cultural competence healthcare essay

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• Plast Reconstr Surg Glob Open
• v.7(5); 2019 May

Cultural Competence and Ethnic Diversity in Healthcare

Lakshmi nair.

From the * Albany Medical College, Albany, N.Y.

Oluwaseun A. Adetayo

† Division of Plastic Surgery, Albany Medical Center, Albany, N.Y.

Today’s model of healthcare has persistent challenges with cultural competency, and racial, gender, and ethnic disparities. Health is determined by many factors outside the traditional healthcare setting. These social determinants of health (SDH) include, but are not limited to, education, housing quality, and access to healthy foods. It has been proposed that racial and ethnic minorities have unfavorable SDH that contributes to their lack of access to healthcare. Additionally, African American, Hispanic, and Asian women have been shown to be less likely to proceed with breast reconstructive surgery post-mastectomy compared to Caucasian women. At the healthcare level, there is underrepresentation of cultural, gender, and ethnic diversity during training and in leadership. To serve the needs of a diverse population, it is imperative that the healthcare system take measures to improve cultural competence, as well as racial and ethnic diversity. Cultural competence is the ability to collaborate effectively with individuals from different cultures; and such competence improves health care experiences and outcomes. Measures to improve cultural competence and ethnic diversity will help alleviate healthcare disparities and improve health care outcomes in these patient populations. Efforts must begin early in the pipeline to attract qualified minorities and women to the field. The authors are not advocating for diversity for its own sake at the cost of merit or qualification, but rather, these efforts must evolve not only to attract, but also to retain and promote highly motivated and skilled women and minorities. At the trainee level, measures to educate residents and students through national conferences and their own institutions will help promote culturally appropriate health education to improve cultural competency. Various opportunities exist to improve cultural competency and healthcare diversity at the medical student, resident, attending, management, and leadership levels. In this article, the authors explore and discuss various measures to improve cultural competency as well as ethnic, racial, and gender diversity in healthcare.

By 2050, it is estimated that 50% of the US population will consist of minorities and unfortunately, today’s model of healthcare has been noted to have persistent racial and ethnic discrepancies. 1 Diverse populations require personalized approaches to meet their healthcare needs. Minorities have been shown to have decreased access to preventive care and treatment for chronic conditions which results in increased emergency room visits, graver health outcomes, and increased likelihood of developing cardiovascular disease, diabetes, cancer, and mental illness. 2 – 5

This disparity has been prominent in the field of plastic and reconstructive surgery. For example, Sharma et al. explains that there are significant racial disparities in breast reconstruction surgery. Specifically, African American, Hispanic, and Asian women are less likely to proceed with breast reconstructive surgery postmastectomy compared with White women. A study using the Surveillance, Epidemiology, and End Results database found that more African American women compared with White counterparts opted not to have immediate breast reconstruction after mastectomy, many stating they were unable to afford surgery. This discrepancy has been supported by future studies after Medicaid expansion and coverage. 1

Health is determined by many factors outside the traditional healthcare setting. These social determinants of health (SDH) include housing quality, access to healthy food, and education. 6 It has been proposed that racial and ethnic minorities have unfavorable SDH that contributes to their lack of access to healthcare. 6 Differences in healthcare treatment and outcomes among minorities persist even after adjusting for socioeconomic factors. 3 We hypothesize that lack of female and minority representation in the field of plastic surgery contributes to delayed healthcare and quality of outcomes in these populations. To be able to cater to these healthcare needs down the pipeline, it is critical that we begin efforts for attraction and retention of skilled female surgeons and minorities farther up in the pipeline chain. Although women compose half of all medical school graduates, only 14% of plastic surgeons and 32% of plastic surgery residents are women. 7

The senior author (O.A.A.) wrote a response to Drs. Butler, Britt, and Longaker regarding the scarcity of ethnic diversity in plastic surgery in 2010. At that time, as a Black female in plastic and reconstructive surgery, O.A.A. represented a mere 3.7% of plastic and reconstructive surgery residents and fellows. 8 It is astonishing that nearly a decade later we still face nearly identical statistics. It is imperative to prioritize diversity in plastic surgery so that by the next decade, we can make significant strides in narrowing this enormous disparity in representation. The authors are not advocating for diversity for its own sake at the cost of merit or qualification, but rather, that organizations and specialties initiate efforts to attract, retain, and promote highly motivated and skilled women and minorities.

Advocating for women and minorities in plastic surgery is one step in acknowledging and catering to various cultural differences. Culture is defined as a cumulative deposit of knowledge acquired by a group of people over the course of generations. 4 Cultural competence is the ability to collaborate effectually with individuals from different cultures, and such competence can help improve healthcare experience and outcomes. 3 , 4

Studies have identified limited national efforts to incorporate cultural competency in healthcare. 9 In a national study of organizational efforts to reduce physician racial and ethnic disparities, 53% of organizations surveyed had 0–1 activities to reduce disparities out of over 20 possible actions to reduce disparities. Some examples of these disparity-reducing activities include providing educational materials in a different language, providing online resources to educate physicians on cultural competence, and awards at national meetings to recognize efforts to reduce racial disparities. The membership size of the national physician organization surveyed and the presence of a health disparities committee were found to be positively associated with organizations with at least 1 disparity-reducing activity. Primary care organizations were more likely to participate in disparity-reducing activities and may serve as role models for other physician organizations to take initiative. 9

Various opportunities exist to improve cultural competency. One of such measures is via education of residents and students before they transition into attending roles. The Accreditation Council for Graduate Medical Education has identified the importance of addressing cultural diversity as part of its professionalism competency, and the Alliance of Continuing Medical Education also devoted lectures at its national annual conference to cultural competency. 10 Such measures will help increase awareness in trainees and bridge the gap of competency as they transition from training to practice. Incorporating diversity training and cultural competence exercises at national plastic surgery meetings such as Plastic Surgery: The Meeting and AAPS with CME accreditation is a feasible way to incorporate this training. Additional efforts at the state and national level are also critical for advancing cultural competency, and some of these efforts are also underway. 6 , 10 For instance, the Health and Human Services Office of Minority Health developed “Think Cultural Health,” a resource center that offers users the ability to earn continuing education credits in cultural competency through online case-scenario-based training. 6 In addition, 5 states established legislature requiring or strongly recommending cultural competency training for physicians. 10 These implementation efforts will help in raising awareness to improve cultural competency and diversity in healthcare.

On the industry level, the lack of diversity in healthcare leadership is dramatic, with 98% of senior management in healthcare organizations being White. 4 This disparity in representation is similarly magnified when looking at minority representation in leadership roles within plastic surgery. Only 7% of department chiefs and chairs of plastic surgery are women. Improving representation of women and ethnic minorities in White-male dominated fields like plastic surgery has the potential to improve access to healthcare in minority populations. In fact, female leadership has even been associated with increased effectiveness. 11

Even when individuals from racially or ethnically under-represented populations attain high level executive positions, most earn lower salaries and are overrepresented in management positions serving indigent populations. 12 It is critical to address these gaps and disparities in healthcare. Some measures are being taken to attain culture competency via targeting upper-level executives to identify cultural competency as a high priority. 4 , 12 Others propose targeting cultural competence in healthcare at the root, namely medical education. Some of the problematic themes identified include lack of exposure and insufficient education and teaching curricula regarding diversity; unfortunately, cultural competence is often perceived as a low priority in an overloaded academic curriculum. 13

In the healthcare industry, efforts have been made to achieve cultural competence with the goal of providing culturally congruent care. 4 A review of culturally competent healthcare industry systems identified 5 interventions to improve cultural competence: (1) gear programs to recruit and retain diverse staff members, (2) cultural competency training for healthcare providers, (3) use of interpreter services to ensure individuals from different backgrounds can effectively communicate, (4) culturally appropriate health education materials to inform staff of different cultural backgrounds, and (5) provision of culturally specific healthcare settings. 14 Through increased awareness and by incorporating these interventions, culture competence can be improved in plastic surgery from bedside to the operating room.

Regrettably, there is a lack of literature linking culturally competent education to patient, professional, organizational outcomes. Horvat et al. created a 4-dimensional conceptual framework to assess intervention efficacy: educational content, pedagogical approach, structure of the intervention, and participant characteristics. It is essential that future studies follow methodologic rigor and reproducibility to best document progress. 15

An examination of 119 California hospitals revealed that nonprofit hospitals serve more diverse patient populations, are in more affluent and competitive markets, and exhibit higher cultural competency. It is argued that there will be a market incentive for implementing culturally competent programs as long as cultural competency is linked to better patient experiences. 16 Policymakers and institutions can capitalize on this and incorporate cultural competence practices into metrics for incentive payments. Additionally, enhancing public reporting on patient care and hospital quality will drive competition in the healthcare field and prompt organizations to aim for cultural competence. 16

Striving for ethnic diversity and cultural competency in plastic surgery is necessary to adequately care for an evolving and diverse patient population. It is imperative that plastic surgery departments adopt evidence-based practices to foster cultural competency including promoting recruitment of diverse healthcare-providers, the use of interpreter services, cultural competency training for healthcare team members, and distribution of information on cultural competency to hospital staff members. As population demographics change, plastic surgery departments must also evolve to suit the needs of a diverse array of modern patients.

Published online 16 May 2019.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Open Access

Peer-reviewed

Research Article

Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Roles Formal analysis, Writing – review & editing

Roles Conceptualization, Funding acquisition, Methodology, Supervision, Writing – review & editing

• Oriana Handtke, 
• Benjamin Schilgen, 

• Published: July 30, 2019
• https://doi.org/10.1371/journal.pone.0219971
• Reader Comments

Culturally and linguistically diverse patients access healthcare services less than the host populations and are confronted with different barriers such as language barriers, legal restrictions or differences in health beliefs. In order to reduce these disparities, the promotion of cultural competence in healthcare organizations has been a political goal. This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for culturally and linguistically diverse patients within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

Methods and findings

A systematic literature search was carried out using three databases (Pubmed, PsycINFO and Web of Science) to identify studies which have implemented and evaluated cultural competence interventions in healthcare facilities. PICO criteria were adapted to formulate the research question and to systematically choose relevant search terms. Sixty-seven studies implementing culturally competent healthcare interventions were included in the final synthesis. Identified strategies and components of culturally competent healthcare extracted from these studies were clustered into twenty categories, which were organized in four groups: Components of culturally competent healthcare–Individual level; Components of culturally competent healthcare–Organizational level; Strategies to implement culturally competent healthcare and Strategies to provide access to culturally competent healthcare. A model integrating the results is proposed. The overall effects on patient outcomes and utilization rates of identified components or strategies were positive but often small or not significant. Qualitative data suggest that components and strategies of culturally competent healthcare were appreciated by patients and providers.

This scoping review used a bottom-up approach to identify components and strategies of culturally competent healthcare interventions and synthesized the results in a model of culturally competent healthcare provision. Reported effects of single components or strategies are limited because most studies implemented a combination of different components and strategies simultaneously.

Citation: Handtke O, Schilgen B, Mösko M (2019) Culturally competent healthcare – A scoping review of strategies implemented in healthcare organizations and a model of culturally competent healthcare provision. PLoS ONE 14(7): e0219971. https://doi.org/10.1371/journal.pone.0219971

Editor: Catherine Suzanne Todd, FHI360, UNITED STATES

Received: January 9, 2019; Accepted: July 6, 2019; Published: July 30, 2019

Copyright: © 2019 Handtke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The study was funded by the Verein zur Förderung der Rehabilitationsforschung in Hamburg, Mecklenburg-Vorpommern und Schleswig-Holstein (vffr) ( http://www.reha-vffr.de ). OH and MM received the funding. The funders did not play any role in the study design, data collection, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

The United Nations state “the world is on the move, and the number of international migrants today is higher than ever before.” [ 1 ]. The associated growing diversification of societies offers many opportunities for societal and economic growth but often presents a challenge for receiving countries. Consequences can include inequalities and discrimination in different areas [ 2 ]. The European Union (EU) and the Constitution of the World Health Organization (WHO) ratified the universal right to health as a fundamental human right. Nevertheless, inequalities in access to healthcare exist worldwide and are related to the legal and socioeconomic status of each individual and the laws and policies of each country [ 3 , 4 ]. In fact, culturally and linguistically diverse patients (CLDP) access healthcare services less than the host populations and are confronted with different barriers [ 3 – 7 ]. These barriers include the organization and complexity of healthcare systems, legal restrictions on access to certain health services, linguistic and cultural barriers, discrimination and limited competencies or unawareness of providers. These are often intertwined with individual factors such as low health literacy, employment status, fear of stigma, language barriers or differences in health beliefs and behaviors [ 2 – 7 ]. Betancourt identified three levels of sociocultural barriers to healthcare: organizational barriers, structural barriers and clinical barriers. Organizational barriers, which affect availability and acceptability of healthcare for CLDP, refer for instance to the degree to which the population’s cultural and linguistic diversity is represented in the leadership and workforce of healthcare organizations. Structural barriers emerge from the complexity and bureaucracy of healthcare systems. Specifically, the absence of interpreter services and of culturally and linguistically adapted materials, increased wait times among CLDP populations and problems in referrals to specialist care cause dissatisfaction and inequalities. Clinical barriers occur in patient/provider interactions and can be seen as sociocultural differences which are not identified, accepted or understood. These can lead to mistrust, dissatisfaction, decreased adherence and poorer health outcomes [ 8 ].

The implementation of cultural competence in healthcare facilities seemed to be the answer to these disparities, and traditional receiving countries have been working towards it [ 8 – 12 ]. Indeed, the demand for culturally competent healthcare systems has reached the political levels of diverse countries. The National Culturally and Linguistically Appropriate Service Standards (CLAS Standards) were introduced in 2000 in the United States [ 13 ], and in 2005 the Australian government published “Cultural competency in health: A guide for policy, partnerships and participation” [ 14 ]. In 2007 the “cultural opening” of healthcare facilities was demanded by a representative of the German federal government [ 15 ] and the NHS has offered the migrant health guide since 2014 [ 16 ].

There are different definitions, names and implementation guidelines for the concept of cultural competence or cultural competency [ 12 , 17 ]. The most commonly used definition is the one by Cross et al. (1989): „Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professions to work effectively in cross-cultural situations” [ 18 ]. This definition emphasizes that cultural competence is implemented on different levels of care. Corresponding to their identified barriers, Betancourt et al. (2003) differentiate between three levels of interventions: organizational, structural and clinical cultural competence interventions [ 8 ]. Fung et al. (2012) take a systemic approach and define cultural competence on macro, meso (institutional and programmatic) and micro levels, by which macro reflects the societal level, meso the organizational and micro the individual clinical level [ 10 ]. The German concept of “cultural opening”describes the process of adapting or “opening”facilities and is hence a process of organizational development which includes interventions on different levels within facilities [ 19 ].

Existing systematic reviews have focused on defining theoretical concepts [ 8 , 9 , 20 ] or on the effectiveness of cultural competence interventions [ 11 , 12 , 17 , 21 , 22 ]. Individual cultural competence among healthcare providers was examined most frequently [ 12 , 20 ]. A systematic review of reviews on cultural competence in healthcare found moderate positive effects of individual cultural competence trainings on provider outcomes (knowledge, skills, attitudes) and on access and utilization outcomes but only weak effects on patient outcomes (satisfaction, health status) [ 12 ]. Other interventions that were often identified by authors of existing reviews were the recruitment of bilingual staff, the use of interpreters and the translation of treatment materials [ 9 , 11 , 12 , 20 ]. All together these reviews were not able to determine the effectiveness of interventions because of the lack of comparative studies and objective outcome measures [ 11 , 12 , 17 , 21 – 23 ]. A number of systematic reviews were conducted which often focused on conceptual models and definitions or broad categories of cultural competence and derived interventions or strategies from those. We chose a bottom-up approach in order to extract culturally competent components or strategies from healthcare interventions designed to be culturally competent. The methodology of a scoping review appears appropriate for capturing the presumed diversity of components and strategies to provide culturally competent healthcare to CLDPs.

This scoping review aims to collect components and strategies from evaluated interventions that provide culturally competent healthcare for CLDPs within healthcare organizations and to examine their effects on selected outcome measures. Thereafter, we aim to organize identified components into a model of culturally competent healthcare provisions.

The review was guided by the question “What are components or strategies extracted from evaluated culturally competent healthcare interventions that were designed to provide healthcare for culturally and linguistically diverse patients (CLDP) in healthcare organizations?”

Search strategy

A systematic literature search was carried out in following databases: Pubmed, PsycINFO and Web of Science. The search was conducted in August 2016 and updated in January 2017 to include studies published during/after August 2016. No restrictions were set. Furthermore, lists of references of relevant articles were manually examined for the purpose of identifying further eligible studies.

The PICO criteria were adapted [ 24 ] in order to formulate the research question and to systematically choose relevant search terms. We concentrated on the criteria Population (e.g., migrants, culturally and linguistically diverse patients), Intervention (e.g., program, standard, strategy) and Outcome (e.g., increasing cultural competences or cross-cultural opening). The search string is available in the S1 File . More precisely, we searched for studies which evaluated cultural competence interventions quantitatively or qualitatively in order to increase cultural competence in healthcare facilities. Additionally, we included the criterion Setting (e.g., hospitals, clinics, health centers) because we were exclusively interested in interventions implemented in healthcare facilities. Analyses of Medical subject Headings (MeSH) and of key terms of related articles were used to identify search terms. These were discussed by the authors and combined to a search string, which was adapted for each database. As recommended by Arksey and O’Malley (2005) we started the search with a wide approach in order to create a comprehensive map of the field.

Eligible criteria and assessment

The selection process was divided into two screening phases. First, a screening of titles and abstracts was conducted followed by full text screening.

In the first screening phase, studies evaluating interventions located at healthcare organizations and aiming to improve cultural competence of healthcare facilities and/or healthcare for CLDP were included. Studies reporting the existing level of cultural competence of healthcare facilities or studies evaluating interventions in other facilities (e.g., schools, community centers) were excluded. In the event that the setting of the intervention was not identifiable in title or abstract, studies were nonetheless included in order to be examined in full text screening. Studies evaluating cultural competence trainings on an individual provider level were excluded because systematic reviews have already shown their positive effect on provider outcomes (e.g., knowledge, skills and attitudes) and their satisfying effect on patient outcomes (e.g., satisfaction, health status) [ 12 ]. At this stage all study types as well as all publication types except for reviews and meta-analysis studies were deemed eligible.

The title and abstract screening was carried out by three independent raters. Prior to this first screening phase all raters screened 100 randomly chosen articles each and reached an interrater reliability of ĸ = 0.7 (main author—first rater) and ĸ = 0.8 (main author—second rater). Disagreement was discussed in regular meetings and screening criteria were specified along the screening process.

Eligible criteria for full text screening were specified and iteratively adapted during the second screening phase [ 25 ]. The criteria were divided into the following categories: Design, Recipient Population, Content, Method and Context. The category Design (criterion 1) included only studies with a sample size of more than two and only studies using primary data. Hence, reviews, meta-analysis studies, study protocols and letters to the editors were excluded. The Recipient Population consisted of migrants, CLDP, ethnic minorities (e.g., Latino population, Native Americans, South Asian Americans) or refugees (criterion 2). In order to be considered eligible regarding their content, studies had to examine interventions that aim to improve healthcare utilization, provision or treatment for CLDP and/or cultural competence in healthcare facilities (criterion 3). Additionally, they needed to be evaluated with quantitative or qualitative research methods (Method; criterion 4). Furthermore, studies that only focus on (psychometric) evaluation of instruments were not eligible. Interventions had to be implemented explicitly in inpatient or outpatient settings such as hospitals; health or medical centers; health facilities; health organizations; (medical) trusts or sites or clinics in order to meet the Context criterion (criterion 5). If study participants were recruited in healthcare facilities, but the intervention was located elsewhere, these studies were excluded. Studies located in general practice or community centers were excluded, as well. Only studies published in English or German and meeting all criteria were included. Detailed screening criteria are available in the S1 Table .

In the full-text screening the remaining articles were screened by two independent researchers. They reached an interrater reliability of k = 0.8, which was considered to be satisfying. Both raters met on a regular basis throughout the screening process to ensure a high level of consensus and to discuss any uncertainties.

Data extraction and summary

Data extracted from the studies were summarized into two spreadsheets. One spreadsheet describing the characteristics of healthcare interventions included following information: Authors, name and location of the intervention, target group and components of the interventions. ( S2 Table ) [ 26 ]. The second spreadsheet incorporated study characteristics and results: outcome measures, study type, study participants (N, ethnicity) and main results ( S3 Table ). To assure the accuracy of extracted data, they were verified by two independent researchers. Single components and strategies for providing culturally competent healthcare extracted from studies were clustered and organized into a model. In order to determine their effects, studies were checked for results relating to single components. Descriptive statistics were used to summarize the data.

Study selection

The initial search in the databases provided a total of 10,701 citations. Through the update in January 2017, an additional 542 publications were found. Four articles were added from a manual search. After adjusting for duplicates 8,801 records remained for the title and abstract screening, and 455 studies met criteria for inclusion in the first selection phase. 23 articles then had to be discarded because the full-text publications of the studies were not available. 432 articles were finally included for the full-text screening. Of these, 67 met the inclusion criteria in the second selection phase and were eligible to be included in the final synthesis ( Fig 1 ).

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https://doi.org/10.1371/journal.pone.0219971.g001

General study characteristics

The general characteristics of included studies are summarized in Table 1 . Studies included in the final synthesis were published between 1990 and 2017 and were all written in English.

https://doi.org/10.1371/journal.pone.0219971.t001

The majority of studies were conducted in the United States (n = 51; 76%). 28% of the interventions were implemented in the mental health field including substance abuse and neuropsychology (n = 19), followed by 16.5% implemented in diabetes care/prevention (n = 11). Included studies applied a quantitative study design in 69%, a mixed method design in 21% and 10% were qualitative studies. Fourteen studies were randomized controlled trials (RCTs) [ 27 – 40 ] with two cluster randomizations [ 27 , 28 ]. RCTs compared one to three interventions with the control intervention, which was typically treatment as usual. Twelve studies were interrupted time series studies [ 41 – 52 ]. Other study types included controlled before and after studies [ 53 – 60 ], historically controlled studies [ 61 – 63 ], cross-sectional studies [ 64 – 67 ], cohort studies [ 68 , 69 ] and incidence studies [ 70 , 71 ]. All mixed methods studies used congruent triangulation [ 72 – 85 ], except for one that chose a sequential transformative design [ 86 ]. Qualitative studies included four case studies [ 87 – 90 ], and the methods of data collection used were interviews [ 90 – 92 ], focus groups [ 89 , 93 ] or open-ended questions [ 88 ]. The number of participants ranged from 6 [ 41 ] to 5963 [ 43 ] participants. Twenty-nine studies focused on one ethnic group [ 27 , 30 – 36 , 39 , 41 , 42 , 47 – 49 , 51 , 57 , 69 , 75 , 77 – 80 , 82 – 85 , 87 , 89 , 92 ] while thirty-three included more than one ethnic group [ 28 , 29 , 37 , 38 , 40 , 43 – 46 , 50 , 52 – 56 , 58 – 68 , 70 – 73 , 86 , 91 , 93 ] and five studies did not report the ethnicity of their participants [ 74 , 76 , 81 , 88 , 90 ].

Measured outcomes were patient outcomes, provider outcomes, organizational outcomes and utilization, coverage and access outcomes [ 12 ]. Psychological health outcomes such as reduction in symptoms of mental illness [ 28 , 33 , 35 , 36 , 47 , 48 , 52 , 59 , 61 , 85 ] and in regard to health, concepts such as self-efficacy [ 34 , 73 , 86 ] or distress [ 49 , 51 ] were assessed the most frequently.

Categorizations of identified culturally competent components and strategies

Extracted components and strategies of the 67 culturally competent healthcare interventions were clustered into 20 sub-categories of components, which were then grouped into four categories: (1) Components of culturally competent healthcare within facilities–Individual level; (2) Components of culturally competent healthcare within facilities–Organizational level; (3) Specific strategies to provide access to culturally competent healthcare; (4) Strategies to implement culturally competent healthcare within facilities. Descriptions of components and strategies including the references can be found in Table 2 . The components of identified culturally competent healthcare interventions and their assigned categories are available in the S4 Table . The component “Cultural and linguistic matching” was identified the most, more precisely in 29 studies, followed by “Use of culturally adapted/appropriate written or visual material”, which was found in 27 studies. The component “Involvement of the facilities’ leadership” as a strategy to implement culturally competent healthcare within facilities was identified the least, specifically in 3 studies. Almost 80% of the interventions were located in outpatient facilities. Only eleven studies collected data in inpatient settings.

https://doi.org/10.1371/journal.pone.0219971.t002

Effects of identified components and strategies

Quantitative and qualitative results from studies implementing the identified components or strategies are reported below. Importantly, only the results which indicate a relation between an isolated component or strategy and an outcome measure are considered. Results related to the implementation of multiple components or strategies simultaneously are not reported because in this case the effects of single components or strategies on outcome measures cannot be confirmed.

Components of culturally competent healthcare–Individual level

Linguistically and cultural matching. After the recruitment of a bilingual Russian internist at the Denver Medical Center (USA) with the goal of improving diabetes care for Russian patients, there was a significant reduction in diastolic blood pressure and cholesterol (p < .0002) among Russian diabetes patients. HbA1c and systolic blood pressure also decreased, albeit not significantly [ 69 ]. The Portuguese-speaking patients of a clinic within an urban safety-net hospital system in the US where 95% of staff members spoke Portuguese, were more likely to receive adequate care with a difference of 28% compared with patients receiving care in other clinics. No differences were found for emergency room use and inpatient care [ 64 ]. Hispanic clients with severe mental illness treated by a Hispanic clinician in the context of assertive community treatment in the US, showed less improvement in symptoms of psychosis than those treated by a White clinician (p = .001). Interactions for other outcomes were not significant [ 59 ]. Patients in a culturally focused psychiatric consultation intervention program for Latino Americans with depression agreed that it is more important that their providers speak their language than that they have the same cultural background [ 82 ].

Incorporation of culturally specific concepts. At the Martha Eliot Health Center (USA) Latino/a patients with anxiety participating in an allocentric (“the tendency to define oneself in relationship to others”) relaxation intervention, which was considered more appropriate for the Latin culture, practiced allocentric imagery exercises significantly (p < .01; M = 3.1, SD = 1.8) more often than idiocentric imagery exercises (M = 2.1, SD = 2.2) [ 48 ]. No group changes in postpartum depressive symptoms were identified compared to treatment as usual after a preventive postpartum depression intervention that put value on integrating different aspects of Latino culture at a public sector women’s clinic (USA). Nonetheless, long-term rates of major depression were lower (14% vs. 25%) representing a small effect size (h = 0.28) [ 36 ]. Aviera (1996) noted that the use of dichos, Spanish language proverbs, in a therapy group for Spanish speaking psychiatric in-patients in the US are useful for “building rapport, decreasing defensiveness, enhancing motivation and participation in therapy, improving self-esteem, focusing attention, facilitating emotional exploration, articulating feelings, developing insight, and exploring cultural values and identity” [ 87 ] for Spanish-speaking patients. The CEVE is a “one-session clinical intervention that integrates the use of shared observations of videotaped interactions with the cultural framing of the family’s problem in a culturally congruent manner”. Families receiving the CEVE at an outpatient clinic in the US reported significantly higher ratings for therapeutic alliance and perceived therapist cultural competence (F(1,15) = 10.03; p < .01) [ 40 ]. The Cultural Formulation Interview, “a cross-cultural assessment tool”, was considered useful in eliciting data to determine the nature of the problem from patients’ perspectives, developing and maintaining the therapeutic relationship and communication, educating the patient and in implementing treatment plans at New York Presbyterian Hospital (USA) [ 91 ].

Use of culturally and linguistically adapted/appropriate written or visual material. Watching characters with the same cultural background in an educational telenovela intervention for diabetes patients in the context of the SHL-program (Sugar, Heart, and Life) at four community health centers in the US led to a mix of low and high levels of viewer identification among participants and to improved feelings of self-efficacy: 17% indicated general optimism or motivation for engaging in diabetes self-care, and 10.5% indicated a specific plan for behavior change [ 34 ].

Involvement if families. Parental satisfaction with a family-centered intervention for children within the Pediatric Resident Continuity clinic at the Mattel Children’s Hospital (USA) were 8.5 points higher for Spanish-speaking families then for English-speaking families, albeit not significantly ( p = .003) [ 65 ]. In the context of a community based approach to diabetes control at multiple heath centers in the US, focus group discussions suggest that through family involvement patients from African American, Latino or Asian background “felt they were better able to treat their disease, that they were more comfortable talking about their diabetes with their families and friends, and that they felt more confident and in control of their lives”. [ 73 ].

Components of culturally competent healthcare–Organizational level

Cultural competence trainings for providers. In a patient-centered culturally sensitive healthcare intervention program based in two community-based primary care clinics in the US cultural sensitivity ratings of providers’ behaviors and attitudes by African American patients increased significantly ( F (1, 14) = 4.549, p = .05) after provider training and more at the intervention clinic than at the control clinic, however, the differences were not significant [ 55 ]. Also, significant increases in providers’ self-rated knowledge ( t (34) = -7.96, p < .001), awareness ( t (34) = -6.79, p < .0019) and skills ( t (34) = - 4.49, p < .001.) in cultural competence was observed after a bilevel cultural competence intervention at a community mental health center in the US [ 45 ]. Furthermore, providers receiving training within the National Center for Healthcare Leadership Diversity demonstration project in two US hospitals presented greater changes on all three individual level competencies–increase in diversity attitudes, decrease in implicit bias, and increase in racial/ethnic identity–than providers in the control hospital [ 60 ].

Human resources development. Two interventions focused on the integration of qualified oversea nurses and midwives in Australia and the UK. The authors described the integration process of oversea nurses and offered support from the recruiting organizations. More than 90% of the questioned oversea nurses found the support strategies useful, especially personal support and a welcoming atmosphere upon arrival and orientation. All nurses who were supported by the program remain employed [ 67 ]. Stakeholders found that the program was resource-intensive and questioned the cost-effectiveness of this method for meeting employment needs. Senior nurses and many ward managers thought it beneficial to promote the ethnic diversity of the nursing workforce [ 93 ]. Another study concentrated on the expansion of the role of pharmacists in treating five minor pediatric conditions in a pediatric clinic (USA). Service provided by pharmacist was comparable to the service provided at the standard acute care clinic; patients were more likely to have shorter wait time (<15-minute wait) and were more likely to receive written information than patients evaluated by physicians. In addition, patient satisfaction was high [ 66 ].

Integration of interpreter services. Bekaert reports that even though a language and advocacy services was installed at Horton General Hospital (UK), relatives were still translating for patients due to costly systems [ 88 ]. Furthermore, some patients in a culturally focused psychiatric consultation intervention program for Latino Americans with depression reported that even though interpreters were available, waiting for interpreters or having interpreters involved in private medical conversations was challenging [ 82 ].

Adaption of the organization’s social and physical environment. After the implementation of a Cambodian menu for postpartum women at Saints Medical Center (USA) in combination with a staff training program on breastfeeding, there were no significant difference between breastfeeding initiation rates among Cambodian women and non-Cambodians (66.7% Cambodian vs.68.9% non-Cambodian p = .874), although before its implementation Cambodian mothers were significantly less likely to initiate breastfeeding than non-Cambodian mothers (16.7% Cambodian vs. 60.6% non-Cambodian p = .003) [ 63 ]. The option of having an ethnic meal was not chosen because patients did not trust the mechanism of provision at Horton General Hospital (UK) [ 88 ], and it was considered enjoyable but not essential by women refugees at an ambulatory healthcare facility [ 75 ]. The installment of a sweat lodge on hospital property, where traditional ceremonies were held, improved care for Native Americans, which resulted in increased admissions of this population (4.77% to 7.50%) [ 70 ].

Data collection and management. Bekaert et al. (2000) reports that at Horton General Hospital (UK) “data collection was still not carried out regularly because staff felt it would be an imposition.”

Strategies for providing access to culturally competent healthcare

Integration of community health workers (CHW) to educate patients during home or clinic visits. CHW were generally bicultural/bilingual and were also able to conduct minor medical procedures. Culica et al. (2008) found significant reductions (p < .05) in mean HbA1c levels of culturally diverse diabetes patients from baseline to six months (8.14% to 7.36%) and 12 months (8.14% to 7%) after attending educational clinic visits carried out by a CHW at an urban community clinic (USA). In the context of a clinic-based colorectal cancer screening promotion program (USA), the integration of a CHW in combination with mailed educational material on colorectal cancer screening increased the number of screenings to 31% compared to 26% in the control group among Hispanic patients but the differences were not significant (p = .28) [ 30 ]. In the study by Tu et al. (2006), a culturally competent clinic-based educational program promoting fecal occult blood testing (FOBT) screenings among Chinese patients including motivational videos on colorectal cancer screening and carried out by a trilingual and bicultural health educator increased the screening rate to 69.5% compared to 27.6% in the treatment as usual condition [ 39 ]. A culturally and linguistically tailored health coach intervention for Chinese-American diabetes patients at two outpatient medical care units, in which patients were closely accompanied by their health coach during and after treatment, resulted in decreased mean HbA1c levels at follow-up (-0.40%) compared to the treatment as usual group (+0.04%), however this difference was not statistically significant [ 57 ]. Black or Latina navigators were integrated at Capital Breast cancer Center (USA) for women with abnormal mammogram results to ensure follow-up screenings among a population with low screening rates. Due to the intervention, 80% of women in need of further screening returned within a median time interval of 39 (range: 6–400) days which is below the recommended time of 60 days [ 68 ]. The advocates or liaisons who are integrated into the clinic team work lower stress for patients and providers through improved communication, increased safety of treatment, improved understanding, trust and connectedness, which in turn leads to higher efficacy of treatment and greater improvements in applying health recommendations in an outpatient oncology clinic (USA) as well as in primary care community clinics (Israel) [ 74 , 79 ].

Telemedicine. Psychiatric treatment offered by a bilingual psychiatrist via webcam led to a significant reduction in symptom severity and disability ratings as well as improvements in quality of life over time (p>.001) among Hispanic patients at a community health center (USA), but differences to treatment as usual delivered by a primary health provider were not significant [ 35 ]. The ratings of acceptability on a five-point-Likert scale ranged between 3.19 to 4.69, showing a high acceptability among Korean-speaking patients who were treated by a Korean-speaking psychiatrist via webcam at two mental health centers in the US [ 84 ]. Multilingual educational videos were significantly more beneficial than usual care (p>.001) for Punjabi and Chinese patients at a university-based pulmonary medicine clinic in Canada [ 37 ].

Outreach methods. An RCT by Coronado (2011) shows that a culturally competent mailed colorectal screening packet led to a 26% screening rate compared to 2% in clinic-based usual care (p < .001) and to a 31% screening rate if combined with telephone reminders and an educational home visit by a health promoter and a medical assistant (p < .001). Additionally, patients assigned to a home-based educational program on Iiving donor kidney transplantation in addition to a clinic based program at Shands Hospital at the University of Florida (USA) were more likely to have had living donor inquiries (OR:1.7; CI = 1.2–3) and a living donor evaluation (OR:2.7; CI = 1.4–5.4) and live donor kidney transplantation (OR: 3.0; CI = 1.5–5.9) than patients in the clinic-based program only [ 38 ]. Watkins et al. (1990) developed a strategy of early case finding by visiting women enrolled in their project and providing them with guidelines to identify culturally diverse pregnant farmworker women and referring them to a migrant health center in North Carolina (USA), which increased prenatal visits from a mean of 7.4 to a mean of 9.7 over one year and decreased the number of children with low birth weight from 13 to 6 over 2 years.

Creating community health networks. In order to improve healthcare for CLDP, health facilities engaged in activities concentrating on cooperation and exchange with other institutions within communities. In the context of a health clinic for refugees in Canada, initial intake assessments and basic services were performed at the reception house by case workers and trained professionals, while comprehensive care was provided at the refugee health clinic and more specialist services by community providers. Language support was also provided by the reception house. As a result, the likelihood of an individual requiring a physician specialist went down 45% as a result of seeing a refugee health clinic physician (OR = .55; p = .004) and refugees’ wait time to see a healthcare provider decreased from 30 to 21 days (Ratio of mean = .70; p < .001) [ 50 ]. A regional health collaborative formed by New York Presbyterian aimed to create a “medical village” by transforming clinics into patient-centered medical homes in a large Hispanic community. Patient-centered medical homes included multidisciplinary care teams, patient education, electronic health records system with up-to-date patient information and, disease registry and were linked to other providers and community institutions. This led to a 9.2% decrease of mean visits per patient to the emergency department following implementation of the model (p = 0.001). During the same period, hospitalizations for the cohort dropped by 5.8% (p = 0.25) [ 43 ].

Strategies for implementing culturally competent healthcare

Promoting changes within the organization. In order to improve healthcare for migrants, the “Migrant Friendly Hospital Initiative” in Geneva (Switzerland) decided to give to all new staff members a brief presentation of the initiative and about interpreter services during their mandatory orientation day. Aside from distributing brochures on the “Health for all Network”, migrant friendly services and information on the work with an interpreter, the hospital also organized numerous public events to raise awareness for its initiative. Hospital staff was significantly more likely to use the service of interpreters and other migrant friendly structures at the hospital. Overall, providers’ awareness increased and difficulties working with migrant patients decreased significantly [ 46 ]. The “Sick-Kids Cultural Competence Initiative” at the Hospital for Sick Children (Canada) established a Champion program in which cultural competence champions obtained advanced cultural competence education and became designated change agents and role models. Over 2,100 hospital staff members attended the workshops. Participants fulfilled 78% of the documented commitments to change and planed on realizing another 16% of commitments. Commitments to change were related to changes in practice, beliefs or attitudes and to continuing education related to culture and culturally competent care. Following a Cultural Competence Initiative promoting interpreter services, a significant increase in the use of face-to-face interpretation and a doubling of the number of minutes of telephone interpretation use was observed [ 76 ].

Model of culturally competent healthcare provision

Extracted components and strategies were organized into a model, the “Model of culturally competent healthcare provision” ( Fig 2 ). Importantly, the model is embedded in the legal context of a given country’s health system that regulates the organization of the system and the access to healthcare for individuals depending on their legal status in the country in question. Then again, the legal context is shaped by the political and social context of a country. In conclusion, the possibilities and usefulness of implementing identified strategies and components depend on the health system in which they are implemented as well as on the legal, social and political context of the country or region.

https://doi.org/10.1371/journal.pone.0219971.g002

This review systematically searched for evaluated culturally competent healthcare interventions from which components and strategies for providing culturally competent healthcare to CLDP were collected and their effects on outcome measures were examined. Twenty categories of components were identified and clustered into four groups. A model integrating those interventions is proposed. Data on the effects of identified components and strategies were not available for all categories because in most studies a combination of multiple strategies and components was implemented simultaneously, and therefore statements about the effects of single categories were not possible. However, for fifteen categories qualitative and/or quantitative data were available, but synthesis of data was difficult because of the diversity of studies and outcome measures. In general, the effects of identified components and strategies were positive but often small or not significant compared to treatment as usual. Qualitative data suggest that these components and strategies were appreciated and found helpful by patients and providers. Furthermore, they confirmed many of the components and strategies proposed by existing conceptual models or frameworks of cultural competence [ 8 – 10 , 21 ]. Existing models and reviews have already mentioned implementing the following strategies: providing care in different languages, recruiting bicultural/bilingual healthcare professionals, training healthcare staff in cultural competence, integrating community health workers, including individual patients’ families into care, adapting the environment by offering ethnic meals and, written material in different languages, collaborating with minority communities and monitoring of the organizational development. Nonetheless, this review identified strategies used to improve healthcare for CLDP which are not included in existing models. These are primarily related to improving access to culturally competent healthcare for CLDP: telemedicine, outreach methods and the creation of community health networks. In fact, it appears that these strategies address the socioeconomic differences often associated with culturally and linguistically diverse backgrounds, rather than the actual cultural backgrounds themselves (e.g., Outreach methods for Hispanic farmworkers). Some strategies are integrated in conceptual frameworks but were not often found in empirical studies. These include adapting policies and integrating traditional healers into care.

Reported evidence is limited in this review because the majority of studies implemented multiple components or used different strategies simultaneously, and outcomes could therefore not be attributed to one specific component or strategy. Other authors noted that the methodological quality of included studies is often insufficient to support the effectiveness of culturally competent interventions [ 9 , 11 , 12 , 21 , 22 ]. Truong’s systematic review of reviews on cultural competence outlined that most reviews only found weak evidence for improvements in patient outcomes and moderate improvement in provider outcomes and utilization rates [ 12 ]. Diaz et al. state in their scoping review that the main cultural competence interventions in 57 of 83 studies were declared beneficial for the primary outcome as well as for secondary outcomes in 13 studies. In 12 interventions no effects were observed compared with standard care [ 22 ]. The effectiveness of organizational system-level interventions was not confirmed because interventions were “context-specific, there were too few comparative studies and studies did not use the same outcome measures” [ 11 ]. In this review comparative studies were available but generally compared an innovative culturally competent health intervention to treatment as usual. This approach is problematic, because it gives no information on whether the health intervention, the culturally competent components or a combination of both can be determined to be effective. Anderson at al. (2003) stated in their review that no sufficient evidence was found to determine the effectiveness of workforce diversity, use of interpreter services, patient-provider matching, use of culturally and linguistically appropriate health education materials and culturally specific settings. In the present review, moderate effects on patient outcomes were found for patient-provider matching. A systematic review on race and racial concordance on patient-physician communication studies demonstrated that racial discordance is related to poorer communication [ 94 ]. Brach and Fraser (2000) highlighted that even though a relationship between communication, adherence and outcomes exists, it has not been demonstrated specifically for linguistic matching. They found some evidence that the provision of professional interpreter had positive effects on utilization and satisfaction and reduced disparities in healthcare [ 9 ], which could not be verified in this review. Integrating community health workers had again positive but modest effects on patient outcomes and utilization rates, which has also been confirmed by Brach and Fraser (2000).

The strength of this review lies in its overall approach. The use of a scoping review methodology with a systematic literature search allowed for a broad overview on studies implementing culturally competent health interventions in healthcare facilities. A bottom-up approach was used, and components and strategies have been extracted from practice instead of deriving interventions from theoretical concepts of cultural competence. In this way we created a model based on feasible and actually implemented interventions. Compared to existing models, this model summarizes a variety of strategies on different levels. The “Analytic framework used to evaluate the effectiveness of healthcare system interventions to increase cultural competence” by Anderson et al. (2003) included five strategies, while the conceptual model by Brach and Fraser (2000) identified nine major cultural competency techniques. Fung et al. (2012) proposed strategies in 24 subdomains organized in eight domains for implementing organizational cultural competence, but these only concentrated on the organizational level. This model provides 20 strategies on four different levels. In addition to strategies on the individual and organizational level, the model points out how change within healthcare organization can be implemented and how patients can better access culturally competent healthcare, which was not as thoroughly considered by previous models. In combination with the detailed description of the strategies and components in Table 2 , this review provides researchers, facility leaders and policy or decision makers with a unique catalogue of feasible strategies aiming to battle healthcare disparities and enhance healthcare for all patients. Importantly, it highlights that health systems and facilities are integrated into specific social, cultural, legal and political contexts that affect one another and influence the possibilities of implementing chosen strategies.

Some limitations must be considered. We included in our search different groups of culturally and linguistically diverse patients, such as migrants including refugees and asylum seekers but also racial or ethnic groups and minorities. Obviously, these groups are very heterogeneous and their needs and perceived barriers to healthcare may differ substantially. Nevertheless, we chose to include all different groups to create a broad overview of generally possible strategies. When implementing strategies, their appropriateness for the specific target group must be considered. In addition, interventions needed to be located explicitly in a healthcare organization, otherwise they were excluded from the review. Notably, interventions for CLDP are often implemented in community institutions such as community centers, churches or schools, but the focus if this review was to identify strategies implemented in healthcare organizations. Only studies published in English or German were considered to be included in the review, which may have caused a selection bias, and some relevant studies in other languages may have been excluded.

The majority of studies (76%) were from the US, and almost all studies were from industrialized countries. The US hosts the largest number of international migrants in the world with approximately 53% of migrants from Latin America, 25% from Asia, 14% and from Europe [ 95 ]. This is also reflected in the targets groups of identified studies, of which 48% were designated for Hispanics or Latinos. Interestingly, only 9% of studies were from the European countries of the UK, the Netherlands and Switzerland, even though Germany, Spain, the UK and France accommodate the highest numbers of approximately 31.9 million non-European Union (EU) nationals in Europe [ 96 ]. The high number of studies from the US is understandable but it limits the generalizability of the results and possibly the transferability to other health systems and groups. Importantly, the developed model does not claim to be comprehensive or completed but rather serves as an empirical baseline that needs to be verified and further developed. In this context it would be an asset to identify connections between target groups, types of implemented strategies, the respective health systems’ organization and perhaps even the legal, social and political context in chosen countries.

Despite the limitations of this review it provides a unique overview and categorization of culturally competent healthcare provision. Unfortunately, the effectiveness of identified components and strategies could not be confirmed and was even often impossible to evaluate because either no control group was available or the chosen control group did not give any information on the effectiveness of the culturally competent components but rather on the health intervention in combination with culturally competent elements. This presents a challenge for future research on the effectiveness of cultural competence in healthcare. An option would be to simplify or reduce the number of implemented components and to choose more appropriate control groups. Another option would be to improve the research methods in order to be able to evaluate single components of complex interventions. Using qualitative study designs might help to better understand what strategies are helpful to overcome healthcare disparities why and for whom. It is essential to keep the heterogeneity among CLDP in mind and to carefully consider interactions between societal, cultural, health related and personal factors to explain and reduce healthcare disparities.

Supporting information

S1 file. search terms..

https://doi.org/10.1371/journal.pone.0219971.s001

S1 Table. Screening criteria.

https://doi.org/10.1371/journal.pone.0219971.s002

S2 Table. Characteristics of healthcare interventions.

https://doi.org/10.1371/journal.pone.0219971.s003

S3 Table. Study characteristics and results.

https://doi.org/10.1371/journal.pone.0219971.s004

S4 Table. Identified culturally competent components/strategies and categorization.

https://doi.org/10.1371/journal.pone.0219971.s005

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– Medical School Blog

Recognizing the Importance of Cultural Competence in Health Care

Cultural competence has risen to the forefront in the conversation about the quality of healthcare in the US. The country’s most recent census data reveals that our population is diversifying even faster than predicted—and with that comes a rapidly evolving range of healthcare needs, systems of beliefs, language barriers, and more.

“Cultural competence is a critical component of practicing medicine because it ensures respect for the patient,” explains Dr. Arlette Herry, assistant dean of multicultural affairs at St. George’s University (SGU).

But what does this look like in practice? Join us as we break down the importance of cultural competence in healthcare and explore how medical schools are equipping future physicians to be effective practitioners for the most diverse and multiracial population the US has ever seen.

What is cultural competence?

When Dr. Herry thinks about cultural competence in healthcare, she focuses on the concept of cultural humility. This, she explains, encapsulates an awareness that your patient is multidimensional—that they come with different identities, including their gender, ethnicity, religion, socioeconomic status, marital status, education level, sexual orientation, and more.

“The willingness to explore and understand how these identities impact care is paramount in addressing health inequities and providing quality healthcare,” Dr. Herry continues. “Embracing cultural humility means the physician is aware of their own biases, understands how those biases inform their provision of care, and demonstrates a willingness to learn from their patients.”

“Embracing cultural humility means the physician is aware of their own biases, understands how those biases inform their provision of care, and demonstrates a willingness to learn from their patients.”

The Agency for Healthcare Research and Quality (AHRQ) notes that healthcare is defined through a cultural lens for both patients and providers. A person’s cultural affiliations can impact everything from where and how they seek care to how they describe symptoms and whether they follow care recommendations.

A culturally competent healthcare system is one able to provide care to patients with diverse values, beliefs, and behaviors. This requires attitudes and policies that support effective cross-cultural interactions. The AHRQ reveals a few examples of what this might look like in practice:

• Language assistance : This can take the form of hiring bilingual clinicians and staff members, along with employing qualified foreign language and American Sign Language interpreters.
• Cultural brokers: These professionals are brought on board to provide mediation between the traditional health beliefs and practices of a patient’s culture and the US healthcare system, acting as a bridge between patient and provider. This role could be filled by community health workers, interpreters, and patient navigators.
• Cultural competence training: Resource and training sessions can be held with the goal of increasing the cultural awareness, knowledge, and skills of clinicians and staff members.

As the American Academy of Family Physicians (AAFP) explains, a culturally competent healthcare system understands that a patient’s language and culture should never act as a barrier to receiving adequate care. Rather, these elements can be utilized as tools to improve outcomes.

Why is cultural competence in healthcare important?

“We have seen throughout history that disparities exist in healthcare,” offers Dr. Kandace LaMonica, family medicine specialist and chief resident for equity and diversity at Southwest Illinois University. The 2018 SGU alumna notes that this has been highlighted even further by the COVID-19 pandemic, with ethnic minorities being disproportionately affected .

“Cultural competence allows practitioners to provide quality care, regardless of a patient’s cultural background,” Dr. LaMonica continues. “In order to do so, providers must first acknowledge that these differences exist and how they can impact a patient’s healthcare needs.”

When it comes down to it, cultural incompetence can lead to some very real issues related to patient safety. One study found that patients with limited English proficiency were more likely to experience adverse outcomes than English-proficient patients. Another revealed that ethnic minorities are more likely to report dissatisfaction with their healthcare experiences and their interactions with physicians, often resulting in delay of care and lower adherence to medical treatments.

Failure to address cultural, language, or health literacy discrepancies can result in things like diagnostic errors, missed screenings, unexpected negative reactions to medication, and inadequate follow-up care. Cultural competency and respect have become critical components to reducing these healthcare disparities, as they help improve access to quality healthcare that is responsive to the needs of a diverse patient population.

“Understanding a patient’s values, beliefs, and backgrounds can open a door to better communication and build the foundation of a strong patient–physician relationship…”

“Understanding a patient’s values, beliefs, and background can open a door to better communication and build the foundation of a strong patient–physician relationship, which we know leads to better health outcomes ,” Dr. LaMonica says.

It’s also helpful to note that the impact of cultural competency in healthcare stretches beyond the realm of direct patient care. The National Institutes of Health (NIH) reports that it’s equally important to prioritize cultural competence when it comes to medical research. Planning that does not consider principles of cultural respect will inevitably produce ineffective care systems.

How does SGU train culturally competent physicians?

The Association of American Medical Colleges (AAMC) has deemed cultural competency to be a vital aspect of every medical school’s curriculum. But different institutions will take different approaches to equipping their students to be effective in a multicultural healthcare system.

“SGU prides itself on preparing its Doctor of Medicine (MD) students to practice cultural humility by infusing diversity, equity, and inclusion into the curriculum,” Dr. Herry says, explaining that the School of Medicine hosts a number of different opportunities for students to explore these topics in greater depth.

“There are implicit bias awareness trainings, along with sessions on care of persons with disabilities or in need of rehabilitation, care of transgender patients, and the social determinants of health,” she continues. SGU often includes a reflective component in each of these experiences, allowing students to take an introspective approach to exploring the type of physician they hope to become.

“Being able to observe and participate in a healthcare system outside the US is a unique experience you won’t find in a lecture hall or by reading a textbook.”

Earning an MD at SGU’s campus on the island of Grenada presents its own unique opportunities for medical students. “Studying in a country with different beliefs and value systems was an opportunity for growth, both personally and professionally,” Dr. LaMonica says. “Being able to observe and participate in a healthcare system outside the US is a unique experience you won’t find in a lecture hall or by reading a textbook.”

While studying at SGU, Dr. LaMonica did her clinical rotations at a hospital where the primary languages were Spanish, Chinese (Mandarin), and Bengali. “I saw firsthand the many challenges patients face stemming from language barriers and different cultural beliefs,” she recalls. “Hearing their stories and learning about their individual beliefs and values helped shape my training.”

She found her experience at SGU helped her adapt and connect with patients from different backgrounds. “I continue to carry these experiences with me even now as a practicing family physician.”

Become a culturally competent physician

Things like cultural awareness and cultural sensitivity are important characteristics that all healthcare providers should display. But the CDC clarifies that cultural competence emphasizes the concept of effectively operating in different cultural contexts and altering practices to reach different cultural groups.

“By focusing on key areas of cultural competence, such as improved access to healthcare, recruitment of minority physicians, partnering with community health workers, and providing cultural competency training sessions, we can start to lay the building blocks needed to bridge gaps that exist today in healthcare,” Dr. LaMonica says.

She found the type of training she was looking for at the St. George’s University School of Medicine . Learn about more potential benefits in our article “ 6 Little-Known Perks of Attending an International Medical School .”

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Cultural Competence in Health Care: Is it important for people with chronic conditions?

Visit profiles to view data profiles and issue briefs from the series Challenges for the 21st Century: Chronic and Disabling Conditions as well as data profiles on young retirees and older workers.

The increasing diversity of the nation brings opportunities and challenges for health care providers, health care systems, and policy makers to create and deliver culturally competent services. Cultural competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of patients.(1) A culturally competent health care system can help improve health outcomes and quality of care, and can contribute to the elimination of racial and ethnic health disparities. Examples of strategies to move the health care system towards these goals include providing relevant training on cultural competence and cross-cultural issues to health professionals and creating policies that reduce administrative and linguistic barriers to patient care.

Racial and ethnic minorities are disproportionately burdened by chronic illness

Racial and ethnic minorities have higher morbidity and mortality from chronic diseases. The consequences can range from greater financial burden to higher activity limitations.

Among older adults, a higher proportion of African Americans and Latinos, compared to Whites, report that they have at least one of seven chronic conditions — asthma, cancer, heart disease, diabetes, high blood pressure, obesity, or anxiety/ depression.(2) These rank among the most costly medical conditions in America.(3)

African Americans and American Indians/Alaska Natives are more likely to be limited in an activity (e.g., work, walking, bathing, or dressing) due to chronic conditions.(4)

The population at risk for chronic conditions will become more diverse

Although chronic illnesses or disabili- ties may occur at any age, the likelihood that a person will experience any activity limitation due to a chronic condition increases with age.(5) In 2000, 35 million people — more than 12 percent of the total population — were 65 years or older.(6) By 2050, it is expected that one in five Americans — 20 percent — will be elderly. The population will also become increasingly diverse (see Figure 2). By 2050, racial and ethnic minorities will comprise 35 percent of the over 65 pop-ulation.(7) As the population at risk of chronic conditions becomes increasingly diverse, more attention to linguistic and cultural barriers to care will be necessary.

Access to health care differs by race and ethnicity

Having a regular doctor or a usual source of care facilitates the process of obtaining health care when it is needed. People who do not have a regular doctor or health care provider are less likely to obtain preventive services, or diagnosis, treatment, and management of chronic conditions. Health insurance coverage is also an important determinant of access to health care. Higher proportions of minorities compared to Whites do not have a usual source of care and do not have health insurance (see Figures 3A and 3B).

Language and communication barriers are problematic

Of the more than 37 million adults in the U.S. who speak a language other than English, some 18 million people — 48 percent — report that they speak English less than “very well.”(8) Language and communication barriers can affect the amount and quality of health care received. For example, Spanish-speaking Latinos are less likely than Whites to visit a physician or mental health provider, or receive preventive care, such as a mammography exam or influenza vaccination.(9) Health service use may also be affected by the availability of interpreters. Among non-English speakers who needed an interpreter during a health care visit, less than half — 48 percent — report that they always or usually had one.(10)

Language and communication problems may also lead to patient dissatisfaction, poor comprehension and adherence, and lower quality of care. Spanish-speaking Latinos are less satisfied with the care they receive and more likely to report overall problems with health care than are English speakers.(11) The type of interpretation service provided to patients is an important factor in the level of satisfaction. In a study comparing various methods of interpretation, patients who use professional interpreters are equally as satisfied with the overall health care visit as patients who use bilingual providers. Patients who use family interpreters or non-professional interpreters, such as nurses, clerks, and technicians are less satisfied with their visit.(12)

Low literacy also affects access to health care

The 1992 National Adult Literacy Survey found that 40 to 44 million Americans do not have the necessary literacy skills for daily functioning.(13) The elderly typically have lower levels of literacy, and have had less access to formal education than younger populations.(14) Older patients with chronic diseases may need to make multiple and complex decisions about the management of their conditions. Racial and ethnic minorities are also more likely to have lower levels of literacy, often due to cultural and language barriers and differing educational opportunities.(15) Low literacy may affect patients’ ability to read and understand instructions on prescription or medicine bottles, health educational materials, and insurance forms, for example. Those with low literacy skills use more health services, and the resulting costs are estimated to be $32 to $58 billion — 3 to 6 percent — in additional health care expenditures.(16)

Lack of cultural competence may lead to patient dissatisfaction

People with chronic conditions require more health services, therefore increasing their interaction with the health care system. If the providers, organizations, and systems are not working together to provide culturally competent care, patients are at higher risk of having negative health consequences, receiving poor quality care, or being dissatisfied with their care. African Americans and other ethnic minorities report less partnership with physicians, less participation in medical decisions, and lower levels of satisfaction with care.(17) The quality of patient-physician interactions is lower among non-White patients, particularly Latinos and Asian Americans. Lower quality patient-physician interactions are associated with lower overall satisfaction with health care.(18)

African Americans, Latinos, and Asian Americans, are more likely than Whites to report that they believe they would have received better care if they had been of a different race or ethnicity (see Figure 4). African Americans are more likely than other minority groups to feel that they were treated disrespectfully during a health care visit (e.g., they were spoken to rudely, talked down to, or ignored). Compared to other minority groups, Asian Americans are least likely to feel that their doctor understood their background and values and are most likely to report that their doctor looked down on them.(19)

WHAT IS CULTURAL COMPETENCE IN HEALTH CARE?

Individual values, beliefs, and behaviors about health and well-being are shaped by various factors such as race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation. Cultural competence in health care is broadly defined as the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the health care system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy. Some common strategies for improving the patient-provider interaction and institutionalizing changes in the health care system include:(20)

1. Provide interpreter services

2. Recruit and retain minority staff

3. Provide training to increase cultural awareness, knowledge, and skills

4. Coordinate with traditional healers

5. Use community health workers

6. Incorporate culture-specific attitudes and values into health promotion tools

7. Include family and community members in health care decision making

8. Locate clinics in geographic areas that are easily accessible for certain populations

9. Expand hours of operation

10. Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing, and other written materials

Cultural competence is an ongoing learning process

In order to increase the cultural competence of the health care delivery system, health professionals must be taught how to provide services in a culturally com-petent manner. Although many different types of training courses have been developed across the country, these efforts have not been standardized or incorpo-rated into training for health profession-als in any consistent manner.(21) Training courses vary greatly in content and teaching method, and may range from three-hour seminars to semester-long academic courses. Important to note, however, is that cultural competence is a process rather than an ultimate goal, and is often developed in stages by building upon previous knowledge and experience.

TRAINING APPROACHES THAT TEACH FACTS ABOUT SPECIFIC GROUPS ARE BEST COMBINED WITH CROSS-CULTURAL SKILL-BASED APPROACHES THAT CAN BE UNIVERSALLY APPLIED

Approaches that focus on increasing knowledge about various groups, typically through a list of common health beliefs, behaviors, and key “dos” and “don’ts,” provide a starting point for health pro-fessionals to learn more about the health practices of a particular group. This approach may lead to stereotyping and may ignore variation within a group, however. For example, the assumption that all Latino patients share similar health beliefs and behaviors ignores im-portant differences between and within groups. Latinos could include first-generation immigrants from Guatemala and sixth-generation Mexican Americans in Texas. Even among Mexican Americans, differences such as generation, level of acculturation, citizenship or refugee status, circumstances of immigration, and the proportion of his or her life spent in the U.S. are important to recognize.

It is almost impossible to know everything about every culture. Therefore, training approaches that focus only on facts are limited, and are best combined with approaches that provide skills that are more universal. For example, skills such as communication and medical history-taking techniques can be applied to a wide diversity of clientele. Curiosity, empathy, respect, and humility are some basic attitudes that have the potential to help the clinical relationship and to yield useful information about the patient’s individual beliefs and preferences. An approach that focuses on inquiry, reflection, and analysis throughout the care process is most useful for acknowledging that culture is just one of many factors that influence an individual’s health beliefs and practices.(22)

GUIDELINES FROM PROFESSIONAL ORGANIZATIONS HELP PROMOTE CULTURAL COMPETENCE

Many professional organizations representing a variety of health professionals, such as physicians, psychologists, social workers, family medicine doctors, and pediatricians have played an active role in promoting culturally competent practices through policies, research, and training efforts. For example, the American Medical Association provides information and resources on policies, publications, curriculum and training materials, and relevant activities of physician associations, medical specialty groups, and state medical societies.(23)

Several organizations have instituted cultural competence guidelines for their memberships. For example, based on ten years of work, the Society of Teachers of Family Medicine has developed guidelines for curriculum material to teach cultural sensitivity and competence to family medicine residents and other health professionals. These guidelines focus on enhancing attitudes in the following areas:(24)

• Awareness of the influences that sociocultural factors have on patients, clinicians, and the clinical relationship.
• Acceptance of the physician’s respon-sibility to understand the cultural aspects of health and illness
• Willingness to make clinical settings more accessible to patients
• Recognition of personal biases against people of different cultures
• Respect and tolerance for cultural differences
• Acceptance of the responsibility to combat racism, classism, ageism, sexism, homophobia, and other kinds of biases and discrimination that occur in health care settings.

ACCREDITATION STANDARDS THAT ADDRESS CULTURAL COMPETENCE IN MEDICAL SCHOOLS HAVE THE POTENTIAL TO REACH MANY FUTURE PHYSICIANS

Accreditation standards are important tools that can have widespread effects on the cultural competence of medical students, health care professionals, and health care organizations. For example, the Liaison Committee on Medical Edu-cation (LCME) — the nationally recognized accreditation body for medical schools in the U.S. and Canada — recently mandated higher standards for curriculum material on cultural competence than were previously in place. As a result, medical schools must now provide students with the skills to understand how people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments. Students must also be able to recognize and appropriately address racial and gender biases in themselves, in others, and in the delivery of health care.(25)

Commitment to cultural competence is growing among health care providers and systems

Health systems are beginning to adopt comprehensive strategies to respond to the needs of racial and ethnic minorities for numerous reasons. First, there are increasingly more state and federal guidelines that encourage or mandate greater responsiveness of health systems to the growing population diversity. Second, these strategies may be seen as essential to meeting the federal government’s Healthy People 2010 goal of eliminating racial and ethnic health disparities. Third, many health systems are finding that developing and implementing cultural competence strategies are a good business practice to increase the interest and participation of both providers and patients in their health plans among racial and ethnic minority populations.

In addition to increasing the cultural competence of health care providers, organizational accommodations and policies that reduce administrative and linguistic barriers to health care are also important. Policies that strive to achieve cultural competence throughout the organization must address issues on all levels, from the organization’s top management to clinicians to office staff to billing and administrative staff. Organizational policies that address language and literacy barriers have been among the most successful efforts.

BILINGUAL AND BICULTURAL SERVICES ARE EFFECTIVE

Traditionally, community health centers that serve the Asian American or Latino communities have the most fully developed linguistic capabilities. For example, Asian Counseling and Referral Services (ACRS) in Seattle is a community-based mental health organization that effectively addresses language needs. They try to provide bilingual and bicultural clinicians that match the client’s background. When this is not possible, ACRS provides trained staff to act as co-providers with a licensed mental health professional. These trained individuals act not only as interpreters, but also help provide a cultural context for the client’s beliefs and practices. Stemming from 30 years of experience in this arena, ACRS has developed a training curriculum, “Building Bridges: Mental Health Interpreter Training for Interpreters of Southeast Asian Languages.” This curriculum will be used as a model for a national mental health interpreter training project to address the needs of limited-English speaking people. This national project includes training for interpreters, trainers, and health providers, as well as a mental health interpreter certification process.(26)

Within the Latino community, the use of promotoras, also known as peer edu-cators, is becoming increasingly popular. Promotoras are generally ordinary people from hard-to-reach populations who act as bridges between their community and the complicated world of health care. They learn about health care principles from doctors or non-profit groups, and share their knowledge with their com-munities. The peer education model is not only cost-effective, but also has been shown to be more effective in terms of reaching populations who find the information more credible coming from someone with a familiar background.(27)

ASSESSING LITERACY LEVELS CAN BREAK DOWN BARRIERS

Methods employed to assess literacy levels include the use of screening instruments that test for certain skills related to functional literacy or less formal tools that allow health care professionals to determine a person’s comfort level with various modes of communication. For example, at the To Help Everyone (T.H.E.) Clinic in Los Angeles, nurses and health care professionals speak individually with patients when they arrive at the health clinic to determine whether the patient prefers to learn by using written materials, pictures, verbal counseling, or some other technique. This method of assessment allows the patient to identify their own learning style preference without having to take a literacy test; it also reduces feelings of fear or humiliation that may occur when singled out.(28)

FEDERAL STANDARDS AND GUIDELINES FOR PROVIDING CULTURALLY AND LINGUISTICALLY APPROPRIATE CARE

1. The Department of Health and Human Services has provided important guidance on how to ensure culturally and linguistically appropriate health care services. The Office for Civil Rights published “Title VI Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency.” Very few states have developed standards for linguistic access. States that have developed such standards have focused on managed care organizations, contracting agreements with providers, and specific health and mental health services in defined settings.(29)

2. In August 2000, the Health Care Financing Administration (now Centers for Medicare and Medicaid Services) issued guidance to all state Medicaid directors regarding interpreter and translation services, emphasizing that federal matching funds are available for states to provide oral interpretation and written translation services for Medicaid beneficiaries.(30)

3. In December 2000, the Office of Minority Health of the Department of Health and Human Services issued 14 national standards on culturally and linguistically appropriate services (CLAS) in health care. These standards are intended to correct current inequities in the health services system and to make these services more responsive to the individual needs of all patients. They are designed to be inclusive of all cultures, with a particular focus on the needs of racial, ethnic, and linguistic population groups that experience unequal access to the health care system. The CLAS standards provide consistent definitions of culturally and linguistically appropriate services in health care and offer a framework for the organization and implementation of services. CLAS standards can be found at http://www.omhrc.gov/CLAS/

4. In 2002, two guides were developed to assist managed care plans with cultural and linguisti-cally appropriate services: “Providing Oral Linguistic Services: A Guide for Managed Care Plans” and “Planning Culturally and Linguistically Appropriate Services: A Guide for Managed Care Plans.” Both guides can be found at www.cms.gov/healthplans/quality/project03.asp  

Cultural competence is not an isolated aspect of medical care, but an important component of overall excellence in health care delivery. Issues of health care quality and satisfaction are of particular concern for people with chronic conditions who frequently come into contact with the health care system. Efforts to improve cultural competence among health care professionals and organizations would contribute to improving the quality of health care for all consumers.

1. Betancourt, J. R., Green, A. R., & Carrillo, J. E. 2002. Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.

2. Collins, K.S., Hughes, D. L., Doty, M. M., Ives, B. L. Edwards, J. N., & Tenney, K. 2002. Diverse communities, common concerns: Assessing health care quality for minority Americans. New York: The Commonwealth Fund.

3. Druss, B.G., Marcus, S.C., Olfson, M., Pincus, H.A. 2002. The most expensive medical conditions in America. Health Affairs, 21, 105-111.

4. Fried, V. M., Prager, K., MacKay, A. P., Xia, H. 2003. Health, United States, 2003: Chartbook on trends in the health of Americans. Hyattsville, MD: National Center for Health Statistics.

6. U.S. Bureau of the Census. 2000. Table DP-1, Profile of general demographic characteristics: 2000. Washington, DC: Author. Retrieved November 13, 2003, from http://factfinder.census.gov.

7. Day, J. C. 1996. Population projections of the United States by age, sex, race, and Hispanic origin: 1995 to 2050. (U.S. Bureau of the Census, Current Population Reports, P25-1130). Washington, DC: U.S. Government Printing Office.

8. Center on an Aging Society analysis of data from the 2000 Census, QT-P17, Ability to speak English. Washington, DC: U.S. Bureau of the Census, Census Summary File 3 ? Sample Data.

9. Fiscella, K., Franks, P., Doescher, M. P., & Saver, B. G. 2002. Disparities in health care by race, ethnicity and language among the insured: Findings from a national sample. Medical Care, 40(1), 52-59.

10. Collins et al. 2002.

11. Carrasquillo, O., Orav, E. J., Brennan, T. A., Burstin, H. R. 1999. Impact of language barriers on patient satisfaction in an emergency department. Journal of General Internal Medicine, 14, 82-87.

12. Lee, L. J, Batal, H. A., Maselli, J. H. Kutner, J. S. 2002. Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic. Journal of General Internal Medicine, 17, 641-646.

13. Kirsch, I. S., Jungeblut, A., Jenkins, L., & Kolstad, A. 2002. Adult literacy in America: A first look at the results of the National Adult Literacy Survey, Third Edition. Washington, DC: U.S. Department of Education, National Center for Education Statistics, Office of Educational Research and Improvement. Retrieved November 13, 2003, from http://nces.ed.gov/pubs93/93275.pdf.

14. Cooper, L. A., Roter, D. L. 2003. Patient-provider communication: The effect of race and ethnicity on process and outcomes of healthcare. In B. D. Smedley, A. Y. Stith & A. R. Nelson (Eds.) Unequal treatment: Confronting racial and ethnic disparities in health care (pp. 552-593). Washington, DC: The National Academies Press.

15. Wilson, J.F. 2003. The crucial link between literacy and health. Annals of Internal Medicine, 139, 875-878.

16. Center for Health Care Strategies. 2003. Impact of low health literacy skills on annual health care expenditures. Lawrenceville, NJ: Author. Retrieved November 17, 2003, from http://www.chcs.org/ resource/pdf/h13.pdf.

17. Cooper & Roter. 2003.

18. Saha, S., Arbelaez, J. J., Cooper, L. A. 2003. Patient-physician relationships and racial disparities in the quality of health care. American Journal of Public Health, 93, 1713-1719.

19. Collins et al. 2002.

20. Brach, C. & Fraser, I. 2000. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review, 57 (Supplement 1), 181-217.

21. American Institutes for Research. 2002. Teaching cultural competence in health care: A review of current concepts, policies, and practices. Report prepared for the Office of Minority Health. Washington, DC: Author.

22. Bonder, B., Martin, L., Miracle, A. 2001. Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Generations, 25, 35-42.

23. American Medical Association. 1999. Cultural Competence Compendium. Chicago: Author.

24. American Institutes for Research. 2002.

25. Liaison Committee on Medical Education. 2001. Functions and structure of a medical school. Retrieved February 2, 2004, from http:// www.lcme.org/functions2003september.pdf.

26. Asian Counseling and Referral Service. 2003. ACRS participates in national effort to train mental health interpreters. Seattle, WA: Author. Retrieved November 25, 2003, from http://www.acrs.org/eventsNews/ newsletter.htm

27. Kolker, C. 2004, January 5. “Familiar faces bring health care to Latinos.” The Washington Post, p. A03.

28. Kiefer, K. M. 2001. Health literacy: Responding to the need for help. Washington, DC: Center for Medicare Education.

29. Goode, T., Sockalingam, S., Brown, M., & Jones, W. 2001. Linguistic competence in primary health care delivery systems: Implications for policy makers. Washington, DC: National Center for Cultural Competence, Center for Child Health and Mental Health Policy, Georgetown University Child Development Center.

30. Westmoreland, T. M. 2000, August 31. Letter to State Medicaid Directors from Timothy M. Westmoreland, Director, Centers for Medicare and Medicaid Services. Retrieved November 18, 2003, from http:// cms.hhs.gov/states/letters/smd83100.asp.

ABOUT THE ISSUE BRIEFS

This is the fifth in a series of Issue Briefs on Challenges for the 21st Century: Chronic and Disabling Conditions. This series is supported by a grant from the Robert Wood Johnson Foundation. The Issue Briefs accompany the Center’s ongoing series of Data Profiles in the same series. Emily Ihara wrote this Issue Brief.

The Center on an Aging Society is a non-partisan policy group located at Georgetown University’s Institute for Health Care Research and Policy. The Center studies the impact of demographic changes on public and private institutions and on the financial and health security of families and people of all ages.

• Research article
• Open access
• Published: 31 January 2007

Cultural competence in mental health care: a review of model evaluations

• Kamaldeep Bhui 1 ,
• Nasir Warfa 1 ,
• Patricia Edonya 1 ,
• Kwame McKenzie 2 &
• Dinesh Bhugra 3  

BMC Health Services Research volume  7 , Article number:  15 ( 2007 ) Cite this article

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Cultural competency is now a core requirement for mental health professionals working with culturally diverse patient groups. Cultural competency training may improve the quality of mental health care for ethnic groups.

A systematic review that included evaluated models of professional education or service delivery.

Of 109 potential papers, only 9 included an evaluation of the model to improve the cultural competency practice and service delivery. All 9 studies were located in North America. Cultural competency included modification of clinical practice and organizational performance. Few studies published their teaching and learning methods. Only three studies used quantitative outcomes. One of these showed a change in attitudes and skills of staff following training. The cultural consultation model showed evidence of significant satisfaction by clinicians using the service. No studies investigated service user experiences and outcomes.

There is limited evidence on the effectiveness of cultural competency training and service delivery. Further work is required to evaluate improvement in service users' experiences and outcomes.

Health professionals are now more aware of the challenges they face when providing health care to a culturally and racially diverse population [ 1 ]. Despite concern about ethnic disparities of access to culturally appropriate mental health care, and calls for cultural competency training to be mandatory, there is little information about the effectiveness of cultural competency training in mental health settings [ 2 – 4 ]. It is well established that in order to provide culturally competent care, knowledge of cultural beliefs, values and practices is necessary otherwise health practitioners can easily fall prey to errors of diagnosis, inappropriate management and poor compliance [ 5 ]. Training curricula for medical, nursing and social work students now generally include lectures and course work on cultural competency in health care provision. Post-graduate training is also being revised (for example in the UK the Royal College of Psychiatrists) to incorporate cultural influences on mental health care. Despite this progress, a recent tragedy in the UK expedited the acceptance of policies to promote cultural competency training. A psychiatric inpatient was medicated under compulsory legislation and died while being restrained following a period during which he was subjected to racial abuse from another patient. The subsequent inquiry concluded that better training was necessary for the management of imminent violence and for staff to develop cultural competence in care provision [ 3 ].

Although such recommendations are laudable, there appear to be several problems with such an approach. There is considerable confusion about what constitutes cultural competence. For example, it may be narrowly interpreted to mean better knowledge of the cultural beliefs and practices of a specific cultural group, with little attention to how culture modifies illness perceptions, illness behaviour, and acceptability of specific interventions. Cultural competency is somehow expected to emerge if the racial and ethnic mix of the workforce is representative of the local population. Not surprisingly, working practices following standardised professional trainings remain similar among staff from different ethnic groups because of the common pattern of training. Indeed, a patient and a health professional, ostensibly belonging to the same ethnic group because of shared country of origin, may actually differ in terms of social class, religious practices, languages, and cultural beliefs about illness and recovery. Despite a growing body of health and educational policies that prioritise cultural competency in health care provision, there is surprisingly little agreement on the meaning of cultural competence training or knowledge about its effectiveness.

In this review we seek to: define the meaning of cultural competence in mental health settings, describe models of cultural competence which have been evaluated in mental health settings, and assess the evidence for effectiveness by reviewing studies that implemented a model of cultural competence and then evaluated its effectiveness.

All accounts of cultural competency published in English since 1985 were identified. This date was applied to ensure relevance to recent practice and profiles of ethnic groups for whom the training is intended to improve outcomes. The searches were undertaken between January 2004 and June 2004. The titles and abstracts of papers were reviewed against inclusion criteria:

showed implementation of a cultural competence model of mental health care AND

provided some evaluation data for a cultural competency model of service provision or training AND/OR included an evaluation of adherence to a pre-defined model of cultural competence in mental health services

Papers meeting these criteria were called A papers (listed in Table 1 ). Other relevant papers were not extracted but read for background information, and for placing some of the findings in a wider context. We included all papers published in English language that were about adults with mental illness. The literature search including the following databases: Ingenta, Medline via Ovid, Medline via Pubmed, Medline Plus, Health Outcomes, HealthPromis, HSTAT, DocDat, National Research Register, NLM Gateway, Cam, ReFer and Zetoc. Research Phrases/terms included combinations of the following: Cultural Competence, Cultural Capability, Cultural Sensitivity, Mental Health, Mental Healthcare, Mental Health settings, Best practice, Cross Cultural Mental Health and Cross Cultural Psychiatry. Websites known to include cultural competency or educational materials were also searched [ 6 – 15 ].

Forward and backward citation tracking was undertaken on A papers to identify any further papers of relevance. We also asked two experts to review the search findings, and recommend any other publications. This yielded a PhD thesis and one paper, but neither met our inclusion criteria as they did not include an evaluation. We aimed to include quantitative and qualitative studies. Two researchers reviewed and extracted data from each of the 9 papers; disagreements on the extracted data were resolved by consensus. Information about the studies was extracted and tabulated, including year of study, author, type of study, country of study, and reference populations (Table 1 ). We undertook a narrative synthesis of the data that is suitable for observational studies where meta-analysis is inappropriate [ 16 , 17 ].

A total of 1554 publications were identified; of these 109 were selected for further scrutiny on the basis of screening the abstract and titles; only 9 of these met our basic inclusion criteria. These studies implemented models of cultural competence that were evaluated by qualitative or participatory methods, or presented an evaluation of an intervention to improve cultural competency. All studies were based in North America. Many other models of cultural competency were reported in other papers that did not meet our inclusion criteria; we did not review these as there was no evaluation to support them as a model for real services settings. Most of these additional papers expressed opinions or experiences of teaching and training in cultural competence.

Scope of Papers

Five papers were on cultural competency for physicians and nurses [ 18 – 20 ], multidisciplinary teams [ 21 ], and medical students [ 22 ]. Five papers included organisational aspects of cultural competency; these referred to the implementation of an assessment and performance framework [ 4 ], assessing and implementing measurable benchmarks for performance management [ 23 , 24 ], interpretation of state legislation, contract language and monitoring for impacts on cultural competency [ 25 ]; one paper explored organisational drivers that promote change, whilst ensuring measurement of performance, and that there was a change of organisational culture; this paper also explored how organisations integrated different programmes of activity [ 16 ]. One government initiative [ 4 ] relied on standards set by the Office of Minority Health [ 26 ], called the Culturally and Linguistically Appropriate Services Standards (or CLAS Standards; see Table 1 ).

Methods Used in Studies

The study methods varied widely, with outcomes that varied across studies; most studies used an action research process, and none used a randomised control trial design. The methodological variability and reliance on exploratory designs precluded meta-analyses, and even quality assignment, as some studies either did not report their analytic methods in enough detail or evolved their methods during the study. Some only measured adherence to a template of cultural competence, rather than the clinical outcome of adherence to a cultural competency model.

Definitions of Culture Competence

The definitions proposed in each of the 9 papers were tabulated (Table 1 ). We present here a synthesis of the key characteristics. Cultural competence included a set of skills or processes that enable mental health professionals to provide services that are culturally appropriate for the diverse populations that they serve. This definition was focussed on an outcome, and included attention to obvious language differences in the consultation, as well as how culture influences attitudes, expressions of distress, and help seeking practices. Consequently, it was suggested that clinical procedures and policies should reflect these. Showing respect for patients' cultural beliefs and attitudes was an important component, especially when their views opposed or differed from the professionals' views. Emphasis was given to a genuine willingness and desire to learn about other cultures, rather than this simply being a managerial requirement. The definitions indicate a common aim, to increase performance and the capabilities of staff when providing service to ethnic minorities. Most studies gave a definition of cultural competence before their evaluation, but one study [ 25 ] reported that different definitions were used in different US states (see Table 2 ).

Mandatory or Discretionary

Table 1 & 2 set out the key components of the models and present the outcome data. The studies of individual professions took an educational approach, subjecting each group to an analysis of how best to teach and learn about culture: the key findings include the need for a desire to learn about other cultures and that this could not be mandated. Three papers recommended that training be discretionary [ 22 , 18 , 24 ], whereas, like UK policy, one paper recommended a compulsory process [ 23 ]. Actual encounters with other cultural groups were considered important in all studies.

Teaching and Learning Methods

Only three studies published their teaching and learning methods. One model of cultural competency recommended participant observation, analysis of case reports, consultation and conferences around specific clinical problems [ 19 ]. Another [ 18 ] recommended discussing and writing about case histories and paying attention to the narratives. Hadwiger's model was developed for nursing working in critical care settings; this deployed interactive lectures and small group teaching with role-play exercises and patient centred interviews to enhance cultural understanding [ 20 ]. Only three studies actually followed up subjects to assess changes in behaviour or adherence to a model of cultural competency following an intervention [ 19 , 22 , 23 ].

Organisational Processes

Four studies evaluated organisational approaches [ 4 , 23 – 25 ], but each study focussed on different processes. Siegel et al developed performance indicators and tested them for feasibility and value within a performance framework for 21 health care organisations [ 23 ]. Kondrat et al identified characteristics of better performing culturally competent organisations (called benchmark agencies), where these distinguished them from less culturally competent organisations (comparison agencies): a pro-agency attitude among staff, openness and flexibility of provision, consistent, pro-active and supportive supervision, and team based functioning and decision making were all essential [ 24 ]. This study also showed that race and culture were rarely considered in care provision.

The US Dept of Health and Human Services developed a performance framework using the nine domains for cultural competent health care provision proposed by the Office of Minority Health [ 26 ]. These include organisational and individual level processes, including a performance framework for culturally competent commissioning and to assess the service impacts (see Table 1 ).

One US study evaluated how legal requirements in five US states for cultural competence in provider organisations are reflected in contract language, monitoring for adherence to the principles of cultural competency, and in the efforts to enforce adherence [ 25 ]. Although four states did include language support, for example, interpretation services, staff capacity and training, none of these contractual expectations were enforced, and there were no penalties for non-adherence.

Quantitative Outcomes

Only three studies gave quantitative outcomes [ 21 – 23 ]. These showed changes in 'intention to modify practice' following training (30%) and actual changes in behaviour (20%) following training [ 22 ]. There was significant (86% of practitioners) satisfaction with the consultation model [ 21 ]; 48% reported better treatment, and 31% expressed improved communication, empathy, understanding and therapeutic alliance. There were concerns that not all the recommendations could be followed due to limited resources. A lack of resources and recommendations that were unrealistic were sources of dissatisfaction among clinicians. Siegel et al reported high levels of training and education in administrative and service delivery aspects of service provision (73–87%) as well as a commitment to culturally appropriate services [ 23 ]; 87% of the services were adapted or developed for specific cultural groups; 29% of these, provided culture-specific services; for 71% of these culture-specific services had been put in place in response to the perceived needs of clients in the community.

The limited evidence recommends: a) specific processes and forms of learning for practitioners, b) in the context of a culturally competent provider that is c) commissioned and performance managed according to agreed benchmarks. The studies were based in the US or Canada, raising questions about the transfer of knowledge between these and other countries. For example, the managed care and insurance based service models in the US may not translate well to contexts where the services rely on public funding.

The histories of migration to each country will also differ; the emphases given in each country to specific forms of citizenship may favour the adoption of special services or propose that immigrants should assimilate and adapt themselves [ 27 ]. Furthermore, histories of colonial rule and positive expectations of each country's response to immigrants from the colonies may lead to disappointment and thwarted aspirations, alongside discrimination that all culminate in particular forms of discourse on cultural competency. For example, in the UK there has been an emphasis on discrimination and racism [ 27 , 28 ]. However, there are general lessons for work in a multi-cultural society and these will now be discussed.

Individual level cultural competence

The findings suggest that a culturally competent person is able to acknowledge, accept, and value the cultural differences of others. That is, such a person has the knowledge and skill that enable him or her to appreciate value and celebrate similarities and differences within, between, and among culturally diverse groups [ 29 , 30 ]. The 'LEARN' model emphasised more specific skills: Listen, Elicit, Assess, Recommend and Negotiate [ 22 ]. The voluntary desire to become culturally competent was seen to reflect an important general attitude towards work with culturally diverse groups [ 30 ].

Several sequential stages were identifiable in the pathway towards cultural competence. A developmental process was proposed moving from cultural awareness to improved cultural knowledge and improved skills through encounters [ 19 , 20 ]. This developmental process involved practitioners looking within themselves to reveal expectations about whether others should adapt to our institutional norms and culture [ 16 ]. This reflexivity is necessary to develop empathy through a better understanding of the patient's predicament [ 31 ], avoid assumptions and stereotypes [ 21 ], and to be aware of ones own attitudes and prejudices [ 32 ]. Empathy relies on precise communication of emotional experiences and worries, despite language barriers or communication through an interpreter. Indeed, with the right attitude to develop skills, and the aptitude to contain uncertainty, contradictions in communications can be positively harnessed to improve the outcome of therapies [ 33 ].

Teaching & Learning Methods

The importance of training and education was highlighted. However, there was little information about appropriate content or learning methods in order to optimise learning and teaching impacts on practitioners' knowledge and skills, nor was there information on whether medical or other mental health practitioners require distinct approaches. Few publications evaluate teaching methods and the content of programmes for medical students and other health professionals. This is quite surprising considering there is acknowledgement of the need to examine policies and procedures regarding cultural sensitivity and competence to improve the experiences of black and ethnic minority services users [ 34 ].

Reviewing the literature reveals that there were no instances of enforced changes within mental health services. Materials to teach cultural competence maybe limited, but there are recommendations and materials available both in the US and UK to develop programmes [ 34 ]. Regrettably, as our review shows, few of these have been subjected to any stringent evaluation of outcomes. Different methods for teaching cultural competence include:

Lectures: these convey lots of information and are cost effective.

Case study discussion: these elicit many views, and participant interactions occur and challenge behaviours and attitudes.

Role-play reveals hidden attitudes and challenges behaviours.

Video materials and video feedback: this enables portrayal of many perspectives, demonstrates non-verbal communication, and raises awareness.

Curriculum Content

Welch divided training content into three areas, knowledge, awareness, and skills [ 35 ]. Knowledge focuses on the perspectives of illness and healing, learning about different views of illness and healing. Concepts and definitions of race, culture ethnicity, and the role of power are important to define. This also covers seeking to understand the family and community structures and functions. Awareness of difference and an ability to discern different health and illness beliefs were essential alongside challenging stereotypes and assumptions. Skills that were recommended focussed on social and language barriers in healthcare. An alternative approach is to use of film as a resource for cultural competency training. Like the studies that used case reports, consultation, and thoughtful discussion, the use of film and the arts can help explore the limitations of existing theories about race and ethnicity [ 36 ]. This approach brings to the fore the individuals' stereotypes that may shape assessment and clinical management recommendations. Policy and organisational constraints on individual practice can also then be discussed if they are witnessed to obstruct innovation.

Organisational Cultural competence

The literature revealed several domains of organisational cultural competency including attention to organisational values, training and communication. Cultural competence at the organisational level must be embedded in the infrastructure and ethos of any service provider. Culturally competent organisations actively design and implement services that are developed according to the needs of their service users. This involves working with others in the community, for example traditional healers, religious and spiritual leaders, families, individuals and community groups. Three studies included domains of assessment and performance management [ 4 , 23 , 24 ]. Clearly, this locates individual training and education in a more complex system of values, finances, policies and contracts [ 16 , 25 ].

However, in the absence of evidence of effectiveness mandatory training is difficult to justify. Thus existing calls for training appear to rely on clinicians' extensive experience of benefits of training, concerns about the uncertainties involved in the care of culturally diverse groups including fears about accusations of discrimination, and political imperatives supported by anti-discriminatory legislation. Careful reading of established training manuals [ 37 , 38 ] show these to be built on complex notions of race, ethnicity and culture, and the interaction with illness experience and behaviour and contexts. Pioneering work is based on experiences of the actual implementation of programmes in many countries in real clinical and service settings [ 39 – 41 ]. In the absence of randomised trials, or clear specification of complex interventions to improve cultural competency, these forms of evidence should be used with care to establish the foundations for future research, training and service development [ 42 ].

Current mental health policies in culturally and racially diverse societies recommend that mental health professionals be cultural competent. However, the response from each country is in part dependent on the specific histories of immigration, and national attitudes towards migrants, citizenship and how to address racial and cultural integration. Cultural competency of care and services may be proposed in quite diverse ways depending on the local context. This mandates the needs for careful research and quality checks on what is proposed and implemented and applied in different countries [ 42 ].

This paper shows that although cultural competency training is important, the form it should take and the organisational performance frameworks to assess impacts are under developed. Most studies were exploratory, and few presented quantitative information. Future work should include randomised trials of complex interventions (teaching and organisational policies), alongside evaluations that include service user based assessment of benefit. In order to establish randomised trials, there needs to be agreement on and the development of appropriate outcome measures for educational and service level interventions. These may be distinct from performance measures at a service level, or commissioning frameworks. Investigations could also explore how 'values' in organisations may shift to produce more conducive environments in which anti-discriminatory practice can become embedded and so allow culturally competent care practices to flourish.

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Kamaldeep Bhui, Nasir Warfa & Patricia Edonya

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Bhui, K., Warfa, N., Edonya, P. et al. Cultural competence in mental health care: a review of model evaluations. BMC Health Serv Res 7 , 15 (2007). https://doi.org/10.1186/1472-6963-7-15

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Cultural Competence and Values of Healthcare Professionals Essay

Cultural competence is an essential part of the professionalism of any healthcare professional. Since nurses carry out most of the work of caring for and monitoring patients’ health, these specialists are capable of the most supportive and allied model of responsibility. Combating racism, prejudice, and language barriers are the foundation for improving healthcare professionals’ competence, as identified by recent research. Personal traits such as empathy, compassion, and dedication are the elements that the next generation of professional nurses should possess.

Culture is a multifactorial concept that covers relationships, food and hobby preferences, and values that a person pursues. Nurses are responsible for understanding that each individual is unique and cherishes certain verbal and non-verbal communication elements that can be identified through interpersonal contact (1). Therefore, empathy and willingness to communicate informally should enhance mutual understanding and trust between the service provider and the patient (2). I value diversity as a self-identification method in a society that allows people to be different and follow their goals. In particular, emotional intelligence as a marker of respect for the client allows the nurse to establish behavioral patterns to help the audience perceive doctors as allies (3). On the other hand, sufficient knowledge of the community’s characteristics provides medical professionals with more comfortable self-development conditions, stress management, and improved personal health through reduced nervous tension during communication (4). Thus, improving the cultural competence of nurses is a beneficial educational course for both patients and society.

Learning about diversity begins with understanding features and how to manage them in medical settings. A readiness to expand awareness is also a nursing trait that is valued in today’s industry. The fight against racism and language barriers must be fundamental and embedded in college and university specialist degrees (5). Besides, recognizing the families’ characteristics reveals information regarding their values and daily life, which is necessary for a client-centered model of care (6). It is essential to understand that continuous learning and openness to new operation methods distinguish qualified medical professionals.

My personal traits influence my work through the psychological awareness of the value of my help to society. It is an integral part of a nurse’s mental well-being since understanding the specialist’s contribution to human health, and the long-term nature of this process motivates to explore the cultural preferences of clients (7). My advantages also cover the desire to ensure patients’ and their families’ safety so that their treatment process is the least stressful. For example, I strive to explain all the procedures used in the therapy process to suppress any misunderstandings and stereotypes. Besides, I am open to dialogue and ready to answer questions of interest so that a person feels my support and sincerity of help. Since similar values have been demonstrated by students of medical specialties (8), nursing’s future growth is a new round in ensuring an allied and safe paradigm of interventions.

The healthcare industry is culturally sensitive, as the patient must feel the care and quality of services without the provider’s discriminatory behavior. The nurse must show empathy, sincerity, and a willingness to learn to be aware of community development dynamics. My values correlate with these factors since I am open to discussions with clients and their families. Moreover, I aim to create the intangible sense of my work, and sincerely wish patients recovery. Further educational updates should include concrete practices of respect for cultural differences and integrating them into daily activities.

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Giménez‐Espert M, Prado‐Gascó V. The role of empathy and emotional intelligence in nurses’ communication attitudes using regression models and fuzzy‐set qualitative comparative analysis models. Journal of Clinical Nursing. 2018: 27(13-14): 2661-2672.

Wesołowska K, Hietapakka L, Elovainio M, Aalto A, Kaihlanen A, Heponiemi T. The association between cross-cultural competence and well-being among registered native and foreign-born nurses in Finland. PLOS ONE. 2018: 13(12).

Biles J. Cultural competence in healthcare: our learning from 2017-2020. Nursing, Midwifery, and Indigenous Health. 2020.

Murcia S, Lopez L. The experience of nurses in care for culturally diverse families: a qualitative meta-synthesis. Revista Latino-Americana de Enfermagem. 2016: 24(0).

Suk M, Oh W, Im Y. Factors affecting the cultural competence of visiting nurses for rural multicultural family support in South Korea. BMC Nursing. 2018: 17(1).

Lee S, Lee M, Peters A, Gwon S. Assessment of patient safety and cultural competencies among senior baccalaureate nursing students. International Journal of Environmental Research and Public Health. 2020; 17(12): 4225.

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Intercultural sensitivity in Chilean healthcare profession students

• Patricia Pineda 1 , 2 ,
• Maura Klenner 3 ,
• Gerardo Espinoza 2 , 4 ,
• Rodrigo Mariño 5 , 6 &
• Carlos Zaror 1 , 2  

BMC Medical Education volume  24 , Article number:  467 ( 2024 ) Cite this article

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Each culture has unique health care related values, habits, perceptions, expectations, norms, etc., that makes cultural competence an important attribute to be developed by healthcare professionals, to ensure they provide effective treatment. Intercultural sensitivity (IS) is the affective dimension of cultural competence. The objective of this study is to explore the self-perceived level of IS in first and last year students of three health sciences professions (i.e., Dentistry, Medicine, and Nursing) at the Universidad de la Frontera, Temuco, Chile. This study adopted a cross-sectional design and a group comparison (e.g., year of study). 312 students completed the Intercultural Sensitivity Scale (ISS). Findings showed that overall ISS scores ranged from 1.83 to 4.94, with a mean score of 4.11 (s.d. 0.43). Group comparison between first and final year students showed statistically significant differences (4.18 vs. 4.00; p  < 0.001). Medical and nursing students had a significantly higher overall mean IS score compared to dental students (4.21 and 4.16, respectively vs. 4.02; p  < 0.01). There were also significant differences between three factors (interaction engagement; interaction confidence; and interaction enjoyment) by healthcare profession. These findings allow for discussion of the need for explicit incorporation and development of cultural competence in on health care professional curricula. Longitudinal research is needed to explore how IS changes over time, along with generating qualitative data from the student populations IS experiences and exposure.

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Within the current trend of globalization and greater population mobility (i.e., migrations) both within and between countries, the importance of cultural diversity constitutes a challenge that healthcare professionals and teams must address as part of their everyday healthcare activities. Different approaches may be required to address healthcare problems of culturally diverse groups compared to mainstream groups [ 1 , 2 ]. Each culture has unique values, habits, perceptions, expectations, norms, etc. about health care, which makes cultural competence of great importance for healthcare professionals [ 3 ]. Although cultural competence is developed in a process, its acquisition must begin during the education of the healthcare professional [ 4 , 5 ].

In the field of healthcare, Cultural Competence (CC) is defined as “a process in which the health care provider continually strives to achieve the ability to work effectively within a patient’s cultural context“ [ 6 ]. Another definition describes CC as the ability to work collaboratively with people who have different cultures and points out that intercultural competence is a construct, which has cognitive, affective and behavioral elements to understand, appreciate, and accept cultural diversity [ 7 ]. Intercultural sensitivity (IS), the affective dimension of intercultural competence, has been described as its main dimension [ 7 ].

Chen and Starosta conceptualized intercultural sensitivity as the “capacity of a person to develop a positive emotion towards the understanding and appreciation of cultural differences that promote appropriate and effective behaviors in intercultural communication” [ 8 ]. People with high levels of IS can provide holistic care to the people they have to care for, have developed elevated levels of moral and ethical sensitivity and complex empathy skills, and are conscious of their own professional responsibilities. An individual who respects cultural diversity has low levels of ethnocentrism, Footnote 1 and as a consequence, shows increased levels of IS [ 9 ].

IS denotes both visibility and affirmation of cultural differences, as well as the rejection of ethnocentric perspectives [ 10 ]. IS contributes to the development of abilities to identify the importance of recognizing, comprehending, and appreciating others in their differences, putting oneself in somebody else’s place in other to in order to access different worldviews [ 11 ].

In any modern society, there are four articulated phenomena that determine the need to teach and display intercultural skills in healthcare: (i) migration; (ii) the different ethnic groups; (iii) cultural diversity; and (iv) the biomedical model inserted in the Western health system [ 1 ]. Furthermore, this scenario of multiculturalism and diversity is also emphasised within each community in terms of rural or urban areas, social, economic, ethnic, and religious differences, among others, which can be challenging for many healthcare professionals. On the one hand, it may be difficult for them to understand the beliefs and healthcare practices of the people they care for and, on the other, they may be concerned about the lack of success in adherence to treatments [ 12 ].

As part of a larger study to help unravel the cultural issues faced by healthcare profession students when treating culturally diverse patients [ 13 ], this study aims to explore the self-perceived level of IS in first and last year students of three health sciences courses (Dentistry, Medicine, and Nursing) at the Universidad de la Frontera (UFRO), Temuco, Chile. The study will establish a baseline for future comparisons. Additionally, the study will explore how cultural competency is influenced by the curriculum as they progress through their health training, using the first and last year as an approximation (proxy) of the length of exposure. These perceptions of IS, together with the review of the cultural challenges faced in implementing healthcare curricula in the context of a diverse patient base [ 13 ], may inform future curricular reviews to fulfil healthcare students’ needs. Furthermore, latest data indicates that 12.8% of the Chilean population declared some First nation identity [ 14 ]. This cultural diversity is increased especially in regions with a high percentage of the population belonging to First nation people such as La Araucanía Region, which stand out for the high percentage of the population that self-identify as belonging to a specific ethnic group (34.3%) [ 14 ].

This study adopted a cross-sectional design and a group comparison (e.g., year of study) to study the IS of Medical, Nursing, and Dental students. Following ethics approval from the UFRO Research Ethics Committee (Ref Nº: 072/19). The study surveyed all first and final year healthcare professions (i.e., Medical, Nursing, and Dental), 18-year-old or older students studying at UFRO, using anonymous self-completed questionnaires, including the Intercultural Sensitivity Scale (ISS). These cohorts’ selection allows an approximation (proxy) of length of exposure to explore the development of students’ IS over time. Data were collected between June 2021 and April 2022.

The Intercultural Sensitivity Scale (ISS) is a self-report scale that has been extensively used in different areas to assess the development of IS [ 8 ]. ISS assesses intercultural sensitivity as the affective dimension of intercultural competence. The theoretical structure of this scale was based on five dimensions, namely: interaction engagement; respect for cultural differences; interaction confidence; interaction enjoyment; and interaction attentiveness, as shown in Appendix 1. ISS is a 24-item scale organised in a 5-point Likert-type scale (1 = strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree). Some items are coded reversely in the scale. Negative questions were reversed to calculate the ISS score. Scale scores range from ‘1’, the lowest to ‘5’, the highest. There is not a cut-off value of the scale. A high score indicates higher intercultural sensitivity [ 15 ]. The ISS was linguistically adapted and validated to be used in the Chilean context [ 11 ].

Due to the COVID 19 restrictions, the instrument was redesigned to be completed online. All first and final year students were briefed about the objectives of the study and invited to participate. Participants were requested to complete the online questionnaire anonymously, using a self-assigned code. Data collection was done via the QuestionPRo platform [ 15 ].

Apart from the variables of age, sex, year of study (first and last of each course), and course (medicine, dentistry, or nursing), region of residence (out of the 16 Regions in which Chile is divided administratively, categorised as ‘ Araucania’; ‘Los Lagos’; ‘Bio-Bio’; and ‘Other’). Students’ ethnicity was also collected (Broad Chilean; Mapuche; and Other). Participants’ family group income was determined using seven monthly income levels in Chilean pesos (‘$300,000 or less’; ‘$300,001 to $600,000’; ‘$600,001 to $1,000,000’; ‘$1,000,001 to $1,500,000’; ‘$1,500,001 to $2,000,000’;’$2,000,001 to $3,000,000’; and ‘More than $3,000,000’). Participants were also asked about the type of secondary education. Secondary education in Chile has three types funding: ‘Private’; ‘Publicly subsidized private’; and ‘Municipal’. Municipal funds focus on lower socio-economic status (SES) individuals, while private education generally covers those in higher SES groups [ 16 ].

The dependent variable represented by the overall IS score and eight socio-demographic and study variables were included in the analysis. Five intercultural sensitivity scores were computed by calculating average responses across the five intercultural sensitivity dimensions. Additionally, an overall intercultural sensitivity score was computed by calculating average responses across all the five intercultural sensitivity factors.

The statistical analysis describes the distribution of the socio-demographic and study variables. To examine whether any independent variables (e.g., year of study) had the same pattern of ISS mean, Analysis of Variance (ANOVA) (continuous measures) were employed. A significant ANOVA was followed by post-hoc comparisons using Tukey’s Honestly Significant Differences (HSD) tests. To explore associations between nominal and ordinal variables (e.g., sex and year of education), chi square analysis was applied. To test if any combination of the various socio- demographic, and study variables, provided a multivariate explanation of the IS score, a linear regression model was fitted using a stepwise selection method. Variables included in the regression model were based on a combination of factors, including the theoretical framework the study, and the literature. However, variables in the final model were retained on statistical criteria. A probability value of 0.05 or smaller was considered to be statistically significant. Data manipulation and analyses were conducted using SPSS PC (Version 27.0).

Four hundred and nineteen students were invited to participate in the survey, with 210 in the first year and 209 in the last year of their course. The overall response rates were 93.8% and 55%, respectively. Among those who completed the survey, 312 cases were included in the analysis after excluding six incomplete forms. Of those, there were 105 nursing students: 76 (response rate: 100%) were in the first year and 29 in the final (response rate: 49.2%) year; and 143 dental students: 68 in first year (response rate: 97.1%) and 75 in the final year (response rate: 100%). There were also 64 medical students: 53 in the first year (response rate: 74.6%) and 11 students in the final year of their studies (response rate: 13.8%).

The mean age of participants was 23.1 (s.d. 3.3) years, and most of them were females, accounting for 68.7%. Publicly subsidized private schooling was the most common type of secondary education among students (54.8%), followed by public schooling (33.0%). The remaining 12.2% attend non-subsidized private schools. Most participants were from the La Araucania Region (77.5%), followed by the Los Lagos Region (7.4%), and Bio-Bio Region (6.4%). The remaining participants were from other 10 Regions (8.7%). With regard to ethnic background, the majority self-identified as without any cultural group different to broad Chilean (78.3%), and 20.7% ( n  = 65) self-identified with another culture. The majority of these (86.3%) as Mapuche people and 7.5% as other cultures. The remaining 6.2% did not specify their ethnicity. Table  1 presents the distribution of students by socio-demographic and study characteristics.

The overall ISS scores ranged from 1.83 to 4.94, with a mean score of 4.11 (s.d. 0.43). The mean scores by subscales were as follows; 4.17 (s.d. 0.53) in the interaction engagement subscale; 4.52 (s.d. 0.51) in the respect for cultural differences subscale; 3.66 (s.d. 0.69) in the subscale of interaction confidence; 4.44 (s.d. 0.58); in the interaction enjoyment subscale, and 3.78 (0.65) in the interaction attentiveness subscale (Table  2 ). Overall, there were statistically significantly differences when comparing first and final year’s ISS scores (4.18 vs. 4.00; p  < 0.001). Differences by healthcare profession were also evident. Medical and nursing students had a significantly higher overall mean ISS score compared to dental students (4.21 and 4.16, respectively vs. 4.02; p  < 0.01). No significant associations were found in the ISS by ethnic group, by Region, by sex, or by type of secondary education.

By ISS dimension, except for dental students, within each profession there were significant differences between the first and final year (See Table  2 ). Furthermore, there were also significant differences between three factors (i.e., interaction engagement; interaction confidence; and interaction enjoyment) by course. However, only medical students reached significance levels with the overall score by year (4.29 vs. 3.86 p  < 0.001).

There were also statistically different ISS scores between the first-year student cohorts (i.e., nursing compared with dental). First year nursing and medical students scored higher than dental students (4.20 and 4.29, respectively vs. 4.06; p  < 0.05). On the other hand, when scores from final year students were compared, there were no significant differences (Table  2 ).

To better understand the variance in the overall ISS score, eight socio-demographic and course variables (age, sex, income, type of education, region of residence, profession, cultural background, and year of study), were entered into a multiple linear regression model. However, age was dropped from the model because of high collinearity with the year of study variable. The final model had two significant variables (i.e., course, and year of study) [F(2,294) = 8.411 p  < 0.001]. The resulting model indicated that, after controlling for other independent variables in the model, those who had the highest IS score were first year students not studying dentistry. The variance accounted for, using the full model, was 5.4% (adjusted R 2  = 0.054) (See Table  3 ).

A fundamental element to achieve Intercultural competence is the development of intercultural sensitivity [ 7 ]. This is the first Chilean study to explore the level of IS which may be required to safely handle culturally diverse health situations. This study reports on the measure of healthcare students’ level of IS. Present findings would indicate that, across all healthcare professions, students tended to exhibit lower levels of self-reported IS in the final year of their studies compared to the first year. It has been reported that explicit instruction on IS in curricula is required to prompt this aspect of CC in healthcare [ 17 ]. As it was reported in other manuscript pertaining to this research [ 13 ], it was found that the sample reported on this study had been exposed to a more traditional biomedical approach in their professional formative process, which did not include the development of CC in a consistent and explicit manner across the curricula of the three programs but is developed in a more tangential mode. Alternative explanations for the decreasing IS levels may be that first-year students had been more exposed to intercultural encounters during their secondary education before entering university around 2020, due to the increasing immigration waves into the country prior to the COVID-19 pandemic [ 18 ].

Intercultural competence can be developed early through schooling processes [ 19 ] In Australia, newly graduated dental practitioners, when surveyed about their training in cultural competence, said that the current curricula did not focus enough on cultural issues and that additional training would be of benefit [ 20 ]. Furthermore, some of them indicated that most of their cultural and social perceptions evolved from their upbringing, high school and primary school education, and past personal experiences, rather than from exposure to the dental curriculum [ 20 ]. This introduces the influence of socio-demographics, personalities, experiences, and other factors. On the other hand, final year students may have had fewer formative opportunities to develop intercultural competencies due to the COVID-19 pandemic and lockdowns starting at the time they were about to start immersing their placements, internships, and clinical work. This, in turn, may have affected their IS.

In the present study, dental students reported lower IS scores compared to nursing and medical counterparts. This is consistent with previous publications from this study, which reports that the dentistry curriculum showed the majority of CC related themes are treated mainly at emerging and intermediate depths of coverage [ 13 ].

This study also revealed that students from La Araucanía, where this university is located, and students who report being Mapuche, do not obtain higher levels of IS. High levels of IS have been linked to multicultural societies in which cultural diversity is socially and institutionally accepted and appreciated [ 21 ]. Although La Araucanía Region has the country’s largest proportion of First Nations people, it has been recognized as the center of historical struggles between the Chilean State and First Nations people, particularly Mapuche people, for the recognition and incorporation of an intercultural view in national policies [ 22 ]. This situation might affect the general population’s IS levels, since the concept of interculturality could be related to social discontent. However, the majority of the students were from contiguous regions (i.e., Los Lagos, Bio-Bio). Therefore, this hypothesis may require further exploration.

The lack of significant difference in IS scores between those students who self-reported Mapuche ancestry and those who did not, questions the concept of ethnic and cultural equivalence of higher education students and may suggest that before or during the process of professionalization there is a common cultural profile to which the majority of students subscribed [ 4 ]. This calls for the examination of a critical question: Are healthcare profession students embedded in a cultural system, defined by their ancestries, or are there universal characteristics that are unique to healthcare profession students? This remains an unanswered empirical question which would need to be answered with further studies. However, it is also possible that the IS instrument loses cultural equivalence when applied to different ethnocultural populations [ 23 ].

Although the study reached an overall response rate higher than expected (i.e., 60%) [ 24 ], limitations of the study include low response rates, particularly, the final year medical students’ responses, relative to the size of the final year medical student population, and to a lesser extent the low response rate for last year nursing students. The invitation to participate was sent during the COVID-19 pandemic lockdown in Chile, which may have contributed to low response rates. On the other hand, low response rates are not unexpected in online surveys. Response rates to online surveys about oral health are within the range of 2.5–26% [ 25 , 26 ].

Another limitation was the self-reported nature of the responses, which may not be an accurate reflection of the actual students’ IS [ 27 , 28 ]. Furthermore, the cross-sectional nature of this study precludes a strong conclusion about IS exposure to healthcare professional education, or the use of year of study as a proxy for years of exposure to opportunities to develop sensitization to issues of cultural diversity during professional training. Another concern is that participants were students at one university (i.e., UFRO) only. As a result, conclusions drawn from this study may not be representative of the IS of all Chilean healthcare profession students [ 29 ].

Thus, it is not implied that a final definitive model of IS among Chilean healthcare profession students has been developed, rather his study raises some factors to be investigated in the future. Nonetheless, despite its limitations, we believe that the current approach was adequate given the exploratory nature of the study. The primary goal of this study was to describe the perceptions of IS among healthcare professions students. The present results show consistent findings with a qualitative review of the healthcare professions curricula at UFRO [ 13 ]. Together, these efforts provide robust evidence about the need to upsurge formative experiences to increase students’ awareness and experience to provide a culturally safe encounter when treating a patient from a culture different to the student’s own.

Research involving the collection of longitudinal data is needed to explore how IS changes over time. Future studies should also involve qualitative data collection from student populations’ IS experiences and exposure. This analysis would generate opportunities for a broader understanding of their intercultural sensitivity, experience, and other contextual issues. Additionally, cooperation with other dental, medical, and nursing schools/Faculties in Chile or overseas would be beneficial in confirming the present results and understanding the influence of IS education on students as the future health workforce.

Against a background of increased international mobility and recognition of indigenous nations within the territory, there is a growing interest in Chile in reviewing the extent to which cultural competence is covered in the healthcare professions curricula to meet the standards and expectations of accreditation organizations [ 30 , 31 ]. While this approach is still incipient, from this perspective, this research is significant because it is among the few to comparatively examine and document IS among healthcare profession students in Chile. This information is central to developing educational programs for the future health workforce. It is also expected that the findings of this project will assist in the development of accreditation standards, policies, and professional competencies for healthcare professionals.

Data availability

Ethics approval was granted on the basis that only researchers involved in the study and could access the de-identified data. The minimum retention period is 5 years from publication. Supporting documents are available upon request to the corresponding author.

Ethnocentrism involves a tendency to evaluate and judge other cultures based on the standards and values of one’s own culture, resulting in a biased interpretation and understanding of other cultures. Merriam-Webster.com Dictionary, Merriam-Webster, https://www.merriam-webster.com/dictionary/ethnocentric . Accessed 20 Mar. 2024.

Abbreviations

One-way analysis of variance

Socio-economic status

Universidad de La Frontera

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Acknowledgements

The submitted manuscript is part of the IAF project N° 19 − 0006 ‘Competencias transculturales de los currículos del área de la salud’ funded by the Dirección de Investigación de la Universidad de La Frontera, Temuco, Chile.

This study received University of La Frontera internal funding from the Dirección de Investigación de la Universidad de La Frontera, IAF 2019 scheme (Ref: IAF N° 19 − 0006). The University of La Frontera acts as a funding body only and will not interfere in any way in the research or influence its outcomes. The researchers will keep, at all times, their independence and autonomy.

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MK: Participated in the conception and design of the study, as well as drafting of the manuscript and its critical revision, read and approval of the final version. PP: Participated in the conception and design of the study; as well as critical revision of the manuscript, read and approval of the final version. RM: Participated in the conception and design of the study, as well as drafting of the manuscript and its critical revision, read and approval of the final version. CZ: Participated in the conception and design of the study; as well as critical revision of the manuscript, read and approval of the final version. GE: Participated in the conception and design of the study; as well as critical revision of the manuscript, read and approval of the final version.

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Key Competences and New Literacies

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• Jarkko Hautamäki 5

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Table of contents (15 chapters)

Front matter, introduction.

• Maria Dobryakova, Isak Froumin

The World Is Changing, and Education Is Changing with It

A framework of key competences and new literacies.

• Maria Dobryakova, Isak Froumin, Gemma Moss, Norbert Seel, Kirill Barannikov, Igor Remorenko

Canada (Ontario): A Unifying Theme for Canadian Education Is Equity

• Michele Peterson-Badali, Elisabeth Rees-Johnstone, Evelyn Wilson, Bev Freedman, Denese Belchetz, Karen Grose et al.

China: Fostering Students with All-round Attainments in Moral, Intellectual, Physical and Aesthetic Grounding

• Huanhuan Xia, You You

England: Knowledge, Competences and Curriculum Reform—Why the English Case Stands Out

• Gemma Moss, Ann Hodgson, Susan Cousin

Republic of Korea: Cultivating Key Competences

• Junehee Yoo, Euichang Choi, Dongil Kim, Kyunghee So, Chan-Jong Kim, Il Lee et al.

Finland: Improving Pupils’ Opportunities for Experiencing the Joy of Learning, for Deep Learning, and for Good Learning Achievement

• Jarkko Hautamäki, Raisa Ahtiainen, Natalia Gustavson, Risto Hotulainen, Sirkku Kupiainen, Marja Tamm et al.

Poland: The Learning Environment that Brought About a Change

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Twenty-First Century Skills and Learning: A Case Study of Developments and Practices in the United States

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Russian Federation: At a Conceptual Crossroads

• Kirill Barannikov, Maria Dobryakova, Isak Froumin, Igor Remorenko

Pedagogical and School Practices to Foster Key Competences and Domain-General Literacy

• Maria Dobryakova, Norbert Seel

A Modern Aspect of Instrumental Literacy: Coding

• Suhas Parandekar, Eugeny Patarakin, Gulcan Yayla

How to Integrate New Literacy in the Curriculum—Example of Environmental Literacy

Maria Dobryakova

How Countries Reform Their Curricula to Support the Development of Key Competences

• Kirill Barannikov, Igor Remorenko, Isak Froumin
• Learning Objectives
• New Literacies
• Canadian Education
• Education in China
• Education in the UK
• Cultivating Key Competences
• Education in Republic of Korea
• Education in Finland
• Education in Poland
• Twenty-First Century Skills and Learning
• Education in USA
• Education in Russia
• Key competencies
• 21st Century Curriculum
• Curriculum Reform
• Transversal Competences
• Functional Literacy
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• Competence-based Education
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About this book

This edited book is a unique comprehensive discussion of 21 st  century skills in education in a comparative perspective. It presents investigation on how eight very different countries (China, Canada, England, Finland, Poland, South Korea, the USA and Russia) have attempted to integrate key competences and new literacies into their curricula and balance them with the acquisition of disciplinary knowledge. Bringing together psychological, sociological, pedagogical approaches, the book also explores theoretical underpinnings of 21 st  century skills and offers a scalable solution to align multiple competency and literacy frameworks.

The book provides a conceptual framework for curriculum reform and transformation of school practice designed to ensure that every school graduate thrives in our technologically and culturally changing world. By providing eight empirical portraits of competence-driven curriculum reform, this book is greatresource to educational researchers and policy makers.

Editors and Affiliations

Isak Froumin

Kirill Barannikov, Igor Remorenko

Jarkko Hautamäki

About the editors

Maria Dobryakova  graduated from the Moscow School of Social and Economic Sciences and Manchester University (M.A. in Sociology) and defended her Ph.D. in social stratification at the Institute of Sociology of the Russian Academy of Sciences. Since 2006 and until 2022 she worked at the National Research University Higher School of Economics, where she headed and coordinated a number of large-scale projects in education, social sciences, as well as publications and translation projects. Prior to that, she had worked at the Independent Institute for Social Policy (as head of publications) and the Ford Foundation (Higher Education and Scholarship program). 

Isak Froumin  headed the Institute of education at the National Research University Higher School of Economics in Moscow (Russia)—the first graduate school of education in Russia—from 2009 to 2021. After beginning his career as a principal of Kransnoyarsk University Laboratory School  (Russia), he worked as the Lead Education Specialist at the World Bank, and the advisor to the Minister of Education and Science of Russian Federation. He is a fellow of the International Academy of Education.

Kirill A. Barannikov  is the vice-rector for strategy, Moscow City University. He is working in MCU since 2015 and has led a number of projects over Moscow schools and the university development. Among the most striking projects are the online platform for teachers to create curricula (www.prok.edu.ru), the electronic platform for assessing the quality of the educational environment (www.ecers.ru, www.sacers.ru), internet service for supporting and developing initiatives  (www.zamisli.pro). Over the past ten years, he headed the center for distance education of children with disabilities of the Pedagogical Academy of Postgraduate Education, the center of curricula design and standards of the Academy of Social Management. He coordinated over 40 research projects of the Department of Education of the City of Moscow, the Ministry of Education and Science of Russia. The main areas of interest are competency models in school education, issues of standardization and curricula design in an international context, change management in schools and universities. 

Jarkko Hautamäki  graduated from University of Helsinki (majors in experimental psychology and social psychology) and defended his Ph.D. Dissertation (Measurement and Distribution of Piagetian Stages of Thinking) in University Joensuu. He became a full professor in Special Education in Helsinki University, served also the dean and founded and directed Helsinki University Center for Educational Assessment. He is the honorary professor of Faculty of Psychology at Moscow State University, member of the Finnish Academy of Science and Letters and member of The Russian Academy of Educational Sciences. His research interests include human development and schooling for thinking, interventions and special education and applying the science of development into schooling. He lives in Helsinki, Finland. 

Gemma Moss  is the professor of Literacy at UCL Institute of Education. She has been the president of the British Educational Research Association (2015–17), was a member of the European Education Research Association Council (2016–18), was director of the Centre for Critical Education Studies at the Institute of Education (2007–11) and was director of the International Literacy Centre at the Institute of Education, UCL (2017-22).  Her main research interests are in literacy as a social practice; literacy policy; knowledge transfer and knowledge exchange; evidence-informed practice and curriculum design; pedagogy and new technologies; primary assessment; and gender and literacy attainment.  Her research includes running multi-site ethnographic case studies, combining quantitative and qualitative methods in innovative ways and using rapid evidence assessment systematic review processes to bring knowledge to bear on contentious questions in education, where funders require rapid answers.  

Igor M. Remorenko  has been holding the post of the rector of the Moscow City University since 2013. He has a Ph.D. and full-doctor degree in Education. From 2009 to 2011, he held the post of the director of the Department of the State Policy and Legal Regulations in Education, Department of the State Policy in Education, Department of the Strategic Development of the Ministry of Education and Science of the Russian Federation; supervised the top-priority national project “Education” and programs to support the innovative development of the higher education institutes. From 2011 to 2013, he is the deputy minister of Education and Science of the Russian Federation. He is the author of a number of the scientific publications, two monographs. He participates in the researches in the field of educational policy, development of managerial approaches in education and multiple international and national projects in the sphere of education.

Bibliographic Information

Book Title : Key Competences and New Literacies

Book Subtitle : From Slogans to School Reality

Editors : Maria Dobryakova, Isak Froumin, Kirill Barannikov, Gemma Moss, Igor Remorenko, Jarkko Hautamäki

Series Title : UNIPA Springer Series

DOI : https://doi.org/10.1007/978-3-031-23281-7

Publisher : Springer Cham

eBook Packages : Education , Education (R0)

Copyright Information : The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023

Hardcover ISBN : 978-3-031-23280-0 Published: 23 August 2023

Softcover ISBN : 978-3-031-23283-1 Due: 23 September 2023

eBook ISBN : 978-3-031-23281-7 Published: 22 August 2023

Series ISSN : 2366-7516

Series E-ISSN : 2366-7524

Edition Number : 1

Number of Pages : VI, 426

Number of Illustrations : 18 b/w illustrations, 27 illustrations in colour

Topics : Curriculum Studies , Study and Learning Skills , International and Comparative Education , Educational Policy and Politics

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Interpreters And Translators' Extra-Linguistic Competence Development

The article focuses on interpreters and translators’ extra-linguistic competence development. Translation Model of competences that is studied by many researchers and organizations, interpreters and translators’ extra-linguistic competence comprehension are in the focus. Interpreters and translators’ extra-linguistic competence is regarded as knowledge of the factors that influence language development and functioning: general encyclopedic, thematic and cultural knowledge about historical, political, economic, social, geographical, physiological and ethical background; precedent phenomena, realia, values, opinions, institutions, common behavior, housekeeping and life conditions in the respective countries; the rules for interaction including non-verbal elements, stylistic relating to a specific community, a register appropriate to a given situation, for a particular document or speech; knowledge about communication context (location, time, audience, parties’ intention and etc.). The experiment that was run at the Linguistics and Translation Studies Department of Institute of Foreign Languages of Moscow City University is described. The aim of it was to determine the development of extra-linguistic competence of the students and to trace further ways of the competence development. The experiment included sentences for translation from English into Russian for prospective translators and interpreters. All the sentences were from The Guardian, The New York Times, The Intercept, The National Interest, The Conversation, The Atlantic city and contained extra-linguistic information. The results of the analysis of the translated sentences are provided. Translators and interpreters’ extra-linguistic competence development is viewed as a process arranged on three levels simultaneously: education at university (training, up-bringing, development), self-education and extra courses training. Keywords: Interpreters and translators’ training extra-linguistic competence

Introduction

Translation and interpretation are quite difficult processes. To translate as a professional one should not only know vocabulary and grammar, but also have enough background knowledge to interpret cross-cultural communication correctly. Language is a reflection of many spheres: customs, traditions, history, religion… According to PACET’s model of building a translation competence ( PACET, 2003 ) extra-linguistic competence is interpreted as predominantly declarative knowledge that comprises general world knowledge, domain-specific knowledge, bicultural and encyclopedic knowledge.

Despite the fact that many countries have been training translators and interpreters for centuries and have their own traditions and approaches, nowadays they are all influenced by the Bologna process. The understanding of translation competence has been extremely discussed by Russian and foreign researchers. Nevertheless, there are no strict rules that regulate translators’ training and international requirements for translation competence all over the world.

Problem Statement

Relevant studies are offered by some authors ( Komissarov, 1990 ; Porshneva, 2004; and others) who research into competence in general, and translators’ competence in particular. Alikina and Shvetsova ( 2012 ), Alikina ( 2017 ), Fox ( 2000 ), Schäffner ( 2000 ), Beeby ( 2000 ) and others investigate Translation Model of competences and extra-linguistic competence. Researchers ( Alikina, 2017 ; Göpferich, 2009 ; Lenartovich, 2015 ; Gavrilenko & Dmitrichenkova, 2017 ; Shevchenko, & Zagajnov, 2019 and others ) also pay attention to translators’ training. But interpreters and translators’ extra-linguistic competence development has not been given a comprehensive study yet. It determines the novelty of the article.

Research Questions

The aim of the research is to find out more about translators and interpreters’ extra-linguistic competence comprehension; to analyze its development during interpreters and translators’ training at the Linguistics and Translation Studies Department of Institute of Foreign Languages of Moscow City University. The consideration of translators and interpreters’ extra-linguistic competence successful and effective development is also in the focus.

Purpose of the Study

The purpose of the study is to determine translators and interpreters’ extra-linguistic competence comprehension and the ways of its successful development through the example of interpreters and translators’ training at the Linguistics and Translation Studies Department of Institute of Foreign Languages of Moscow City University.

Research Methods

The first stage of the research is the analysis of theoretical information on the topic: articles, dissertations, researches, documents and etc. It helps to generalize and systematize the comprehension of translators and interpreters’ extra-linguistic competence in Russia and other countries, students’ professional training and competence development. The aim and the structure of the coming experiment are also distinguished.

The second stage is devoted to the experiment preparation. The target audience is distinguished and formed. The experiment involves 60 students: fifteen first-year students, fifteen second-year students, fifteen third-year students and fifteen fourth-year students. A test with sentences for translation from English into Russian from The Guardian, The New York Times, The Intercept, The National Interest, The Conversation, The Atlantic city that contain extra-linguistic information is formed.

The third stage involves the experiment conducting. The respondents are asked to translate the test – the sentences with extra-linguistic information – personally without using dictionaries or the Internet. All the students have an equal time limit for translation. The time when the student finishes the translation is marked on the test paper.

The forth step gives an account of the experiment results analysis that is devoted to students’ translations evaluation. The extra-linguistic information translation is paid special attention to. The consideration of translators and interpreters’ extra-linguistic competence successful and effective development at university is also in the focus.

The analysis of the articles, dissertations, researches and documents helps to find out that extra-linguistic competence is mostly regarded as a part of translation competence. In PACTE Translation Competence Model ( PACET, 2003 ) it is made up of encyclopedic, thematic and bicultural knowledge.

Schäffner’s (2000) Translation Model mostly regards cultural competence as general knowledge about historical, political, economic, cultural, etc. aspects in the respective countries (p. 146).

Fox’s (2000) Translation Model dwells on the translation competence that includes socio-cultural competence. It is treated as awareness of the socio-cultural text context (p.117).

EMT expert group ( 2009 ) regards intercultural competence (that has dual perspective – sociolinguistic and textual) as a part of professional translators’ competence. Sociolinguistic detention means knowing how to:

recognize function and meaning in language variations (social, geographical, historical, stylistic);

identify the rules for interaction relating to a specific community, including non-verbal elements (useful knowledge of negotiation);

produce a register appropriate to a given situation, for a particular document (written) or speech (oral).

Beeby’s (2000) Translation Model embraces a translation competence model that comprises extra-linguistic competence. This competence includes knowledge of pragmatic and semiotic differences between the cultures, documentation skills (pp.186-187).

Vereshchagin and Kostomarov ( 1980 ) consider extra-linguistic knowledge to include basic (facts, events, traditions, holidays), regional (the same as basic but region oriented) and cross-cultural knowledge.

Alikina and Shvetsova ( 2012 ) believe that translators’ extra-linguistic competence might feature:

common extra-linguistic knowledge (sociocultural and historical background, precedent phenomena, realia);

expert knowledge for the specific situation of the translation (substantive thematic knowledge);

current events knowledge (awareness of current evets and the events of the last fifteen years);

knowledge of communication context (location, time, audience, parties’ intention and etc.).

Komissarov ( 1990 ) comprehends culture wider. He includes history, sociology and phycology of the nation, its traditions, values, opinions, institutions, common behavior, housekeeping and life conditions. In other words, all aspects of being and consciousness.

Vîlceanu ( 2018 ) insists that encyclopedic and cultural knowledge represents an essential dimension of the translator’s competence packaging.

Analyzing, generalizing and interpreting the information above we come to the conclusion that interpreters and translators’ extra-linguistic competence should be regarded as knowledge of the factors that influence language development and functioning:

general encyclopedic, thematic and cultural knowledge about historical, political, economic, social, geographical, physiological and ethical background;

precedent phenomena, realia, values, opinions, institutions, common behavior, housekeeping and life conditions in the respective countries;

the rules for interaction including non-verbal elements, stylistic relating to a specific community, a register appropriate to a given situation, for a particular document or speech;

Taking into consideration the understanding of the interpreters and translators’ extra-linguistic competence its was decided to analyze its development during interpreters and translators’ training at the Linguistics and Translation Studies Department of Institute of Foreign Languages of Moscow City University.

The experiment was run in 2019 and involved 60 students: fifteen first-year students, fifteen second-year students, fifteen third-year students and fifteen fourth-year students. The respondents were asked to translate the test personally without using dictionaries or the Internet during the classes. All the students had an equal time limit for their translation. The time when the student finished the translation was marked on their test papers. The first-year students needed more time for translation as they are less skillful then other students. The fourth-year students needed less time and finished the translation even earlier.

The test with the sentences for translation from English into Russian (from The Guardian, The New York Times, The Intercept, The National Interest, The Conversation, The Atlantic city ) contained extra-linguistic information. Some examples of the sentences or their parts that contain extra-linguistic information and the results of the translations analyses (statistic methods) are further provided:

Its not only means that Barack Obama allowed an attack of the magnitude of Pearl Harbor and 9/11 to happen on his watch…

The sentence contains an acronym 9/11 that stands for the September 11, 2001 when a series of terrorist attacks committed by al-Qaeda (the Islamic terrorist group) against the United States took place.

67% of the first-year students left the acronym in their translations as its was without any reference to the event, 33 % used the word tragediya (tragedy) to enlarge the translation.

40% of the second-year students used the acronym in their translations as its was, 60% – interpreted the acronym as sobytiya 11 sentyabrya 2001 goda v SSHA (the events of the September 11, 2001 in the USA) .

33% of the third-year students used the acronym in their translations as its was, 67% – broadened the acronym as tragediya 11 sentyabrya 2001 goda v SSHA / terakt 11 sentyabrya 2001 goda / krushenie bashen-bliznecov 11 sentyabrya 2001 goda iz-za terakta (the tragedy of the September 11, 2001 in the USA / terrorist attacks in the September 11, 2001 / Twin Towers collapse on the September 11, 2001 due to the terrorist attacks) .

27% of the fourth-year students used the acronym in their translations as its was, 73% – extended the translation as terakt 11 sentyabrya 2001 goda, sobytiya, svyazannye s krusheniem bashen-bliznecov (terrorist attacks in the September 11, 2001 / Twin Towers collapse on the September 11, 2001 due to the terrorist attacks).

Well, the nearest we get to a car chase comes in London, where Nate, driving a van, decides to take an exit ramp on his way to Heathrow .

The sentence comprises the name of the major international airport in London, the United Kingdom – Heathrow.

20 % of the first-year students didn’t translate or interpret this extra-linguistic information in the sentence. 67% – decided to leave its as its was – Hitrou (Heathrow) ; 13 % of the respondents widened the translation as aeroport Hitrou (Heathrow airport).

27% of the second-year students didn’t translate or interpret this extra-linguistic information in the sentence. 40% – decided to leave its as its was – Hitrou (Heathrow) ; 33 % of the respondents expanded the translation as aeroport Hitrou (Heathrow airport).

60% of the third-year students left this extra-linguistic information in the sentence as its was – Hitrou (Heathrow) ; 40 % of the respondents extended the translation as aeroport Hitrou (Heathrow airport).

7% of the fourth-year students didn’t translate or interpret this extra-linguistic information in the sentence. 40% left this extra-linguistic information in the sentence as its was – Hitrou (Heathrow) ; 53% of the respondents enlarged the translation as aeroport Hitrou (Heathrow airport).

However, the main action in Game of Thrones is inspired, according to Martin, by the Wars of the Roses …

The sentence contains extra-linguistic information that refers to the Wars of the Roses that stands for a series of English civil wars for control of the throne of England between supporters of the two rival branches: the House of Lancaster (represented by a red rose) and the House of York (represented by a white rose).

60% of the first-year students left the extra-linguistic information in their translations as its was without any reference to the events Vojna roz (The Wars of the Roses) , 40% of the respondents used the extended variant for their translation but without details Vojna Aloj I Beloj roz (The Wars of the Red and White Roses) .

53% of the second-year students also left the extra-linguistic information in their translations as its was without any reference to the events Vojna roz (The Wars of the Roses) , 47% of the respondents used the widened variant for their translation but without details Vojna Aloj I Beloj roz (The Wars of the Red and White Roses) .

47% of the third-year students left the extra-linguistic information in their translations as its was without any reference to the events Vojna roz (The Wars of the Roses) , 53% of the respondents broadened their translation but without details Vojna Aloj I Beloj roz (The Wars of the Red and White Roses) .

33% of the fourth-year students also left the extra-linguistic information in their translations as its was without any reference to the events Vojna roz (The Wars of the Roses) , 27% of the respondents broadened their translation but without details Vojna Aloj I Beloj roz (The Wars of the Red and White Roses) . 40% – dwelled on the extra-linguistic information in their translations by adding details: protivostoyanie dvuh anglijskih dinastij v bor’be za tron, izvestnoj kak vojna Aloj I Beloj roz (the fight for the throne between two rival English branches, known as The Wars of the Red and White Roses).

The other extra-linguistic samples from the sentences that were successfully translated by the students refer to Shakespeare’s words ( much ado about nothing, nothing will come of nothing, we have seen better days ) and Bible words ( daily bread, dust and ashes, eat one’s words ), some slang words on the contrary caused difficulties ( Blighty ). Also, the students faced political, economic, social, geographical facts the translation of which helped to distinguish that high level of translators’ and interpreters’ extra-linguistic competence is achieved gradually, step by step.

The competence should be developed throughout their life: both private and professional, as life itself is changing every day and by changing itself it changes the language. The competence will progress successfully if it is developed by students consciously throughout their lives. Some universities do offer special Lifelong Learning Programmes ( Kordić, 2016 ). But it is almost impossible to cultivate the competence only at university: professors cannot teach everything a translator or interpreter should know to succeed in cross-cultural communication in four or two years. It is also problematic to know everything about the world around so a translator or interpreter should have motivation to continue to work on the competence development personally after university graduation.

The results fit with other available evidence ( Akbari et al., 2018 ; Alikina, 2017 ; Gavrilenko, & Dmitrichenkova, 2017 ; Göpferich, 2009 ; Guliyants, & Guliyants, 2017 ; Lara, 2016 ; Lenartovich, 2015 ; Waterlot, 2016 ; Oțăt, 2017 ; Percec, & Pungă, 2017 ; Vermes, 2017 ; Shevchenko, & Zagajnov, 2019 ), that after systematizing these ideas on translators’ and interpreters’ extra-linguistic competence development, it seems logical to arrange the process on three levels simultaneously:

education at university (training, up-bringing and development);

self-education;

extra courses training.

The research findings are valuable and their analysis enables to find profitable solutions. The gained experience may be applicable for translators and interpreters training. So, to help students develop their translators’ and interpreters’ extra-linguistic competence the amount of extra-linguistic information should be increased. Culture, history, geography, economy, politics should be thoroughly scrutinized while getting the degree at university. Integrated approach combining task-based approaches with approaches that are based on critical discourse analyses, problem-solving and decision making formats help to foster extra-linguistic competence ( Huertas Barros & Buendía Castro, 2017 ).

To develop translators’ and interpreters’ extra-linguistic competence of the students of the Linguistics and Translation Studies Department of Institute of Foreign Languages professors:

offer for their interpretation at sight and consecutive interpretation articles from authentic newspapers and news programs, presenting both current and historical information to broaden their horizons;

devote special attention to extra-linguistic information discussions during role-play, brainstorming and team-work sessions;

organize reading, translating and interpreting of the newspaper articles;

provide watching, translating and debating about news, films, TV programs that can help to pay more attention to traditions, values, opinions, institutions, common behavior, housekeeping, life conditions, famous people and places, events – all the aspects of being and consciousness.

The professors, lecturers, tutors and students take part in the work of Oxford Russia Fund that enables them to read and work on authentic literary works (“Contemporary British Stories” and “Morality Play” by B. Unsworth, “Portobello” by R. Rendell, “Atonement” by I. McEwan, “A Week in December” by S. Faulks, “Capital” by J. Lanchester and etc.) and commentaries with annotations to them. Working on the book special attention is paid to extra-linguistic information and cross-cultural communication aspects, to the points that help to get the idea of the author of the book. Even tiny details are discussed: the choice of the characters’ names due to their social status; political and social situation and its influence on the characters’ behavior and words; the description of the architecture, buildings, furniture, clothes; colors meaning in the culture and etc.

Much attention is also given to employing multicultural information from the books that explore the differences and similarities of countries, for instance, “Understanding Britain Today” by K. Hewitt, “Where Russians Go Wrong in Spoken English: Words and Expressions in the Context of Two Cultures” by L. Visson, “Watching the English: The Hidden Rules of English Behaviour” by K. Fox and etc. That enables the students to research cross-cultural communication deeper.

The department members help the students to understand that translators’ and interpreters’ extra-linguistic competence is an integral part of their professional competence. The students are explained that to succeed as professionals in their future they should be ready for self-education and lifelong learning. The Linguistics and Translation Studies Department of Institute of Foreign Languages experience:

shared visiting of the galleries, cinema, theaters and etc. and its further discussions to help the students to be in touch with art;

analyses of photos, archives, footage to inspire students to know more about history of their own country and to get more information about the world around;

collaboration with practicing translators and interpreters, successful university alumni to inspire to have their goals and to be persistent, logical and consistent in their achieving;

participating in the probations abroad, conferences, lectures and seminars to develop professional skills and competences;

on-line trainings by means of FutureLearn, Coursera and other educational platforms to motivate to widen horizons, develop professional skills and competences, as well as translators’ and interpreters’ extra-linguistic competence.

To recapitulate what is said earlier, we need to take into account that language is the reflection of many spheres: customs, traditions, history, religion and etc.

To become a successful professional translator or interpreter one should not only know vocabulary and grammar, but form interpreters and translators’ extra-linguistic competence, which includes knowledge of the factors that influence language development and functioning: general encyclopedic, thematic and cultural knowledge about historical, political, economic, social, geographical, physiological and ethical background; precedent phenomena, realia, values, opinions, institutions, common behavior, housekeeping and life conditions in the respective countries; the rules for interaction including non-verbal elements, stylistic relating to a specific community, a register appropriate to a given situation, for a particular document or speech; knowledge of communication context (location, time, audience, parties’ intention and etc.).

The experiment, ran at the Linguistics and Translation Studies Department of Institute of Foreign Languages of Moscow City University, helps to distinguish that high level of translators and interpreters’ extra-linguistic competence is achieved gradually, step by step. And the competence will progress if it is developed throughout their lives: both private and professional, as life itself is changing every day and by changing itself it changes the language.

To arrange the process of extra-linguistic competence development with advantage, translators and interpreters’ professional training should be organized simultaneously at three levels: education at university (training, up-bringing and development), self-education and extra courses training.

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20 November 2020

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https://doi.org/10.15405/epsbs.2020.11.03.22

978-1-80296-094-5

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Sociolinguistics, discourse analysis, bilingualism, multilingualism

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The Importance of Cultural Immersion in Learning a Foreign Language

Discover the importance of cultural immersion in learning a foreign language and learn how to create an immersive language learning experience., introduction.

Learning a foreign language opens up new opportunities and broadens our horizons. While studying vocabulary and grammar are essential, true fluency comes from cultural immersion. Cultural immersion refers to fully engaging with the language, customs, traditions, and people of the target language's culture. In this essay, we will explore the importance of cultural immersion in learning a foreign language and discuss strategies to create an immersive language learning experience.

1. Understanding the Cultural Context

Language and culture are deeply intertwined. To truly grasp a foreign language, it is crucial to understand the cultural context in which it is used. Cultural immersion provides insights into the values, beliefs, and social norms of a community. By immersing yourself in the culture, you gain a deeper understanding of idiomatic expressions, gestures, and culturally-specific ways of communicating. This understanding enables you to use the language more naturally and effectively.

2. Enhancing Language Acquisition

Cultural immersion accelerates language acquisition. When you immerse yourself in the target language's culture, you expose yourself to authentic language use in various contexts. By listening to native speakers, engaging in conversations, and consuming media in the target language, you improve your pronunciation, vocabulary, and overall comprehension. Immersion provides constant exposure to the language, leading to faster and more natural language acquisition.

3. Developing Intercultural Competence

Cultural immersion fosters intercultural competence, which is the ability to navigate and communicate effectively across different cultures. By immersing yourself in a foreign culture, you develop empathy, open-mindedness, and a greater appreciation for diversity. These skills are not only valuable for language learning but also essential in today's globalized world, where intercultural communication is increasingly important.

4. Creating an Immersive Language Learning Experience

Creating an immersive language learning experience is possible, even if you can't travel to a foreign country. Here are some strategies to bring cultural immersion into your language learning journey:

a. Surround Yourself with the Language

Immerse yourself in the target language as much as possible. Change the language settings on your devices, listen to podcasts or music in the target language, and watch movies or TV shows without subtitles. By surrounding yourself with the language, you create an immersive environment that facilitates learning.

b. Engage with Native Speakers

C. travel to a language immersion program.

If possible, consider participating in a language immersion program in a country where the target language is spoken. These programs provide a complete immersion experience, allowing you to practice the language with native speakers, attend cultural activities, and explore the local community. It's an excellent opportunity to deepen your understanding of the language and culture while making lasting connections with people from around the world.

d. Embrace Authentic Cultural Resources

Immerse yourself in authentic cultural resources such as literature, films, music, and art from the target language's culture. Read books by native authors, watch movies in the original language, listen to music, and visit museums or cultural events that showcase the traditions and history of the language community. These resources not only enhance your language skills but also offer valuable cultural insights.

e. Participate in Cultural Activities

Engage in cultural activities that allow you to experience the traditions, customs, and celebrations of the target language's culture. Attend festivals, join cultural clubs or groups, try traditional cuisine, and participate in language-related events. These experiences give you firsthand exposure to the cultural nuances and help you connect with the language on a deeper level.

f. Practice Cultural Etiquette

Learn about the social norms, etiquette, and gestures specific to the target language's culture. Being aware of cultural norms helps you navigate social interactions more effectively and shows respect for the local culture. Pay attention to greetings, body language, and customs to ensure you communicate appropriately and build positive relationships with native speakers.

Cultural immersion is a vital component of learning a foreign language. It provides a deeper understanding of the language, accelerates language acquisition, and develops intercultural competence. By creating an immersive language learning experience through strategies such as language exposure, engaging with native speakers, participating in cultural activities, and embracing authentic resources, you can enhance your language skills while gaining a profound appreciation for the richness of the target language's culture. Embrace cultural immersion, and open yourself to a world of language and cultural exploration.

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