OBJECTIVES: To identify demographic, educational, and experiential factors associated with perceived self-efficacy in cultural competency (PSECC) for pediatric residents and faculty at a large, tertiary-care children’s hospital and to identify key barriers to the delivery of culturally competent pediatric care.
METHODS: We conducted a cross-sectional assessment of cultural competency (CC) education, training, and skills using an online survey of residents and faculty at a large children’s hospital. With our data analysis, we sought associations between PSECC skills, cross-cultural training or work experience, and demographic background. Participants were asked to identify and rank barriers to CC care and additional training they would like to see implemented.
RESULTS: A total of 114 residents (55%) and 143 faculty (65%) who responded to the survey assessing PSECC. Residents were more likely to have had CC training than faculty. More than half of the residents and faculty had participated in an underserved-group clinical experience domestically or abroad. Those residents with underserved-group experience were more likely to be comfortable with interpreter use (P = .03) and culturally sensitive issues (P = .06). Faculty who participated in underserved-group care in the United States were more likely to believe that cultural bias affects care (P = .005). Both identified time constraints, language barriers, and lack of knowledge as chief barriers to acquiring CC, and both desired more training.
CONCLUSIONS: Residents and faculty at a large children’s hospital believe that they lack adequate CC training. Underserved-group clinical experiences both domestically and abroad are associated with perceived improved cross-cultural care skills. Increasing the extent and quality of CC education in both resident training and faculty development is needed.
For more than a decade, those in residency training programs have developed and implemented curricula pursuant to the Institute of Medicine’s 2003 recommendation that all health care professionals be trained in cross-cultural communication.1 Despite a growing body of literature, much in this emerging field remains unsettled, including common terminology, robust metrics, and evidence-based best practices.1–3 However, the need for culturally competent medical providers remains acute, especially in pediatrics.4
Of US children, 25% currently live in immigrant households with family members who speak little to no English. By 2020, children from non-Hispanic, non-white backgrounds will comprise more than half of the US pediatric population.5 Despite a growing need for effective cultural competency (CC) training in pediatric residents, significant gaps remain.4 In a recent cross-sectional survey of graduating pediatric residents, nearly all (96%) felt “prepared to care for patients from diverse backgrounds,” yet less than half were comfortable caring for families with beliefs contrary to Western biomedicine.4 Cross-cultural (ie, non–Euro-american and nonbiomedical) experience in residency is associated with greater comfort in caring for children with varied language skills, countries of origin, and religious practices.4,6–8 Medical experience with underserved populations in the United States and other countries enhances resident efficacy.9–11
Other factors associated with resident cross-cultural preparedness include formal CC training curricula, mentoring, and faculty engagement in cross-cultural issues.7,8,12–14 Researchers have used focus groups to solicit the attitudes and beliefs of residents and faculty about CC training, but few researchers describe CC training, skills, knowledge, or perceived self-efficacy of pediatric faculty, and none directly compare the perceived needs of pediatric residents and faculty.14,15 Addressing faculty needs has been suggested as a key factor in improving residency CC training.3,8,13–15
A major obstacle to understanding faculty and resident needs for CC training and ongoing education is the absence of standard terminology and metrics. Although no one questions the importance of doctor–patient communication skills, no standard outcome metrics have been established in the literature to assess the quality of CC training, skills, and knowledge.16,17 Were such quality measures available, it would remain exceedingly difficult to isolate the effects of CC on clinical outcomes from other factors, such poverty, access to care, and social discrimination.16,17 Survey assessments of perceived self-efficacy are limited by potential bias or lack of insight into one’s abilities. Nevertheless, they have been used in many previous studies.7,8,18 Alternative approaches include cultural Objective Structured Clinical Examinations,19 focus groups,12 or implicit association tests.20–23 These more complex and time-consuming tools are less suited to a wide, cross-sectional needs assessment.
Our first objective in this initial study is to identify demographic, educational, and experiential factors associated with perceived self-efficacy in cultural competency (PSECC) for pediatric residents and faculty at a large, tertiary-care, academic children’s hospital. The second objective was to identify and compare key training gaps and barriers in both groups through a needs assessment to assist in planning future training interventions. We define CC as “the practices of understanding, acknowledging, and adapting to the variations and dynamics of cross-cultural encounters and relations to meet the unique, specific needs of populations outside of the provider’s own,” (adapted from Betancourt et al24). This is to carefully differentiate between culture-specific knowledge (eg, Maasai tribal practices of umbilical cord care) and CC skills (eg, discussing safe newborn care with families who practice traditional child-rearing practices).2,9,24–26 Culture-specific knowledge, although valuable and often perceived by learners as especially valuable, does not adequately prepare pediatricians to care for culturally diverse patient populations at home or abroad.1,4,9,11 We hypothesized that higher PSECC is associated with formal CC training and cross-cultural experiences. Our goal is to describe the results of the survey and suggest further improvements in CC curricula for residents and faculty.
Study Population and Setting
Our institution is a large, urban, tertiary-care teaching pediatric hospital that employs >200 residents and 700 full- and part-time faculty. All current residents (categorical and combined) were invited to participate in the survey, as were all faculty in the divisions of cardiology, emergency medicine, gastroenterology, general and community pediatrics, hematology and oncology, and hospital medicine. The selected divisions have broad exposure to the institution’s patient population and represent a cross-section of both general and subspecialty care. In 2016, our patient population included 51% patients of color (42% African Americans and 9% other). The Department of Interpretive Services receives ∼200 requests per month for non–English-speaking patients, with the 2 most common languages being Spanish and Arabic.
This study is a cross-sectional assessment of CC training and PSECC. We developed separate online surveys for residents and faculty. (Figs 1 and 2) Survey content and wording were identical with the exception of added questions for faculty regarding CC training and postresidency experiences. Both surveys began with the definition of CC quoted above. Surveys were posted on https://www.qualtrics.com/ for 2 weeks from January 2014 to February 2014. E-mails linked users to the survey, and explanations of the study design were sent to each resident and faculty. Voluntary participation was encouraged by divisional and residency program announcements. Reminder e-mails were sent at weekly intervals to improve response rates.
Primary outcomes were PSECC and adequacy of CC training. Because no validated survey measures exist, we asked respondents to quantify PSECC on a 5-point Likert scale, with 0 (“strongly disagree”) corresponding to no efficacy and 5 (“strongly agree”) corresponding to high efficacy. We quantified self-perceived adequacy of CC training on a similar 5-point Likert scale.
To quantify factors potentially related to PSECC or adequacy of CC training, we collected demographic information (including age, race, ethnicity, and country of citizenship), years of medical training, experience with international and/or underserved populations, and languages spoken. Finally, we listed potential barriers to providing quality culturally competent care. We asked participants to rank these and identify other barriers and possible training improvements in free-response format.
Results were analyzed by using descriptive statistics and summarizing respondent demographics and training. Statistical significance was defined as an α of .05. The distribution of each question’s Likert responses was evaluated and dichotomized on the basis of any level of agreement or disagreement (ie, agree and strongly agree versus others) because our analysis was not focused on the degrees of agreement or disagreement.
Associations between dichotomized responses and demographic or training information were compared by using χ2 tests. Rank-order responses of perceived existing barriers and possible improvements to culturally competent care at our institution were collated. Themes of free-text responses were reviewed, coded, and discussed among the investigators for consensus.
E-mails with links to the appropriate questionnaire were sent to 207 residents and 218 faculty. We received completed questionnaires from 114 residents (55%) and 143 faculty (65%). Most responding residents and faculty identified as white, had degrees from US medical schools, and spoke English as their primary language (Table 1). Compared with faculty, residents reported more CC training in medical school. Most faculty had <10 residency hours devoted to CC training. Approximately half of the residents and faculty reported previous medical experience with underserved populations in the United States or internationally.
Training and Experience
Among faculty, no association was found between PSECC and the number of hours or perceived quality of CC training in medical school or residency, nor was an association found between PSECC and international experience (data not shown).
Residents without international underserved-group experience were more likely than residents with such experience to disagree that physicians from minority groups (62% vs 32%, P = .003) or lower socioeconomic backgrounds were better equipped to handle cultural exchanges (71% vs 42%, P = .004). Faculty and residents who participated in US-specific underserved-group experiences were more likely than nonparticipants to agree that cultural biases affect care (residents 66% vs 46%, P = .06; faculty 48% vs 25%, P = .005).
Participant Language, Race, and Location of Training
Resident or faculty race was not a significant factor in perceiving minority-group physicians or physicians from lower socioeconomic backgrounds as better equipped for cross-cultural care (Tables 2 and 3). Residents and faculty of color were less likely than their white colleagues to be comfortable with an interpreter (residents 69% vs 89%, P = .03; faculty 87% vs 97%, P = .04). Residents who were graduates of US medical schools were less likely than non–US medical school graduates to disagree that minority physicians were better equipped to provide culturally competent care (52% vs 12%, P = .02), yet US graduates were more likely to be comfortable with an interpreter (88% vs 54%, P = .01). Participants who spoke a second language were not any more comfortable with an interpreter and did not claim in our survey to have any stronger grasp of sensitive cultural issues.
Training Barriers and Perceived Needs
Residents and faculty identified similar barriers to providing culturally competent care, including time constraints, language differences, and a lack of knowledge about specific cultures or minority groups (Table 4). Both groups overwhelmingly wanted culture-specific knowledge. Residents wanted culturally sensitive interviewing skills and strategies. Faculty wanted more specific knowledge about the use of interpreter services. In free-text responses, emerging themes included balancing provider with family needs and expectations of care and the need for debriefing and shared learning after cross-cultural encounters (Table 4).
This cross-sectional survey of 257 participants revealed that PSECC was more highly associated with the content of CC training (ie, international, underserved-group experiences) than total training hours, demographics, language skills, or previous life experiences. Residents and faculty both perceived inadequacies in their CC training, including training duration, culture-specific skills, cross-cultural interview skills, and appropriate expectations. Both groups desire more opportunities to debrief and learn from recent clinical experiences.
Although most respondents had some form of CC training, 49% of residents and 67% of faculty had <10 hours total. However, no association was found between total training hours and perceived skills. This is not surprising given the relatively few hours of CC training most respondents received. As in previous national resident surveys, the majority of residents felt prepared overall, but when asked specific questions about populations and skills, perceived gaps emerged. This suggests that even programs with dedicated CC training are not yet meeting learners’ perceived needs.4,8 Until standardized quality metrics for CC training are developed, assessing CC training content and learners’ perceived deficits rather than the duration of CC curricula is necessary.
The overlap of culture, discrimination, poverty, and health disparities as well as the skills required to address them has long been noted.1,3,24,27,28 As in previous studies, medical experience with underserved populations (domestic and international) is associated with enhanced resident PSECC skills and attitudes, including comfort using an interpreter, cultural sensitivity, awareness of the effect of cultural bias on care, and appreciation of the unique skills of colleagues from minority or lower socioeconomic status (SES) backgrounds.9–11 However, faculty with underserved-group experiences did not perceive significant improvement in PSECC skills. Reasons for this discrepancy are unclear, although this may indicate an improvement in the educational quality of underserved-group experiences over time, with more attention paid to learner-appropriate experiences, as described in the literature.11 Alternatively, it is possible that faculty and residents have different perceptions of how CC skills translate from 1 underserved-group experience to another. Finally, it may be that faculty with more experience than residents have acquired greater cultural humility (eg, providers and patients learn from each other and develop a commitment to shared awareness and evaluation in cross-cultural care).2,24,29,30
Similarly, speaking a second language was not perceived as a significant factor for PSECC by residents or faculty. This may reflect the inherent complexity of patient–provider communication in that differences in health literacy, variant dialects, and cultural conceptions of illness and appropriate care arise even when all parties speak the same language.31,32
Previous studies have revealed that health professionals from diverse backgrounds may be more comfortable with CC skills and experiences.7,8,12–14,23 In our survey, however, residents and faculty of color were less likely than their white colleagues to be comfortable using an interpreter and were no more likely to agree that minority or low-SES physicians were more equipped to provide CC care. Although analysis is limited by the small number of minority-physician survey respondents, these providers may have a greater awareness of the challenges (eg, different perceptions of illness, historical mistrust, language or cultural barriers, or economic or access-to-care barriers) inherent to cross-cultural medical encounters. Educators should not assume minority providers are (or see themselves as) uniquely prepared to care for diverse patient populations.
As with previous studies, survey respondents identified a lack of time and knowledge of specific cultures as key barriers or gaps in CC.8,15 Other studies have revealed that providers often identify a lack of culture-specific knowledge as a major gap in CC education.8,9,13–15 When asked to elaborate, respondents identified a lack of time for culture-specific training while engaged in direct patient care and difficulty matching the expectations of families and providers. Although researchers in other studies identified a lack of faculty role models as a key barrier, this was not the case in our study.6,8,9,13,14 Nevertheless, faculty respondents identified perceived gaps in their training. Improved resident CC training may well require enhanced faculty development.
When asked to recommend additional content to improve existing training, both faculty and residents ranked culture-specific knowledge first. This is consistent with previous studies, although the desire for CC training focused on lists of characteristics of a cultural group has been criticized by educators and minority advocates for oversimplifying the role of culture in medical care.2,14,29 Designing CC training solely around culture-specific knowledge can lead to stereotyping.2,14,27 Common requests in resident and faculty free-text responses included better understanding of cultural expectations, debriefing after challenging cross-cultural encounters, and identification of best practices. Debriefing and acknowledgment of cultural dissonance may be teachable moments in cultural humility.2,24,29,30
This study has several limitations. It is limited to a single pediatric center in the Midwest with a majority of white, US-trained providers. Our results may not be generalizable to other sites. Responses were self-reported and subjective, which is a limitation in most assessments of CC curricula. Most responses were captured on a Likert scale and subsequently dichotomized for ease of display and interpretation with the concomitant loss of finer degrees of measurement. Self-reported perceived efficacy is a far less robust metric than standardized outcomes, which do not yet exist. However, much in this survey is consistent with previous national resident surveys. We address a gap in the literature by comparing perceived CC needs of residents and faculty as a first step toward improved care of patients from diverse backgrounds. We agree with other researchers that thoughtful CC training should be integrated into residency-associated learning opportunities in global health and medically underserved populations in the United States.11,33,34 Our survey results suggest that CC training should be considered for pediatric faculty. The results also suggest important areas for future study, including quality benchmarks for cross-cultural training, further study of the development of cultural humility, assessment and support for faculty cross-cultural training, and improved training for pediatric residents to care for patients from diverse backgrounds.
This survey of 257 pediatric residents and faculty at a large, tertiary-care pediatric referral center documents perceived inadequacy of CC training for residents and faculty. Perceived cultural efficacy was improved by domestic or international experience with underserved groups. Providers expressed the desire for interventions with sufficient time for debriefing and evaluation of challenging encounters. This desire and buy-in is an opportunity for improved resident and faculty CC training at our institution and elsewhere.2,24 Future studies are needed to assess the quality of training experiences and determine how to best facilitate the development of CC skills for residents and faculty.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Divisional funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Smedley BD,
- Smith AY,
- Nelson ARE
- Frintner MP,
- Mendoza FS,
- Dreyer BP,
- Cull WL,
- Laraque D
- ↵US Census Bureau. 2013 US census report on children. 2013. Available at: https://www.census.gov/programs-surveys/popest.html. Accessed July 6, 2018
- Butteris SM,
- Schubert CJ,
- Batra M,
- et al
- Ha JF,
- Longnecker N
- FitzGerald C,
- Hurst S
- ↵National Academies of Sciences. Engineering and MH and MDB on PH and PHPC on C-BS to PHE in the US. In: Baciu A, Negussie Y, Geller A, Weinstein JN, eds. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017:1–582
- Webb E,
- Sergison M
- Pitt MB,
- Gladding SP,
- Suchdev PS,
- Howard CR
- Copyright © 2018 by the American Academy of Pediatrics