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Year : 2021  |  Volume : 19  |  Issue : 4  |  Page : 288-293

Cultural competence assessment in a health-care university

Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission31-Aug-2021
Date of Decision24-Sep-2021
Date of Acceptance08-Nov-2021
Date of Web Publication15-Dec-2021

Correspondence Address:
Chandrashekar Janakiram
Department of Public Health Dentistry, Amrita School of Dentistry, Amrita Vishwa Vidyapeetham, Kochi – 682 041, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_158_21

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Introduction: Cultural competence of health-care professionals has a vital role in health-care system. The first step toward this orientation is the assessment of cultural competence level of clinical graduate students. Objective: The objective of the study was to assess the cultural competence of clinical graduate students of various courses in a health-care university, Kerala, India. Methods: A cross-sectional study was conducted among 398 clinical graduate students in a health-care university in Kerala, India. The self-administered questionnaire had 27 items adapted from various validated scales. Data analysis was done by the analysis of variance (ANOVA) using SPSS software (version 23). P < 0.05 was considered statistically significant. Results: The overall mean of the responses ranged from 2.81 (confidence interval [CI]: 2.70–2.93) to 4.50 (CI: 4.43–4.57). ANOVA revealed statistically significant differences between the courses in competencies related to specific competencies. Conclusion: Our findings suggest that cultural competence of health-care graduates can be improved by incorporating cultural competence training in the curriculum.

Keywords: Cultural competency, culturally competent care, curriculum, health occupation students, India

How to cite this article:
Balachandran P, Krishna DM, Janakiram C. Cultural competence assessment in a health-care university. J Indian Assoc Public Health Dent 2021;19:288-93

How to cite this URL:
Balachandran P, Krishna DM, Janakiram C. Cultural competence assessment in a health-care university. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Aug 11];19:288-93. Available from: https://www.jiaphd.org/text.asp?2021/19/4/288/332525

  Introduction Top

Health is a fundamental aspect of an individual's life. Factors that have direct as well as indirect bearing on health and disease, therefore, must be critically evaluated and reinforced for positive outcomes. With the growing inclination toward globalization and patient-centric health-care delivery, cultural background of patients is emerging as an important domain in health-care system. This reform also reflects the transition from the conventional paternalistic attitude of caregivers to a more patient-tailored approach.

Health is a cultural construct. Culture is defined as “a concept including knowledge, belief, arts, morals, law, custom, and any other capabilities and habits acquired by human beings as a member of society.”[1] Within the purview of health-care system, culture refers to “the integrated form of human behavior that relates to thoughts, communications, actions, customs, beliefs, values and institutions of a racial, ethnic, religious or social group that is relevant to everyone's health care.”[2]

Culture has a profound effect on the way a layman understands his/her illness, lifestyle, and well-being. The meaning attributed to health and diseases by the health-care professional and health-care seeker is often divergent, causing a negative treatment experience and poor treatment outcomes.[3] An important challenge to health-care providers is provision of culturally sensitive care because patients from different cultures have specific health-care needs and expectations.[4] In addition, the difference in comprehension and judgments among the health-care professional and patient, owing to preconceived notions and cultural experiences, can result in implicit bias. Therefore, an integration of cultural knowledge, attitudes, and skills in the health professional's clinical practice is an effective strategy to redress these issues.[5]

Cultural competence is defined as “the ability to understand and work effectively with patients whose beliefs, values and histories differ from one's own.”[6] Globally, efforts have been made to incorporate cultural competence in health-care training. Training programs designed for specific courses such as nursing, pharmacy,[7] dentistry, [8],[9] and physiotherapy are popular in many countries. Since cultural competence development is a lifelong process, inclusion of its training in medical education has shown to improve the cultural sensitivity of health-care trainees to patients, thereby resulting in enhanced communication, treatment adherence, follow-up, and treatment outcome.[10],[11]

Virtual community training of nursing students showed enhanced cultural awareness among student participants, and similar technological innovations were recommended to overcome the cost and implementation barriers of cultural competence training in medical education.[12]

Association of American Medical Colleges recommends the integration of cultural competence training with clinical training for health-care students. This early career sensitization of health-care trainees toward patient preferences and heterogeneity was found to improve their professional attitude, patient-centered approach, and clinical skills.[13]

Ironically, a richly diverse and densely populated country like India has limited efforts in this vital domain.[2] In India, cultural impact on the decision-making of an individual is manifested through language, social, familial, and gender contexts. In such cases, contrary to western understanding, patient autonomy has to been viewed in a broader aspect. This cultural underpinning in India often results in difficult distinctions between culture, mores, religion, caste, and spirituality. Lack of adequate training, neglect to cultural aspect of health care and deep-rooted impact of culture, therefore, results in patient alienation, misinterpretation of diseases, and complications.

An important step toward filling this existing “cultural gap” in health care is incorporating cultural competence enhancement programs in the curricula of health-care professionals. For this, an assessment of the cultural competence levels of the health-care trainees is essential. There are limited studies that assess the cultural competence of various health-care professionals in India. Such studies might enable comparisons between the courses and aid in developing a curriculum as per the requirement of each course. The present study was designed to address this gap in literature. The primary objective of the study was to assess the cultural competence of clinical graduates of various courses in a health-care university.

  Methods Top

A cross-sectional study was conducted among the clinical graduate students in a health-care university in Kerala, India. Since we focused on graduate trainees who had clinical postings, 3rd year and final year students of medical, dental, nursing, and pharmacy courses as well as interns of medical and dental courses were eligible for the study. The study was approved by the Institutional Ethics Committee (IRB-AIMS-2020-132). The study was designed as a census survey and all clinical graduate students were invited to participate.

Based on the literature review, a questionnaire was developed combining various assessment scales.[4],[5],[14],[15] Consenting participants were administered the questionnaire through online mode. A Google Form comprising of participant information sheet, certificate of consent, demographic details of participants, and questionnaire was sent to their respective E-mail ids and social media such as WhatsApp application. A reminder was mailed after 2 weeks to promote participation.

The questionnaire comprised of 27 items adapted from validated scales such as cultural capacity scale,[4] cultural awareness scale,[5] and nurse cultural competence scale[15] to assess the cultural competence levels of the study participants. A 5-point Likert scale with values for responses ranging from strongly disagree to strongly agree was used.

Statistical analysis was performed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, N. Y., USA). Comparison of mean and standard deviation (SD) between the different groups was done by one-way analysis of variance. This was followed by post hoc analysis using Bonferroni test. P < 0.05 was considered statistically significant.

  Results Top

Out of the 398 participants, females constituted 86.7% and males 13.3%. Majority were dental students (34.4%) followed by nursing (28.4%), medical (25.9%), and pharmacy (11.3%) students. Demographic details of the study participants are given in [Table 1]. The mean age of the participants was 21.29 (SD = 1.326). Almost 94% of participants were from Kerala. 1.5% of participants were not interested to disclose their religion [Table 1].
Table 1: Characteristics of study participants

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The mean score of responses to each item was assessed [Table 2]. The overall mean score of the responses was found to range from 2.81 (confidence interval [CI]: 2.70–2.93) to 4.50 (CI: 4.43–4.57). A statistically significant difference was not observed between the courses for most items. The reference score of the Likert scale was taken as four (representing the score if the respondent “agreed” with the listed competences). Only three items had a mean score equal to or greater than 4. These items were the role of communication skills while interacting with patients from diverse backgrounds (4.50 ± 0.73), assisting friends or colleagues in communication with patients (4.16 ± 0.76), and identification of the care needs of patients from diverse cultural background (4.00 ± 0.68) [Table 2].
Table 2: Comparison of mean and standard deviation between the various courses

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Medical students (4.75 ± 0.56) [Table 2] reported a higher competence related to role of communication skills while interacting with patients from diverse cultural background. Medical students showed a lower competence level (2.65 ± 0.90) than others regarding eliciting information related to patient's beliefs or behaviors. A statistically significant difference was found between medical students and students of nursing and pharmacy courses in their competence level related to assisting friends or colleagues in communicating with patients from diverse cultural and linguistic background [Table 2].

Nursing students (3.79 ± 0.75) were competent in fulfilling the needs of patients from diverse cultural background than their medical counterparts (3.49 ± 0.77). Nursing students (3.74 ± 0.77) had higher competence in methods for collecting health- and culture-related information than dental (3.26 ± 0.96) and medical students (3.19 ± 0.97). Medical (4.20 ± 0.65) and dental (4.04 ± 0.63) students felt that it was essential to identify the care needs of patients from diverse cultural backgrounds [Table 2].

Medical students (3.06 ± 0.86) were less competent in explaining the possible relationships between health beliefs and patient culture. Nursing students (3.96 ± 0.72) had a higher competence in this regard than dental counterparts (3.39 ± 0.91). Pharmacy students (3.73 ± 0.78) exhibited a higher competence than others regarding discussing the patient's differences in health beliefs and health-care knowledge [Table 2].

Medical students (4.21 ± 0.74) utilized the help of bilingual–bicultural staff for effective patient communication than dental and nursing students. Compared to dental students, nursing students (3.75 ± 0.77) understood that patient's religion and beliefs influence their response to disease and death [Table 2].

  Discussion Top

According to Campinha–Bacote's model of cultural competence in health care, cultural competence is a lifelong process.[16] Since the participants belonged to diverse health-care courses, states, mother tongues, and religions, this study represents a comprehensive picture of cultural competence level of health-care clinical graduates in India. Our study assessed the cultural competence of students using a self-administered questionnaire with 27 items.

We considered the value of four (corresponding to the response “agree”) of 5-point Likert scale to be the ideal score in evaluating the responses. Out of the 27 items, only 3 items showed a mean score ≥4. This was in relation to the overall responses irrespective of the course. These were the items related to competence in communication skills, language barriers, and understanding care needs of patients [Table 2].

Language barriers pose a significant challenge in communication with patients. Our study showed that medical students were comparatively competent than others in communication skills and utilizing the assistance of bilingual–bicultural staff for overcoming language barrier. However, they were less competent in eliciting patient information [Table 2]. Good communication skills have a positive impact on patient–caregiver interactions and patient satisfaction. The Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” highlights the importance of language in improving communication with heterogeneous patients.[17] Systematic reviews recommend training of health-care professionals to develop competent, patient-centered communications.[18]

Nursing students were found to be competent than their counterparts in collecting information and fulfilling the health-care needs of multicultural patients. This competence is quite relevant in the context that certain diseases are presented by patients in a culturally appropriate manner owing to the stigma associated with them.[19] This insight into the cultural aspect of symptom presentation should be followed by the health-care providers efforts to discuss the differences in the patient's beliefs and scientific knowledge. Such discussions enable dissipating common misbeliefs of patients. Pharmacy students were found to be competent in discussing such differences with patients.[19]

Our results showed that each course was comparatively culturally competent than others in specific areas like fulfilling the needs of patients from other cultural backgrounds and understanding the influence of patient's culture in their health beliefs. Since the 27 items of our questionnaire assessed the various aspects of cultural competence among the residents, the results suggest that there is a need for developing transcultural competence development of graduate trainees of all health-care courses for reducing health-care disparities concerning patients from diverse cultural backgrounds. Studies suggest that interdisciplinary cultural competence courses offered at early stages of health-care training give better results than profession-centric training.[20]

Strengths and limitations

This is the first study in an Indian setting to compare the cultural competence of graduate students of diverse health streams within a campus. The sample consisted of participants from various states and cultures, thereby providing a comprehensive assessment. Such an assessment enables review of the existing institutional policies and development of cultural competence training programs to the residents. Deficiency of similar studies that compare the cultural competence of various health-care streams of the same clinical setting has reduced our scope in results comparison. Such comparisons would have given a better understanding of the social and interdisciplinary implications of the proposed cultural competence curriculum integration. Social desirability bias is a possible limitation of this study.

  Conclusion Top

Our study shows that the various health-care streams had specific competencies while interacting with multicultural patients. Only three items showed an overall mean of ≥4, which was considered as the ideal score. This shows that there is a need for developing a cultural competence training program for health-care trainees for enhancement of their transcultural communications and health-care services.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kumar R, Bhattacharya S, Sharma N, Thiyagarajan A. Cultural competence in family practice and primary care setting. J Family Med Prim Care 2019;8:1-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
Dangmei J, Singh A. Embracing cultural competence to reduce disparities and inequities in the public health care services of India. Asian J Res Bus Econ Manage 2017;7:288-97.  Back to cited text no. 2
Okoro ON, Odedina FT, Reams RR, Smith WT. Clinical cultural competency and knowledge of health disparities among pharmacy students. Am J Pharm Educ 2012;76:40.  Back to cited text no. 3
Cruz JP, Colet PC, Bashtawi MA, Mesde JH, Cruz CP. Psychometric evaluation of the cultural capacity scale Arabic version for nursing students. Contemp Nurse 2017;53:13-22.  Back to cited text no. 4
Rew L, Becker H, Cookston J, Khosropour S, Martinez S. Measuring cultural awareness in nursing students. J Nurs Educ 2003;42:249-57.  Back to cited text no. 5
Capell J, Dean E, Veenstra G. The relationship between cultural competence and ethnocentrism of health care professionals. J Transcult Nurs 2008;19:121-5.  Back to cited text no. 6
Okoro O, Odedina F, Smith WT. Determining the sufficiency of cultural competence instruction in pharmacy school curriculum. Am J Pharm Educ 2015;79:50.  Back to cited text no. 7
Holyfield LJ, Miller BH. A tool for assessing cultural competence training in dental education. J Dent Educ 2013;77:990-7.  Back to cited text no. 8
Alrqiq HM, Scott TE, Mascarenhas AK. Evaluating a cultural competency curriculum: Changes in dental students' perceived awareness, knowledge, and skills. J Dent Educ 2015;79:1009-15.  Back to cited text no. 9
Lie DA, Lee-Rey E, Gomez A, Bereknyei S, Braddock CH 3rd. Does cultural competency training of health professionals improve patient outcomes? A systematic review and proposed algorithm for future research. J Gen Intern Med 2011;26:317-25.  Back to cited text no. 10
Genao I, Bussey-Jones J, Brady D, Branch WT Jr., Corbie-Smith G. Building the case for cultural competence. Am J Med Sci 2003;326:136-40.  Back to cited text no. 11
Giddens JF, North S, Carlson-Sabelli L, Rogers E, Fogg L. Using a virtual community to enhance cultural awareness. J Transcult Nurs 2012;23:198-204.  Back to cited text no. 12
Carpenter R, Estrada CA, Medrano M, Smith A, Massie FS Jr. A web-based cultural competency training for medical students: A randomized trial. Am J Med Sci 2015;349:442-6.  Back to cited text no. 13
Cultural Competency and Tuberculosis Care: A Guide for Self-Study and Self-Assessment | National Prevention Information Network | Connecting Public Health Professionals with Trusted Information and Each Other. Available from: https://npin.cdc.gov/publication/cultural-competency-and-tuberculosis-care-guide-self-study-and-self-assessment. [Last accessed on 2020 Nov 13].  Back to cited text no. 14
Perng SJ, Watson R. Construct validation of the nurse cultural competence scale: A hierarchy of abilities. J Clin Nurs 2012;21:1678-84.  Back to cited text no. 15
Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services: A model of care. J Transcult Nurs 2002;13:181-4.  Back to cited text no. 16
Formicola AJ, Stavisky J, Lewy R. Cultural competency: Dentistry and medicine learning from one another. J Dent Educ 2003;67:869-75.  Back to cited text no. 17
Shen MJ, Peterson EB, Costas-Muñiz R, Hernandez MH, Jewell ST, Matsoukas K, et al. The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. J Racial Ethn Health Disparities 2018;5:117-40.  Back to cited text no. 18
Kundhal KK, Kundhal PS. MSJAMA. Cultural diversity: An evolving challenge to physician-patient communication. JAMA 2003;289:94.  Back to cited text no. 19
Pecukonis E, Doyle O, Bliss DL. Reducing barriers to interprofessional training: Promoting interprofessional cultural competence. J Interprof Care 2008;22:417-28.  Back to cited text no. 20


  [Table 1], [Table 2]


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