A students’ survey of cultural competence as a basis for identifying gaps in the medical curriculum
BMC Medical Education
A students' survey of cultural competence as a basis for identifying gaps in the medical curriculum
Conny Seeleman 0
Jessie Hermans 1
Majda Lamkaddem 0
Jeanine Suurmond 0
Karien Stronks 0
Marie-Louise Essink-Bot 0
0 Department of Public Health, Academic Medical Centre, University of Amsterdam , P.O. Box 22660, 1100 DE Amsterdam , The Netherlands
1 Netherlands School of Public and Occupational Health , Utrecht , The Netherlands
Background: Assessing the cultural competence of medical students that have completed the curriculum provides indications on the effectiveness of cultural competence training in that curriculum. However, existing measures for cultural competence mostly rely on self-perceived cultural competence. This paper describes the outcomes of an assessment of knowledge, reflection ability and self-reported culturally competent consultation behaviour, the relation between these assessments and self-perceived cultural competence, and the applicability of the results in the light of developing a cultural competence educational programme. Methods: 392 medical students, Youth Health Care (YHC) Physician Residents and their Physician Supervisors were invited to complete a web-based questionnaire that assessed three domains of cultural competence: 1) general knowledge of ethnic minority care provision and interpretation services; 2) reflection ability; and 3) culturally competent consultation behaviour. Additionally, respondents graded their overall self-perceived cultural competence on a 1-10 scale. Results: 86 medical students, 56 YHC Residents and 35 YHC Supervisors completed the questionnaire (overall response rate 41%; n= 177). On average, respondents scored low on general knowledge (mean 46% of maximum score) and knowledge of interpretation services (mean 55%) and much higher on reflection ability (80%). The respondents' reports of their consultation behaviour reflected moderately adequate behaviour in exploring patients' perspectives (mean 64%) and in interaction with low health literate patients (mean 60%) while the score on exploring patients' social contexts was on average low (46%). YHC respondents scored higher than medical students on knowledge of interpretation services, exploring patients' perspectives and exploring social contexts. The associations between self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour were weak. Conclusion: Assessing the cultural competence of medical students and physicians identified gaps in knowledge and culturally competent behaviour. Such data can be used to guide improvement efforts to the diversity content of educational curricula. Based on this study, improvements should focus on increasing knowledge and improving diversity-sensitive consultation behaviour and less on reflection skills. The weak association between overall self-perceived cultural competence and assessed knowledge, reflection ability and consultation behaviour supports the hypothesis that measures of sell-perceived competence are insufficient to assess actual cultural competence.
Cultural competence; Assessment; Curriculum development; Diversity education; Reflection ability; Consultation behaviour; Medical education
Patient populations in many western countries show
increasing ethnic diversity. In the Netherlands, for
example, around 20% of the population is from non-Dutch
background and in the largest Dutch cities about 33% of
the population is from non-Western ethnic background
. Culturally competent care has been proposed as an
important strategy to combat ethnic inequalities in quality
of care [2,3]. The term cultural competence derives from
the United States and started to appear in the literature
during the 1990s. Originally cultural competence programs
focused on teaching beliefs and characteristics of specific
cultural and ethnic groups. Over the years the concept of
cultural competence has expanded beyond culture, and
now addresses a broad array of topics relevant to (ethnic)
inequalities in healthcare quality [4,5].
Cultural competence is commonly defined as the
combination of knowledge, attitudes and skills necessary for
care providers to effectively interact with culturally and
ethnically diverse patient populations . Concerning the
knowledge element, care providers should have knowledge
of the processes that influence health and healthcare of
minority patients (e.g. ethnic inequalities in health, ethnic
composition of the population). As for attitudes, care
providers should be aware of diverse health values, beliefs,
and behaviours and should be able to reflect on their own
sociocultural background and personal biases or tendency
to stereotype. The skills element focuses on
communication skills such as the ability to explore (cultural) patient
perspectives, to interact with patients with low health
literacy and to overcome language barriers [6-9].
The concept of culturally competent care is closely
related to the generic concept of patient centred care.
Patient centred care also promotes responsiveness of
healthcare to individual patient preferences, needs and
values . The potential complexity of interaction
with patients from an ethnic minority group, due to for
example language barriers, cultural distance or
influence of personal bias requires distinct care provider
qualities additional to general competencies for patient
In various countries, licensing bodies and curricular
objectives require medical education curricula to address
cultural competence [11-13]. In spite of this, content
analysis of medical curricula shows that cultural
competence training has rarely been systematically implemented
in undergraduate and postgraduate medical education
[13-16]. In addition to content analysis, equally important
and under-studied is an evaluation of whether culturally
competent learning objectives are met.
Educational needs assessment is a critical stage in the
development or review of an educational programme .
While preparing the development and implementation
of a cultural competence educational program in two
curricula (an undergraduate medical curriculum and a
postgraduate curriculum for Youth Health Care (YHC)
physicians), we assessed the cultural competence level
of students who completed most of the present regular
curriculum. The results would allow pinpointing the
domains of cultural competence that the current
curriculum is able to deliver, in the absence of a
comprehensive cultural competence program, and the potentially
Various measures exist to evaluate healthcare providers
cultural competence (e.g. IAPCC-R, CCHPA, CCCQ)
[18-20]. However, these measures have a strong
reliance on self-perceived cultural competence rather than
more objective indicators [21,22]. A literature review
demonstrated that in most studies, there is little, none,
or an inverse relationship between self-perceived and
objectively measured medical competence . Other
evidence showed that care providers are unconsciously
incompetent regarding care provision to an ethnically
diverse patient population [24,25].
We performed an assessment of the level of cultural
competence of students who had already completed the
majority of the curriculum, using a newly developed
instrument. We chose for a self-assessment questionnaire
but we aimed to assess cultural competence more
objectively than with self-perception measures. We assessed
knowledge with a multiple choice test; and we assessed
culturally competent behaviour with items referring to the
respondents actual behaviour in specific situations. We
assessed reflection ability with a validated instrument (the
Groningen Reflection Ability Scale ).
In this paper we outline the outcomes of the
assessment and the association between self-perceived overall
cultural competence and assessed knowledge, reflection
ability and consultation behaviour. Finally we discuss how
assessing cultural competence can support the
development of a cultural competence training program.
The study population consisted of three groups:
medical students in the clinical phase of their education,
Youth Health Care Physician Residents in training
(YHC Residents) and Youth Health Care Physician
Supervisors (YHC Supervisors). We selected these groups
because we planned to implement cultural competence
training in the curricula of these medical students and
physicians. In the Netherlands YHC physicians are
public health physicians, specialized in assessing,
monitoring, interpreting and promoting the mental and
physical health at an individual and population level of
all children (019 years of age) while taking the childrens
environment (family, social network, events etc.) into
We recruited the YHC respondents at the Netherlands
School of Public & Occupational Health. Of the 163
individuals registered (95 residents, 68 supervisors), 13
refused and 32 did not react to the request of using their
e-mail address, bringing the total sample at 118 YHC
respondents. We randomly selected a sample of n= 274
medical students of the University of Amsterdam Medical
School in the 2nd, 3rd and 4th phase of their
rotationprogram (internships) for participation. We chose
students from these phases because they have experience
in individual patient contacts.
The students and YHC respondents were invited to
participate via e-mail. The invitation emphasized voluntary
participation, that participation and outcomes would not
influence study progress, and responses would be
confidential. Two follow-up reminders were later sent. After
consultation with student representatives, we decided to
raffle two rewards of 200 Euro each among the medical
students who completed the questionnaire . There
was no incentive for the YHC respondents.
According to Dutch law, formal ethical approval was
not required, but we took every effort to effectively inform
the respondents and protect their privacy.
Development of the questionnaire
The cultural competence framework of Seeleman et al.
 provided the theoretical basis for developing the
web-based questionnaire to assess respondents cultural
competence. The initial item pool was screened by
expert researchers and pilot-tested with 31 public health
physicians. A debriefing with these experts provided
support for the relevance, acceptance, and feasibility of
the items. A few that were considered ambiguous were
excluded from the final questionnaire (not shown). The
final questionnaire comprised three domains. Table 1
provides insight in the operationalisation of the
framework into questionnaire domains.
The three cultural competence domains were:
1) General Knowledge: We developed eight multiple
choice items to assess the general knowledge of
ethnic minority care provision, and six multiple
choice items to assess respondents knowledge of
interpretation services (see Table 1 for examples).
For both dimensions, the score was calculated as the
sum of correct answers (correct=1 point, not
correct and do not know=0 points; general
knowledge range 08; knowledge of interpreter
services range 06). For reasons of comparability of
scores across the various domains, all scores are also
presented as percentage of the maximum possible
score. For example a mean score of 5 correct
knowledge item responses out of 8 equals a score of
5/8100= 63%. The scores on the knowledge
domains showed a normal distribution.
2) Reflection Ability: For culturally competent doctors,
reflection is required for insight into ones own
understanding of prejudice and cultural frames of
reference . We included the Groningen
Reflection Ability Scale (GRAS) in the questionnaire:
a validated scale which measures respondents
general ability of personal reflection . The GRAS
was developed to assess reflection ability in medical
students and consists of 23 statements. Respondents
rate their level of agreement with each statement on
a five point Likert scale (1= totally disagree, 5= totally
agree; see Table 2 for examples). Although the GRAS
measures reflection ability in general, it includes
various statements especially relevant with regard to
cultural competence (e.g. I am aware of the cultural
influences on my opinions). We transformed the
scores (23115) into a scale between 110 by dividing
by 23. Cronbachs alpha was 0.79 for the GRAS in this
study. High scores indicate higher reflection ability.
3) Culturally Competent Consultation Behaviour: In this
domain we ask respondents to report their professional
behaviour as doctors in medical consultations with
ethnic minority patients. We defined culturally
competent consultation behaviour of doctors as
applying a patient-centred communication style with a
focus on issues of specific importance in the care of an
ethnically diverse patient population. The respondents
report on their own behaviour in terms of what they
do and/or how often. To this end, we developed:
1. two short case scenarios to assess respondents
behaviour in a) exploring patient perspectives,
and b) interaction with patients of low health
literacy level (see Table 1 for an example).
Normative response options were determined,
following recent literature [8,9]. Scores for these
items ranged from 03 (summing the culturally
2. an 11-item scale to assess how respondents
explored patients social contexts. This score
was summed (<25%= 0; 25-50%= 1; 50-75%= 2;
>75%= 3) and divided by 11 (range 03). In the
results, all scores are also presented as a percentage
of the maximum scores. Cronbachs alpha for the
social context scale was 0.86 in this study.
3. 2 items about the frequency and type of
interpreter used in the six months prior to this
survey (e.g. professional interpreter, informal
interpreter, patients child older than 16; patients
child younger than 16). Because medical students
during their rotation are not allowed to decide
about professional interpretation without
Table 1 Development of the questionnaire
The cultural competence framework
Competencies defined in the
framework (Seeleman et al. 2009)
Operationalisation for questionnaire
What we want to measure (the
numbers between brackets refer
to the competencies defined in
What we measure
Type of assessment
1. Knowledge of epidemiology and manifestation of diseases in various ethnic groups
2. Knowledge of differential effects of treatment in various ethnic groups Knowledge of:
- the context and processes that
influence health and health care
of minority patients (such as
ethnic inequalities in health,
ethnic composition of the
- interpretation services (e.g.
when and how to use professional
interpreters in medical practice) (6)
a) general knowledge of ethnic
minority care provision
Multiple choice items
a) 8 items on general knowledge
of ethnic minority care provision
(4 response options, including
do not know)
b) 6 statements on knowledge
of interpretation services
(true/false/do not know)
- General knowledge of ethnic
minority care provision
1. In 2010, 20% of the Dutch
population had a migrant
(non-Dutch) background. What
was the proportion of Western
vs. non-Western migrants?
a) 30/70 (Western/non-Western)
b) 50/50 (Western/non-Western)*
c) 70/30 (Western/non-Western)
3. Awareness of how culture shapes individual behaviour and thinking
4. Awareness of the social contexts in which specific ethnic groups live
5. Awareness of ones own
Ability to reflect on how a care
providers own frame of
reference (e.g. cultural), and
prejudice and stereotypes,
influences his practice (3,5).
6. Ability to transfer information in a way the patient can understand and to know when to seek external help with communication
Behaviour showing that the care
provider effectively takes patients
social context and culture into
account (3,4), and applies the
strategies in diverse contexts (6).
GRAS (Groningen Reflection
Self-assessment measure: 23
statements with 5 point Likert
scale (Aukes et al. 2007)
- Statements from the GRAS
To what extent do the following
statements apply to you?
I take a closer look at my
own habits of thinking
I am aware of the emotions
that influence my thinking
I can see an experience
from different standpoints
I am aware of the cultural
influences on my opinions
- Case based questions with
correct (culturally competent) and
incorrect (culturally incompetent)
response options (2 items)
- 11-item scale on knowledge of
patients individual social context
- asking preference for (students)
or actual use in past months of
(YHC respondents) different types
of interpreters (1 item)
1. Which communication techniques
do you apply in a consultation with
a migrant patient that only has
finished primary education?
(there is no language barrier)
(maximum of 4 answers)
I am concise in my information
I use laymens language*
I check the patients knowledge
level before I start my information*
Table 1 Development of the questionnaire (Continued)
2. During Ramadan, religious
Muslims are not allowed to
eat and drink between sunrise
and sunset. Do Muslims in the
Netherlands apply these fasting
rules to medication as well
(i.e., they will not use
sunrise and sunset)?
a) Yes: many Muslims in the Netherlands apply these fasting rules to medication use.*
b) No: Muslims in the Netherlands seldom apply these fasting rules to medication use.
c) Partly: these fasting rules
are applied to alternative
medication, but not to
medication that is prescribed
d) Do not know
1. Patients are responsible to take care for an interpreter (true/false*/do not know)
2. A professional interpreter
(in the Netherlands) is trained
to explain cultural issues, in
addition to translation
(true/false*/do not know)
I am able to understand people
with a different cultural/religious
Answers on 5-point scale
(1 meaning totally disagree
until 5 totally agree)
I start a next consultation repeating
I provide written information as
much as possible
2. Take in mind the newly registered
migrant patients of the past two
months. Of which part of these
patients you know the following
country of origin
composition of family
patients social network
Answers on 4-point scale (<25%;
25-50%; 50-75%; >75%)
*reflect correct answers.
approval from their supervisors, we did not ask
what they did, but what preference for type of
interpreter they had.
of the population of non-western ethnic origin is much
higher in these cities compared to other places in the
Finally we measured respondents own grading of their
overall cultural competence on a 110 scale (i.e.
selfperceived overall cultural competence). We described
cultural competence in this single item as: the
knowledge, attitudes and skills required to provide adequate
healthcare to patients of non-Dutch background.
Other variables in the questionnaire included ethnic
origin of participants, assessed by country of birth of the
respondents parents and classified as Dutch, Western
ethnic origin (Europe, North America, Japan) and
nonWestern ethnic origin; Professional experience with
minority patients, assessed by asking the respondents to
estimate the proportion of ethnic minority patients in
their current rotation/practice (5 categories:<5%; 5-10%;
10-25%; 25-50%; >50%), and by classifying the current
location of the practice as urban (Amsterdam, Rotterdam,
The Hague, Utrecht) or non-urban, because the proportion
Descriptive statistics were used to summarize
characteristics of the respondents, and the scores on the
various domains of cultural competence. We used one-way
analysis of variance (ANOVA) to compare the average
scores between the respondent subgroups. Post-hoc
procedures were performed with the Bonferroni
correction. We compared the results with a priori expectations
about the direction of the differences to find support for
the validity of the questionnaire. For example, if there was
a significant difference in consultation behaviour, we
expected the YHC respondents to perform better than the
medical students. The relation between self-perceived
overall cultural competence and assessed knowledge,
reflection ability and consultation behaviour was analysed
with Pearson correlation. All analyses were performed
using SPSS 20.00 for Windows.
Table 2 Demographic characteristics of the study population and clinical experience with diversity in patients
Experience with ethnic diversity
Practice in one of the four largest cities
Response and population background characteristics
The overall response rate was 41% (n= 177), with lower
participation among medical students (25%) than among
YHC physician groups (56%). In total 86 medical
students (40 in 2nd phase 2; 29 in 3rd phase; 15 in 4th phase;
2 missing), 56 YHC Residents and 35 YHC Supervisors
completed the questionnaire. The comments reported
by the respondents at the end of the questionnaire were
generally positive and did not point at a negative attitude
towards the subject of culturally competent care, neither
at a low acceptance or unclear structure of the
questionnaire. Table 2 presents the characteristics of the study
Assessed cultural competence
Table 3 displays the scores for the three cultural
Average scores on general knowledge of ethnic
minority patients were low, with on average only 46% of the
items answered correctly. We found differences in scores
between various knowledge items. For example, 81% of
the respondents knew the correct response to an item
on Vitamin-D deficiency in migrant women, while only
15% knew the ratio of western to non-western ethnic
minorities in the Dutch population. Scores on knowledge
of interpreter services were low as well. Whereas 80% of
respondents knew that professional interpretersa are
preferred in medical practice, only 15% knew that
professional interpreters in the Netherlands are not trained to
provide information about cultural issues. These response
patterns (e.g. items that were responded correctly or not)
were comparable among all respondent groups.
The average score on reflection ability was 8.0 (on a
scale 110), indicating high reflection ability in general.
Scores on culturally competent consultation behaviour
varied among the different items and among respondent
groups. While all respondents scored adequately on
interaction with low health literacy (the average score
being 60% of maximum score), medical students scored
low on exploring patient perspectives and exploring
social context (52% and 38% of culturally competent
answers, respectively), while these scores were better
among the YHC groups. Within the social context scale
we saw that most respondents explored country of origin,
composition of the patients family and patients work/
daily routines. The least explored aspect pertained to
patients healthcare uses in countries of origin.
Regarding use or preference for type of interpreter,
most YHC respondents indicated making use of informal
interpreters brought in by their patients in the past six
months. Medical students also preferred this type of
interpreter. Least used and preferred were children
under 16 years old, although 61% of YHC Residents
Assessed cultural competence domains
General knowledge of ethnic minority care provision (score 08)
Mean score (95% CI)
% of maximum score
Mean score (95% CI)
% of maximum score
GRAS score (score 110)
Knowledge on interpretation services (score 06)
Culturally competent consultation behaviour
Exploring patient perspective (score 03)
Interaction with low health literacy (score 03)
Mean score (95% CI)
% of maximum score
Mean score (95% CI)
% of maximum score
Mean score (95% CI)
% of maximum score
Exploring social context (score 03)
Self-perceived cultural competence
Self-perceived cc (score 110)
Table 3 Scores on knowledge, reflection ability, consultation behaviour, self-perceived cultural competence per
Mean score (95% CI)
4.4 (3.9-5.0)b,c Low level of general knowledge in
55%b,c all respondent groups
Low level of knowledge on interpretation
3.7 (3.4-4.1)b services among medical students, and
moderate level among YHC Residents
62%b and YHC Supervisors.
8.1 (7.9-8.3) High ability to reflect in all respondent
Low score on exploration of patient
perspectives in medical students,
moderate among YHC Residents
and YHC Supervisors.
Moderate score on interaction with
low health literacy in all groups
Low score on exploration of social
context among medical students
and YHC Residents and moderate
among YHC Supervisors.
Moderate self-perceived cultural
competence among all respondent
Mean score (95% CI)
Scores presented as mean scores and mean score as percentage of maximum score.
Significant differences in scores between respondent groups (p< 0,05);represented by:
aindicating a significant difference between medical students and YHC Residents.
bindicating a significant difference between medical students and YHC Supervisors.
cindicating a significant difference between YHC Residents and YHC Supervisors.
interpretation:<60%= low; 60-80%= moderate; >80%= high.
*N= 176 (1 student missing).
N= 85 (1 student missing).
and 49% of YHC Supervisors had used children
younger than 16 for interpretation, and 38% of the medical
students found a child younger than 16 sometimes
preferable. Such practices differ from the literature and
in Dutch professional practice guidelines, in which formal
interpreters are preferred, and the use of children below
16 years is strongly discouraged .
Association between self-perceived and assessed cultural
Table 3 shows the scores for overall self-perceived cultural
competence. The average rating of self-perceived cultural
competence was 6.8 (on a scale 110). Medical students
and YHC Supervisors perceived themselves as equally
culturally competent (7.0 and 6.9 on average, respectively).
Residents perceived themselves significantly less culturally
competent than medical students (6.4 on average). Table 4
shows the associations between self-perceived overall
cultural competence and assessed knowledge,
reflection ability and consultation behaviour. The significant
associations were all positive, but weak.
We assessed cultural competence with a questionnaire
survey among medical students, YHC Residents and YHC
Supervisors and identified gaps in general knowledge of
ethnic minority care provision and interpreter services,
whereas ability to reflect seemed adequate. Scores on
Table 4 Correlations overall self-perceived cultural competence and assessed knowledge, reflection ability and
General knowledge of ethnic minority care provision 0.16*
Knowledge on interpretation services
Culturally competent consultation behaviour
Exploring patient perspective
Interaction with low health literacy
Exploring social context
consultation behaviour varied between respondent groups:
reported exploration of patients perspectives and
interaction with low health literacy suggested moderate
culturally competent behaviour, whereas reported exploration of
patients social contexts seemed inadequate. The
associations between self-perceived overall cultural competence
and assessed knowledge, reflection ability and consultation
behaviour were weak.
Until now, cultural competence training was not
structurally implemented in the curricula of these respondents.
This possibly explains their generally low scores on the
knowledge domains. Low knowledge among physicians
and medical students regarding the use of interpreter
services were found in other studies as well [24,31].
In the current curriculum of both medical students
and YHC Residents, education about reflection is well
implemented, which probably explains these high scores.
In the literature about assessing reflection, a distinction
is made between the process of reflection (e.g. ability to
formulate learning goals) and the content of reflection
(e.g. what situation is reflected upon) . The scores
on the GRAS suggest that general reflection skills seem
well-developed, but they do not provide insight in actual
reflection around ones own prejudices or cultural values.
Variation in scores on reported culturally competent
consultation behaviour might be explained by the strong
relation between cultural competence and patient centred
communication . Patient centredness is increasingly
regarded as the norm in communication skills training
, therefore some aspects of culturally competent
behaviour (e.g. exploring patients perspectives) might
to some extent already be covered in the current curricula.
Although, patient centred attitudes were reported to
decline when medical students progress through medical
school and transfer to clinical practice , the YHC
respondents in our study scored higher on most aspects
of culturally competent consultation behaviour than the
students. YHC professional activity is characterized by a
focus on patients social contexts, and the YHC physicians
in our sample were strongly embedded in an educational
We found a weak association between self-perceived
overall cultural competence and the assessed cultural
competence domains. This is coherent with the study
reported by Hudelson et al. for competence in working
with a medical interpreter  and highlights the
additional value of assessing cultural competence beyond
selfperception [21,22]. Taking the conscious competence
learning model in mind , self-perceived competence
will provide insight in incompetence of which respondents
are aware of. However, a more objective indicator also
shows incompetence of which respondents are unaware.
The response rate among medical students was quite
low (25%), despite the raffle. In the survey-invitation we
did not mention that their knowledge was tested (we
mentioned: gaining insight in learning needs) and we
made it explicit that their responses would not influence
individual study progress. The comments reported by
respondents at the end of the questionnaire were generally
positive and did not indicate a negative attitude towards
the subject of cultural competence, neither a low
acceptance nor unclear structure of the questionnaire. Generally,
students who were more interested in the area of cultural
competence are more likely to have participated. Therefore
we cannot assume that our results are fully representative
of the local medical student population.
We used a self-developed questionnaire. Validation of
any measure is a permanent process . The strong
base of the items in theory supports the content validity
of the measure. The differences in average scores between
various domains of cultural competence in the three
respondent groups were mostly concordant with a
priori expectations and support the construct validity
of the questionnaire. For example, the average scores
of YHC Residents on exploring social context were
significantly higher than those of the medical students.
This is in line with expectations, because YHC physicians
are specifically trained to address social determinants of
We chose to develop a web-based questionnaire because
this allows for data collection at a large scale at relatively
low costs. We believe that this questionnaire allows for
getting insight in the level of cultural competence of large
groups in a relatively easy way. However, despite the fact
that we tried to assess cultural competence as objectively
as possible, the use of a questionnaire implies that we had
to rely on self-reported behaviour. The relationships of
the domain scores with real behaviour in medical practice
remains to be investigated by, for example, by observing
clinical practices. However, by testing knowledge with a
multiple choice test and by questioning respondents past
or intended behaviour we have developed a questionnaire
that goes beyond respondents rating their own level of
knowledge and behaviour.
Although we used a normative framework describing
the required domains of cultural competence, the
interpretation of the scores for the various dimensions of
cultural competence in terms of sufficient or
insufficient may be less straightforward as we have presented. It
is likely that the requirements regarding cultural
competence are context dependent; for example, the context of
providing care to asylum-seekers requires more specified
cultural competence than the context of paediatric asthma
Guidance for development of a cultural competence
Assessing cultural competence of medical students and
physicians allows for the identification of gaps in
knowledge and appropriate behaviour that reflect specific
areas for improvement of the diversity content of their
educational curricula. Low scores on knowledge of the
context and processes that influence health and
healthcare of minority patients suggest gaps in the curricula
in delivering contextual knowledge that should be
addressed in the future curriculum. With regard to
culturally competent consultation behaviour we saw that
medical students scored low on exploring the patient
perspective (52%) and the social context (46%). This
emphasizes the importance of addressing these issues
in communication training. The weak associations
between self-perceived overall cultural competence and
assessed knowledge, reflection ability and consultation
behaviour suggest that respondents are probably
unaware of their educational needs in this field. Creating
awareness of students incompetence should become
part of the training program itself or a learning activity
before actual cultural competence training starts.
The outcomes of the questionnaire provide guidance
for curriculum improvement, but need to be supplemented
by a curriculum-scan (for example by means of the TACCT
) to provide concrete indications for what curriculum
elements need to be improved and what are didactically
the most natural places to address the missing issues. For
example, a curriculum scan would provide insight if there
is training which explicitly addresses reflection around
ones own prejudices or cultural values. If such training is
non-existent, it should be added to the existing reflection
Assessing knowledge of issues relevant for care provision
to ethnic minority patients, ability to reflect, and culturally
competent consultation behaviour enabled us to identify
gaps regarding cultural competence training in the current
curricula of medical students, YHC Residents and
professional education of YHC Supervisors. In combination with
a curriculum-scan, the results of such an assessment will
provide the basis for concrete recommendations of what
diversity-related issues should be addressed where in the
curriculum. At the same time the assessment outcomes
could serve as a baseline score that can be used as a
benchmark in a subsequent assessment later on, after
curriculum improvements have been realized. We
believe this cultural competence assessment is a valuable
addition to existing curriculum assessments and measures
of self-perceived cultural competence.
aA formal interpreter in the Dutch context is a
professional interpreter whose language skills have been assessed
and who adheres to a professional code of conduct that
safeguards objectivity, professionalism, integrity and
The authors declare that they have no competing interests.
CS, KS and MLE-B deigned the study. CS and JH collected the data. Data
were analyzed by CS, JH, ML, JS and MLEB. CS drafted the article and all
others contributed intellectual content to the paper, provided comments on
subsequent drafts and approved of the final version.
This study was funded by the Netherlands Organisation for Health Research
and Development (ZonMw), and The Netherlands Organisation for Scientific
Research (NWO). We thank all respondents for participating in our study.
Additionally we thank Ines Rupp for her thoughtful comments on earlier
versions of this paper.
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