Need for ensuring cultural competence in medical programmes of European universities

The neighborhood walk: introducing first-year medical students to social determinants of health in underserved neighborhoods

BACKGROUND

Social determinants of health (SDoH) contribute to up to 80% of an individual's health, underscoring its importance in medical education. Research has shown that community exposure and engagement during undergraduate medical education increases the likelihood of students working in underserved areas in the future. Given the limited research on the feasibility and educational effects of SDoH experiences implemented at the early stages of medical education, this study presents a unique perspective on an interactive learning opportunity during the preclinical curriculum. The purpose of this study is to evaluate the educational impact of an immersive social determinants of health learning intervention for first-year medical students.

METHODS

First year medical students visited one of five underserved neighborhoods in Pittsburgh during Orientation Week. Students received materials about neighborhoods and community engagement etiquette prior to their visit. Visits spanned four hours with two groups of approximately 15 students for each neighborhood, led by at least one faculty member and two student facilitators. Students visited two to four community organizations in each neighborhood and participated in a debrief session. Students completed a feedback survey, and results were analyzed with Chi-square Test of Independence (p < 0.05).

RESULTS

The survey response rate was 58.2%. Students ranked the intervention as "Excellent" (77%), "Above Average" (14%), and "Good" (7%). When asked to rate the comfortability of helping patients obtain community resources on a scale of 1-5, 64.3% of students rated 4 or above. Similarly, 91.6% of students rated 4 or above when asked about knowledge of available resources in their neighborhood. The major learning outcomes from students were richness of community resources/history (35.7%), food insecurity (26.2%), and dissipation of previous stigma (23.8%). There was a significant association between growing up in Pittsburgh and self-rating of comfortableness with helping patients obtain community resources (p = 0.02). Students who completed pre-visit materials were more likely to rate the materials (p < 0.01) and debrief session as helpful (p < 0.01).

CONCLUSIONS

Prior exposure to and information about communities was found to enhance the neighborhood learning experience. This initiative demonstrates the benefit of early engagement with community resources and neighborhood-based health disparities in undergraduate medical education.

Community-Oriented Dentistry Education: A Narrative Review

Community-oriented dental education (CODE) is a teaching and learning approach in dentistry that occurs at a location outside the traditional dental education institution which bridges the gap between theoretical knowledge and practical application. CODE programs differ in terms of student involvement, rotation duration, types of services offered, and the structure of community partnerships. The nature and structure of the programs that are implemented in specific places determine the precise impacts of the CODE. Hence, the current narrative review highlights the determinants of CODE, challenges associated with the implementation of CODE, and opportunities for advancement. The six determinants highlighted consist of addressing community needs, promoting social responsibility, implementing CODE for oral health challenges, enhancing cultural competence and sensitivity, collaborating with organizations, and integrating public health principles. Moreover, it illustrates opportunities for advancement consisting of technological innovations, global exchange programs, and interdisciplinary collaboration which enhance the effectiveness and impact of CODE. However, the review discusses various challenges that involve resistance to change, limited resources, and difficulties in assessing outcomes that result in the complexities of the implementation of CODE. Hence, the CODE bridges knowledge and applied education models, allowing for a comprehensive approach to training graduates to tackle oral health inequalities and advance equity.

Student perspectives of equity, diversity, and inclusion in the curriculum of a UK medical school-A mixed-methods study

BACKGROUND

Equity, inclusion, and diversity in medical education are increasingly recognized as crucial for enhancing student engagement and improving health outcomes. This paper aims to analyze trends and assess student attitudes toward ethnic equity, inclusion, and diversity within campus-based modules at the University of Buckingham Medical School, UK.

MATERIALS AND METHODS

A mixed-methods approach was employed, involving 97 medical students aged 18-24 years (86.6%) between 2021 and 2023. Quantitative data were gathered through a pretested questionnaire using a five-point Likert scale and analyzed using SPSS software (version 26). Qualitative insights were obtained from five focus group sessions with randomly selected medical students and analyzed thematically.

RESULTS

The findings of this study indicated a significant proportion of Asian descent students (56.7%). First-year and White ethnicity students perceived the curriculum as more representative compared to second-year counterparts and peers from other ethnic backgrounds. Notably, first-year students showed a heightened understanding of social science terms, especially "ethnicity," and 67% of female students demonstrated a deeper comprehension of sociocultural factors influencing health behaviors. Across demographics, there was consistent recognition of these factors impacting patient care. Qualitative findings underscored the importance of representation in medical education, biases in recruitment, and advocated for greater faculty diversity. Additionally, there is a need for a curriculum reflecting diverse dietary habits and including role models from various ethnic backgrounds.

CONCLUSION

This study emphasizes the critical need for curricular reform in medical education to prepare students for a multicultural society. Addressing disparities in curriculum representation and promoting diversity within faculties are essential for equipping future healthcare professionals with the skills to provide culturally competent care and navigate diverse patient populations effectively.

Barriers and Unmet Educational Needs Regarding Implementation of Medication Adherence Management Across Europe: Insights from COST Action ENABLE

BACKGROUND

Medication adherence is essential for the achievement of therapeutic goals. Yet, the World Health Organization estimates that 50% of patients are nonadherent to medication and this has been associated with 125 billion euros and 200,000 deaths in Europe annually.

OBJECTIVE

This study aimed to unravel barriers and unmet training needs regarding medication adherence management across Europe.

DESIGN

A cross-sectional study was conducted through an online survey. The final survey contained 19 close-ended questions.

PARTICIPANTS

The survey content was informed by 140 global medication adherence experts from clinical, academic, governmental, and patient associations. The final survey targeted healthcare professionals (HCPs) across 39 European countries.

MAIN MEASURES

Our measures were barriers and unmet training needs for the management of medication adherence across Europe.

KEY RESULTS

In total, 2875 HCPs (pharmacists, 40%; physicians, 37%; nurses, 17%) from 37 countries participated. The largest barriers to adequate medication adherence management were lack of patient awareness (66%), lack of HCP time (44%), lack of electronic solutions (e.g., access to integrated databases and uniformity of data available) (42%), and lack of collaboration and communication between HCPs (41%). Almost all HCPs pointed out the need for educational training on medication adherence management.

CONCLUSIONS

These findings highlight the importance of addressing medication adherence barriers at different levels, from patient awareness to health system technology and to fostering collaboration between HCPs. To optimize patient and economic outcomes from prescribed medication, prerequisites include adequate HCP training as well as further development of digital solutions and shared health data infrastructures across Europe.

Cultural competence training of dieticians: development and preliminary evaluation

INTRODUCTION

Training can improve healthcare providers' cultural competence and increase their awareness of bias and discrimination in medical decision-making. Cultural competences training is lacking in the education of dieticians in the Netherlands. The aim of this study was to describe the pilot-implementation of a cultural competence training for dieticians and preliminary evaluation of the training.

METHODS

A training was developed based on Seeleman's cultural competence framework and previously held interviews with migrants, dieticians, and experts. The training consisted of a mixture of didactic and experiential methods, alternating knowledge transfer with exercises to increase awareness, reflection, and feed-back on recorded consultations, and communication training with migrant training actors. The training was piloted in 8 participating dieticians and preliminary mixed-method evaluation was done using a Cultural Competence Questionnaire, Experience Evaluation Questionnaire, and consultation observations.

RESULTS

The questionnaires showed that dieticians were positive about the training. They found it valuable and educational. Participants reported an increase in self-perceived cultural competence and attitudes. Knowledge and skills remained approximately the same. The observations showed that dieticians applied the teach-back method and discussed treatment options more often after training. There was no increase in the use of visual materials.

CONCLUSION

The training was well appreciated and, although a small-scale pilot, this mixed-method study suggests an ability to change cultural competence. The combination of a self-assessment instrument and consultation observations to evaluate cultural competence was highly valuable and feasible. These encouraging results justify a broader implementation of the training.

Exploring the implicit meanings of 'cultural diversity': a critical conceptual analysis of commonly used approaches in medical education

Existing approaches to cultural diversity in medical education may be implicitly based on different conceptualisations of culture. Research has demonstrated that such interpretations matter to practices and people concerned. We therefore sought to identify the different conceptualisations espoused by these approaches and investigated their implications for education. We critically reviewed 52 articles from eight top medical education journals and subjected these to a conceptual analysis. Via open coding, we looked for references to approaches, their objectives, implicit notions of culture, and to implementation practices. We iteratively developed themes from the collected findings. We identified several approaches to cultural diversity teaching that used four different ways to conceptualise cultural diversity: culture as 'fixed patient characteristic', as 'multiple fixed characteristics', as 'dynamic outcome impacting social interactions', and as 'power dynamics'. We discussed the assumptions underlying these different notions, and reflected upon limitations and implications for educational practice. The notion of 'cultural diversity' challenges learners' communication skills, touches upon inherent inequalities and impacts how the field constructs knowledge. This study adds insights into how inherent inequalities in biomedical knowledge construction are rooted in methodological, ontological, and epistemological principles. Although these insights carry laborious implications for educational implementation, educators can learn from first initiatives, such as: standardly include information on patients' multiple identities and lived experiences in case descriptions, stimulate more reflection on teachers' and students' own values and hierarchical position, acknowledge Western epistemological hegemony, explicitly include literature from diverse sources, and monitor diversity-integrated topics in the curriculum.

Nursing educators' experiences of cultural competence in the nursing education program: A qualitative descriptive study

BACKGROUND

To meet the population's increasing diversity and the health system's needs, it is necessary to prepare nursing schools to produce culturally qualified students.

PURPOSE

This study aimed to extract the experiences of nursing educators about the cultural competence of nursing students.

METHOD

In this qualitative descriptive study, data were collected through in-depth, semi-structured interviews with 15 nursing educators affiliated with three medical sciences universities in southeastern Iran. Purposive data sampling and analysis were performed using Graneheim and Lundman's conventional content analysis methods.

RESULTS

One main theme, 5 categories, and 18 subcategories were extracted. The main theme was "cultural equality, the essence of care and education". Categories included "Toward culturally-based caring and education", "Charter of cultural rights", "The need for cultural competence facilitators", "Cultural exposure", and "Modifying the curriculum policies".

CONCLUSION

This study shows that nursing educators strive to take into account students' cultural competence, even though cultural competence is not explicitly integrated into nursing curricula. The acquisition of cultural competence requires multifaceted changes in education, in clinical centers, and in the creation of cultural infrastructure.

Involuntary admissions for non-affective psychotic disorders in young refugees and peers in Denmark: A population cohort study

INTRODUCTION

People with psychotic disorders are at increased risk of experiencing involuntary hospital admissions relative to other psychiatric patients. Within this group, refugees and other minority groups may be at even greater risk. However, little is known about the role of migration background in the risk of involuntary admissions around the time of first psychosis-related treatment.

METHOD

We utilized nationwide administrative data from Denmark covering the period 2006-2018. We included all persons aged 18-35 years in first treatment for psychotic disorders [inpatient and hospital-based outpatient settings (N = 11,871)]. We estimated odds ratios (OR) of any involuntary inpatient admission within three months of first treatment using logistic regression, and rate ratios (RR) of further involuntary admissions, total number of involuntary admissions, and days of involuntary care among patients initially admitted involuntarily using Poisson regression. We compared refugees with majority peers (native-born with native-born parent), other migrants, and descendants of non-refugee migrants.

RESULTS

Compared with the majority group, refugees, non-refugee migrants and descendants were at increased risk of involuntarily admissions (ORrange = 2.12-2.69). Differences in sex, age, education, household income and family situation did not explain these disparities. In contrast, the risk of subsequent involuntary care did not differ between groups (RRrange = 0.77-1.31).

CONCLUSIONS

The findings highlight the need to review if and why processes of needs detection and voluntary treatment enrolment are less effective for minorities in Denmark. Further studies should investigate the pathways to care across population groups to inform interventions that address disparities.

Cultural Competence in Ophthalmic Dispensing Education: A Qualitative Study

Purpose

Understanding and acknowledging cultural diversity in healthcare is essential in providing culturally competent care. Higher education institutions are critical to providing students with the necessary knowledge, attitudes, and skills to respond to cultural diversity in various contexts. Cultural competence teaching in ophthalmic dispensing education has emerged as an essential concept that needs to be included in the curriculum. This study explored ophthalmic dispensing lecturers' understandings, experiences, and attitudes in teaching cultural competence.

Methods

This study used a qualitative approach within an interpretivist paradigm by conducting semi-structured interviews with lecturers (n = 7) in the ophthalmic dispensing program. Braun and Clarke's framework for thematic analysis was utilized. The research was conducted at an ophthalmic dispensing department at a South African university.

Results

The analysis of the semi-structured interviews indicated three main themes of importance regarding factors influencing cultural competence education in the ophthalmic dispensing curriculum: the interplay between experiences and understandings of cultural competence, cross-cultural exposure and teaching practices, and inclusion of cultural competence into the curriculum. The participants recognized that cultural competence was not explicitly included in the curriculum. Including culture in education was rather unsystematic and, in most cases, unplanned.

Conclusion

Further training of lecturers on cultural competence skills and evidence-based teaching and assessment strategies are required to assist in developing curricula that include cultural competence.

Immigrant assimilation in health care utilisation in Spain

Abundant evidence has tracked the labour market and health assimilation of immigrants, including static analyses of differences in how foreign-born and native-born residents consume health care services. However, we know much less about how migrants' patterns of healthcare usage evolve with time of residence, especially in countries providing universal or quasi-universal coverage. We investigate this process in Spain by combining all the available waves of the local health survey, which allows us to separately identify period, cohort, and assimilation effects. We find robust evidence of migrant assimilation in health care use, specifically in visits to general practitioners and emergency care and among foreign-born women. The differential effects of ageing on health care use between foreign-born and native-born populations contributes to the convergence of utilisation patterns in most health services after 15 years in Spain. Substantial heterogeneity by the time of arrival and by region of origin both suggest that studies modelling future welfare state finances would benefit from a more thorough assessment of migration.

Capacity building in migration and health in higher education: lessons from five European countries

Capacity building in migration and health in higher education is key to better, sustainable, and equitable health care provision. However, developments so far have been patchy, non-structural, and often unsustainable. While training programs have been evaluated and competency standards developed, perspectives from individual teachers are hardly accessible. We present expert perspectives from five European countries to illustrate good examples in higher education and identify gaps to further the advancement of capacity building in migration and health. Based on these perspectives, we have identified thematic areas at four levels: conceptual evolution, policy and implementation, organization at the academic level and teaching materials and pedagogies. Finally, we propose creating spaces to share concrete educational practices and experiences for adaptation and replication. We summarize key recommendations for the advancement of capacity building in migration and health.

Equity in education for migrant and racialized students in Southern Spain: From multilevel analysis to participatory recommendations

This paper aims to analyze equity in education policies and practices in Southern Spain that ensure cultural competence in services and the inclusion of migrant and racialized students. Our model for defining and analyzing equity in education was adapted from the Migrant Integration Policy Index (MIPEX) and includes five dimensions: (E1) equity in mission/goal, (E2) equity in access, (E3) quality/sensitivity of services, (E4) equity in participation, and (E5) development of partnerships and opportunities. Through transformative mixed methods (i.e., documental analysis of 13 policies, 15 interviews with professionals, one focus group with mothers of Afro-descendant students), the results showed that equity was 100% present in the mission/goal of the Andalusian education system, although there were gaps in its practical implementation, especially in participation and quality/responsiveness. These results were discussed and recommendations for improving equity in education policies and practices are proposed participatively.

What influences Indonesian medical educators' intentions to teach public health? A qualitative study

PURPOSE

Medical educators are central in ensuring future doctors have sufficient public health skills. Attitudes, norms, and perceived control about the significance of teaching a subject determines whether or not it is taught and how well. This qualitative study aims to explore medical educators' perceptions about what factors influence their intention to teach public health in Indonesian undergraduate medical schools.

METHODS

Semi-structured interviews were conducted with eighteen medical educators from different Indonesian medical schools. Interviews were analyzed thematically using the Theory of Planned Behavior domains: attitudes, subjective norms, and perceived behavioral control.

RESULTS

Five subthemes emerged under these domains: attitudes (defining public health); subjective norms (room in the medical curricula; teaching and assessment); and perceived behaviour control (medical educator confidence; institutional support). Most participants had a limited understanding about the scope of public health. This coupled with an already overcrowded medical curriculum made it challenging for them to incorporate public health into the medical curriculum dominated by clinical and biomedical content. Although believing that public health is important, medical educators were reluctant to incorporate public health because they were not confident incorporating or assessing content.

CONCLUSION

Strong institutional support is to improve public health quality and content in the medical curriculum. Including public health educators in discussions is critical.

Diversity competence training for health professionals in Europe: a modified delphi study investigating relevant content for short or online courses

BACKGROUND

Diversity is a reality in our societies, requiring health professionals to adapt to the unique needs of all patients, including migrants and ethnic minorities. In order to enable health professionals to meet related challenges and reduce health disparities, long and demanding training courses have been developed. But due to busy schedules of professionals and often scarce resources, a need for shorter training courses exists. This study aims to investigate which topics and methods should be prioritised in designing basic diversity training courses that provide health professionals the opportunity to foster this competence.

METHODS

The study provided an expert panel of 31 academic and clinical migrant health experts with the content and methods of an existing diversity training course. The panel was asked to prioritise training topics and teaching methods in a two-stage process, using an adapted Delphi method. In the first stage, experts rated 96 predefined items, commented on those items, provided answers to eight open-ended questions and suggested additional content for a short course. In the second stage, they commented on the ratings from Round 1, and rated new suggested content. Consensus for training topics was set to 80% and for teaching methods 70%.

RESULTS

The entire panel deemed 'health effects of migration (pre-, during- and post-migration risk factors)' to be important or very important to include in a short/online, basic diversity training (100% consensus). Other high-scoring items and therefore topics to be included in trainings were 'social determinants of health' (97%) and 'discrimination within the healthcare sector' (also 97%). A general trend was to focus on reflective practice since almost all items regarding reflection reached consensus. 'Reflection on own stereotypes and prejudices' (97%) was the highest-rated reflection item. 'Opportunities and best practices in working with interpreters' was the highest-scoring skills item, both on consensus (96%) and mean value (5.77).

CONCLUSIONS

Experts' prioritizations of teaching content and methods for diversity training can help the design of short (online) trainings for health professionals and reduce unnecessary course content, thereby fostering professional development and enabling diversity competence trainings to be implemented also when time and/or financial resources are limited.

Improving health literacy responsiveness to reduce ethnic and social disparity in stillbirth and infant health: A cluster randomized controlled effectiveness trial of the MAMAACT intervention

OBJECTIVE

The MAMAACT intervention aims to reduce ethnic and social disparities in stillbirth and infant death by improving communication between pregnant women and midwives regarding warning signs of pregnancy complications. This study evaluates the effect of the intervention on pregnant women's health literacy (two domains from the Health Literacy Questionnaire) and complication management - interpreted as improved health literacy responsiveness among midwives.

DESIGN

Cluster randomized controlled trial, 2018-2019.

SETTING

19 of 20 Danish maternity wards.

PARTICIPANTS

Cross-sectional survey data were collected using telephone interviews (n = 4150 pregnant women including 670 women with a non-Western immigrant background).

INTERVENTION

A six-hour training session for midwives in intercultural communication and cultural competence, two follow-up dialog meetings, and health education materials for pregnant women on warning signs of pregnancy complications - in six languages.

MAIN OUTCOME MEASURES

Differences in mean scores at post-implementation of the domains Active engagement with healthcare providers (Active engagement) and Navigating the healthcare system from the Health Literacy Questionnaire, and differences in the certainty of how to respond to pregnancy complication signs between women in the intervention and control group.

RESULTS

No difference was observed in women's level of Active engagement or Navigating the healthcare system. Women from the intervention group were more certain of how to respond to complication signs: Redness, swelling, and heat in one leg: 69.4 % vs 59.1 %; aOR 1.57 (95 % CI 1.32-1.88), Severe headache: 75.6 % vs 67.3 %; aOR 1.50 (95 % CI 1.24-1.82), and Vaginal bleeding: 97.3 % vs 95.1 %; aOR 1.67 (95 % CI 1.04-2.66).

CONCLUSION

The intervention improved women's certainty of how to respond to complication signs, but was unable to improve pregnant women's health literacy levels of Active engagement and Navigating the healthcare system, likely due to barriers related to the organization of antenatal care. A reorganization of antenatal care and a care model sensitive to diversity within the entire healthcare system might help reduce disparities in perinatal health.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03751774.

Effectiveness of alternative approaches to integrating SDOH into medical education: a scoping review

BACKGROUND

There is increasing recognition of including social determinants of health (SDOH) in teaching for future doctors. However, the educational methods and the extent of integration into the curriculum vary considerably-this scoping review is aimed at how SDOH has been introduced into medical schools' curricula.

METHODS

A systematic search was performed of six electronic databases, including PubMed, Education Source, Scopus, OVID (Medline), APA Psych Info, and ERIC. Articles were excluded if they did not cover the SDOH curriculum for medical students; were based on service-learning rather than didactic content; were pilot courses, or were not in English, leaving eight articles in the final study.

RESULTS

The initial search yielded 654 articles after removing duplicates. In the first screening step, 588 articles were excluded after applying inclusion and exclusion criteria and quality assessment; we examined 66 articles, a total of eight included in the study. There was considerable heterogeneity in the content, structure and duration of SDOH curricula. Of the eight included studies, six were in the United States(U.S.), one in the United Kingdom (U.K.) and one in Israel. Four main conceptual frameworks were invoked: the U.S. Healthy People 2020, two World Health Organisation frameworks (The Life Course and the Michael Marmot's Social Determinants of Health), and the National Academic of Science, Engineering, and Medicine's (Framework For educating Health Professionals to Address the Social Determinants of Health). In general, programs that lasted longer appeared to perform better than shorter-duration programmes. Students favoured interactive, experiential-learning teaching methods over the traditional classroom-based teaching methods.

CONCLUSION

The incorporation of well-structured SDOH curricula capturing both local specification and a global framework, combined with a combination of traditional and interactive teaching methods over extended periods, may be helpful in steps for creating lifelong learners and socially accountable medical school education.

Medical educators' perspectives on the barriers and enablers of teaching public health in the undergraduate medical schools: a systematic review

Background

Having relevant public health content in the undergraduate medical curriculum is critical to preparing medical doctors for emerging health issues and increased public health roles. Medical educators are central to this effort.

Objective

This systematic review synthesises the most relevant and up-to-date evidence on medical educators’ perspectives regarding the barriers and enablers on incorporating public health teaching in the undergraduate medical curricula.

Methods

Seven databases were searched for articles published between 1 January 2010 and 31 December 2021. Articles were included if they were available in full-text English or Indonesian language, peer-reviewed, and focused on medical educators’ perspectives on teaching public health in the undergraduate medical curricula. Findings were integrated to answer the review question using thematic analysis.

Results

Twenty-nine articles were included in the final review. Three major themes emerged: (i) space in the medical curricula, (ii) confidence/capabilities of medical educators, and (iii) institutional support. Overcrowded curricula, lack of consensus about the scope and level of public health to incorporate into teaching, ensuring the quality and the relevance of content with what is required in real practice, as well as inadequate institutional support are major challenges in teaching public health to medical students.

Conclusions

Integrating public health into other subjects is largely seen as a solution. This requires strong institutional support in the form of financial, logistic, and technical support; structured training for medical educators on how to incorporate the content into their subjects; and a recognition of the important role that public health educators play.

Implicit and explicit ethnic biases in multicultural primary care: the case of trainee general practitioners

Background

General Practitioners (GPs) are the first point of contact for people from ethnic and migrant groups who have health problems. Discrimination can occur in this health care sector. Few studies, however, have investigated implicit and explicit biases in general practice against ethnic and migrant groups. This study, therefore, investigated the extent of implicit ethnic biases and willingness to adapt care to migrant patients among trainee GPs, and the factors involved therein, in order to measure explicit bias and explore a dimension of cultural competence.

Methods

In 2021, data were collected from 207 trainee GPs in the French-speaking part of Belgium. The respondents passed an Implicit Association Test (IAT), a validated tool used to measure implicit biases against ethnic groups. An explicit attitude of willingness to adapt care to diversity, one of the dimensions of cultural competence, was measured using the Hudelson scale.

Results

The overwhelming majority of trainee GPs (82.6%, 95% CI: 0.77 – 0.88) had implicit preferences for their ingroup to the detriment of ethnic and migrant groups. Overall, the majority of respondents considered it the responsibility of GPs to adapt their attitudes and practices to migrants’ needs. More than 50% of trainee GPs, however, considered it the responsibility of migrant patients to adapt to the values and habits of the host country.

Conclusions

This study found that the trainee GPs had high to very high levels of implicit ethnic bias and that they were not always willing to adapt care to the values of migrants. We therefore recommend that they are made aware of this bias and we recommend using the IAT and Hudelson scales as educational tools to address ethnic biases in primary care.

Mind the Gate: General Practitioner's Attitudes Towards Depressed Patients with Diverse Migration Backgrounds

This study aims to examine (a) whether there are differences in general practitioners' (GPs) attitudes towards native Belgian patients, patients of foreign descent and asylum seeking patients who all express symptoms of major depression, and (b) whether these differences depend on GPs' experience with cultural competency training and interethnic contact. Using a video vignette study among 404 Flemish (Belgium) GPs, we find evidence of a provider bias. While GPs regard a patient of foreign descent as less trustworthy and less able to adhere to medical recommendations than a native Belgian patient, they also hold more pessimistic views on a potential recovery of an asylum seeking patient. In addition, we find that cultural competency training might alter GPs' attitudes of asylum seeking patients in a positive way. Summarized, our research highlights the need to target stereotypes among GPs for interventions designed to reduce migration-based disparities in healthcare use and health status.

Overcoming language barriers, enhancing collaboration with interpreters - an interprofessional learning intervention (Interpret2Improve)

BACKGROUND

Language barriers (LB) are common in patient care. They can negatively impact the quality of care, and increase costs. LB can be overcome by using interpreters. However, collaboration with interpreters is a professional activity which can and needs to be learnt. Interpret2Improve is an innovative educational intervention where medical and nursing students learn together how to address LB and effectively collaborate with interpreters.

METHODS

The three-hour course has two parts: After a short introduction on the relevance of LB and resulting issues of patient safety etc., students in interprofessional teams of two practice conversations with non-German-speaking simulated patients and professional interpreters. The course is evaluated in a pre-post format with the Freiburg Questionnaire for Interprofessional Learning Evaluation which has been validated in prior studies.

RESULTS

Fifty-one students (thirty of the participants were medical students, 21 participants were students in nursing care) participated from 11/2016-07/2018. Overall, the course was very well received (mean 1.73 (SD 0.85) on a five point scale: 1 = very good, 5 = insufficient). The evaluation by medical and nursing students differed significantly. Fourteen out of twenty-one items show a self-assessed increase in interprofessional knowledge or skills.

CONCLUSIONS

Students felt that their skills in addressing LB by effectively collaborating with interpreters increased during this interprofessional format. Further studies are needed to obtain further evidence beyond self-assessment and regarding the long-term outcomes.

Cultural Competence in Healthcare Leadership Education and Development

Cultural competence is a phenomenon that straddles many disciplines and fields of study. There is no settled definition of the term, and it is argued that this is not necessary to explore or discuss the phenomenon as it is context-dependent across diverse societies. Explorations of cultural competence in clinical education and training are well-established, but there has been less attention towards its expression in the field of developing healthcare leaders. There is a debate about whether cultural competence is best achieved primarily through training-based educational inputs or by being infused in all areas of curriculum development. Using an exploration of selected literature followed by the case of an ambitious set of leadership development programmes in the English National Health Service, this paper explores the balance and interdependencies of cultural competence in healthcare leadership development as knowledge, skills and attitudes. The paper concludes that it is important for educators in this field to provide space for reflection, develop skills of reflexivity and facilitate sensitive discussions of sometimes contested ideas and concepts. A further evaluation of the impact of teaching and learning interventions, while mapping developments in perceptions of knowledge, skill and attitudes would be an area ripe for future research.

Differences in quality of care, mortality, suicidal behavior, and readmissions among migrants and Danish-born inpatients with major depressive disorder

Background

The increasing global migration has made migrants’ health a pertinent topic. This article aimed to examine whether migrants were less likely than Danish-born residents to receive guideline recommended care when hospitalized for major depressive disorder (MDD) and potential differences in clinical outcomes, including all-cause mortality, suicidal behavior, and readmissions during 1-year follow-up after first-time admission.

Methods

A national cohort study was performed, including all adult MDD inpatients at mental care units in the period 2011–2017. Migrants and two migrant subgroups (non-Western and Western) were compared with Danish-born patients. Quality of care was examined using multivariable Poisson and linear regression models. Clinical outcomes were examined using Cox proportional hazards regression analysis.

Results

Migrant-status was associated with a non-significantly lower chance of receiving high-quality care (relative risk [RR] = 0.93, confidence interval [CI] 0.86:1.01) and lower readmission rates for depression (hazard rate ratio [HR] = 0.93, CI 0.86:1.01), and significantly higher all-cause mortality (HR = 1.55, CI 1.19:2.01) and lower all-cause readmission rate (HR = 0.88, CI 0.83:0.94). No clear association was found regarding suicidal behavior. While associations were comparable for migrant subgroups regarding readmission, the associations with low quality of care and of all-cause mortality appeared strongest among Western migrants.

Conclusions

Among inpatients with MDD in a universal tax-financed healthcare system, being a migrant was associated with a potential lower quality of in-hospital care and worse clinical outcomes. These results warrant further investigation to clarify the underlying explanation for these inequalities and to develop and test interventions to ensure better quality of care and clinical outcomes for migrant patients.

The road to equitable healthcare: A conceptual model developed from a qualitative study of Syrian refugees in Norway

BACKGROUND

Refugees in high-income countries face barriers to healthcare access even when they have the same rights and entitlements as the host population. Disadvantages in healthcare access contribute to differences in health outcomes and impact acculturation. This study explores perceived changes in health status and experiences with the Norwegian healthcare system of Syrian refugees living in Norway, using a trajectory perspective.

METHODS

We conducted 15 semi-structured interviews in April 2020 among purposefully recruited adult refugees from Syria resettled in Norway. Interviews were carried out in Arabic and analysed with Systematic Text Condensation using NVivo software. We used Lévesque's access model and Edberg's migration trajectory perspective as theoretical frameworks. A conceptual model was developed - The Migrant Sensitive Access Model - that highlights the factors contributing to a positive versus negative healthcare journey.

RESULTS

Findings were summarized under three main themes: changes in health and well-being, expectations, and trust. Perceived changes in health status and attributed causes for change were related to the resettlement phase, gender, and were highly informed by pre-migration and migration experiences. The users' perception of the caregiver, communication, and time were identified as key factors in the care-access journey in inspiring trust or distrust in the caregiver.

CONCLUSION

Syrian refugees in Norway appreciate the Norwegian healthcare system but are impeded in their access to care. Many of the barriers can be bridged during the doctor-patient interaction with a diversity sensitive caregiver. The model we propose gives a comprehensive overview of key areas determining the healthcare experience of this population. The results of this study can be useful to policymakers and healthcare providers when addressing disparities in healthcare access for forced migrants.

Alternatives to Student Outbound Mobility-Improving Students' Cultural Competency Skills Online to Improve Global Health Without Travel

Introduction

Student outbound mobility is a major element in internationalization of medical education and global health education. However, this approach is often criticized, as it is inherently inequitable. Internationalization at home is a newer concept that aims to provide students with international skills and experiences without exchange travel. We report detailed outcomes of an international online program during the COVID-19 pandemic, which aimed to include acquisition of cultural awareness and competency-similar to what the students would have obtained if they had travelled abroad.

Method

Sixty-eight students from 12 international universities participated in international small peer group collaborative work, and online networking. Perceived improvement of cultural competency using Likert scale and open-ended questions was used as a measure of success. Furthermore, students' definition of cultural competency in the different countries was obtained.

Results

Students improved their cultural competency skills. Data analysis supported statistically significant improvement of the above skills after the program, in comparison to the start of the program.

Discussion

Internationalization of medical education can be achieved at home-via structured online peer exchanges-and can provide students with intercultural skills and networking opportunities that are typically achieved via international in-person travel. The above represents a socially just and equitable way to reach all students and can result in improvement of their cultural competency, preparing them for their work in global health, and thereby resulting in improvement of global health.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-021-01332-9.

Health literacy responsiveness: a cross-sectional study among pregnant women in Denmark

Aims: Communication barriers in healthcare encounters contribute to ethnic inequality in health outcomes. This study aimed to examine, in a large national Danish sample of women, whether ethnicity was associated with pregnant women's Active engagement with healthcare providers. Methods: A cross-sectional survey of 1898 pregnant women attending 19 Danish maternity wards. The key variable of interest was maternal ethnicity among ethnic Danish, European, African and Asian immigrant women and their descendants. Syrian immigrant women were studied as a subgroup. The outcome was the health literacy questionnaire domain Ability to engage actively with healthcare providers (five-item domain scored from 'cannot do/always difficult' (1) to 'always easy' (5)) which is a reflection of a respondent's lived experiences of engaging with healthcare providers. Adjusted mixed effect multivariate linear regression was used to compare Active engagement across groups expressed as the mean difference (95% confidence interval). Results: Lower means of Active engagement were reported for immigrant women compared to ethnic Danish women in all models. When adjusting for age, parity, complications and occupation, the difference between ethnic Danish women's Active engagement and other groups was smallest among European -0.15 (-0.26 to -0.05), slightly larger in African -0.19 (-0.40 to 0.02), and largest in Asian immigrant women -0.31 (-0.41 to -0.21). Syrian immigrant women had the largest difference -0.42 (-0.58 to -0.27). Conclusions: Pregnant immigrant women reported lower means of Active engagement than ethnic Danish women did. Increased health literacy responsiveness in maternity care is required to mitigate the potential for differential care and health inequity.

Nurse teacher's perceptions on teaching cultural competence to students in Finland: a descriptive qualitative study

BACKGROUND

Cultural diversity in healthcare settings requires that care professionals are able to provide culturally competent care. This means that educational institutions have a crucial role to play in equipping students with the skills to deal with diversity in cross-cultural and multicultural contexts. Ensuring that cultural competence is part of the educational curriculum is therefore essential.

PURPOSE

This study aims to examine what elements influence the implementation of cultural competence content in nursing education from a nurse teacher's perspective.

METHODS

A descriptive qualitative design was used consisting of semi-structured interviews with nurse teachers (n = 12). Inductive content analysis was applied to explore their perceptions on teaching cultural competence at a University of Applied Sciences (UAS) in Southern Finland.

RESULTS

Analysis from the open coding of interviews indicated that there are three main categories of importance regarding students' cultural competence education: exposure to diversity in the teaching environment; teacher's experience and understanding of cultural competence; and integrating cultural competence into the curriculum.

CONCLUSIONS

The findings suggest that more transparency and cooperation between nurse teachers and the university administration is necessary to ensure the inclusion of cultural competence in nursing education. For instance, teachers should receive training related to cultural competence and evidence-based teaching methods. The curriculum should include a course or workshop about cultural competence with clear learning objectives and evaluation criteria for the purpose of grading. Finally, the educational institution should commit to developing a culturally competent organisation through internationalization and the maintenance of a diverse environment.

Nursing Lecturers' Perception and Experience of Teaching Cultural Competence: A European Qualitative Study

Cultural competence is an essential component in providing effective and culturally responsive healthcare services, reducing health inequalities, challenging racism in health care and improving patient safety, satisfaction and health outcomes. It is thus reasonable that undergraduate nursing students can develop cultural competency through education and training. The aim of this paper was to investigate nursing lecturers' perception and experience of teaching cultural competence in four undergraduate nursing programs. A phenomenological approach was selected to illicit nursing lecturers' perception of culture and experience of teaching cultural competence. Semi-structured personal interviews were held with a sample of 24 lecturers from four European universities. The anonymized transcripts were analyzed qualitatively following Braun and Clark's phases for thematic analysis. Six themes and fifteen subthemes emerged from thematic analysis of the transcripts. Cultural competence was not explicitly integrated in the nursing curricula. Instead, the lecturers used mainly examples and case studies to illustrate the theory. The integration of cultural content in the modules was unplanned and not based on a specific model. Nursing programs should be examined to establish how cultural content is integrated in the curricula; clear guidelines and standards for a systematic integration of cultural content in the nursing curriculum should be developed.

Cultural competence among pre-graduate nursing students, new graduate nurses, nurse mentors, and registered nurses: A comparative descriptive study

BACKGROUND

Achieving and improving cultural competence in nursing is an ongoing process, beginning in the student period and continuing through the professional career.

OBJECTIVES

The present study aims to compare pre-graduate students, newly graduated nurses, registered nurses, and nurse mentors in Taiwan in terms of their respective levels of cultural competence, and to determine associated influencing factors.

DESIGN

A comparative cross-sectional study.

SETTINGS

Three universities and three hospitals (one regional hospital and two teaching hospitals) in Taiwan.

PARTICIPANTS

A total of 756 nurses/students (103 pre-graduate nurses, 321 newly graduated nurses, 101 registered nurses, and 231 nurse mentors).

METHODS

The Cultural Competence Scale for Pre-Graduated Students to Licensed Professionals was used to measure the cultural competence level. One-way analysis of variance and hierarchical regression analysis were used for statistical analysis.

RESULTS

For overall cultural competence and the subscales of knowledge, awareness, and skills, the pre-graduate students scored lower than the other three groups. Experience of caring for patients from diverse cultures and countries significantly influenced the cultural competence of all four groups. Ability to speak fluent English and receiving cultural competence education during nursing education only significantly influenced the cultural competence of the pre-graduate and new graduate nurses. Current job position and primary practice setting significantly influenced the cultural competence of the registered nurses and nurse mentors.

CONCLUSION

Pre-graduate students, newly graduated nurses, registered nurses, and nurse mentors have differing levels of cultural competence and differing influencing factors. Cultural competence education that accords with the influencing factors for each nursing position would continuously cultivate nursing staff's cultural competence.

Hereditary angioedema: the challenges of cross-border family investigation and treatment

Hereditary angioedema (HAE) is a rare genetic disorder characterised by recurrent swellings involving subcutaneous and submucosal tissue that can be potentially life threatening in cases involving the upper airway. In this case report, we present a Syrian refugee family with HAE who have lived in Denmark since 2014. The index patient is an 8-year-old girl diagnosed with HAE after being hospitalised in Denmark with an angioedema attack. Her younger sister and father were diagnosed later, following investigation of the family. Exploring the family history, deaths due to suffocation were described in previous generations and other family members based in Sweden, Germany, Turkey, Saudi Arabia, USA and Syria could also potentially be affected. This highlights the need for a cross-border effort to diagnose and treat this inherited disorder.