation of learners’ attitudes, knowledge and skills

8 SELECTION CRITERIA  Exclusion criteria:  Review articles  Articles focused solely on teaching language skills  Health professionals in fields other than medicine, nursing, pharmacy and dentistry  Reporting only qualitative results or course evaluations

9 DATA EXTRACTION  122 articles read, 14 met inclusion criteria  Data abstraction by 2 reviewers for each article including:  Participants (number, level & profession)  Duration of curricular experience  Educational objectives  Teaching methods  Evaluation results

10 STUDY STRENGTH  Strength of each study ranked on the basis of:  Study design  Sample size  Duration of educational experience  Type of outcome measurements  Possible range from low (4 pts) to high (12 pts)

11 FINDINGS  Study design  57% (8/14) were cohorts without controls  One randomized control trial (RCT)  Populations included  Medical students and residents (9/14 or 64%)  Nurses and Nursing students (5/14 or 36%)  Experiences ranged from 3 hours to 2 years  Study strength ranged from 5 to 10 (scale: 4 –12)

12 FINDINGS  Areas of curricular emphasis  awareness of sociocultural factors on patients’ health beliefs, values and behaviors  knowledge of specific cultural issues including social and historical factors shaping health behaviors, disease epidemiology, ethno- pharmacology and complementary health practices  Communication skills such as eliciting patients’ health beliefs, participatory decision-making, and working with medical interpreters.

13 FINDINGS  Vast majority of learning objectives only addressed attitudinal change (11/14 or 79%)  50% (7/14) programs included knowledge-based objectives  A minority ( 4/14 or 29%) of programs focused on skill acquisition  Evaluations relied on self-administered surveys  Few used existing measurement scales (e.g., Cultural Self-Efficacy Scale)

14 THERE IS A NEED FOR…  Consensus about core competencies  Clear and consistent learning objectives  Assessment linking behavior change among learners to patient satisfaction and health outcomes data  Objective measurements of program effectiveness  Resources devoted to faculty development to integrate core competencies into curricula