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Academic Medicine, Vol. 95, No. 5 / May 2020 803
Review
Abstract
Purpose
To explore best practices for increasing
cultural competency and reducing
health disparities, the authors
conducted a scoping review of the
existing literature.
Method
The review was guided by 2 questions:
(1) Are health care professionals and
medical students learning about implicit
bias, health disparities, advocacy, and the
needs of diverse patient populations?
(2) What educational strategies are
being used to increase student and
educator cultural competency? In
August 2016 and July 2018, the authors
searched 10 databases (including Ovid
MEDLINE, Embase, and Scopus) and
MedEdPORTAL, respectively, using
keywords related to multiple health
professions and cultural competency
or diversity and inclusion education
and training. Publications from 2005 to
August 2016 were included. Results were
screened using a 2-phase process (title
and abstract review followed by full-text
review) to determine if articles met the
inclusion or exclusion criteria.
Results
The search identified 89 articles
that specifically related to cultural
competency or diversity and inclusion
education and training within health
care. Interventions ranged from single-
day workshops to a 10-year curriculum.
Eleven educational strategies used to
teach cultural competency and about
health disparities were identified. Many
studies recommended using multiple
educational strategies to develop
knowledge, awareness, attitudes, and
skills. Less than half of the studies
reported favorable outcomes. Multiple
studies highlighted the difficulty of
implementing curricula without trained
and knowledgeable faculty.
Conclusions
For the field to progress in
supporting a culturally diverse patient
population, comprehensive training
of trainers, longitudinal evaluations of
interventions, and the identification and
establishment of best practices will be
imperative.
By 2050, 50% of the U.S. population
will be of non-European origins.1–3
Additionally, more than 10 million
Americans identify as lesbian, gay,
bisexual, transgender/transexual, queer/
questioning (LGBTQ), and the middle
class has shrunk from 57% in 1970 to 45%
in 2018.4 Within this context of shifting
demographics, our health care system
must strive to provide treatment and
services that are culturally appropriate
and effective. Providers cannot deliver
health care without taking into account
differences in ethnicity, religion, gender,
age, sexual orientation, socioeconomic
status, language, education, ability, and
geographic background.
In addition to these sometimes
overlapping identities, every patient
possesses a distinct worldview, influenced
by their cultures. Though culture is
difficult to define,5 Leininger describes it
as “the learned, shared, and transmitted
values, beliefs, norms, and lifeways of a
particular [group of individuals] that
guides thinking, decisions, and actions
in patterned ways [that are also often
intergenerational].”6(p10) Patients view
health promotion and treatment through
the lens of their cultures, which in turn
impacts their overall health.7 Culture
can influence everything from how
people view Western medicine to their
comfort with a doctor of the opposite
gender. We assert that one’s culture has an
inextricable and meaningful relationship
with health needs, care, and outcomes.
Groups from different cultures have
varying levels of health and wellness in
the United States. Health care disparities
refer to differences in access to or
availability of facilities and services.
Health status disparities are the varied
rates of disease and disability that exist
between socioeconomic, racial/ethnic,
geographically defined, and other
groups.8 Health disparities encompasses
both health care disparities and health
status disparities as well as the process for
connecting various types of disparities,
leading to the health outcomes a person
experiences. Both types of health
disparities are largely the result of
historic systemic inequalities. Without
understanding the impact of the political,
socioeconomic, and geographic factors
that led to these inequalities, it is nearly
impossible to address them. Regardless of
a health care provider’s good intentions,
a lack of cultural understanding can lead
to decreased patient compliance and
poor health outcomes.9 Thus, to this day,
health disparities have continued or even
worsened.
Research suggests that one way to
address health disparities and increase
positive health outcomes is to provide
Supplemental digital content for this article is
available at http://links.lww.com/ACADMED/A748,
http://links.lww.com/ACADMED/A749, and http://
links.lww.com/ACADMED/A750.
Toward Cultural Competency in Health Care:
A Scoping Review of the Diversity and Inclusion
Education Literature
Melissa R. Brottman, OTR/L, OTD, Douglas M. Char, MD, MA, Robin A. Hattori, MA,
Rachel Heeb, OTR/L, OTD, and Steven D. Taff, PhD, OTR/L
Please see the end of this article for information
about the authors.
Correspondence should be addressed to Douglas M.
Char, Division of Emergency Medicine, Campus Box
#8072, Washington University School of Medicine
in St. Louis, 660 South Euclid Ave., St. Louis, MO
63110; telephone: (314) 362-4346; email: chard@
wustl.edu.
Copyright © 2019 by the Association of American
Medical Colleges
Acad Med. 2020;95:803–813.
First published online September 17, 2019
doi: 10.1097/ACM.0000000000002995
XXX
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 95, No. 5 / May 2020
804
culturally appropriate care.10–13 The
Accreditation Council for Graduate
Medical Education, Liaison Committee
on Medical Education, World Health
Organization, and Institute of Medicine
all endorse training health professionals
and students in this area,14–20 as education
that helps providers understand the
cultural differences—and health beliefs
and practices—of diverse groups makes a
difference.21
But there are ongoing challenges to
implementing diversity and inclusion
training that enables students and
professionals to deliver health care
effectively to diverse populations or
to garner cultural competence. The
term cultural competence itself is
contentious as it can be interpreted as
suggesting that there is a theoretically
finite body of knowledge that can
be mastered to become culturally
competent.22 Other terms, often used
interchangeably, include culturally
compatible, culturally appropriate,
culturally congruent, culturally sensitive,
cross-cultural, culturally informed,
and culturally responsive.23,24 Tervalon
and Murray-García25 propose that
cultural humility—which incorporates
commitments to lifelong self-evaluation
and learning, to redressing power
imbalances in the patient–physician
dynamic, and to developing mutually
beneficial and nonpaternalistic clinical
and advocacy partnerships with
communities—is a more suitable goal
than cultural competence. However,
cultural competence remains the most
widely used term in the literature
and thus is used in this paper with an
acknowledgment of its shortcomings.
Many educators agree on the 4 major
tenets of cultural competence noted
by the Liaison Committee on Medical
Education: awareness, attitudes,
knowledge, and skills.16 Each tenet25
(see Table 1) describes concepts that
health care providers need to be sensitive
toward people of differing backgrounds.
However, there is a dearth of guidelines
for imparting the 4 tenets effectually.15
Many educators feel less prepared to
teach about diversity than science-related
subject contents. They may provide
basic knowledge on the influence of
race or gender specific to patient care
and health outcomes, for example, but
disregard political, socioeconomic,
and geographical impacts on health.
The assumption is that students can
extrapolate material and generalize
concepts to approach various situations
specific to diversity and inclusion, but, in
the end, this can lead to students not fully
appreciating the complex, interdependent
nature of the issues, which can actually be
counterproductive.26
Surveys show that health care
professionals still remain unaware of
the actual impact of health disparities
nationwide.15,27 Developing and teaching
a comprehensive curriculum that
includes the entire scope of cultural
competency is a recognized challenge.
Reliance on a biomedical model of
education is problematic, as many health
care providers postulate that health
care as an institution shoulders some
responsibility for the persistence of health
disparities.28
Exploring the approaches used to teach
cultural competency has the potential
to enhance learning and application
of culturally appropriate care. This
analysis may lead to curricular changes
that have the potential to increase
awareness, reduce bias, increase
health care accessibility, and provide
effective health services for people from
diverse backgrounds. To explore best
educational practices for increasing
cultural competency and reducing
health disparities, we conducted a
comprehensive scoping review of the
existing literature. The use of a scoping
review provides a cumulative map of the
existing literature to assist in identifying
knowledge gaps within a given topic. The
use of a scoping review does not assess
the quality of the literature; however,
it provides a comprehensive approach
to investigating a topic from multiple
disciplines and varying study designs.
Method
Research questions
We focused our scoping review on
answering the following questions:
(1) Are health care professionals and
medical students learning about implicit
bias, health disparities, advocacy, and the
needs of diverse patient populations?
(2) What educational strategies are being
used to increase student and educator
cultural competency (i.e., awareness,
attitudes, knowledge, and skills in
providing culturally appropriate care)?
Search strategy
Designed by a medical librarian (A.
Hardi, MLS), our search strategy
focused on multiple health professions,
including medicine, nursing, audiology,
pharmacy, occupational therapy, and
physical therapy, plus concepts of
cultural competency or diversity and
inclusion education and training. We
did not look at specific groups (e.g.,
LGBTQ, certain ethnicities), as we
sought to explore the larger global issue
of cultural competency and health
disparities. We used a combination of
standardized terms and keywords that
were implemented in Ovid MEDLINE,
Embase, Scopus, CINAHL, Cochrane
Database of Systematic Reviews,
Cochrane Central Register of Controlled
Trials, Database of Abstracts of Reviews
of Effects, ERIC, ProQuest Dissertations
Table 1
Definitions of the Four Major Tenets of Cultural Competencya
Tenet Definition
Awareness Awareness or insight into your own biases and reactions to various cultures that
are different from your own.
Attitudes Noting the “difference between just being aware of cultural differences” and
“analyzing your own internal belief systems.”
Knowledge Tervalon and Murray-García25 found that regardless of an individual’s morals,
beliefs, and values, how they think may not align with how they act causing
increased prejudice when interacting with those from a different culture. By noting
this gap, focusing on improving understanding or knowledge is key to improving
one’s own cultural competence.
Skills “Taking practices of cultural competency” and working to integrate them as
a part of one’s daily actions. A typical skill one needs to work on is effective
communication with a focus on both verbal and gestural communication.
a Definitions derived from Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical
distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved.
1998;9:117–125.25
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 95, No. 5 / May 2020 805
and Theses, and Clinicaltrials.gov. Our
initial search was conducted on August
5, 2016. In July 2018, we conducted a
secondary search of MedEdPORTAL.
For all searches, we applied database-
supplied language limits and confined
results to English publications from 2005
to August 2016. We exported results to
EndNote and removed 2,989 duplicates
for a remainder of 4,267 unique citations.
See Supplemental Digital Appendix 1 (at
http://links.lww.com/ACADMED/A748)
for the full search strategies.
Inclusion criteria
The research lead (M.R.B.) screened
the literature with specific inclusion
and exclusion criteria. D.M.C. and
S.D.T. modified the inclusion criteria
throughout the study selection process to
narrow the focus of the selected articles.
In phase 1 (title and abstract review), the
initial 4,267 articles were reviewed and
included if their abstracts had specific
terminology that focused on health
care professionals or students, followed
an American or European school
system, and discussed or explained an
educational curriculum and instruction.
Articles did not have to be peer reviewed
to be included.
A full-text review conducted by M.R.B.,
R.H., and an undergraduate assistant
(I. Chen) confirmed that 717 articles
met all of the aforementioned criteria.
Because there was still an overabundance
of literature, we added the following
criterion during phase 2 (full-text review):
articles must discuss culturally relevant
education, educational strategies, and
instruction. The final screening process
identified a total of 89 articles that met all
of the inclusion criteria. A flow diagram
(Figure 1) was adapted from the PRISMA
(Preferred Reporting Items for Systematic
Reviews and Meta-Analyses)29 guidelines
and used during the screening process.
Starting with purposefully general criteria
minimized the risk of potential bias. Any
disagreements were resolved by D.M.C.
and S.D.T.
Data organization and extraction
M.R.B. and R.H. used the Guideline
for Reporting Evidence-Based Practice
Education Interventions and Teaching
(GREET)30 checklist to organize our
results. Educational intervention can be
complicated to assess in scoping reviews
due to educators frequently modifying
lessons and curricula. Therefore, we
used a modified GREET checklist to
provide information on each educational
intervention.30 The modified checklist
combined 17 categories into 7. This
merging of items allowed us to analyze
each article without having to separate
details into constrictive subcategories.
For instance, the full GREET checklist
divides intervention outcomes into the
categories of how well, planned changes,
and unplanned changes, whereas the
modified checklist incorporated all 3 of
these categories into the single category
of intervention outcomes.
Three reviewers (M.R.B., R.H., and
I. Chen) extracted data regarding
study design in the following GREET
categories: participants; theory, model,
or framework; learning objectives;
educational strategies; delivery personnel;
intervention schedule and/or length; and
intervention outcomes. Coding occurred
in 3 distinct phases: coding, sorting, and
synthesizing. First, codes were assigned
to track common trends and patterns
throughout multiple categories based
on each reviewer’s interpretation of
the literature (e.g., use of simulators,
role-play, standardized patients).31 The
reviewers collaborated to generate a
single list of codes to decrease individual
bias. After the initial cycle of coding, they
sorted each coded list into categories
based on similarities and underlying
meaning. From there, the reviewers
generated themes encompassing all of
the initial codes and the categories into
which they were sorted. For instance, one
intervention used objective structured
clinical examination (OSCE), which
was coded as simulation. From there,
the intervention was categorized with
similar intervention approaches (such
as use of OSCE and role-play) and
Figure 1 Adapted PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-
Analyses)29 flow diagram for an August 2016 scoping review exploring best educational practices
for increasing cultural competency and reducing health disparities. A secondary search of
MedEdPORTAL was conducted in July 2018. All numbers reported in the figure include articles
from both searches.
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 95, No. 5 / May 2020
806
placed into broader code families (such
as simulation). Finally, we placed all
simulation codes under the larger theme
of educational strategies.
Results
Included studies
Our searches identified 4,267 studies after
duplicates were removed, of which 89
articles related to cultural competency
or diversity and inclusion education and
training within health care.2,3,7,11,12,15,18–20,23,
24,32–109 Detailed information on the included
studies can be found in Supplemental
Digital Appendix 2 (at http://links.lww.com/
ACADMED/A749). Due to the diverse,
inconsistent, and unstructured nature
of education-based articles, we did not
develop comparisons to rate papers or draw
conclusions regarding specific outcomes.
Study characteristics
Interventions ranged from single-day
workshops3,11,32–43 to a 10-year effort
to integrate cultural competence
throughout a curriculum.44 Table 2
displays participant characteristics. Of
89 studies, 78 (87.6%) were conducted
with graduate and undergraduate
students; the remaining articles focused
on health care professionals12,15,45–51
and educators.15,23,42,49,78,85,100,108,109 The
maximum number of participants in a
single intervention was 562.19 Nursing
and medicine comprised the primary
professions providing diversity and
inclusion education and training.
Many of the studies were descriptive in
nature and did not provide enough detail to
draw comparisons, demonstrate outcomes,
or evaluate the efficacy of interventions.
Studies noted sequential outcomes of
acquiring knowledge, awareness, attitudes,
and skills. Of the 89 studies, 19 (21.3%)
described an increase in students’ cultural
knowledge.2,19,20,36,38,50,52,53,55,57–59,61–65,70,77
Twenty-two (24.7%) studies observed
changes in students’ attitudes and level of
cultural awareness.2,11,19,24,35,37,48,50–52,58,61,62,67–74,92
Fourteen (15.7%) studies noted a general
increase in students’ perceived level of
applicable skills.3,18,19,34,36,38,43,52,53,72–74,77,78 Only
2 (2.2%) studies tracked outcomes to find
that students developed new skills specific
to culturally competent care, in addition
to increased knowledge and awareness.19,52
Thirty-eight (42.7%) studies tracked at least
one outcome, while over half of the articles
did not report any specific outcomes.
The review revealed 5 themes—theories,
models, and frameworks; teaching
strategies; assessments; curriculum and
course design; and educator training—
which are discussed in more detail below.
Theories, models, and frameworks.
Various tools are used to organize
different concepts and information
within a specific context. Theories
are tested knowledge that informs
aspects of human behavior, models are
visual representations that describe
relationships among concepts, and
frameworks are structures of concepts
used to communicate ideas and values.110
This review found that 53/89 (59.6%)
studies used at least one theory, model,
or framework to guide the development
of their educational intervention, while
37/89 (41.6%) did not.
The most frequently referenced model
was Campinha-Bacote’s111 Process of
Cultural Competence in the Delivery of
Healthcare Services.2,23,48,49,51,55,64,70,72,79–82
This model identifies the development
of cultural competence as a process
embedded within 5 constructs:
cultural awareness, knowledge, skills,
encounters, and desires.2,23,64 Other cited
models were Giger and Davidhizar’s9
Transcultural Assessment Model,23,51,65,81
Purnell’s112 Model for Cultural
Competence,23,44,51,65 and Berlin and
Fowkes’s113 LEARN (Listen, Explain,
Acknowledge, Recommend, Negotiate)
Communication Model.2,62,68,71,83,84
Teaching strategies. Almost all studies
(80/88, 90.9%) cited mixed teaching
strategies (outlined in Supplemental
Digital Appendix 3 at http://links.
lww.com/ACADMED/A750). One of
89 (1.1%) studies did not mention
any teaching strategies used during
their intervention, so it was not
analyzed for teaching strategies.109
Many studies recommended using
multiple methodologies, such as
lectures, discussion groups, and, less
frequently, presentations and papers
to develop knowledge, awareness,
attitudes, and skills. Seventy-nine of
Table 2
Participant Characteristics Among the Studies Included in an August 2016 Scoping
Review Exploring Best Educational Practices for Increasing Cultural Competency
and Reducing Health Disparitiesa
Participant characteristic No. (%) of studies
Health profession
Medicineb30 (33.7)
Nursing 28 (31.5)
Pharmacy 10 (11.2)
Dental 4 (4.5)
Physical therapy 4 (4.5)
Emergency medicine 2 (2.2)
Family medicine 2 (2.2)
Occupational therapy 2 (2.2)
Public health 2 (2.2)
Audiology 1 (1.1)
Radiology 1 (1.1)
Social work 1 (1.1)
Role
Graduate or undergraduate student 78 (87.6)
Health care professional 9 (10.1)
Educatorc9 (10.1)
Residents/clerkshipsd8 (9.0)
aA secondary search of MedEdPORTAL was conducted in July 2018. For some studies, data on the specific target
population were not available for extraction. One study could include more than one health profession or role,
so percentages may exceed 100. The total number of included studies was 89.
bThe overall category medicine was used when no specific type of practice was identified and includes both pre-
and post-doctoral students.
cSpecific to the articles that focused interventions on faculty members.
dPre- and postdoctoral students.
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Review
Academic Medicine, Vol. 95, No. 5 / May 2020 807
88 (89.8%) studies used more than
one educational strategy; 36 of these
79 (45.6%) studies reported favorable
outcomes.2,3,11,18–20,34,36–38,48,51–55,57,58,60–66,
68,70–75,77,82,86,87 However, only 2/79 (2.5%)
studies reported that the intervention
improved participants’ skills (beyond
awareness, attitudes, and knowledge).19,52
Nine of 88 (10.2%) studies used only one
educational strategy. Of those 9 studies, 5
(55.6%) cited favorable outcomes50,56,67,69,88
and 3 (33.3%) reported no significant
change.89–91
We identified 11 educational strategies,
which are described in more detail below,
used to teach cultural competency and
about health disparities: immersion
experiences, simulation, discussion
groups, lectures, reflection, educational
technology, case-based learning, papers,
presentations, readings, and videos
(Table 3 shows the distribution of these
across the included studies).
Immersion experiences. Immersion
experiences were employed in 30/88
(34.1%) studies. Of these 30, there
were 12 (40.0%) studies that used
clinical rotations to acquire cultural
knowledge24,44,49,52,62,69,74,78,83,87,92,104 and
1 (3.3%) that provided 2 clinical
placements to enhance the application
of culturally competent care.70 Another
program provided an immersive
international experience that increased
students’ awareness and ability to
understand a variety of environmental
and sociocultural factors impacting
health.78 While promising, the program
proved costly and was limited based on
follow-up discussions.
Simulation. Simulation was incorporated
in 40/88 (45.5%) studies. Twenty-
eight of those 40 (70.0%) studies used
role-play with students or standardized
patients.33,34,37,40,45, 46,48,51–55,59,61,63,66,71,73,79,85–88,
93–97 Vyas and Caligiuri71 indicated
that student-led role-play negatively
influenced outcomes due to inaccurate
simulation. In contrast, Mihalic and
colleagues53 found their student role-
play intervention increased cultural
knowledge and skills. Of the 40
studies, 6 (15.0%) used standardized
patients,39,42,43,76,78,94 3 (7.5%) used an
OSCE,61,85,98 and 4 (10.0%) combined
standardized patients and an
OSCE.34,46,77,80 OSCEs proved an especially
effective approach to increasing cultural
knowledge according to self-reported
measures61 and further facilitated tracking
of performance over time.34
Discussion groups. Discussion groups
were cited in 52/88 (59.1%) studies as a
means of cultural competency education.
In 10 of these 52 (19.2%) studies,
discussions occurred within small-group
settings of 8–15 students.11,41,43,47,75,85,93,
95,99,100 Additional formats included
panel, large-group, activity-based, and
faculty-facilitated discussions. Smith and
colleagues15 found that the use of smaller
cohorts promoted a safe environment for
students, enhancing self-reflection and
evaluation. Discussion groups were not
only employed with students but were
also cited as a tool to train educators to
facilitate meaningful dialogue.33
Lectures. Lectures were used as a
method of disseminating foundational
information about health disparities in
50/88 (56.8%) studies. Lectures ranged
from 15 minutes73 to 2 hours56,58 and
were conducted by various individuals
including, but not limited to, community
members and guest lecturers (without
specification of expertise),37,45,54,75 experts
within the field,48,53,54,90 and faculty.20,35,
38,46,56,58,61, 68,85,96,97,101 The effectiveness of
lectures varied; 2/49 (4.1%) studies found
that lectures proved less beneficial than
active learning activities.11,101 Combining
lectures with other educational
strategies (such as role-playing, group
discussions, etc.) generally led to more
positive outcomes in terms of increasing
knowledge and awareness, implying
that lectures alone are not a sufficiently
robust tool for educating individuals on
the topics of cultural competency and
diversity and inclusion.
Reflection. Reflection was included as an
educational strategy in 36/88 (40.9%)
studies. For example, students at one
institution used Blackboard to develop a
reflection portfolio.2 The use of reflection
positively influenced students’ cultural
knowledge, awareness, and skills.64,70,74
However, 1/36 (2.8%) studies reported
needing more time for reflection
due to minimal changes in behaviors
and attitudes.11 Another 2/36 (5.6%)
studies paired reflection with activities
like hands-on experiences and group
discussions and found greater synthesis
of the information previously learned.57,80
Finally, the benefits of reflection double
as both a teaching tool and a means
of appraising changes in students’
knowledge and awareness.23,66
Educational technology. Educational
technology was used as an educational
strategy in 15/88 (17.0%) studies in the
forms of web conferencing64; Internet
training36,52,67,81,82,89; online forums102;
e-lectures76; distance learning103;
Table 3
Distribution of Educational Strategies Across the Included Studies in an August
2016 Scoping Review Exploring Best Educational Practices for Increasing Cultural
Competency and Reducing Health Disparitiesa
Educational
strategy No. (%) of
studies Studies
Immersion experiences 30 (34.1) 12,19,20,23,24,36,38,44,46,47,49,52,55,57,62,68–72,74,78,79,83,87,92,93,97,103,104
Simulation 40 (45.5) 7,23,33,34,37,39,40,42,43,45,46,48,51–55,59,61,63,66,71,73,76-82,85–88,93–98
Discussion groups 52 (59.1) 3,11,15,19,20,32–41,43,44,46–49,51–55,57–60,62,64,66,71,72,75,79,82,84–87,92,93,95,
99–102,106–108
Lectures 50 (56.8) 3,11,12,15,18–20,32–41,45,46,48–50,53,54,56,58,61–65,68,70,71,73–75,77,81,82,85,86,87,
90,93,96,97,99,101,104
Reflection 36 (40.9) 2,3,11,15,18,23,24,32,36,38,40,44,47–49,57,62,64–66,70–72,74,78,80,82–84,91,94,96–98,
103,105
Educational technology 15 (17.0) 7,36,40,41,52,54,64,67,76,81,82,89,92,102,103
Case-based learning 28 (31.8) 2,3,15,34,38,40,44,45,53,58,60,61,66,71,77,80–82,84,85,92,93,95,99–101,103,105
Papers 5 (5.7) 23,47,49,57,71
Presentations 5 (5.7) 20,23,81,83,85
Readings 17 (19.3) 2,12,20,35,40,46,51,52,54,64–66,75,80,100,103,108
Videos 24 (27.3) 2,3,34,40,45,51,54,58,62,63,65,66,71,72,80,84,92,97,101–103,106–108
aA secondary search of MedEdPORTAL was conducted in July 2018. Out of a total of 88 studies; 1 study was
not included here because it did not mention teaching strategies used during the intervention, so it was not
analyzed for teaching strategies.109
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Review
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online self-, pre-, and postassessment
tools40,41,54,92; and high-fidelity simulators.7
Outcomes depended on the type of
technology used. Two of these 15 (13.3%)
studies concluded that the use of skill-
based online modules and audiovisual
tools did not change physicians’ scores
on cultural competency assessments or
meet learning objectives.67,89 Another
2/15 (13.3%) studies found that using a
combination of technology and reflection
increased knowledge,64 attitudes,52 and
skills.52 The majority of educational
technology interventions were not
fully described, making replication
challenging.
Case-based learning (CBL). CBL
was cited in 28/88 (31.8%) studies.
CBL focuses on developing student
skills through real-life and clinical
scenarios.114 Among other things, studies
integrated CBL through simulation,38,82
vignettes,40,53,71 case-based reflections,84
small-group problem-based cases,101 and
case-based discussions.34,61,66,81,101 Two
of these 28 (7.1%) studies made use of
simulation games—BaFa’ BaFa’ cultural
simulation66 and the Clown Culture82—to
educate students on culturally competent
care, but neither reported clear outcomes.
Educators also used CBL in fieldwork
experiences through discussing and
applying cultural knowledge in role-plays
of real cases.61 Sixteen of the 28 (57.1%)
studies mentioned that they used CBL
within their educational interventions
without explaining how,2,3,15,44,45,58,60,77,80,81,85,
93,95,99,103,105 making it difficult to fully
articulate how this educational strategy
works in practice.
Papers. Papers were incorporated in 5/88
(5.7%) studies. Martinez and colleagues47
used essays as assessment and application
tools in evaluating behaviors through
case-based questions. In most studies,
papers were used in conjunction with
other educational strategies. The majority
of studies did not provide details on how
papers were structured or formatted.
Presentations. Presentations were used
in 5/88 (5.7%) studies, including both
oral23,83,85 and poster presentations.20,81
Vela and colleagues20 had students
present posters to illustrate a health
disparities topic as part of a 5-day
elective experience for health professions
students. Similar to papers, presentations
were used in conjunction with other
educational strategies with little
description on the format or structure
used.
Readings. Readings appeared in
17/88 (19.3%) studies as an optional
assignment,20,40 a preparatory tool,2,12,51,54,64,
66, 75,80,100,103,108 and/or the focus of class
discussion and reflections.35,46,52,65,66,103
Resources such as The Spirit Catches You
and You Fall Down115 and La Doctora116
provided students with an understanding
of culture within health care systems.66
Poirier and colleagues2 assigned readings
before class to build foundational
knowledge on cultural issues, then used
class time to apply the information. They
reported that their students demonstrated
increased awareness and knowledge.
Two of these 17 (11.8%) studies
found that readings presenting real-
life encounters increased participants’
cultural awareness.35,66 For instance, one
intervention used letters and factual
accounts of individuals living in poverty
to stimulate discussions about how these
circumstances might compromise one’s
health.35
Videos. Videos were incorporated in
24/88 (27.3%) studies in the form of
clips, movies, documentaries, television
shows, and training videos. Four of the
24 (16.7%) studies mentioned specific
videos2,62,66,103 like If These Walls Could
Talk117 and Patient Diversity: Beyond
the Vital Signs.118 The most commonly
cited film was Worlds Apart,119 about a
Muslim man who refused chemotherapy
due to cultural beliefs. Pilcher and
colleagues62 used the facilitator’s guide
for this film120 to assist in discussions that
promoted reflection and introduced new
perspectives. Studies combining videos
with other educational strategies reported
an increase in knowledge,2,58,62,65,97
awareness,2,51,62,71,72,97,106 and skills.97
Assessments. Assessments evaluate
the level of changed behaviors and
acquired knowledge and skills related
to an educational intervention. This
review found many programs used
papers, projects, and reflections to assess
learning. Eight of 89 (9.0%) studies used
a pre- and post-test method to assess
learning20,48,50,52,60,66,69,87 and 1 (1.1%)
study conducted a follow-up 30 days
post intervention.87 The 2 assessments
most frequently cited were the Cultural
Self-Efficacy Scale121 and the Inventory
for Assessing the Process of Cultural
Competency Among Healthcare
Professionals,122 which were each cited by
5/89 (5.6%) studies.2,51,87,103,105
Curriculum and course design. The
studies reviewed did not discuss how
they developed or arrived at their
interventions. There was great variance
in the design of cultural competency
training; examples ranged from a
20-minute intervention34 to 600 hours
of training embedded throughout a
curriculum.83 The interventions included
workshops, curricula, courses, clinical
rotations, and remote education. Fifteen
of 89 (16.9%) studies used a single-day
workshop varying in length and in the
amount of information covered.3,11,32–43,76
Related to the theme of assessment,
a large portion of short courses and
workshops only measured immediate
outcomes to determine the level of
knowledge, skills, and behavior changes;
no study established its format as a best
practice for overall curriculum or course
design.
Educator training. Studies have noted
that successful implementation of a
cultural competency curriculum begins
with those delivering it: the faculty
and teaching staff.23,44,61,97 Twenty of 89
(22.5%) studies noted the importance of
effectively training those who are educating
others about diversity and inclusion to
the successful implementation of such
curricula.15,23,33,40,42–44,46,49,56,61, 78,85,91,93,97,100,
103,108,109 Two of these 20 (10.0%) studies
mentioned that a majority of educators
teaching cultural competence have
interest in the topic but lack extensive
training.23,78 Seven of the 20 (35.0%)
studies endorsed training faculty and
teaching staff to deliver health disparity
information15,23,42,49,78,85,100; however, only
2 of these 7 (28.6%) described how to
train them.15,100 Kumagai and Lypson33
recommended group discussions,
reflections, and simulation activities. Even
with such training, however, students
found that educators could not facilitate a
thorough conversation.42
Discussion
Health care educators acknowledge
that cultural appropriateness grows
increasingly critical in the face of
changing demographics and widening
health disparities, but it is clear that we
need to do more work to identify best
practices. For example, none of the
studies included in our review declared
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 95, No. 5 / May 2020 809
their approach to be a best practice for
teaching cultural competency in health
care.
Both the University of Rochester37 and
St. John Fisher College59 used the Deaf
Strong Hospital program developed at
the University of Rochester School of
Medicine and Dentistry. Although these
institutions used the same program
guide as the basis for their training,
one incorporated a longitudinal self-
assessment survey and the other included
a reflective writing assignment. This
shows how cultural competency training
can be altered beyond the initial design
and thus vary in content, delivery, and
outcomes.
Within the literature, we note a scarcity
of evidence citing the effectiveness
of educational approaches72 with the
majority of studies hesitant to state a
clear positive outcome. Many articles
used various models, theories, and/
or frameworks to support their cross-
cultural education interventions;
however, none of them were reported
as producing more favorable outcomes
than the others. It may be that the choice
of model, theory, and/or framework is
not as critical as the existence of one to
guide a curriculum or training. Beyond
the general formatting for the curriculum
or course, the approaches for assessing
outcomes were vague. Many assessment
tools followed a self-report format, which
cannot always accurately determine
changes in skills related to cultural
competence. Unfortunately, many of the
studies did not explain their process or
appear to have an assessment process at
all. This was one area where many studies
fell short.
This scoping review reveals that educators
seek resources and ways to combine
educational strategies to increase the
cultural awareness, attitudes, knowledge,
and skills of their students. Considering
the range of models, theories,
frameworks, and educational strategies
identified, education specific to diversity
and inclusion and cultural competence
seems to have been embraced by the
health professions and will likely continue
to proliferate.
Several barriers to progress in efforts to
increase cultural competency and health
disparities education and training are
noteworthy. First, education for those
who are doing the educating has not
been sufficiently addressed. Educators
are being trained with a narrow focus
that does not adequately prepare them to
teach future health professionals about
the complex topics of culture, bias, and
health disparities. Many studies thus
recommend relying on and training
faculty to become experts within the
field to most effectively deliver education
based on diversity and inclusion and
cultural competence.15,56,109 To implement
programs with a diverse cultural focus
into health professions education
effectively, faculty and teaching staff
need to have a level of comfort and
proficiency with a variety of topics
(i.e., understanding of various models,
theories, and frameworks associated with
culture; therapeutic use of self-concepts
associated with effective communication;
etc.). While methods used to teach
students can also be effective for
other audiences, there is no universal
standard for training educators. Garet
and colleagues123 explored the factors
that make professional development
effective and found that a focus on
content knowledge, opportunities for
active learning, and connection to
other learning activities all increased
educator’s knowledge and skills and
improved classroom practices. Regular
training of faculty and teaching staff
using these strategies will lead to a more
knowledgeable and skilled cadre of
educators who can handle the breadth
and depth of issues related to cultural
competence.
This barrier may also resolve in time as
health care students and professionals
who have benefitted from cultural
competency training and who have
actively incorporated those lessons into
their practice go on to become the next
generation of educators. Until that time,
the question remains how to fill the gap.
Many programs make use of external
experts, but they are scarce and in high
demand. A train-the-trainer124 model may
be more productive.
This scoping review also shows that an
assessment of what works the best in
the short term and/or longitudinally
has yet to be completed. Many of the
studies indicated positive changes in
student awareness or knowledge. But
these were largely based on self-reported
indicators, which may be biased and
are unreliable for predicting future
behavior or long-term effectiveness. Our
review of the literature found only a
few assessment scales that were used in
the included studies. Other tools need
to be explored and validated so that the
myriad of models, theories, frameworks,
educational strategies, and interventions
used can be accurately evaluated. As it
stands, many health care professionals
and students can claim that they have
had some exposure to training in cultural
competency. However, it is not evident
that these efforts change behavior or lead
to more culturally sensitive services that
decrease health disparities.
The lack of assessment in cultural
competency training explains why there
is no consensus as to the most effective
methodologies. Educators often employ
a multimodal curricular approach,
incorporating lectures, discussion groups,
educational technology, and CBL. No
particular approach is all-encompassing,
nor is that necessarily feasible. There is
no right way to address the complex,
dynamic, and sometimes emotionally
charged subject matter that is cultural
competency training. The very nature
of diversity and inclusion education
implies that training can never be
complete; rather, it is a lifelong process.
It is impossible for a student to become
proficient after a single educational
session or even a year of training,
and individuals will absorb and apply
information differently, even if they share
similar backgrounds. Both educators and
students in health care must embrace this
nuanced process as an essential aspect of
their career-long endeavors to improve
cultural competency within health care.
A potential solution lies in introducing
cultural competency training at the
start of professional health studies and
embedding these concepts throughout
curricula and clinical experiences.
Including cultural competence in
accreditation standards and as part of
continuing professional education can
enhance the longitudinal presence and
congruency necessary to fortify these
efforts.
Health professions programs
acknowledge that gaining knowledge,
awareness, and skills are necessary for
attitude and behavior changes but rarely
measure outcomes to determine if those
objectives are being met. A next step
toward successful training might be
future investigation into the effectiveness
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited.
Review
Academic Medicine, Vol. 95, No. 5 / May 2020
810
of a variety of efforts undertaken at 3
partner institutions including 7 health
professions programs: general medicine,
occupational therapy, physical therapy,
nursing, pharmacy, audiology, and deaf
education. Washington University in St.
Louis, the St. Louis College of Pharmacy,
and the Goldfarb School of Nursing at
Barnes-Jewiss College offer programs
such as a week-long immersive didactic
and experiential initiative that focuses
on health care disparities and their
myriad causes, an interactive poverty
simulation, an implicit bias workshop,
and group discussions focused on
providing culturally appropriate
care. Educational institutions need
to take a closer look into the design
and assessment of programs like these
to ensure educators are creating the
necessary outcomes related to the 4
major tenets of cultural competency:
skills, knowledge, attitudes, and
awareness.
Future research has the potential to
determine best practices for teaching
cultural competency and about health
disparities. Only when we can pinpoint
what works, how, and why, can we
inculcate cultural competency as an
essential value for health care providers
and begin to dismantle health disparities.
Limitations
Our review was limited to English
titles and focused on educational
practices rather than clinical studies.
We only focused on school systems in
the United States or Europe. Though it
was as comprehensive as possible, our
scoping review is likely an incomplete
snapshot. Many health professions
programs may be implementing cultural
competency training without reporting it.
Additionally, the programs that reported
about their efforts may have since
modified their approaches.
Conclusions
A wealth of examples in the area
of cultural competency and health
disparities education training for
health professions exist. These varied
interventions are acknowledged
as important and provide critical
opportunities for students to learn,
empathize, and reflect. For the field
to progress in supporting a culturally
diverse patient population, however,
comprehensive training of trainers,
longitudinal evaluations of interventions,
and the identification and establishment
of best practices will be imperative.
Funding/Support: This study was funded by
the Faculty Fellows and Emerging Scholar-
Professional Grant Program, Center for Diversity
and Inclusion, Washington University in St.
Louis.
Other disclosures: None reported.
Ethical approval: Reported as not applicable.
Previous presentations: The principal investigators
presented the preliminary results of this scoping
literature review orally at the iTeach Symposium
at Washington University in St. Louis, St. Louis,
Missouri, in January 2018. Preliminary results
were presented as a poster at the National
Academies of Practice Annual Meeting & Forum
in Atlanta, Georgia, in April 2018.
M.R. Brottman is currently occupational therapist,
Schwab Rehabilitation Hospital, Chicago, Illinois.
At the time of writing, she was a third-year clinical
doctorate student, Program in Occupational Therapy,
Washington University School of Medicine in St.
Louis, St. Louis, Missouri.
D.M. Char is professor of emergency medicine
and director of faculty development for emergency
medicine, Washington University School of Medicine
in St. Louis, St. Louis, Missouri.
R.A. Hattori is senior project manager, Program in
Occupational Therapy, Washington University School
of Medicine in St. Louis, St. Louis, Missouri.
R. Heeb was a third-year clinical doctorate student,
Program in Occupational Therapy, Washington
University School of Medicine in St. Louis, St.
Louis, Missouri, at the time of writing. She is
currently a rehabilitation and participation science
doctoral student, Program in Occupational Therapy,
Washington University School of Medicine in St.
Louis, St. Louis, Missouri.
S.D. Taff is associate professor of occupational
therapy and medicine and director, Division of
Professional Education, Program in Occupational
Therapy, Washington University School of Medicine
in St. Louis, St. Louis, Missouri.
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“I buy a pack on Sundays and we eat one
every night.”
My patient, a 63-year-old woman seeking
treatment for diabetes and hypertension,
sat across from me shifting in her seat.
She looked down at her hands and
waited.
Five minutes before, we had reviewed
her blood pressure readings from the
past few clinics. Today it was 165/100.
We had discussed whether or not she
was taking her medications, all 3 of her
antihypertensives, as prescribed. She
was, she told me, taking them all. We had
started talking about her fingersticks,
given that her A1c was elevated at 9.8%.
I had asked her what she had eaten for
dinner the night before and she had
responded, “Hot dogs.” I asked, “Why hot
dogs?” and she looked at me and said,
“Well, my grandson lives with me and he
likes hot dogs. It’s what I can afford, and
he likes it, so on Sundays I buy a pack and
we each eat one every night until they are
gone.”
She paused just for a moment before
saying almost to herself, “It’s what I can
afford.” Then she waited, looking at her
hands nervously.
In that moment, I saw all my years of
education, training, certifications, and
exams. My diplomas on the wall. My
congratulatory letters for passing my
internal medicine and then my endocrine
boards. They meant nothing then because
I had no response that would help my
patient. After 9 years of training, and now
2 years into professional life, all I knew
how to do was change her medications.
But I realized it wasn’t the best thing to
do.
That seminal moment forever changed
my understanding of what it meant to be
an educated physician. The curricula at
medical schools continue to change, but
there remain some persistent holes and
silos of information that never connect,
often to our patients’ detriment. For
decades medical education has lagged
in providing nutrition instruction for
students; I was one of many trainees who
was not taught this critical information.
The topic of the social determinants of
health has now made its way into many
a medical school curriculum but most
often in the form of singular lectures
or seminars scattered among the years
of training. My own medical school
education had included topics such as
poverty, literacy, and domestic violence.
However, they seemed like islands by
themselves, and on the wards the task
of addressing pertinent social issues was
quickly handed off to the social worker
assigned to our floor.
The intersection of nutrition and the
social determinants is where my patient
stood all those years ago, and I had no
compass to direct me on how best to help
her. I did not know what food insecurity
was or how it affected my patient. I had
no knowledge of the resources in my
community that could have provided
assistance. I didn’t know how to guide
her to better food choices when she had
limited resources. In this patient, I saw
that I was unable as a mature provider to
address all of her needs through simply
identifying and discussing them. I could
change her medications, or add more, but
I could not address what was wrong.
In the years since, I have sought to fill
my own holes in knowledge and taught
my students how to bridge those gaps in
patient care so they are better prepared
than I was at the end of training. I
encourage robust appreciation for and
connection with community agencies that
address people’s nonmedical needs, such
as food insecurity and domestic violence.
Today I am as prepared to recommend
healthy food options on a budget as I am
to add another antihypertensive. That
intersection of addressing medical and
nonmedical needs is always my target
now that I have a compass of my own.
Anita Ramsetty, MD
A. Ramsetty is assistant professor, Department
of Family Medicine, Medical University of South
Carolina, Charleston, South Carolina; email:
ramsetty@musc.edu.
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Teaching and Learning Moments
Stranded at the Intersection
