Cultural competence is a set of congruent. Cultural Competency Education in Academic Dental Institutions in Australia and New Zealand: A Survey Study

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1 Cultural Competency Education in Academic Dental Institutions in Australia and New Zealand: A Survey Study Sheree L. Nicholson, BOH, BHSc; Melanie J. Hayes, BOH, BHSc, GCPTT, GCALL, PhD; Jane A. Taylor, BDS, BScDent, MScDent, PhD Abstract: The aim of this study was to assess the status of cultural competency education in Australian and New Zealand dental, dental hygiene, and oral health therapy programs. The study sought to explore the extent to which cultural competence is included in these programs curricula, building on similar studies conducted in the United States and thus contributing to the international body of knowledge on this topic. A 12-item instrument was designed with questions in four areas (demographics, content of cultural competency education, organization of overall program curriculum, and educational methods used to teach cultural competence) and was sent to all Australian and New Zealand dental, dental hygiene, and oral health therapy educational programs. Of the total 24 programs, 15 responded for a response rate of 62.5%. The results showed that lectures were the most frequent teaching method used in cultural competency education; however, the variation in responses indicated inconsistencies across study participants, as discussions and self-directed learning also featured prominently in the responses. The majority of respondents reported that cultural competence was not taught as a specific course but rather integrated into their programs existing curricula. The variations in methods may indicate the need for a standardized framework for cultural competency education in these countries. In addition, the notion of cultural competency education in academic dental institutions demands additional evaluation, and further research is required to develop a solid evidence base on which to develop cultural competency education, specifically regarding content, most effective pedagogies, and assessment of student preparedness. Ms. Nicholson is a dental hygienist and recent graduate of the University of Newcastle, Newcastle, Australia; Dr. Hayes is Lecturer in Oral Health, University of Melbourne, Melbourne, Australia; and Dr. Taylor is Associate Professor and Head of Discipline for Oral Health, University of Newcastle, Newcastle, Australia. Direct correspondence to Dr. Melanie Hayes, Melbourne Dental School, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, 720 Swanston Street, Melbourne, VIC 3010, Australia; (03) ; melanie.hayes@unimelb.edu.au. Keywords: dental education, allied dental education, cultural competence, cultural competency education, Australia, New Zealand Submitted for publication 11/23/15; accepted 1/19/16 Cultural competence is a set of congruent behaviors, attitudes, and policies that enable health care systems and professionals to work effectively in cross-cultural situations. 1,2 In culturally diverse societies such as those of Canada, United States, United Kingdom, and Australia, there is a need for dental education to adjust to keep pace with the changing composition of the patient population. As these societies become increasingly ethnically and racially diverse, it is essential that health care practitioners are prepared to provide culturally competent health care. In Australia, the 2011 census revealed that over a quarter (26%) of the population was born overseas. 3 Similarly in New Zealand, the population continues to diversify with the 2013 census revealing 25.2% of the population was born overseas. 4 The increasing number of patients from diverse racial and ethnic groups may present challenges to health care practitioners as each culture possesses an array of health beliefs, practices, and linguistic needs. Data from Dental Health Services Victoria in Australia indicate that a high proportion of its patient base is from culturally and linguistically diverse groups. 5 In this sociocultural context, the future Australian and New Zealand oral health workforce must not only be clinically competent, but must also possess cross-cultural skills in order to provide culturally competent care. Culture can have important clinical consequences for the patient-practitioner relationship and can profoundly influence clinical care and patient management. Khanna et al. s study is an example of research focused on the potential role of cultural competency training for health care practitioners in reducing health care disparities. 6 Although some providers continue to debate the benefits and limitations of cultural competency training in health care, Flores found that it not only improved patient-practitioner communication but also, in the long term, increased patient satisfaction and compliance. 7 While cultural competence is widely recognized as integral to re- 966 Journal of Dental Education Volume 80, Number 8

2 duction of disparities in health care, efforts are ongoing to define and implement this broad construct. However, current frameworks addressing cultural competency education in Australian universities are poorly integrated into dental education. Frameworks such as the National Best Practice Framework for Cultural Competence in Australian Universities place a strong emphasis on Indigenous Australian education, yet fail to address the broader range of ethnicities that are represented in the Australian population. 8 In Australia and New Zealand, there has been growing interest in transcultural health care supported by education. Most notably, the Australian Dental Council and Dental Council of New Zealand 2014 accreditation standards for dental education programs require that Cultural competence is integrated within the program and clearly articulated as required disciplinary learning outcomes: this includes Aboriginal, Torres Strait Islander, and Māori cultures (p. 4). 9 In addition, the New South Wales (NSW) Ministry of Health, in conjunction with the state government, developed a plan aimed at health care providers to address the government s multicultural health policy. The NSW Health Policy and Implementation Plan for Healthy Culturally Diverse Communities, aims to improve the health of NSW residents from groups that are culturally, religiously, and linguistically diverse. 10 The status of cultural competency education has been studied in U.S. dental schools. 11,12 However, research on the subject in Australia and New Zealand remains preliminary and underdeveloped. In 2010, a study was conducted to assess the degree of cultural competency training in dental education in Australia. In that study, Mariño et al. compared the level of transcultural content in the undergraduate curricula of three health science disciplines (medicine, dentistry, and physiotherapy) at the University of Melbourne. 13 That study was the first attempt to describe cultural competency education in Australian dental curricula, and its findings highlighted the inconsistencies present. Building on Mariño et al. s findings, 13 the aim of our study was to determine how cultural competency education is being implemented in current dental, dental hygiene, and oral health therapy education in universities across Australia and New Zealand. This research project allowed close examination of the existing status of cultural competency education in academic dental institutions. The study also has the potential to prompt further research in this field and will add valuable information to the current body of knowledge on cultural competency education in diverse societies. Methods Ethics approval for the study was granted by the University of Newcastle Human Research Ethics Committee in 2014 (Approval No. H ) with a low-risk research status. Our research consisted of a descriptive, cross-sectional study of the status of cultural competency education in Australian and New Zealand dental, dental hygiene, and oral health therapy programs. The study was modelled on research conducted by Saleh et al., 11 who assessed the status of cross-cultural education in U.S. dental schools. Our 12-question survey instrument was based on the survey used in Rowland et al. s study. 12 Their survey s questions were modified to address our research aims and to make them relevant to Australian and New Zealand educational terminology. The survey instrument collected data pertaining to four key areas: 1) demographic characteristics of respondents; 2) the content of cultural competency education being delivered; 3) the organization of the curriculum at each institution; and 4) the educational methods used to deliver cultural competency education. The survey was tested through peer review. Dentistry, dental hygiene, and oral health therapy programs were identified with the Australian Health Practitioner Regulation Agency website using the approved programs of study search tool. 14 The total number of potential participants identified was 24, which accounted for all tertiary institutions across Australia and New Zealand that offered dentistry or dental hygiene or oral health therapy programs. A summary of the degrees granted at these institutions appears in Table 1. Names and contact addresses of the dean or course convener at each were identified. Individuals were contacted via inviting them to participate in the study. The contacted individuals were deemed the most appropriate to complete the survey due to their academic position. A participant information statement and consent form were included with the invitation. Eight weeks following the initial , a follow-up was sent to all individuals on the list in an attempt to achieve higher participation. Due to the limited sample size, responses were not entirely anonymous since the identity of educational institutions, though not explicitly stated, August 2016 Journal of Dental Education 967

3 Table 1. Overview of degrees granted by academic dental institutions in Australia and New Zealand participating in study Degree Qualification Type Length Registrable Qualification Explanatory Note on Registration Doctor of Dental Surgery Postgraduate 4 years Dentist Dentists provide assessment, diagnosis, treatment, management, and preventive Bachelor of Dental Surgery Undergraduate 5 years Dentist services to patients of all ages. The education requirement for a graduate dentist to Bachelor of Dental Science Undergraduate 5 years Dentist be registered is a minimum four-year full-time education program approved by the Bachelor of Oral Health in Undergraduate 5 years Dentist National Board. Dental Science Bachelor of Dentistry Undergraduate 4 years Dentist Bachelor of Oral Health Undergraduate 3 years Dental Hygienist Dental hygienists provide oral health assessment, diagnosis, treatment, management, Advanced Diploma of Undergraduate 2 years Dental Hygienist and education for the prevention of oral disease to promote healthy oral behaviors Oral Health to patients of all ages. The education requirement for a graduate dental hygienist to (Dental Hygiene) be registered is a minimum two-year full-time or dual-qualified minimum threeyear full-time education program approved by the National Board. Bachelor of Oral Health Undergraduate 3 years Oral Health Therapist Dental therapists provide oral health assessment, diagnosis, treatment, management, Bachelor of Science Undergraduate 3 years Oral Health Therapist and preventive services for children, adolescents, and young adults. Their scope may (Oral Health Therapy) include restorative/fillings treatment, tooth removal, additional oral care, and oral Graduate Diploma in Undergraduate 1 year Dental Therapist, Oral health promotion. Oral health therapy is a combination of dental therapy and Dental Therapy Health Therapist dental hygiene skills. The education requirement for a graduate dental therapist to be registered is a minimum two-year full-time or dual-qualified minimum three-year full-time education program approved by the National Board. Source for explanatory notes: Dental Board of Australia. Guidelines for scope of practice At: Scope-of-practice.aspx. Accessed 18 Oct could be inferred. As a result, consent was obtained from all participants. Data were entered into an Excel spreadsheet for coding and exported to JMP version 11 for statistical analysis. Simple descriptive statistics were determined for the majority of responses. Short answer responses were coded according to themes. Nonparametric and parametric statistical tests lack statistical power with small samples and preclude achieving statistical significance, so those tests were not conducted. Results Of the 24 dental, dental hygiene, and oral health therapy programs invited to participate, representatives from 15 institutions completed the survey, for a response rate of 62.5%. Two institutions declined to participate; there was no response from the other seven. Five of ten institutions offering dentistry (50%), two of three institutions offering dental hygiene (66.7%), and eight of 11 institutions offering oral health therapy (72.7%) responded. In Australia, three of 13 responses came from Queensland (23.1%), four (30.8%) from New South Wales, three (23.1%) from Victoria, two (15.4%) from South Australia, and one (7.7%) from Western Australia. Two responses were from institutions in New Zealand. Content of Cultural Competency Education Although 100% of the respondents reported their programs offered education in cultural competence or cultural sensitivity, the responses showed wide variability in the content being taught. While some respondents provided a comprehensive overview of their content, describing the meaning of the concept of culture and the social and structural determinants of health relating to cultural groups, other respondents provided content in more general terms. Analysis of responses indicated that while some programs attempted a thorough investigation of cultural competency content, others failed to explicitly provide instruction on relevant concepts. In those situations, broad themes such as terminology and communication were introduced, but more complex information such as understanding barriers and influences may be lacking. Four-fifths of the respondents (80%) explicitly stated that their programs address Indigenous cultural groups in their instruction (Aboriginal and 968 Journal of Dental Education Volume 80, Number 8

4 Torres Strait Islanders and/or Māori) (Table 2). Seven respondents reported addressing culturally and linguistically diverse groups, which they specified as non-english speaking groups or different religious groups and cultures. Five respondents named refugees as one of the cultural groups included, and two specified including migrant groups. One respondent did not specify any cultural groups but rather stated the broad sense of the word culture was explored. While the majority of programs included multiple cultural groups, two programs reported including only Indigenous cultures (Aboriginal and Māori). Organization of Cultural Competency Education The study found limited variability in how cultural competency content was incorporated into their programs curricula. The majority of respondents stated that cultural competence was not taught as a specific course, but rather was integrated across their curricula. Nine of the respondents (60%) reported that cultural competency education was integrated across several courses in their programs, which accounted for the most frequently reported method. Three programs (20%) incorporated content as a module within a course, and two (13.3%) taught cultural competence as a core course. One respondent stated that cultural competency content was taught as a unit of its required competencies. Of the 15 participating institutions, 11 (73.3%) addressed cross-cultural education throughout the duration of their undergraduate programs. Only two respondents (13.3%) reported teaching cultural competence in the first year of their programs only; those schools taught it as either a separate unit of the required competencies or as a module within a course. A further two respondents (13.3%) reported teaching cultural competence in the third year only, and those reported the content was integrated across several courses. Regarding the length of time cultural competence had been included in the programs curricula, eight (53.3%) of the respondents reported five to ten years, two reported fewer than five years, and four reported 11 to 20 years. One institution reported having teaching content on cultural competence for 40 years since the inception of the course. Similarly, four other institutions stated that cultural competence had been taught since the inception of their respective courses. The average number of years cultural competence had been taught was 10.6 (minimum Table 2. Cultural groups addressed in cultural competency education, by number and percentage of programs responding (n=15) Cultural Group Number (%) Culturally and linguistically diverse 7 (46.7%) Indigenous (ATSI)/Māori 12 (80%) Refugees 5 (33.3%) Migrants/migrant groups 2 (13.3%) Note: Respondents could choose all that applied. One program (6.7%) also reported teaching a broad definition of the term cultural group. ATSI=Aboriginal and Torres Strait Islander three, maximum 40). The most frequently reported response was five years. Considerable variation was reported in the estimated number of hours devoted to cultural competency education in the programs curricula. Four respondents stated that their programs cultural competency education was hard to quantify due to the content being integrated within the curricula and often being opportunistic. Five respondents reported their programs devoting ten to 20 hours on cultural competency education, while two devoted 21 to 50 hours. Three respondents stated that 108, 140, and 220 hours, respectively, were devoted to cultural competency education throughout their curricula. These outlying responses came from all types of programs (dentistry, dental hygiene, and oral health therapy); two were from New South Wales, one was from New Zealand. One program s response was deemed invalid because an outline of the content rather than a quantifiable answer was provided. All 14 respondents stated that student feedback on the content was gathered. Educational Methods The survey results showed that cultural competency education was being taught with a variety of pedagogical methods (Table 3 and Figure 1). Although all respondents reported using more than one educational method in their programs, no one method was consistently used. Eleven programs (73.3%) used four or fewer teaching methods, while four (26.7%) used five or more. The most frequently reported educational method was lectures (N=12, 80%). Other commonly reported methods were discussion (73.3%), self-directed learning (66.7%), group work (60%), and workshops (60%). A less August 2016 Journal of Dental Education 969

5 common method reported was problem-based learning (PBL) (26.7%), as well as other methods (26.7%) such as placements, online tutorials, community visits, and videos. Half of the responding programs used multiple methods to assess cultural competence, while the re- maining programs used only one form of assessment. Additionally, one program that reported including cultural competency education in its curriculum did not use any form of assessment. Written assessment was the most frequently cited method with nine (60%) programs using this technique. Assignments, Table 3. Teaching methods used in cultural competency education by each program participating in study Method Program # Discussions Lectures Workshops PBL Group Work SDL Other Total n (%) 11 (73.3%) 12 (80%) 9 (60%) 4 (26.7%) 9 (60%) 10 (66.7%) 4 (26.7%) PBL=problem-based learning; SDL=self-directed learning Percentage Discussion Lectures Workshops PBL Group work SDL Other Figure 1. Teaching methods used in cultural competency education, by percentage of responding programs (N=15) PBL=problem-based learning; SDL=self-directed learning 970 Journal of Dental Education Volume 80, Number 8

6 reflective writing, group projects, exams, essays, and written reports were among the most common written assessments described by respondents. Six institutions (40%) assessed students through oral presentation, five (33.3%) used clinical assessment, and four (26.7%) used other methods of assessment including final written exams and ongoing assessment tasks. Discussion With the rapid influx of immigrants and a distinct change in the cultural demographics of Australia and New Zealand, education in meeting the needs of a culturally diverse society is fundamental in producing empathetic and culturally sensitive health care providers. This study examined the current status of cultural competency education in Australian and New Zealand dental, dental hygiene, and oral health therapy programs and aimed to ascertain baseline data on the inclusion of cross-cultural education in their curricula. All programs (100%) that participated in this study reported having a curriculum inclusive of cultural competency education. This scope of coverage was much broader than that found in a survey of U.S. medical schools, which found cultural issues of minority groups were taught by only 17% to 28% of participating schools. 15 However, our study found a distinct lack of uniformity among programs concerning the ethnic minority groups addressed. Although 80% of participants reported addressing Indigenous cultural groups in their cultural competency education, only 33.3% specified including refugees, and even fewer (13.3%) specified migrant groups. Migration continues to be the major provider of population growth in Australia, with the overseas-born population growing by 51.2% to 6.4 million between June 1996 and June One study found that the dental health of refugees, particularly untreated decay, compared poorly to that of Indigenous Australians, who already experienced worse dental health than the general population. 17 Greater cultural understanding of this at-risk group may help reduce the dramatic disparities in oral health. Many strategies for managing a cross-cultural population emphasize practitioner education; however, our study found considerable inconsistencies in the way in which cultural competency education was being delivered to our future oral health workforce. Efforts should now focus on developing research-based standards that specifically guide these programs to address not only Indigenous cultures but the broader range of minority cultural groups that comprise the Australian and New Zealand populations. Consistent with research conducted in dental schools in the U.S., 11,12 our study found that 60% of responding institutions in Australia and New Zealand did not devote entire courses to cultural competency education; rather, it was integrated into larger courses across the curriculum. The percentage of positive responses in our study was higher than a recent study of cultural competency education in U.S. dental schools, in which 55.6% of respondents indicated cross-cultural issues were integrated into other courses. 11 A previous study in Australia found that transcultural and communications skills concepts were presented as peripheral rather than core curricula, 13 and although there is no standard way to teach cultural competence, another previous study suggested the process of obtaining cultural proficiency is comprised of curricular components that are both knowledge- and skills-based. 18 Core curricula must be designed and implemented so as to provide comprehensive education on both fundamental concepts and more complex cultural themes. Flores et al. recommended that medical schools consider teaching cultural issues in a separate, dedicated course and expressed the belief that adequate instruction on essential concepts can be accomplished only in a semester-long (or longer), separate, required course. 15 By simply integrating the content into other courses, institutions risk underrepresenting key topics. This recommendation is in contrast to current practice in Australian and New Zealand dental education programs, with our overall findings indicating cultural competency education was more frequently integrated into their overall curricula rather than being taught as a separate course or elective. Alternatively, and in support of contemporary methods, Dolhun et al. reported that leaders in the field of cultural competency education emphasize broadbased, integrative curricula that encompass a range of cross-cultural content areas. 19 These conflicting recommendations highlight the need for further research into the most effective way to deliver cross-cultural content in oral health education. Dental educators require a solid evidence base on which to design and deliver cultural competency education. As the ethnic diversity of the Australian and New Zealand population continues to increase, dental educators should consider developing and implementing a August 2016 Journal of Dental Education 971

7 standardized, separate cultural competency course or framework that acknowledges and applies evidencebased recommendations. Our results found wide variation in the educational methods used to deliver cultural competency instruction, which reinforces the need for a standardized framework. In our study, 80% of participating programs presented cultural competency education in a lecture-based format, with discussion (73.3%) and self-directed learning (66.7%) also featuring prominently in responses. Similarly, lectures were found to be the most frequently reported teaching method used for cultural competency education in U.S. dental schools, 11,12 with Saleh et al. reporting that 95.1% of their respondents used that pedagogy. 11 However, in contrast to our findings, Azad et al. reported that PBL was the most frequently employed method for teaching cultural competence in Canadian medical schools, with it being used by 50% of the respondents. 2 Use of PBL to teach cultural competence seems to be underrepresented in Australian and New Zealand dental schools (26.7% of our respondents) and may indicate a potentially significant pedagogical technique that remains unexplored in these countries. Dolhun et al. reported that the quest for a standard pedagogy by which to teach cross-cultural issues continues and that the ability to set national standards hinges on developing a common language with which to develop and implement curricula. 19 While lectures are widely reported as the most frequently used method, further studies are required to determine if delivering cross-cultural education in this format is the most effective. Further research could also explore student experiences and perspectives on the efficacy and educational values of these teaching methods. Evaluation of student preparedness for the cross-cultural workplace could also offer valuable information to the existing body of knowledge. Based on our study of cultural competency education in Australian and New Zealand academic dental institutions, it appears New Zealand programs devote more comprehensive attention to the subject than their Australian counterparts. The longest period of time in which cultural competence had been taught 40 years was reported by a New Zealand program. Similarly, the New Zealand programs devoted the highest number of hours to cross-cultural education (220 hours). This more extensive instruction in cultural education could possibly be linked to the larger Indigenous population in New Zealand: 15% of its total population identified with Māori ethnicity in 2013, 4 compared to only 2.5% of the total Australian population who identify as Aboriginal or Torres Strait Islander. 20 Comparative studies of cultural competency education related to Indigenous Australian and Indigenous Māori in dental programs could allow for collaboration and exchange of expertise and ideas. Furthermore, modifying and adapting the methods used in New Zealand programs could help with the development of Indigenous education in Australia, as well as guide the development of cross-cultural education relating to other ethnic minority groups. Many Australian programs in our study reported introducing cultural competence in the previous five to ten years. This recent change may be attributed to publication of a document by the dental programs accrediting authority in 2010 that outlined the attributes and competencies of a newly graduated practitioner. 21 This document clearly states that dental graduates in Australia should be able to understand and apply the principles of culturally safe and sensitive practice. While the results of our study offered some interesting findings, the nature of this cross-sectional, survey-based research may limit generalization of the results. The sample size is limited due to the small number of academic institutions in Australia and New Zealand that offer courses in dentistry, dental hygiene, and oral health therapy. Although small, the sample allowed more specific and concise data to be collected. As only 62.5% of invited participants responded, the results may not be a true reflection of the current status. Results are dependent on the response rate of participants, and non-response bias may distort the findings. However, as we believe, anecdotally, there is a general consensus indicating cultural competency education in these countries is inadequate and our results were relatively consistent, such limitations would not impact our findings. Another potential limitation is possible overor underreporting. Data on cultural competency education may not correspond to the actual content taught; so the study results may overestimate the prevalence, content, and ethnic coverage of cultural competency education or conversely overlook the informal teaching on culturally competent topics that may occur. Finally, the use of self-reporting may introduce response bias; however, the instrument and method were based on that of a previous study, 12 which allowed for comparisons to be made between the current status of U.S. dental schools and their Australian and New Zealand counterparts. 972 Journal of Dental Education Volume 80, Number 8

8 Conclusion Cultural competency education is at a relatively early stage of development; therefore, the teaching of cultural competence remains fragmented and often insufficient. Overall, this study suggests cultural competency education in Australian and New Zealand dental education programs is inconsistent and fails to sufficiently address the minority cultural groups that comprise the population. An important consideration for dental educators is the need for standardization in how cultural competency education is delivered. There is a great deal of uncertainty surrounding how cultural competence should be taught in programs curricula; this study highlighted the inconsistencies and will hopefully prompt further research into the content and organization of cultural competency education for future oral health providers. We also found that significant variation existed among pedagogical methods used to teach cultural competence, which reinforces the need for a standardized framework. The inconsistencies in recommendations of researchers in this field highlight the need for an evidence-based overhaul of cultural competency education in dental programs. Future research should aim to describe cultural competency content in more detail. Furthermore, we hope this study has helped confirm a need for continued research into the efficacy of the various pedagogical methods, as well as the overarching development of cultural competency education for the practice of health care in culturally diverse societies. Acknowledgments The authors gratefully acknowledge the support of all program conveners and heads of school who completed our survey. REFERENCES 1. Cross T, Bazron B, Dennis K, Isaacs M. Towards a culturally competent system of care: a monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Centre, Azad N, Power B, Dollin J, Chery C. Cultural sensitivity training in Canadian medical schools. Acad Med 2002;77(3): Australian Bureau of Statistics. Cultural diversity in Australia, reflecting a nation: stories from the 2011 census. At: ain+features Accessed 15 March New Zealand Government census quick stats about culture and identity. At: census/profile-and-summary-reports/quickstats-cultureidentity/birthplace.aspx. Accessed 22 Oct Dental Health Services Victoria. Culturally and linguistically diverse communities At: au/_data/assets/pdf_file/0013/3226/cald-kit.pdf. Accessed 15 June Khanna SK, Cheyney M, Engle M. Cultural competence in health care: evaluating the outcomes of cultural competency training among health care professionals. J Gen Intern Med 2009;101(9): Flores G. Culture and the patient-physician relationship: achieving cultural competence in health care. J Pediatr 2000;136(1): Universities Australia. National best practice framework for cultural competence in Australian universities At: Guiding_P/GuidingPrinciples.html. Accessed 15 March Australian Dental Council, Dental Council of New Zealand. Accreditation standards for dental practitioner programs At: approved.pdf. Accessed 26 May New South Wales Ministry of Health. The NSW health policy and implementation plan for healthy culturally diverse communities, At: nsw.gov.au/policiesandguidelines/pdf/policy-and-implementation-plan-for-healthyculturallydiverse pdf. Accessed 15 March Saleh L, Kuthy RA, Chalkley Y, Mescher KM. An assessment of cross-cultural education in U.S. dental schools. J Dent Educ 2006;70(6): Rowland ML, Bean CY, Casamassimo PS. A snapshot of cultural competency education in U.S. dental schools. J Dent Educ 2006;70(9): Mariño R, Hawthorne L, Morgan M, Bata M. Transcultural skills content in a dental curriculum: a comparative study. Eur J Dent Educ 2012;16(1):e Australian Health Practitioner Regulation Agency. Approved programs of study At: Education/Approved-Programs-of-Study.aspx. Accessed 10 March Flores G, Gee D, Kastner B. The teaching of cultural issues in U.S. and Canadian medical schools. Acad Med 2000;75(5): Australian Government Department of Immigration and Border Protection. Australia s migration trends, At: migration-trends glance.pdf. Accessed 15 Oct Davidson N, Skulls S, Caloche H, et al. Holes aplenty: oral health status a major issue for newly arrived refugees in Australia. Aust Dent J 2006;51(4): Wear D. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med 2003;78: Dolhun EP, Muñoz C, Grumbach K. Cross-cultural education in U.S. medical schools: development of an assessment tool. Acad Med 2003;78(6): August 2016 Journal of Dental Education 973

9 20. Australian Bureau of Statistics census counts: Aboriginal and Torres Strait Islander peoples. At: www. features Accessed 23 Oct Australian Dental Council. The ADC professional attributes and competencies of the newly qualified dentist At: Attributes&Competencies_Dentist%20v1.0%20Final % %20Updated%20July% pdf. Accessed 11 Jan Journal of Dental Education Volume 80, Number 8