doi: 10.56294/mw202213

REVIEW

Cultural competence in medical and health education: an approach to the topic

Competencia cultural en la educación médica y de la salud: una aproximación al tema

Jose Ignacio Robaina Castillo¹ *

¹Universidad de Alcalá de Henares, España.

Cite as: Castillo JIR. Cultural competence in medical and health education: an approach to the topic. Seminars in Medical Writing and Education 2022; 1:13. https://doi.org/10.56294/mw202213.

Received: 09-06-2022          Revised: 15-07-2022          Accepted: 20-10-2022          Published: 22-10-2022

Editor: Dr. José Alejandro Rodríguez-Pérez

ABSTRACT

Cultural competence is essential to ensure safe, high-quality healthcare; and adequate preparation is necessary to provide culturally congruent care. A literature review was conducted to examine the theoretical foundations of cultural competence and its application to medical and health education. The search for information in databases was carried out using the terms “cultural competence”, “health education”, “medical education”, “cultural sensitivity” and “cultural humility”. Cultural competence is the ability of a student or healthcare professional to provide culturally appropriate and specifically tailored care to patient populations with diverse values, beliefs, and behaviors. The development of cultural competency in medical education has occurred surprisingly rapidly in response to gaps in student training and skills identified by educators, clinicians, and care provider and accrediting bodies. The acquisition of cultural competencies by health professionals addresses: the interest in learning about other cultures, learning about another culture, interactions with people from different cultures and the set of capabilities to respond to people’s health needs. from another culture. Competition consistently directs attention to political and social circumstances as well as individual considerations that can alleviate suffering and promote health and well-being.

Keywords: Cultural Competence; Health Education; Medical Education; Cultural Sensitivity; Cultural Humility.

RESUMEN

La competencia cultural es esencial para garantizar una atención sanitaria segura y de alta calidad; y es necesaria una preparación adecuada para brindar atención culturalmente congruente. Se realizó una revisión bibliográfica para examinar los fundamentos teóricos de la competencia cultural y su aplicación a la educación médica y de la salud. Se ejecutó la búsqueda de información en bases de datos con el empleo de los términos “competencia cultural”, “educación en salud”, “educación médica”, “sensibilidad cultural” y “humildad cultural”. La competencia cultural es la capacidad de un estudiante o profesional de la salud para brindar atención culturalmente apropiada y específicamente adaptada a poblaciones de pacientes con diversos valores, creencias y comportamientos.  El desarrollo de la competencia cultural en la educación médica se ha producido sorprendentemente rápido en respuesta a las lagunas en la formación y las habilidades de las estudiantes identificadas por educadores, médicos y organismos proveedores de atención y acreditadores. La adquisición de competencias culturales por parte de profesionales de la salud aborda: el interés para conocer otras culturas, el aprendizaje sobre la otra cultura, las interacciones con personas de distintas culturas y el conjunto de capacidades de respuesta a las necesidades en salud de las personas de otra cultura. La competencia dirige consistentemente la atención a las circunstancias políticas y sociales, así como a las consideraciones individuales que pueden aliviar el sufrimiento y promover la salud y el bienestar.

Palabras clave: Competencia Cultural; Educación En Salud; Educación Médica; Sensibilidad Cultural; Humildad Cultural.

INTRODUCTION

Globalization, characterized by transnational integration and the expansion of political, economic, and sociocultural values, significantly impacts health sciences and health professionals' training processes.^(1,2,3)

As a result of international migration and the process of globalization, health systems face challenges in providing equitable health care in increasingly diverse and multicultural societies. Promoting and embracing diversity is a common challenge for healthcare organizations. Improving the cultural competence of healthcare professionals has been identified as critical to reducing health disparities and improving healthcare delivery to culturally and linguistically diverse groups.^(1,2)

Policies, strategies, and actions are needed to overcome linguistic and cultural barriers and to improve cultural competence and quality of care at the individual, organizational, and system levels.^(1,3)

Systems-level approaches include engagement and collaboration with affected populations, organizational readiness and commitment to implementing cultural competence strategies, and implementation of cultural competence in multiple settings.^(1,2)

Cultural competence is essential to ensure safe, high-quality health care, and adequate preparation is necessary to provide culturally congruent care.^(1,3,4)

There has yet to be a consensus on a single definition of cultural competence. It has been widely adapted and modified. It is "a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or profession that enables it to function effectively in cross-cultural situations. "^5,6 The concept encompasses all the knowledge and habits of society, promotes analysis between culture and language and their practical implications, and promotes analysis between culture and language and their practical implications.⁽⁷⁾

The U.S. Department of Health and Human Services Office of Minority Health defines cultural competence as the ability to function effectively within the scope of cultural beliefs, behaviors, and needs presented by consumers and their communities. Specifically in the area of health care, it refers to "the ability of health systems to provide care to patients from diverse backgrounds, including the adaptation of health care delivery to meet the social, cultural and linguistic needs of the patient",^(6,8) or as "the ongoing process in which the health care provider strives to achieve the ability to work effectively within the cultural context of a client (individual, family, community)".^(1,4)

For this article, cultural competence is the ability of a student in the health professions to provide culturally appropriate and specifically tailored care to patient populations with diverse values, beliefs, and behaviors.^{(1,2,3,4,5,6,8)}

Other terms similar to cultural competence, such as cultural humility, have emerged to convey the idea of more effective cross-cultural capabilities. Cultural humility" has been defined as a lifelong commitment to self-assessment and critique, to redress power imbalances, and to develop mutually beneficial, non-paternalistic partnerships with communities on behalf of defined individuals and populations”.^(6,9)

"Culture" should not be limited to dimensions such as racial or ethnic identity but should include, for example, the culture of the physician or public health professional, which also requires humility in dealing with patients, families, and communities.⁽⁹⁾ It has been suggested that cultural humility is a more appropriate goal for multicultural medical education than cultural competence.⁽⁶⁾

This literature review aims to examine the theoretical underpinnings of cultural competence and its application to medical and health education.

METHODS

A search for information was carried out in September-November 2023 in the databases Redalyc, Elsevier Science Direct, PubMed/Medline, and SciELO, as well as in the ClinicalKeys services and the Google Scholar search engine. Advanced search strategies were used to retrieve the information by structuring search formulas using the terms "cultural competence," "health education," "medical education," "cultural sensitivity," and "cultural humility," as well as their equivalents in English. From the resulting documents, we selected those that provided theoretical and empirical information on cultural competence in health education in Spanish or English.

DEVELOPMENT

Increasing racial, ethnic, cultural, and linguistic diversity in the population, primarily in developed countries, poses a unique challenge for all health professions. Race and ethnicity are associated with persistent and often growing health disparities among diverse sectors of the population.^(2,6,10)

Bias, stereotypes, and clinical uncertainty on the healthcare provider's part with patients can also contribute to health disparities. Another factor contributing to health disparities is low levels of health literacy (the ability to read, understand, interpret, and act on health information) among patients.^(6,11)

Disparities in health and health care can arise from a healthcare provider's inability to offer culturally appropriate healthcare services to multiethnic patients based on cultural and linguistic barriers.^(6,11,12)

Modern medicine must consider patients' beliefs, values, and attitudes. It must seek information about cultural issues that influence health behaviors, disease epidemiology, ethnopharmacology, and complementary health practices, which increases the importance of being aware of multiculturalism when providing health care.⁽¹⁰⁾

Healthcare providers must develop the necessary communication skills to obtain information from patients and their families and understand their health beliefs, ultimately facilitating their participation in healthcare decisions.⁽¹⁰⁾

In individual medical consultations, physicians must be aware of the dynamic interplay between patients' culture and their gender, socioeconomic status, and power position, as well as the degree of discrimination or persecution they experience, the degree of integration into society, and, at times, their connections to circumstances, people, care providers, and health beliefs in distant locations.⁽²⁾

Consequently, there is a growing need for health professionals to be more responsive to the population's needs.^(6,10)

It is an institutional and social justice imperative that healthcare providers, employers, and health plans recognize the need to provide culturally competent care and services to improve health outcomes, reduce the overall cost of care, and improve patient health and satisfaction.^(4,9)

Therefore, the acquisition of cultural competence should be a didactic objective and established in the curriculum and study plans. Some authors consider the foreign language classroom the most suitable didactic space.⁽⁷⁾

Educating healthcare students about cultural competence, including cultural knowledge, awareness, and sensitivity, can help bridge the gaps between provider and patient relationships.^(2,6)

There is some evidence that cultural competency training improves healthcare professionals' knowledge and can improve their attitudes and skills, as well as patient satisfaction. However, more information is needed about the impact of such training on patient adherence, equity of services among racial groups, or the impact on patient health status. Likewise, more is needed to know about the costs of cultural competency training.⁽⁶⁾

Cultural Competence in Medical/Healthcare Practice

Cultural competency education must contain a coherent theoretical foundation that includes educational theories and theories explaining cultural competence development and human behavioral change.⁽¹⁾

Cultural competency education must be adapted to different cultures so that students grasp the appropriate cultural context. Education is likely needed to improve cultural competence; organizational or systemic approaches that consider cost-effectiveness and issues related to individual and organizational contexts are needed to improve cultural competence.^(1,13)

Complexities concerning differences in race, culture, ethnicity, religion, and other social constructs do not receive adequate consideration in academic medicine in general.^(6,8,10)

To fully appreciate the diversity of people at work or in the community, one must first understand one's culture. Only after assessing attitudes and values toward diversity can one promote mutual understanding, tolerance, and recognition of diversity.⁽⁵⁾

Being culturally competent requires subjects to lower their defenses, take risks, and practice behaviors that may feel unfamiliar and uncomfortable. This may mean putting aside some beliefs to which they are attached and making room for others whose value is unknown. It may also mean changing what you think, say, and how you behave.⁽⁵⁾

Cultural Competence in Health Worker Education

Education needs to be tailored to meet the needs of specific groups of health professionals, and future studies should consider the potential advantages and disadvantages of implementing multidisciplinary versus health sciences-specific cultural competency education.^(1,13)

The development of cultural competency as an essential element of the curriculum in medical education has occurred surprisingly quickly in response to gaps in student training and skills identified by educators, practicing physicians, major hospitals, care providers, and accrediting bodies;^(2,4,14) and this has made it a key feature in health care accreditation standards and processes. In Latin America, the incorporation of this notion is incipient.⁽¹⁴⁾

The acquisition of cultural competencies by health professionals addresses interest in learning about other cultures, learning about other cultures, interactions with people from different cultures, and the set of skills needed to respond to the health needs of people from another culture.⁽¹⁵⁾

Changing behaviors, attitudes, and policies within the health professions to address cultural competence is most effective early in professional education by implementing a culturally competent curriculum that addresses health disparities.⁽⁶⁾

One tactic is to develop, implement, and expand didactic and training resources for culturally competent programs in schools. The curriculum should focus on the reality of evidence-based health disparities among racial and ethnic minority populations, the importance of providing culturally competent care and communication to meet the health needs of diverse patient populations and exposure to cultural diversity. Overall, students should be grounded in cultural awareness and cultural sensitivity.^(6,8)

A core curriculum that includes cultural competency training provides students with experience and understanding of providing high-quality care to multiethnic populations. However, this requires profound changes in the existing context of health professions education.⁽⁶⁾

Some of the considerations include hiring experts in cultural diversity training and assessment methods that are institutionally supportive, identifying faculty members willing to develop and teach content, identifying course coordinators willing to integrate training content into the curriculum, and acquiring training resources and tools that include faculty development workshops that use teaching aids to address cultural competence.^(6,11)

Curriculum restructuring may be needed to allow for cultural diversity teaching orientation activities, such as didactic and experiential face-to-face courses. Curricula should be supplemented with knowledge and skills from other disciplines, such as the social and behavioral sciences.^(6,15)

There is a great deal of flexibility within the model to encourage the teaching of cultural competency in health professions schools across the curriculum to enable students to work with other health professionals to address health disparity issues.^(6,15,16)

Health professions students should be trained within the context of the model early in their careers to work in multidisciplinary teams for better patient care that is culturally appropriate and patient-centered. Diversity fosters learning, knowledge, skills, and abilities vital to professionalism. Learning is enhanced in environments where individuals are part of a diverse group of people who are not like themselves. In particular, diversity in training environments enhances all participants' cross-cultural training and cultural competencies. In addition, interaction among learners from diverse backgrounds helps to challenge assumptions and broaden perspectives on racial, ethnic, and cultural differences, thus facilitating professionalism.^(6,8,9,11) This would be of great importance since, in general, the teaching and learning of cultural competence in health professional education curricula has focused on theoretical rather than experiential learning.^(3,15)

Internationally, there is evidence of the inclusion of cultural competence in curricula in health professional education and training for professionals.^(3,14)

Limitations of cultural competence in health education.

The recent focus on cultural competence has been a significant health education advancement. Four curricula have been associated with positive attitudinal changes and learners' skill development. However, curricula are constrained by complex cultural and socioeconomic variations among patients and the challenges of transnational patient encounters. The focus on cultural competence is increasingly sidetracked by the purchasing power of corporations that may seek to exploit it for profit and undermined by the inability of institutions to demonstrate improved health indicators and reduced inequities.⁽²⁾

One group of critics argues that cultural competency should be more onerous for already overburdened medical school curricula. Moreover, in contrast, some authors believe that the frameworks of many cultural competency curricula are limited by a relatively narrow conceptual scope and insufficient depth of depth and preparation.⁽²⁾

Fundamentally, the cultural competency model typically needs more conceptual consensus and breadth. In the absence of conceptual clarity, curriculum components are variable and fragmented. Some programs equate cultural competency with communicative competence rather than developing a comprehensive set of skills.⁽²⁾

In a context of increasing population mobility, education intended to teach mastery of specific domestic interactions between two cultures has diminished utility in today's dynamic, diverse, hybrid, and complex patient care environment.^(2,17)

Curricula emphasize reliance on lists of ethnocultural characteristics rather than patient-centered investigations. In an increasingly global world, one of the outcomes of medical education must be the ability to identify and consider the unique circumstances that surround and define the individual patient.⁽²⁾

In general, cultural competency curricula need more pedagogical cohesion. In many cases, longitudinal integration across the curriculum still needs to be met.⁽²⁾

Teaching methods are not convincingly related to developing and reinforcing a desired set of skills.⁽²⁾

Student competence must be formally assessed according to explicit learning outcomes. Currently, medical schools find assessing student cultural competence problematic because of a need for more consensus regarding core attitudinal and knowledge goals and competencies of education.^(2,13)

CONCLUSIONS

In the future, healthcare workers will increasingly face the challenge of working with ethnoculturally and socially diverse patients. By providing a common framework for health education in an era of globalization, cultural competence will be applicable in the education of future professionals in vastly different countries and healthcare settings. Being culturally or transnationally competent will promote professional mobility by preparing students for multiple practice sites. Perhaps most importantly, competency consistently directs attention to political and social circumstances and individual considerations that can alleviate suffering and promote health and well-being.

REFERENCES

1. Oikarainen A, Mikkonen K, Kenny A, Tomietto M, Tuomikoski A, Meriläinen M, et al. Educational interventions designed to develop nurses ’ cultural competence: A systematic review. International Journal of Nursing Studies 2019;98:75-86. https://doi.org/10.1016/j.ijnurstu.2019.06.005.

2. Koehn PH, Swick HM. Medical Education for a Changing World: Moving Beyond Cultural Competence into Transnational Competence. Academic Medicine 2006; 81:548-56.

3. Shari N, Adib-hajbaghery M, Naja M. Cultural competence in nursing: A concept analysis. International Journal of Nursing Studies 2019;99:103386. https://doi.org/10.1016/j.ijnurstu.2019.103386.

4. Kaihlanen A, Hietapakka L, Heponiemi T. Increasing cultural awareness: qualitative study of nurses ’ perceptions about cultural competence training. BMC Nursing 2019:18:38.

5. California Childcare Health Program. Salud y Competencia Cultural 2006.

6. Shaya FT, Gbarayor CM. The Case for Cultural Competence in Health Professions Education. American Journal of Pharmaceutical Education 2006; 70:1-6.

7. Reina García L, Gómez Bernal D, Saavedra Borroto I. El desarrollo de la competencia cultural en clases de practica integral de la lengua francesa. Revista Conrado 2020;16:335-42.

8. Berger JT, Ribeiro Miller D. Health Disparities, Systemic Racism, and Failures of Cultural Competence. The American Journal of Bioethics 2021:1-11. https://doi.org/10.1080/15265161.2021.1915411.

9. Cigna. Cultural competency in health care. 2016.

10. Zavaleta A. La competencia cultural y la prestación de servicios de salud a poblaciones latinas. Revista Internacional de Ciencias Sociales y Humanidades, SOCIOTAM 2006;XVI:163-81.

11. Shepherd SM, Willis-esqueda C, Newton D, Sivasubramaniam D, Paradies Y. The challenge of cultural competence in the workplace: perspectives of healthcare providers. BMC Health Services Research 2019:19:135.

12. Serrano-Garcia L, Fernández-Reynaldo GD, Niño-Escofet S, Peña-Rojas L. La formación cultural del uso de las investigaciones diagnósticas microbiológicas del médico: antecedentes, debilidades y fortalezas. Revista de Ciencias Médicas de Pinar del Río 2023; 27:e5890.

13. Young S, Guo KL. Cultural Diversity Training: The Necessity of Cultural Competence for Health Care Providers and in Nursing Practice. The Health Care Manager 2020;39:100-8. https://doi.org/10.1097/HCM.0000000000000294.

14. López-Díaz L. La competencia cultural, una clave para mejores resultados en salud. Med UNAB 2016;18:163-5.

15. Veliz-rojas L, González LZ, Bianchetti-saavedra A. Simulación como estrategia de desarrollo de competencias culturales en estudiantes del área de la salud. Educación Médica Superior 2021;35:e2428.

16. Ramírez-Isacc JA, Pérez-Assef JJ. ¿Los valores se han perdido en los profesionales de las Ciencias Médicas? Universidad Médica Pinareña; 2022;18:e504.

17. Benítez-Rojas L de la C, Castro-Querol O, Flores-Charles D, Mercantete-Sosa MM. Evaluación de la sensibilidad bioética en estudiantes de Ciencias Médicas. Universidad Médica Pinareña 2023;19:e901.

FINANCING

No external financing.

CONFLICTS OF INTEREST

None.

AUTHORSHIP CONTRIBUTION

Conceptualization: José Ignacio Robaina Castillo.

Research: Jose Ignacio Robaina Castillo.

Original writing: Jose Ignacio Robaina Castillo.

Editing and proofreading: Jose Ignacio Robaina Castillo.