Racial Dynamics and Cultural Competence Training in Medical and Pharmacy Education

Racial Dynamics and Cultural Competence Training in Medical and Pharmacy Education Margarita Echeverri, Theresa Dise Journal of Health Care for the Poor and Underserved, Volume 28, Number 1, February 2017, pp. 266-278 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2017.0023 For additional information about this article https://muse.jhu.edu/article/648761 No institutional affiliation (5 Sep 2018 17:51 GMT)

ORIGINAL PAPER Racial Dynamics and Cultural Competence Training in Medical and Pharmacy Education Margarita Echeverri, PhD, MSc Theresa Dise, MD Abstract: Using the Self- Assessment of Perceived Level of Cultural Competence (SAPLCC) questionnaire, frequencies, means, and ANOVAS were determined to create medical and pharmacy student profiles of cultural competence. Profiles were used to identify needs for training and underscore critical issues that should be given priority in the curriculum. Significant differences were found in several domains of cultural competence (knowledge, skills, attitudes, and abilities); they may be explained by differences in the implementation of a pilot curriculum, the racial composition of students in both programs, and other characteristics. However, in the awareness domain, the main differences found may be explained only by respondents attitudes and their personal experiences. Results confirm the importance of examining the racial dynamics factor and the need to address this sensitive topic early in the academic programs so students are prepared more fully to have sincere and meaningful encounters with their patients during the clinical years and as health care providers. Key words: Cultural competence, pharmacy students, medical students, student profiles, curriculum, assessment. Changes in the demographic characteristics of the U.S. population and the organization of health care services under the Patient Protection and Affordable Care Act (PPACA) require culturally competent health care providers who are capable of practicing in a multicultural society and working together in an integrated care delivery system to enhance coordination of care, improve safety and quality, address patient needs, increase patient satisfaction, and improve health outcomes. 1 Culturally competent health care professionals must be aware of their own biases and stereotypes and also of different cultural, racial/ethnic, and linguistic factors that can form barriers to patients understanding of and adherence to prescribed regimens and to optimal health outcomes. 2 3 Academic accreditation agencies have mandated that health- related professions include cultural competence in the list of competencies that students should demonstrate by graduation. Specifically, the Liaison Committee on Medical Education MARGARITA ECHEVERRI is an Associate Professor and Educational Coordinator Health Disparities, Diversity and Cultural Competence at the Center for Minority Health and Health Disparities Research and Education, Xavier University of Louisiana, College of Pharmacy. THERESA DISE is an Associate Professor of Pediatrics at Tulane University School of Medicine. Please send correspondence to Margarita Echeverri; Xavier University of Louisiana, College of Pharmacy; 1 Drexel Drive, New Orleans, LA 70125; phone: (504) 520 6719; email: mechever@xula.edu. Meharry Medical College Journal of Health Care for the Poor and Underserved 28 (2017): 279 302.

280 Racial dynamics cultural competence training (LCME) standards state that medical students must be self- aware of personal biases in their approach to health care delivery and must demonstrate an understanding of the effects that social- cultural systems have on patients health, as well as how to recognize and address gender- related, cultural, and racial and ethnic biases and disparities in the diagnosis and treatment of diseases. 4 Similarly, the Accreditation Council for Pharmacy Education (ACPE) requires that pharmacy curriculums address patient safety, cultural 5[p. 18] appreciation, health literacy, and health care disparities. Although a growing body of research shows that curricula using a variety of instructional strategies have been implemented in different health- related professions to teach cultural sensitivity concepts and skills, 6 7 most of them are stand- alone educational initiatives that do not fully address academic standards and students needs. Building student profiles of cultural competence has been recommended as a systematic process to define student-specific needs for training, to prioritize the topics to include in very demanding academic programs, and to track change across the whole curriculum. 8 Previous publications concerning student cultural competence profiles have included information related to individual characteristics such as profession, academic level, gender, and race/ethnicity; languages spoken and experiences with other cultures; previous training in cultural competence; and self- assessment of cultural competence in six main educational domains: knowledge, skills, attitudes, awareness, encounters, and abilities. 8 In this study, and as an important component of an integrated pilot curriculum in cultural competence in the first two years of the medical and pharmacy programs at two universities, we assessed students perceived level of cultural competence with two purposes: to create student profiles and to identify relevant issues that should be given priority in the curriculum. Considering that previous studies with pharmacy students found important differences by race/ethnicity in the awareness of racial discrimination, White privilege, and power imbalance, 8,9 it is also our intent to investigate whether the same results would be obtained in a more diverse and interdisciplinary student population, as recommended by external reviewers. Methods Instrument. We selected the Self- Assessment of Perceived Level of Cultural Competence (SAPLCC) to assess students perceived level of cultural competence and build student profiles. The SAPLCC was the result of a combination of two tools the Clinical Cultural Competency Questionnaire (CCCQ) 10 and The California Brief Multicultural Competency Scale (CBMCS), 11 which were validated with pharmacy students (Cronbach s alpha 0.96 and 0.92, respectively). 9,12 The resulting tool, the SAPLCC (Cronbach s alpha 0.96), comprises 68 items organized into 13 factors in six domains of cultural competence: knowledge, skills, attitudes, encounters, awareness, and abilities (Table 1). The SAPLCC scale for all responses ranges from one to four (1 = Not at all, 2 = A little, 3 = Quite a bit, 4 = Very). Curriculum. Although the content in the curriculum in both programs (Box 1) was focused on the same topics and the teaching was carried out using the same materials and the same instructor, different approaches were used according to time and

Table 1. SELF- ASSESSMENT OF PERCEIVED LEVEL OF CULTURAL COMPETENCE (SAPLCC) QUESTIONNAIRE Domains, Factors and Items Statistics Mean Scores (% respondents) Knowledge Domain (K) N Mean a SD Low b Moderate c High d F1 Addressing Population Health Issues 539 2.30 0.633 17.4 75.3 7.2 K4 Knowledge on health disparities K5A Knowledge on health promotion K5B Knowledge on reproductive health K5C Knowledge on child health K5D Knowledge on adolescent health K5E Knowledge on adult health K5F Knowledge on geriatrics K5G Knowledge on women s health F2 Understanding the Context of Care 539 1.82 0.602 56.8 40.3 3.0 K7 Understanding different healing traditions K9 Understanding Title VI of Civil Rights Act K10 Understanding CLAS standards e S3 Eliciting information on use of folk remedies S4 Eliciting information on use of folk healers (Continued on p. 282)

Table 1. (continued) Domains, Factors and Items Statistics Mean Scores (% respondents) Skills Domain (S) N Mean a SD Low b Moderate c High d F3 Providing Culturally Responsive and Effective Services 539 2.03 0.740 40.3 54.2 5.6 S5 Conducting physical examination and diagnosis S6 Negotiating treatment plans S7 Providing patient education and counseling S8 Providing clinical preventive services S10 Addressing Health literacy F4 Managing Cross- Cultural Clinical Challenges 539 1.96 0.786 38.4 57.0 4.6 S12 Dialing with problems in diagnosis or treatment S13 Dealing with adherence/compliance problems S14 Dealing with ethical conflicts S16 Dealing with issues in the informed consent (Continued on p. 283)

Table 1. (continued) Domains, Factors and Items Statistics Mean Scores (% respondents) Attitudes Domain(A) N Mean a SD Low b Moderate c High d F5 Recognizing Disparities- Related Discrimination 536 2.92 0.738 5.6 59.3 35.1 A1G Ageism (prejudice based on age) A1H Sexism (prejudice based on sex) A1I Racism (prejudice based on race) A1J Classism (privilege based on economic status) A1K Ableism (prejudice against disabled people) A1L Homophobia (prejudice against homosexuals) F6 Improving Interpersonal/ Intercultural Interactions 537 3.16 0.750 3.5 54.7 41.7 A2A Interacting with patients A2B Interacting with colleagues A2C Interacting with classmates A2D Interacting with staff F7 Engaging in Self- Reflection 537 3.24 0.611 1.5 45.1 53.4 A3A Own racial, ethnic, or cultural identity A3B Own racial, ethnic, or cultural stereotypes A3C Own biases and prejudices A4 Training in diversity and cultural competence (Continued on p. 284)

Table 1. (continued) Domains, Factors and Items Statistics Mean Scores (% respondents) Encounters Domain (E) N Mean a SD Low b Moderate c High d F8 Increasing Comfort During Cross- Cultural Clinical Encounters 537 2.46 0.662 17.3 67.0 15.6 E1 Caring for patients from culturally diverse backgrounds E2 Caring for patients with limited English proficiency E4 Identifying hiding beliefs that interfere with treatment E5 Understanding non- verbal communication and gestures E6 Interpreting expressions of pain, distress, and suffering E7 Advising change of behaviors or practices E8 Speaking in an indirect rather than a direct way E10 Working with culturally diverse professionals F9 Coping with Aggressiveness and Bias 538 2.09 0.833 33.3 58.7 8.0 E11 Working with colleagues who make derogatory comments E12 Treating patients who make derogatory comments (Continued on p. 285)

Table 1. (continued) Domains, Factors and Items Statistics Mean Scores (% respondents) Abilities Domain (AB) N Mean a SD Low b Moderate c High d F10 Assessing Population Health Needs 537 2.67 0.637 6.5 79.9 13.6 AB2 Persons with disabilities AB5 18 Lesbians, gays, bisexuals, transgender and questioning (LGBTQ) AB6 Older adults AB13 Men AB20 Women AB21 Poor AB22 Children and adolescents AB23 Different cultural, racial and/or ethnic backgrounds F11 Multicultural Knowledge 535 2.74 0.506 6.0 76.6 17.4 AB7 Identify strengths and weaknesses of different tests AB9 Communicate appropriately with patients AB12 Critique multicultural research AB15 Discuss differences among racial, ethnic or cultural groups AB16 Identify reactions based on stereotypes AB17 Discuss research regarding health issues AB19 Differentiate acculturation models (Continued on p. 286)

Table 1. (continued) Domains, Factors and Items Statistics Mean Scores (% respondents) Awareness Domain (AW) N Mean a SD Low b Moderate c High d F12 Barriers to Health Care 537 3.06 0.515 1.7 68.2 30.2 AW2 Providers values that might affect their patients AW4 Institutional barriers that may affect patients AW11 Providers attitudes/beliefs about diverse groups AW14 System barriers that may inhibit use of health services F13 Racial Dynamics 537 2.71 0.611 7.1 72.1 20.9 AW1 Awareness of racial discrimination AW8 Awareness of power imbalance AW10 Awareness of white privilege TOTAL SCALE 532 2.55 0.389 6.8 81.6 11.6 a Range 1 to 4. b Scores < 2.0. c Scores between 2.0 and 3.0. d Scores > 3.0. e National Standards on Culturally and Linguistically Appropriate Services CLAS Standards.

Box 1. PILOT CURRICULUM IN CULTURAL DIVERSITY COMPETENCE (2009 2010) Medicine Year 1 Year 2 Awareness Knowledge One 2- hour introductory lecture on health disparities and cultural competence, including case studies from the documentary film Worlds Apart. a Four 1- hour sessions, followed by lead- discussions, based on four episodes from the documentary series Unnatural Causes: is inequality making us sick? b 4- hour online training on the unified approach to health communications, including communication tools to address poor Health Literacy, Cultural Competence, and Limited English Proficiency (includes videos, quizzes and cases) c One 3- hour small group session on multicultural and diversity One 2- hour session on culturally competent interview models issues in healthcare Skills Two standardized- patients sessions working with limited English proficiency patients and interpreters (Continued on p. 288)

288 Racial dynamics cultural competence training Box 1. (continued) Pharmacy Year 1 Year 2 Awareness Knowledge Skills Two 1- hour introductory lectures on health disparities and cultural competence, including case studies from the documentary film Wolds Apart. a Small group session and an independent research paper assessing population health needs and Healthy People 2020 initiatives to decrease health disparities in chronic diseases. d 1 semester teaching minority children about healthy behaviors (nutrition, fitness, exercise, and smoking prevention). One 3- hour small group session on multicultural and diversity issues in healthcare 4- hour online training on the unified approach to health communications (includes videos, quizzes and cases). c Participation in health fairs serving limited English proficiency patients (Hispanic and Vietnamese) and working with interpreters. a Grainger- Monsen M, Haslet J. Worlds Apart: A Four- Part Series on Cross- Cultural Healthcare, Boston, MA: Fanlight Productions, 2003, ISBN 1572958057, http://www.fanlight.com. b Unnatural Causes: is inequality making us sick? Produced by California Newsreel with Vital Pictures, presented by the National Minority Consortia, www.unnaturalcauses.org; www.news reel.org. c U.S. Health Resources and Services Administration (HRSA), 2003. Effective communication tools for healthcare professionals: Addressing health literacy, cultural competency, and limited English proficiency (LEP). [Rockville, MD]: HRSA, course ID 1010508, Train.org. d U.S. Department of Health and Human Services (DHHS). Office of Disease Prevention and Health Promotion. Healthy People 2020. Washington, DC, https://www.healthypeople.gov. scheduling constraints, classroom dynamics, and student interests. Among the main differences were: Medical students watched four sessions of the video series, Unnatural Causes: is inequality making us sick? 13 focused on awareness of barriers to health care (F12, Table 1), attended discussions with experts about the issues presented in the videos, and wrote personal reflections on the main points of interest, whereas pharmacy students did not.

Echeverri and Dise 289 Pharmacy students discussed the context of care (F2, Table 1), which includes knowledge of legislation prohibiting discrimination and protecting human rights and the requirements of the National Standards on Culturally and Linguistically Appropriate Services (CLAS Standards) in smaller group sessions (40 students/ session), while medical students only had an overview of these points in one of the introductory lectures (all students in one session). Pharmacy students, working in smaller group sessions, received instruction about the federal Healthy People initiative, 14 navigated its webpage, completed relevant research, and wrote a paper regarding assessing population health needs (F10, Table 1) and initiatives to decrease health disparities in chronic diseases, while medical students did not. Medical students reinforced skills working with standardized patients while pharmacy students did so teaching minority children and attending multicultural and multilingual health fairs. Participants. After obtaining institutional review board approvals from both Tulane University and Xavier University of Louisiana, we invited all students enrolled in the first two years of the medical and pharmacy programs to complete the SAPLCC. Students completed the survey after finishing the training (Box 1); Year 2 students completed the training during both academic years (2009 2011) while Year 1 students were exposed only to the first year of training (2010 2011). Questionnaires were hand- delivered on paper, and students completed and returned the questionnaires during class. Statistical analysis. Frequencies and mean scores were obtained for the demographic variables and the individual items included in each one of the 13 factors. Total scale mean scores were calculated by adding the responses to all items and dividing by 68, the total number of items. Subscale scores (factor level) were calculated by adding the responses to the items in each factor and dividing the sum by the number of items in the factor. 15[p. 450] For descriptive purposes, mean scores were considered low if below 2.0, moderate if between 2.0 and 3.0, and high if above 3.0. The sample was analyzed using academic program (medicine and pharmacy), academic level (year in academic program) and race (self- reported race/ethnicity) to look for statistical differences in the mean subscale scores. Analyses of variance (ANOVAs) were conducted to test for significant differences at the factor level and to create student profiles. Tukey s Honestly Significant Differences for post hoc analysis were conducted to explain the significant differences in subscale scores between the groups. SPSS, version 12.0 (SPSS Inc., Chicago, IL) was used to carry out the data analyses. Results Characteristics of respondents. In total, 539 students out of 675 completed the SAPLCC (overall response rate 79.9%). Of those, 254 (out of 366) were medical students and 285 (out of 309) were pharmacy students (response rates 69.4% and 92.2%, respectively). Distribution of participants by program and academic year was similar (Table 2). However, there were gender and racial differences between the schools: more than half the medical students were men (156/254 = 61.4%) and self- identified themselves as

290 Racial dynamics cultural competence training Table 2. DEMOGRAPHICS OF RESPONDENTS Medicine Pharmacy Total Demographics n % n % N % Total Participants 254 47.1 285 52.9 539 100.0 Academic Level Year 1 149 27.6 158 29.3 307 57.0 Year 2 105 19.5 127 23.6 232 43.0 Race Asian Americans 51 9.5 98 18.2 149 27.6 African Americans 2 0.4 127 23.6 129 23.9 White Americans 167 31.0 47 8.7 214 39.7 Other 34 6.3 13 2.4 47 8.7 Gender Female 98 18.2 169 31.4 267 49.5 Male 156 28.9 116 21.5 272 50.5 Speak another Language additional than English None 86 16.0 154 28.6 240 44.5 Spanish a 66 12.2 15 2.8 81 15.0 Vietnamese a 8 1.5 79 14.7 87 16.1 Chinese a 25 4.6 2 0.4 27 5.0 French a 19 3.5 5 0.9 24 4.5 Other language 44 8.2 27 5.0 71 13.2 More than 2 b 49 9.1 9 1.7 58 10.8 Contact with other cultures Had visited other countries 241 44.7 159 29.5 400 74.2 Had lived in a country other than United States 136 25.2 47 8.7 183 34.0 a Participants who speak two of these languages are counted twice. b Participants who speak two or more languages different than English. Whites (167/254 = 65.7%), while more than half the pharmacy students were women (169/285 = 59.3%) and self- identified themselves as African Americans (127/285 = 44.6%) and Asian Americans (98/285 = 34.4%). More than half the respondents (55.5%) reported speaking English plus a second language and one- tenth reported speaking two or more languages in addition to English. The most common languages spoken other than English were Spanish for medical students and Vietnamese for pharmacy students. Additionally, more than two- thirds of respondents (74.2%) reported that they had visited other countries (tourism, vacations, visiting friends, or attending conferences), and more than one- third (34.0%) had lived in a country other than United States (study abroad or actual residence).

Echeverri and Dise 291 Student profiles of cultural competence. The student profiles (Table 3) were divided into the six domains and 13 factors of cultural competence (Table 1). Total mean score was 2.55 (scale from 1 to 4); while 81.6% of participants had a moderate total mean score (between 2.0 and 3.0) in cultural competence, 11.6% scored higher (>3.0) and only 6.8% scored lower (<2.0). Overall, the higher percentages in all subscale mean scores fell into the moderate category except in Understanding the Context of Care (F2) where majority of participants (56.8%) scored lower, and in Engaging in Self-reflection (F7) where majority (53.4%) scored higher. No significant differences were found when using gender, language (speaking a language other than English) or international exposure (have visited and/or lived in a country other than United States) as covariates. As shown in Table 3, statistically significant differences (p values <.05) were found by program in factors Providing Culturally Responsive and Effective Services (F3), Recognizing Disparities-Related Discrimination (F5), Engaging in Self- Reflection (F7), and Assessing Population Health Needs (F10); by academic year in Understanding the Context of Care (F2); and by race in factors Understanding the Context of Care (F2), Recognizing Disparities-{\h}Related Discrimination (F5), Engaging in Self- Reflection (F7), Assessing Population Health Needs (F10) and Racial Dynamics (F13). Discussion of these differences is presented in the following analysis by domain and factor. Knowledge Domain (K). The Knowledge Domain includes two factors (Table 1): Addressing Population Health Issues (F1) and Understanding the Context of Care (F2). F1 encompasses physical characteristics, behaviors, attitudes and health risks of different populations over the lifespan (childhood, adolescence, adulthood, and elderly) that should be considered to provide appropriate health prevention and management such as child vaccinations, reproductive health, and geriatrics. F2 encompasses the consideration and respect for patients alternative views of disease and health (folk remedies and healing traditions) and the compliance of regulations and standards prohibiting discrimination and calling for the provision of health care compatible with cultural beliefs, practices and preferred language such as the Title VI of Civil Rights Act and the CLAS standards. Overall, scores for F1 were moderate while scores for F2 were the lowest ones in the entire scale (Table 1). Significant differences found in F2 by academic year (Table 3): Year 2 students reported significantly higher knowledge than Year 1 students in understanding different healing traditions (p =.021), Title VI (p >.001), and the CLAS standards (p =.027). By race/ethnicity, significant differences in F2 were explained by Asian Americans scoring significantly higher in their understanding of healing traditions (p <.001), and use of folk remedies (p =.007) and folk healers (p =.020). Skills Domain (S). The Skills Domain includes two factors (Table 1): Providing Culturally Responsive and Effective Services (F3) and Managing Cross- Cultural Clinical Challenges (F4). F3 encompasses providers skills in providing culturally responsive services in health care along the continuum of health: from prevention and counseling, to examination and diagnosis, to treatment. F4 encompasses the skills providers need to deal with cross- cultural conflicts that could negatively affect the patient- provider relationship. Significant differences were found in F3 (Table 3): pharmacy students reported significantly higher scores than medical students in developing treatment plans (p =.013) and providing culturally- sensitive education and counseling services (p <.001).

Table 3. STUDENT PROFILES OF CULTURAL COMPETENCE: MEAN DIFFERENCES AT THE FACTOR LEVEL BY PROGRAM, ACADEMIC YEAR AND RACE Program Academic Year Race Domains and Factors p Med Pha p Y1 Y2 p African Americans Asian Americans White Americans Knowledge Domain (K) F1 Health Issues.764 2.29 2.31.080 2.26 2.35.449 2.35 2.23 2.31 F2 Context of Care.215 1.78 1.85.034* 1.77 1.88a.023* 1.78 1.93 a 1.74 Skills Domain (S) F3 Effective Services.021* 1.95 2.10 a.825 2.02 2.04.349 2.03 2.05 1.98 F4 Clinical Challenges.173 1.91 2.00.464 1.93 1.98.165 1.93 2.07 1.89 Attitudes Domain (A) F5 Patient Discrimination.001* 2.75 3.08 a.303 2.95 2.88.025* 3.08 a 2.91 2.87 F6 Intercultural Interactions.101 3.11 3.21.633 3.15 3.18.726 3.18 3.14 3.19 F7 Self- reflection.019* 3.18 3.30 a.127 3.28 3.20.017* 3.39 a 3.22 3.17 Encounters Domain (E) F8 Comfort in Encounters.513 2.44 2.48.261 2.49 2.43.479 2.44 2.52 2.43 F9 Coping with Bias.863 2.08 2.10.691 2.08 2.11.958 2.11 2.06 2.10 Abilities Domain (AB) F10 Needs Assessment.001* 2.51 2.80 a.054 2.71 2.61.001* 2.84 a 2.68 2.57 F11 Cultural Knowledge.279 2.72 2.76.602 2.75 2.73.607 2.77 2.71 2.73 Awareness Domain (AW) F12 Barriers to health care.107 3.10 3.03.251 3.08 3.03.762 3.04 3.04 3.08 F13 Racial Dynamics.969 2.71 2.71.799 2.71 2.70.002* 2.82 2.79 2.60 b TOTAL SCALE.002* 2.50 2.61 a.820 2.55 2.54.429 2.59 2.56 2.52 *Significant differences p <.05; Med = Medicine; Pha = Pharmacy; Y1 = Year 1; Y2 = Year 2 a This group has significant HIGHER scores than the counterparts. b This group has significant LOWER scores than the counterparts.

Echeverri and Dise 293 Attitudes Domain (A). The Attitudes Domain includes three factors (Table 1): Recognizing Disparities-Related Discrimination (F5), Improving Interpersonal and Intercultural Interactions (F6), and Engaging in Self- Reflection (F7). F5 encompasses importance given to health care providers discrimination and biases (sexism, ageism, ableism, racism, homophobia, and classism) as factors contributing to health disparities. F6 encompasses the importance given to sociocultural issues affecting health care providers interactions with patients, colleagues, residents/students, and staff. F7 encompasses the respondents awareness of their own racial, ethnic, and cultural identity, stereotypes, biases and prejudices, and the importance given to receiving training in cultural diversity and multicultural health care. Mean scores for the three factors in this domain were among the highest in the entire scale (Table 1). Significant differences were found in F5 and F7 by program and race (Table 3). Pharmacy students had significantly higher scores than medical students when rating their attitudes regarding discrimination practices (p <.001) based on age (ageism), sex (sexism), race (racism), disabilities (ableism) and sexual orientation (homophobia), as well as in the importance given to receiving training in cultural competence (p <.001). Furthermore, by race, African Americans had significantly higher scores than their counterparts in almost all items. Encounters Domain (E). The Encounters Domain includes two factors (Table 1): Increasing Comfort during Cross- Cultural Clinical Encounters (F8) and Coping with Aggressiveness and Bias (F9). F8 encompasses the respondents comfort when working in cross- cultural situations that involve such components as the use of non- verbal communication, limitations in English proficiency, existence of different health behaviors and beliefs, and hidden assumptions and mistrust. All of these could have an impact on effective communication during the patient- provider encounter. F9 encompasses the respondents comfort when dealing with aggressiveness and biases from colleagues or patients who make derogatory remarks about specific population groups, including one s own group. No significant differences were found in this domain at the factor level (Table 3). Abilities Domain (AB). The Abilities Domain includes two factors (Table 1): Assessing Population Health Needs (F10) and Multicultural Knowledge (F11). F10 encompasses respondents self- assessment of their ability to access accurately the health needs of diverse populations such as people with disabilities, older adults, the poor and underserved, and people with various sexual and gender orientations. F11 encompasses respondents self- assessment of their ability to work in a multicultural environment and discuss topics related to multicultural research, acculturation models, minority health issues, cross- cultural communication models, and the impact of biases and stereotypes in diagnosis and treatments. Significant mean score differences by program and race were found in F10 (Table 3). While pharmacy students reported significantly higher scores than medical students in all items in F10 (p <.001), African American students scored significantly higher than their counterparts on all those items except when assessing health care needs of lesbians, gays, bisexuals, transgendered, and questioning (LGBTQ). Awareness Domain (AW). The Awareness Domain includes two factors (Table 1): Barriers to Health Care (F12) and Racial Dynamics (F13). F12 encompasses respondents awareness of barriers (at the patient, provider, and institutional level) that minority patients experience when seeking health care. F13 encompasses respondents awareness

294 Racial dynamics cultural competence training of the existence of three important structural issues that have strong roots in American society: racism, White privilege, and power imbalance. Significant mean differences at the factor level were found only by race/ethnicity in F13 (Table 3). These differences were explained at the item level by African Americans reporting significantly higher and Whites significantly lower means in awareness of racial discrimination (p <.001) and White privilege (p =.009), while Asian Americans reported significantly higher means in awareness of power imbalance (p =.021). A deeper analysis of the items in this factor (Table 4), revealed that awareness of power imbalance (AW8) was inversely related to awareness of racial discrimination (AW1) and awareness of White privilege (AW10) for all three racial/ethnic groups. While the majority of students agreed that being born a White person in this society carries with it certain advantages (AW10, White privilege), and that being born a minority in this society brings with it certain challenges that White people do not have to face (AW1, racial discrimination), the majority of students disagreed with the statement that I am aware that I frequently impose my own cultural values upon others (AW8, power imbalance). However, significant differences, regardless of program, were found in the higher percentages of African Americans recognizing the existence of racial discrimination (92.19%) and White privilege (85.16%), the lower percentages of White students recognizing the existence of these issues (68.08% and 68.54%, respectively), and the higher percentage of Asian Americans recognizing the existence of power imbalance (34.23%), all of them when compared with their respective counterparts. Discussion In summary, results show significant differences in the student profiles in six out of 13 factors of cultural competence. While differences in some factors were found only by program (F3 Providing Culturally Responsive and Effective Services) or race (F13 Racial Dynamics), in other factors differences found were in both program and race (F5 Recognizing Disparities-Related Discrimination, F7 Engaging in Self-Reflection, and F10 Assessing Population Health Needs). These differences may be explained, in part, by differences in the curriculum (Box 1), differences in the wide racial differences of students in the two samples (Table 2), and/or other variables not included in this study such as socio- economic status, personal experiences, and academic environment. Differences in both program and race (F5, F7, F10). Significant differences were found in factors related to Recognizing Disparities-Related Discrimination (F5), Engaging in Self-Reflection (F7), and Assessing Population Health Needs (F10) by both program and race (Table 3). However, the lack of control groups make difficult to separate these effects. While the majority of pharmacy students belong to the minority groups (African Americans and Asian Americans), the majority of medical students belong to the mainstream group (Whites). The significantly higher scores of African Americans (pharmacy students) in items in F5 related to impact of prejudice based on age (A1G), sex (A1H) and race (A1I) in contributing to health disparities as well as awareness of biases and prejudices (A3C); this may be explained by personal experiences outside of the curriculum. It is widely known that African Americans suffer the most disproportionate health disparities among all the racial and ethnic groups included here, 16

Table 4. RACIAL DYNAMICS FACTOR (F13): CROSS- TABULATION OF ITEMS BY RESPONDENTS RACE AND ACADEMIC PROGRAM (PERCENTAGES) (N = 492) AW8 Power Imbalance AW1 Racial discrimination AW10 White Privilege Race Program n Agree or strongly agree Disagree or strongly disagree Agree or strongly agree Disagree or strongly disagree Agree or strongly agree Disagree or strongly disagree African-Americans Medicine 2 50.00 50.00 100.00 0.00 100.00 0.00 Pharmacy 127 17.46 82.54 92.06 7.94 84.92 15.08 Total 129 17.97 82.03 92.19 7.81 85.16 14.84 Asian-Americans Medicine 51 23.53 76.47 98.04 1.96 78.43 21.57 Pharmacy 98 39.80 60.20 86.73 13.27 76.53 23.47 Total 149 34.23 65.77 90.60 9.40 77.18 22.82 White Americans Medicine 167 26.95 73.05 74.25 25.75 74.85 25.15 Pharmacy 47 21.74 78.26 45.65 54.35 45.65 54.35 Total 214 25.82 74.18 68.08 31.92 68.54 31.46 All Medicine 220 25.20 74.80 78.74 21.26 74.80 25.20 Pharmacy 272 27.21 72.79 81.98 18.02 74.91 25.09 Total 492 26.25 73.75 80.45 19.55 74.86 25.14 AW1 = Being born a minority in this society brings with it certain challenges that White people do not have to face. AW8 = I frequently impose my own cultural values upon the others. AW10 = Being born a White person in this society carries with it certain advantages.

296 Racial dynamics cultural competence training and being part of that population may increase their awareness and sensitivity about these issues. Differences by race, but not by program (F2 and F13). Significant differences found by race, regardless of program, were in Understanding the Context of Care (F2) and awareness of Racial Dynamics (F13). Although it could be argued that differences in these items are because the racial composition of both academic programs, it calls the attention that differences are not observed in these two factors also at the program level. A similar study focused only in the pharmacy program (African Americans 47.8%; Asian Americans 30.2%; and Whites 17.4%) found similar results among the same racial groups. 8 Some results may not be related to the instruction received in the program but to the personal and cultural experiences of students self- identified in each one of the three main racial groups: Asian American students may be more familiar than others with healing traditions and folk remedies used in the Eastern medicine, and African American students may be more sensitive than White students to issues related to racism and discrimination. The higher scores of Asians American students in the awareness of power imbalance (AW8) may be connected to the racial stratification of Asian Americans, who are often stereotyped as the model Minority or honorary Whites. 17 Although, Asian Americans are a very heterogeneous group with great differences among them (culture, language, education, health outcomes and socioeconomic status), in general, they are considered as a buffer in conflicts between the polar opposites of Whites and Blacks, as they still are classified as minorities but may share some characteristics (family commitment, nonviolence, education, and wealth) that conform to the norms and values of White Americans. 18 Student profiles. The value of this study lies not in comparing different academic programs, curriculums, or racial/ethnic groups, but in identifying that there are areas in which all practitioners should self- reflect and engage in self- improvement in order to work more effectively as a team and provide strong patient care to a diverse population. The SAPLCC is one way in which individuals may be able to self- assess for self- improvement, and educators may be able to identify main points to focus the curriculum. Student profiles could be used to identify needs of training throughout the analysis of critical factors such as those with the lower or higher mean scores (Table 1) and/or the those with more significant differences among groups (Table 3). Specifically, in our case, results helped us to identify the need to improve content regarding context of care (F2) and include self- reflection activities to address differences in racial dynamics (F13). Importance of receiving training. Comments received from students during the training may help on understanding the significant differences found about the importance ascribed to receiving training in cultural competence (F7, item A4). While some students asked for more training, others questioned the worth of spending their time on these issues when they could use the time on other courses considered to be more important such as anatomy, biochemistry, physiology, and immunology. Common comments were that racism, biases, and stereotypes were issues of the past; that they do not need this training because they are a new multicultural and global generation that already knows how to deal with diversity issues; and that cultural competence is

Echeverri and Dise 297 not a topic to learn in the classroom but in socio- cultural encounters in diverse real communities. These attitudes may exist because the overt racism of the past is not encountered as frequently in the U.S. today as it was in earlier times, even though the degrees of inequalities that are seen in African American population are not fully explained by poverty and poor educational attainments. 19 According to Bonilla- Silva, Contemporary racial inequality is reproduced through New Racism practices [color- blind racism] that are subtle, institutional, and apparently nonracial. 20[p. 3] One critical point of color- blind racism especially may affect health care providers perceptions of patients, and may be relevant when addressing the racial dynamics factor (F13): the belief that minorities are behind (lower socioeconomic status, education attainment, housing conditions, and health care outcomes) not because of racial/ethnic differences or White privilege but because they do not work hard enough or because they are less intelligent, more likely to abuse drugs or alcohol, or less adherent to health care treatments or health behavior changes. 20,21 The influence of provider- patient demographic characteristics and racial concordance on clinical practice and patient care has been well documented. 22,23,24 Considering that the majority of medical and pharmacy school graduates are Whites and Asians from high socioeconomic status groups, 25,26 Nahvi argued that patients sometimes struggle to be understood by well- meaning but, ultimately, privileged doctors who sometimes cannot relate to patients from other backgrounds, 27[p. 907] and Berger discussed common unconscious differences practitioners have when treating patients from other races or genders. 22 Awareness of racial privileges and of color- blind racism must be included in cultural competence curricula in order to broaden health care providers understanding of these issues so that they can communicate better and create meaningful relationships with their patients. Limitations. Although several limitations affect the interpretation and generalization of this study s results, our intent is to encourage reflection and begin the discussion about the main issues found. First, this study is an early step of an ongoing program to implement and assess training in cultural competence; building student profiles is used, in this step, to identify additional training needs and recommend curricular changes instead of measuring changes due to the curriculum. Second, the lack of control groups, in both medicine and pharmacy programs, does not allow making conclusions about the effect caused by the implementation of the curricular content. Third, differences found in student profiles are not fully explained by program, academic year, and/or race/ethnicity; although no significant differences were found in this study about gender, languages spoken or international exposure, other variables not included in this study such as socioeconomic status, personal experiences, and academic environment may also have an important impact. Fourth, this study used the racial categories defined in the U.S. Census and did not consider the great heterogeneity within these populations; therefore, results should be interpreted cautiously, always avoiding blame, overgeneralization, and stereotyping. Fifth, data used to create student profiles were collected using a self- assessment tool where students self- rated their own competencies; considering that research has found that students tend to overestimate their competencies, 28 it is important to clarify that the intent is not to measure cultural competence but students

298 Racial dynamics cultural competence training perceived level, as clearly stated in the tool used. Finally and most important, the wide variation in the racial/ethnic composition of students in the two samples may have had an important effect on the results; although similar results were found in previous studies focused only on pharmacy students, 8,9 our findings must be used with caution. Conclusions and recommendations. Student profiles in cultural competence showed statistically significant differences in several factors by academic program and race/ethnicity. Although differences found by program may, in part, being explained by differences in the curriculum implemented, explanations of the differences found by race/ethnicity almost certainly go beyond the instruction to the participants life experiences and also the racial dynamics that may be reinforced in majority White or majority Black academic institutions. 27,29 This study confirms the need to use and/or develop specific tools to assess potential racial discrimination or bias of both majority and minority health care providers 30 and to implement training in cultural competence specifically to address and measure issues of racial discrimination, White privilege and power imbalance. 8,31,32 Specifically we recommend the implementation of tools such as the Race, Skin, Age, Gender, Sexuality and Disability Implicit Association Tests (IATs) to explore students unconscious biases, stigmas, and prejudices that could be a source of dissonance in the patient- provider encounters. 31 As result of this study, we strongly believe that although acquiring knowledge, skills, and abilities are necessary when becoming culturally competent health care providers, they cannot be acquired if there is not a sincere desire to understand Others, recognize one s own limitations, challenge comfort zones, and embrace diversity. Cultural competence is a lifelong process that requires humility, sensitivity, and commitment to change ourselves. 33 Recognizing and addressing students own racial and ethnic stereotypes and biases should be the first step in this process. Instead of being a topic that is often carefully avoided when developing curriculum and training in cultural competence, it should be the priority to address this topic and allow safe places for open conversations and sincere reflections and self- improvement. The teaching challenge is that the audience is at varying levels of development in their progression to cultural competence. Murray- Garcia et al. 34 discussed challenges in forming a cultural competence curriculum when there is resistance from some students in dealing with personal beliefs, medical ethics, patient counseling, and cultural competence in the clinical practice. Considering the results of this study, we wonder if a curriculum in cultural competence should be divided into two parts. The first one, early in the program (basic science years), focused on analyzing the impact of social determinants of health in health disparities as well as addressing students attitudes, stereotypes, and biases, and using self- assessment tools combined with racial discrimination scales, such as the implicit association tests (IATs) mentioned. 30 The second one focused on increasing knowledge and developing skills, which could be gasped more easily late in the program (clinical years) when students will have daily encounters involving ethical issues, cultural competence issues, and the other behavioral parts of clinical training. As Gregg and Saha put it, Context is critical in cross- cultural curricula in health care settings; when students are face- to- face with patients they finally get the relevance to

Echeverri and Dise 299 the curriculum, whereas, in the classroom, cultural competence may simply appear as another concept to memorize. 35 Regardless of the academic program and learning environment, an important challenge to address racial dynamics is finding room in the curriculum to embed cultural immersion experiences, face- to- face multicultural encounters, guided discussions leading to self- reflection, and de- briefing sessions after multicultural and racial encounters. Another important challenge is finding enough senior faculty and health care providers who have the time and are trained safely to take students out of their comfort zones when being resistant to addressing inherent biases and stereotypes. 34 Future studies could focus on defining strategies to address these challenges as well as analyzing differences in perceptions among students who had important immersion experiences such as study- abroad and real- life significant encounters with culturally diverse populations such as foreign- born immigrants and refugees. Funding/Support Project was supported in part by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number D34HP00006 (Centers of Excellence) and the National Institute on Minority Health and Health Disparities (NIMHD) grant number 5S21MD0000100 11 (Endowment). References 1. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family- centered care: a roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010. Available at: http://www.jointcommission.org/assets/1/6 /ARoadmapforHospitalsfinalversion727.pdf. 2. Levy R, Like RC, Shabsin HS. Origins and strategies for addressing ethnic and racial disparities in pharmaceutical therapy: the health- care system, the provider, and the patient. Washington, DC: National Minority Quality Forum, 2009. Available at: http://www.nmqf.org/ebooks/disparitiespharmtherapy.pdf. 3. Smedley BD, Stith AY, Nelson, AR, eds. unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press, 2003. 4. Liaison Committee on Medical Education (LCME). Standards for accreditation of medical school programs leading to the M.D. degree. Washington, DC: LCME, 2010. Available at: https://www.med.unc.edu/ome/lcme/sub-committees/lcme-documents /LCMEFunctionsStructMS10 11.pdf. 5. Accreditation Council for Pharmacy Education (ACPE). Accreditation standards and guidelines for the professional program in pharmacy leading to the Doctor of Pharmacy degree. Chicago, IL: ACPE, 2011. Available at: http://www.acpe- accredit.org/pdf/finals2007guidelines2.0.pdf. 6. O Connell MB, Rodriguez M, Poirier T, et al. Cultural competency in health care and its implications for pharmacy, part 3A: emphasis on pharmacy education curriculums and future directions. Alexandria, VA: American College of Clinical Pharmacy (ACCP) Board of Regents, 2012. Available at: http://www.accp.com/docs/positions /whitepapers/accp_cultcomp_3a.pdf.

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