Transforming the Face of Health Professions Through Cultural & Linguistic Competence Education:
The Role of the HRSA Centers of Excellence

Appendix C: COE Assessment and Promising Practices Report

ASSESSMENT & PROMISING PRACTICES RESULTS HRSA, DHHS
Centers of Excellence Cultural Competence Assessment
& Curriculum Development Project, Magna Systems, Incorporated
August 27, 2004

ABSTRACT

The Assessment and Promising Practices Results describe the cultural and linguistic competence activities of HRSA Centers of Excellence (COE) grantees. This report on assessment and promising practices is a result of an assessment of COEs and a collection of “promising practices” that COEs provided in response to a questionnaire.

For the assessment, the authors collected information from the 2001-2002 Uniform Progress reports, which COE grantees complete annually. The authors examined reports from 29 COEs, and coded and cataloged activities according to an assessment matrix, developed by the Expert Team of this project. The matrix was arranged by topic: Content, Teaching Delivery/Methods, Non-Teaching Delivery/Methods, and Evaluation. Another source of assessment information came from two focus group interviews held on March 19, 2004, in Washington D.C., in conjunction with the COE directors’ conference. The purpose of the focus groups was to gather the opinions of the COE directors to enable Magna Systems and the Expert Team to draft a curriculum guide for COEs.

To complement the assessment, additional findings were collected that describe the cultural and linguistic competence activities that the HRSA Centers of Excellence (COE) grantees have determined to be “Promising Practices.” These practices are based on responses solicited from COEs in a questionnaire. Each COE provide its own definition of “promising practices,” and using this definition, selected activities to include in its response.

The following are some of the main findings from the assessment and collection of “promising practices”:

• The topic taught with the most frequency among the 29 COEs was “Different Population Groups.” This topic includes the general health-related and cultural beliefs of ethnic groups, and instruction on diversity and multiculturalism.
  
• The teaching method the COEs employed most frequently was “classroom-directed learning.” This method includes classroom-directed learning that has been incorporated into the curriculum either as a required course, elective, or unit in an established course.
  
• The non-teaching method most frequently used was “research pertaining to people of color.” This category is included as a way to determine the COEs’ activities involving academic or community-based research pertaining to people of color.
  
• A few COEs conducted evaluations for their programs. Three COEs conducted an evaluation of their cultural and linguistic competence curricula.

This project is being conducted by Magna Systems, Incorporated under contract with the HRSA Division of Health Careers Diversity and Development.

Introduction

The Centers of Excellence (COE) Program is a program of the Federal Health Resources and Services Administration of the Department of Health and Human Services. The goal of this program is to assist health professional schools in supporting various programs in health professions education for underrepresented minorities. The purpose of this Assessment and Promising Practices Report of the COE grantees’ activities is to identify their past cultural and linguistic competency educational activities and highlight selected current activities.

Methodology: Assessment and Promising Practices

The primary source of data for the assessment was the 2001-2002 Uniform Progress Reports, which COE grantees complete annually. The data from the 2001-2002 reports are the most recent set of comprehensive data available from HRSA. Each report contains a narrative section that details the COEs’ objectives and accomplishments for the past year. The Expert Team examined reports from 29 COEs. Of the 29 COEs, ten were Hispanic/Latino Centers of Excellence, three were African American, four were American Indian, one was Native Hawaiian, and eleven were Other. The activities were coded and catalogued according to an assessment matrix that the Expert Team developed.

A secondary source of assessment data came from two focus group interviews held on March 19, 2004, in Washington, D.C., in conjunction with the COE directors’ conference. The purpose of the focus groups was to gather examples of current COE activities as well as solicit opinions from COE directors to enable Magna Systems and the Expert Team to develop a curriculum guide for COEs. Among the questions that were posed during the focus groups were the following:

• How can we share promising practices among the COEs?
  
• What kind of cultural and linguistic competency curricula are the COEs currently using?
  
• How can the COEs emerge as leaders in cultural and linguistic competency?

In the two focus group sessions, there were 31 participants altogether, although not all participants stayed for each full session. These participants represented COEs from medical, osteopathic medicine, pharmacy, and dental schools. The suggestions gathered during the two focus groups became the initial basis for the assessment matrix, which the Expert Team than further refined and expanded.

After the activities for the assessment matrix were identified and coded, the Project Team recorded the number of activities in the matrix and calculated the sum for each cell. The Content and Teaching Delivery/Methods matrices have two numbers in each cell. One number is the total number of activities in which the COE participated. Some COEs had multiple activities for a single category, meaning the total number would be more than 29 in some cases (There were 29 COE grantees’ reports examined in the assessment). The second number in the cell represents the number of COEs that participated in the activity. The numbers in the Non-Teaching Delivery/Methods and Evaluation matrices refer to COEs; no COEs had multiple activities for each category.

After the numbers were tabulated, the Project Team chose examples to illustrate various levels of participation. Some COEs are just beginning to initiate activities in certain areas, while others have more established programs. Although two activities may teach students about similar content topics, the objectives and methods may be very different.

The assessment tool was developed through the previously mentioned Focus Groups with additional input from the Expert Team members. The tool consists of four matrices: Content, Teaching Delivery/Methods, Non-Teaching Delivery/Methods, and Evaluation. The matrices allow a detailed overview of the COE grantees’ activities by showing activities that address cultural and linguistic competence at the patient-client level, as well as at the organizational level. In an attempt to capture a detailed view of activities, each matrix contains topics that serve as examples of more general categories. For example, some categories in the Content matrix address an individual’s cultural and linguistic competence, such as “Clinical Practice Issues,” while others address an organization’s competence in such areas as the CLAS standards, for instance.

The audience for each matrix remains the same and ranges from the individual student to the surrounding community. The audience refers to the groups that participate in or receive the cultural and linguistic competence activity. Each of the audience fields is described below:

• Student: students in health professional schools
  
• Residents: residents in any year of residency
  
• Fellows: health professional school fellows who have completed post-graduate training and are either teaching or conducting research
  
• Faculty: junior or senior faculty within the health professional school
  
• Staff: COE staff members
  
• Manager: COE managers
  
• Deans/leader: COE deans or leaders
  
• COE-wide: All individuals affiliated with the COE, including all individuals listed above
  
• Community-wide: practitioners, service providers, or other health workers in the COE’s community

In addition to audience fields, the assessment and promising practices data are disaggregated by COE type and the COEs gear their recruitment and curricula toward specific groups, including African Americans, American Indians, Latinos/Hispanics, Native Hawaiians, and Others.

The accompanying promising practices are included to complement the assessment data. The promising practices are based on solicited responses from COEs who defined their promising practices and, using their own definitions, selected activities to include in their responses. The following is a sample definition:

“Promising practices are identified strategies, approaches, and activities that are designed to enhance and underscore cultural and linguistic competency education for medical students, residents, faculty, and staff. These practices include defining cultural and linguistic competence within the context of the patient-doctor clinical encounter. As a practice, the concept of cultural and linguistic competence expands to include the recognition of culture as dynamic societal happenings with norms, mores, and customs outside of the political concept of race and ethnicity.”

In contrast another COE defined promising practices more generally as:

“Educational activities that utilize creative ways of implementing and assessing cultural and linguistic competence curricula.”

COEs reported their activities in a free format, which allowed them to stress whichever aspects of the promising practices they believed were most important. A total of 16 COEs responded and provided more than 70 examples of promising practices. Since it is cumbersome to include descriptions of all the responses, several activities were selected to illustrate promising practices on topics that are also included in the assessment information matrices, such as “different population groups” or “curriculum development.”

The report also includes a matrix of promising practices which is meant to quantify the responses received thus far from COEs for informational purposes. By clustering COEs by the populations they serve, we hope to highlight areas of focus that may be pertinent to particular communities. The quantified data on promising practices are not meant to be analyzed along with the assessment information.

In addition to being arranged by COE population-served, the matrix on promising practices is also arranged by content versus process: cultural awareness, cross-cultural communication, alternative treatments, awareness of disparities, language acquisition, workforce diversity, evaluation, cultural and linguistic competency pedagogy, community-based research, community-based practice, curriculum development, recruitment/retention, information dissemination, organizational development, and other.

While certain schools listed more than 20 activities, other schools listed only one, a factor that tends to skew the data if one looks only at the frequency at which activities were reported. Although definitions of promising practices are relatively similar among schools, they are not identical; and because reports were submitted in various formats, comparisons among schools are not included.

The difficulty in quantifying qualitative data is that there is often an element of subjectivity in the interpretation process. Thus, when coding the various activities, the greatest efforts were made to rely on the stated purpose or criteria of the promising practice in order to place the activity in the appropriate category and limit interpretation. Many schools listed a large number of promising practices but provided no descriptions of what the activities entailed. These practices, due to a lack of information, were omitted from this report.

Content Matrix

The Content Matrix catalogs the various topics that are included in cultural and linguistic competence education. The Content Matrix is closely related to the Teaching Delivery/Method Matrix. The methods the COEs use to teach the content categories are catalogued in the Teaching Delivery/Method Matrix.

The different population groups category refers to the general health-related and cultural beliefs of an ethnic group. This category also includes teaching diversity and multiculturalism. COEs taught this topic the most frequently among the other cultural and linguistic competence topics. There were 18 COEs that conducted 32 activities related to Different Population Groups for their students. Of the 18 COEs, six were Other, six were Hispanic/Latino, four were American Indian, one was African American, and one was Native Hawaiian.

Six of the COEs chose to teach students about different population groups through classroom-based learning. This method was the most frequently employed method of teaching about different population groups. Some COEs taught general multiculturalism and diversity issues. The objectives of one COE’s cultural and linguistic competence curriculum include the following:

• Have students recognize their own attitudes, beliefs, and values and the effect of these attitudes on clinical practice
  
• Increase understanding of similarities in attitude, beliefs, and values across groups
  
• Communicate effectively
  
• Increase knowledge of variation.

Another COE developed a core set of cultural concepts to incorporate into their curriculum.

Other COEs used classroom-based methods to teach students about a particular ethnic group. One COE developed a course in Native Hawaiian health issues. Another COE offered two elective courses on Native American health for its students, “Seminars in Indian Health” and “Health Outside the Mainstream.” An example of a “Promising Practice” on this topic is “Consulting the Family Ghost: Using Cultural Genograms to Promote Cultural Awareness.” This practice has been adapted to multiple formats for first-year medical students, senior internal medicine residents, and attending faculty as a way for learners to introduce themselves, deepen group cohesion, and raise awareness about themselves and the diversity of their peers. In the activity, small groups of learners introduce themselves by drawing and narrating a personal “cultural genogram” including factors such as race/ethnicity, religion, socioeconomic status, geographical influences, formative family events (e.g. immigration, illnesses, etc.), and family medical and psychiatric histories. When appropriate, facilitators asked probing questions to promote reflection.

Other COEs taught students about different population groups through experiential clinical practice, such as through community immersion. At one COE, the Native American students take clinical rotations at sites that treat Native American patients either exclusively or in large numbers. Rotations are four weeks long, and nine Native American medical students participated in these activities. Ten dental students at another COE participated in six- to eight-week summer clinical rotations in communities of URMs.

Another method the COEs used to teach about different population groups was through Web-based learning. One COE incorporated computer-aided instruction in all seven of its clinical sciences department curricula. Another COE developed a COE Website that includes curricula regarding Native American health issues.

One COE incorporated cultural and linguistic competence as a required training topic for residents, thus combining instruction on clinical issues and different population groups.

Faculty members at some COEs also received instruction on different population groups. One COE had plans to initiate diversity training for all faculty members. At the time the report was submitted, the COE was planning the program and conducting a preliminary survey to assess the need for such training.

One COE used two different methods to educate the community about Hispanic/Latino health issues. This COE held a bi-National health issues lecture series for faculty, staff, and service providers at a hospital and sponsored a Latino health conference for community health workers.

Clinical practice issues arise when treating different ethnic populations and when practicing cultural and linguistic competence in clinical settings. The eight COEs addressed clinical practice issues through community immersion, case studies, workshops and trainings, and classroom learning. Four of the COEs were Hispanic/Latino, three were Other, and one was Native Hawaiian. All of the nine catalogued activities were directed at students.

One COE coordinated a lecture, “Cultural Sensitivity in Clinical Interactions” for all third-year students. Another COE emphasized cultural and linguistic competence during interviewing skills in its “Fundamentals of Medicine I and II” courses for first- and second-year students.

A number of COEs used community immersion clinical programs among ethnic populations to train students. Ten students in one COE participated in six- to eight-week summer clinical rotations in areas with a high population of ethnic groups. All students at another COE received clinical exposure to medical training at sites away from the main campus that are heavily populated with Native Hawaiians. One school cited a promising practice that included the development of a simulation program to recreate a clinical setting, monitor actual clinical interactions, and adjust the clinical situation to maximize learning. Interactions can be videotaped, and instructors can provide immediate feedback, allowing for dynamic learning in a “real” environment.

Communication, language, and literacy issues encompass all teaching content related to proper communication with ethnic populations, including such topics as medical language, interpreter issues, health literacy, and clinical communication. The majority of communication and language issues addressed Spanish-speaking populations. No COE offered courses in medical language in any language other than Spanish.

The five COEs that chose to address communication, language, and literacy issues did so using classroom-based measures. Two were African American COEs and the other three were Hispanic/Latino. Many COEs offered medical Spanish courses that ranged from 10 to 16 hours a week. One COE used a combination of teaching methods in its medical Spanish course. Students received didactic instruction in a classroom at the beginning of the semester and then met in small groups for the remainder of the semester. The COE also offered a Spanish-only rotation as an elective. One COE offered a conversational Spanish class for faculty. Other COEs offered courses that instructed students on working effectively with translators.

In one instance cited as a promising practice, a COE videotaped students’ interactions with standardized patients who did not speak English. The students were required to perform a focused history, assess the patient’s understanding of the disease, explain what procedures they were to conduct, and provide patient education. After the interview, the standardized patients provided feedback on the students’ communication skills.

Community, public health issues includes the different issues that affect the larger community in which the COE is a part. Many of the COEs taught this topic to students using clerkship or community immersion programs in community-based clinics. One COE developed a community health internship for its students. Another COE developed a community preceptorship program and recruited community-based health professionals as preceptors. One such promising practice was the rural health clerkship for senior medical students. This clerkship was designed to teach students how to interact successfully with diverse groups of people; students were assigned readings, held discussions, and planned activities to raise awareness of cultural diversity in the health care system. Students were expected to understand the effects of socioeconomic status, race/ethnicity, cultural values, and community and family support on health status of rural residents and communities. During the clerkship, students resided in rural communities for four weeks to learn in a dynamic, participatory way.

Health and illness related topics relate to physical health and illness, including health disparities and specific diseases that affect certain populations. Four COEs had programs related to health and illness topics. One COE had a lecture series that featured a lecture on minority health disparities. Another COE developed two problem-based learning cases on Native American and Hispanic/Latino health issues. One COE assembled specialists from various departments and created grand rounds presentations, which included a presentation on health disparities.

At another school, as a result of student requests, a symposium was conducted called “Patient Experiences, Diversity, and Disparities: A Cross-Cultural Documentary.” This session provided a brief didactic overview of racial and ethnic disparities and cross-cultural care, followed by the viewing of a video vignette and breakout discussions led by volunteer faculty from the COE and affiliated hospitals. The activity was reported as a promising practice.

Teaching Delivery/Methods

This matrix catalogs the delivery and methods the COEs used when teaching cultural and linguistic competence.

Classroom directed learning catalogs such learning that has been incorporated into the curriculum either as a required course, elective, or unit in an established course. It was the most frequently used method for teaching cultural and linguistic competence. Of the 14 COEs that used classroom directed learning as a teaching method for students, four were Other, four were Hispanic/Latino, four were American Indian, two were African American, and one was Native Hawaiian.

Six of the COEs produced their own curriculum, all for students. One COE developed and implemented five modules: minority health core competency, culture and development, culture of the patient-culture of the physician, medicine minorities and cultures in literature and medicine, and history of African Americans in medicine. One COE developed a course called “Culturally Competent Care” and is pending approval by the school of medicine’s curriculum committee. Another COE also developing a questionnaire to be completed by pharmacy faculty and current students to assess the presence of designated core concepts in the curriculum. The faculty members are identifying the core concepts.

The faculty members of another COE are guiding the development of a multicultural curriculum. The objectives of this curriculum include:

• Having students recognize their own attitudes, beliefs, and values and the impact of these beliefs on clinical practice
  
• Increasing understanding of similarities in attitudes, behaviors, and values across groups
  
• Communicating effectively
  
• Increasing knowledge of variation

For this course, the students are required to complete 50 hours of cultural and linguistic competence training during their preclinical years.

Other COEs developed curricula specific to particular ethnic groups. One COE developed and implemented a course that provides an introduction on research methodology and research topics while incorporating Native Hawaiian health issues. Another COE used funds to maintain the course, “Native American Health Care Issues” as a requirement for students. This course addresses Indian cultural issues, tribal governance, art in Native American culture, and presentations by various guest lecturers who are familiar with Indian health.

Some COEs made cultural and linguistic competence part of the required curriculum. One incorporated cultural and linguistic competence as required resident training topics. Another school required three sessions (10 hours) of a new series called "Culture Matters" for its entire first-year class. One COE reported a promising practice that described the ongoing attempt to develop a cultural and linguistic competency curriculum for the entire medical school.

Other COEs incorporated cultural and linguistic competence discussions into the standard curriculum. One COE discussed issues of culture and ethnicity in lectures on such topics as cultural and linguistic competency and health, cancer, theories of health promotion, obesity, physical activities, access to health care, and health disparities. The first-year students at another COE took a course titled, "Introduction to the Patient Care Model" that focused on cultural and linguistic competency issues.

Other COEs offered communication and language issues in a classroom-based atmosphere. Many COEs offered medical Spanish courses for medical students. One COE offered a Spanish medical terminology course that was 16 hours a week of didactic teaching.

Community immersion activities allow students to experience clinical practice in a community setting. Fourteen of the COEs had students work with different population groups in community-immersion activities. Six of the COEs were Hispanic/Latino, five were Other, and there was one each of Native Hawaiian, African American, and American Indian. Nearly all of the 15 of the community immersion activities were directed at students, except one program for residents, which was conducted by a Hispanic/Latino COE.

Some community immersion activities were directed primarily at specific ethnic groups. Native American students at one COE took clinical rotations at sites that treated exclusively or large numbers of Native American patients. These rotations were four weeks long, and nine Native American medical students participated in these activities. Another COE had its medical students conduct rotations in colonias clinics. Colonias are unincorporated settlements along the U.S.—Mexico border that often lack basic water and sewer systems, paved roads, and safe and sanitary housing. Another COE offered home care electives in the community in which 90% of the homes were occupied by African Americans. One COE offered Spanish-only rotations as an elective for some of their medical students. All medical students at another COE receive clinical exposure at community sites with large populations of Native Hawaiians.

In other community immersion activities students worked at community-based sites with a variety of ethnic groups. One COE had 25 of its URM students complete a summer practical immersion experience (PIE) of 3 to 12 weeks at clinical sites in predominantly URM, rural, or underserved areas. One school incorporated the students’ experiences in the community-based clinic into its cultural and linguistic competence teaching curriculum.

A promising practice in this area is a four-week immersion program designed to encourage students to consider practicing in Native Hawaiian communities and increase cultural and linguistic competency. The Native Hawaiian health care elective includes traditional healers as teachers and mentors and has several purposes, including having students:

• Gain an appreciation for the unique cultural and societal aspects of Native Hawaiian health
  
• Learn about the importance of traditional healing for Native Hawaiian patients
  
• Understand how to interact with traditional healers (by working with traditional healers)
  
• Improve their cultural and linguistic competence by being immersed them in the medical-cultural-social milieu of a Native Hawaiian community

Precepting/clerkships include activities that place students in clerkships with preceptors. This was the third-most used teaching method. All of the preceptored experiences and clerkships are for students. The majority of these programs are set in community-based settings with large ethnic populations. Of the 13 COEs that had clerkships, seven were Other, four were Hispanic/Latino, and two were Native American.

Many of the preceptors are recruited from community clinics. One COE created a community health internship program in which students are supervised by preceptors as they carry out health projects in community based organizations. Another COE developed a program, the American Indian Clerkship Pathway, which created clerkship options in three tribal communities.

Some COEs are making community-based clerkships readily available for their URM students. One COE provides all of its American Indian medical students with the opportunity to receive clinical preceptorships at a facility that serves an American Indian population. Another COE is proposing that all of its URM students receive preceptored experiences in community health. One COE reported a promising practice family medicine clerkship that uses problem-based learning to demonstrate and illustrate cases in a culturally relevant manner paying attention to the psychosocial and cultural factors in health and illness that is reflective of the local community. Additional activities in the clerkship include an introduction to the history of the neighborhood, discussion of immigration to the community, and a bus tour of various parts of the neighborhood. Visits were also conducted to local complementary health care sources.

Some centers are developing their clerkship programs by concentrating on hiring faculty. One COE hired a clinical preceptor director who has developed two clinical sites in the community.

Seminars and lectures related to cultural and linguistic competence were used in five different activities among the COEs and the target audience varied. Three of the COEs were Other, one was Hispanic/Latino and one was African American. Due to the short time length of seminars and lectures, COEs may have considered this an effective way to reach out to non-students. Most of the seminars or lectures featured guest lecturers. One COE had a seminar series with one lecture on minority health disparities. Another COE sponsored or coordinated five nationally recognized speakers on Hispanic/Latino and Native American health issues. All faculty at another COE attended a two-day seminar on cultural and linguistic competence. One COE sponsored a professional lecture series for all residents, faculty, providers, and staff on bi-National health. Another COE reported a promising practice that included lectures by health professionals on such topics as traditional Indian medicine, paleopathology, urban/reservation Indian health care, and social problems.

Workshops and training on cultural and linguistic competence differ from seminars and lectures in that they place a greater emphasis on the delivery and acquisition of a specific set of skills or knowledge, generally for a clear purpose. They differ from classroom-based learning methods in that they are typically individual events that have not been incorporated into the curriculum.

Some COEs had workshops directed at students. One COE created a diversity training session for first-, second-, and third-year students. Another COE held a cultural and linguistic competence workshop as a required part of intern, resident, and faculty orientation sessions. Another COE created a workshop session called “Appropriate Use of a Medical Interpreter” for students in clinical rotations.

Faculty also attended workshops and trainings. One COE held cultural and linguistic competence workshops for preceptors. The workshops were called “Cultural and linguistic competence 101: Becoming an Effective Preceptor and Pharmacist.” One COE director participated in a workshop on cultural and linguistic competence at Georgetown University. Another COE is planning to initiate diversity training for all faculty. The first step toward implementation was to evaluate the current status and survey faculty members to assess whether a need for training exists.

A promising practice in this area is a series of Native Hawaiian conferences done in collaboration with community organizations focusing on Native Hawaiian health issues and faculty development. The target audience is both clinical and academic faculty. In these conferences, the purpose is to teach and train faculty in cultural and linguistic competency as well as general faculty development topics.

Topics that have been addressed include:

• Overview of Native Hawaiian health with an emphasis on disparate rates of cardiovascular disease, cancer, diabetes, and obesity
  
• Conflict resolution training including an introduction to Hooponopono, the traditional Native Hawaiian practice of conflict resolution
  
• The “Dos” and “Don’ts” of conducting research in Native Hawaiian communities
  
• Writing scientific papers
  
• The long-term effects on nuclear testing on the culture and health of Pacific islanders
  
• Leadership skills training including the special role of being a leader in the Native Hawaiian community
  
• Genetic and related research in indigenous communities
  
• The lost generations, which includes a discussion of the psychosocial, behavioral, economic, generational, and cultural effects of generations lost to adoption (when adopted outside of the birth culture), drugs and alcohol, prison, domestic and sexual abuse, and other forms of exploitation
  
• The effect of emerging infectious diseases on Pacific Islander populations
  
• Cultural and linguistic competency in faculty and in curriculum development
  
• Geriatrics and the medical, psychosocial, and economic challenges on Native Hawaiian elderly
  
• The role of la`au lapa`au (herbal medicine) in Native Hawaiian health and healing

Case studies involve actual studies of patients’ cases and simulated patient interactions. The COEs that used case studies to teach cultural and linguistic competence created culturally relevant case simulations. One COE developed 14 problem-based learning cases, two of which addressed Hispanic/Latino and Native American health issues. All freshman and sophomore students at another COE interviewed Native American simulated patients. At another COE, all first years spent 15 minutes in case simulation with culturally relevant simulation patients with a feedback period. A promising practice in this area is a standardized patient (SP) program in which Native Americans were trained as SPs not only to simulate a disease or disease process, but also to exhibit a number of behaviors and effects that were cultural in nature and not necessarily related to the disease.

Non-Teaching Delivery/Methods

This matrix is meant to catalog other non-teaching delivery mechanisms and methods that the COEs use to increase their cultural and linguistic competence capacity.

Research pertaining to people of color. This category is meant to determine the COEs’ activities involving academic or community-based research pertaining to people of color. The research activities could generally be divided into two categories. The first is both underrepresented minority and non-URM students and faculty conducting research on URM communities. The second is URM student and faculty-conducted research.

Student research was widely done across the COEs, and 16 COEs were involved in such research. Seven of the COEs were Other, five were Hispanic/Latino, three were American Indian, and one was African American. It appears that the COEs’ goal in student research is supporting students’ educational and research capacity. One COE developed a tracking system to monitor the participation of URM students in research activities. In one COE, 47 of the 71 research projects for faculty and staff were relevant to URM health issues in New Mexico. Some COEs created research programs for URM students. For example, students from one COE participated in summer research projects for nine weeks that focused on Native American health issues. Another COE established what it called a Cultural Diversity Summer Research Experience, in which students participated in didactic seminars, received one-on-one mentoring from faculty preceptors, and completed presentations on various topics. Other schools established fellowships for students. One COE is examining the possibility of having all 24 medical students complete a senior thesis as a requirement to graduation, and the research must be related to health care for the underserved.

Faculty research was also widely conducted. Faculty researched URM health-related issues in ten of the COEs. One COE hired a research associate to coordinate research activities and support faculty research projects. It also established a faculty advisory committee to identify research mentors and support academic and research mentoring of individual faculty scholars.

Some COEs made their URM research activities COE-wide. One COE established a Center on Diversity and Disparity in Health. Another COE maintains a registry of minority health projects, funding support, research training and services, and developed a Center for Health Equity Research and Promotion. It also hosted a conference, “Current Opportunities and Trends in Health Research for a Diverse America.”

A COE cited a promising practice that is designed to improve cultural and linguistic competency by exposing students to Native Hawaiian health issues and traditional practices by teaching them about how to work with the Native Hawaiian community especially with regard to conducting research, which is an area of much controversy in indigenous cultures. The Native Hawaiian Community Medicine Research Program is an elective within community medicine. It is designed to:

• Give students formal research training in the basics of research methodology, design, and implementation
  
• Expose students to traditional Native Hawaiian health care practices
  
• Expose students to Native Hawaiian researchers, topics, and issues involving conducting research in Native Hawaiian communities
  
• Have students conduct research projects in an area dealing with Native Hawaiian health

This program uses Native Hawaiian faculty, a diverse student group (of Native Hawaiian and non-Native Hawaiian students), and Native Hawaiian community elders and experts. By teaching students about Native Hawaiian health issues, traditional healing, and the importance of respecting and working within a community, the elective is designed to produce students that are more culturally competent.

Recruiting included students, residents, fellows, and faculty. The assessment team recorded recruiting activities for URM individuals. A diverse student body and faculty is one indicator of developing organizational cultural and linguistic competence.

COEs recruited URM students to their respective schools by using a variety of methods. Fourteen COEs recruited students; eight were Other, five were Hispanic/Latino, and one was American Indian. Some methods included sponsoring summer camps, institutes, and academies, making health career presentations at schools, and offering test preparation classes. Other COEs worked directly with high schools, community colleges, and undergraduate institutions to identify URM pre-medical students and invite them to participate in research or academic programs. One COE created a two-pronged plan that distinguished between targeting URM students for 1) application and enrollment (acute plan) and 2) placement in the competitive student applicant pool (long-range plan).

Faculty recruitment activities were not as detailed as student recruitment. The reports did not provide the actual activities that each school conducted, but rather just stated that the COEs recruited faculty. One COE established a faculty steering committee to develop recommendations to improve the recruitment and retention of both URM faculty and students and to link with community effort to promote the goals. Two COEs offered fellowships to junior URM faculty. Thirteen COEs were involved in faculty recruitment.

Two COEs recruited fellows to their programs by creating fellowships. One maintained a Hispanic/Latino COE health services fellowship in general pediatrics. Another COE established one Latino research fellowship and two faculty research positions at 25% each at the UCSF-Fresno Latino Center.

One COE recruited Hispanic/Latino residents by meeting with resident directors to assist in recruiting and developing brochures.

Development activities were designed to increase the capacity of URM students, residents, faculty, and others. By helping the development of URM individuals, the COEs also may be advancing their diversity.

Student development activities centered primarily on academic assistance, including tutorial programs, mentoring, and supplemental instruction. One COE developed a program for URM students, the HCOE Scholars Program, that provides advisors and tutorials. Ten COEs conducted student development activities.

Faculty development activity was conducted in 15 COEs. Most COE URM faculty participate in development programs that advance professional skills in teaching and research. These programs vary in length from a six workshop session (84 hours) to two years. All six URM faculty members at one COE are currently enrolled in the General Clinical Research Center Scholars Training Program, a 10-module intensive training for junior faculty in research, statistics, writing, public presentation, and pedagogical skills. The COE provides additional professional development workshops. One COE granted five faculty development awards. Another COE conducted Blackboard training sessions and paired new African American faculty with tenured faculty for mentorship as part of its faculty development program. Hispanic/Latino junior faculty at another COE completed the school’s National Center of Leadership in Academic Medicine, a program developed by the COE and institutionalized in the school of medicine.

One promising practice involving community immersion described a four-day conference at an isolated island for faculty and medical students. Access was restricted and participants had to bring in their own food and water, take a boat, swim to shore (since there were no piers or docks), and camp. Family members were allowed to participate. All activities were related to Hawaiian values, such as sharing work (including loading and unloading gear, cooking, and cleaning).

Other cultural activities included learning chants to request permission to enter and leave, hiking to historical and archaeological sites, time for meditation and group sharing, one on one interactions, and work projects to restore damaged parts of the island. More traditional activities also were offered, including lectures and demonstrations by a variety of traditional and complementary and alternative medicine healers and group discussions and lectures on the meaning of cultural and linguistic competency and how to increase the cultural and linguistic competency of practices.

Resource building for minority health issues. All of the catalogued activities were for the benefit of the entire COE with the exception of one activity that was directed toward the community. Many COEs added to their library’s collection of materials related to minority health. Two COEs obtained additional user licenses for OVID online articles that facilitated the access to articles related to minority health.

Other COEs developed their own resource centers on minority health. One COE developed a minority health information resources center that included print, video and audio media, computer based resources, and access to National health information and databases. Faculty, staff, and students use the center. Another COE developed a new Web page that integrates three collections of diverse holdings, including one on complementary and indigenous medicine, one on diversity, and COE additions. Similarly, one COE cited Website development as a promising practice and offered cross-cultural cases and cultural and linguistic competency resources for faculty and students on its site.

Some COEs compiled existing literature on minority health. One COE completed a literature review of resources for Indian health and cultural and linguistic competency in 2002. The resource list is used to develop competency concepts and curriculum topics. Another COE is establishing a clearing house that will include a database of Native Hawaiian health issues.

One COE's activities were intended to affect the community when it developed a partnership with an alcohol research center to disseminate information on alcohol-related research outcomes to health care practitioners.

Other. Three COEs established other student-directed programs that could not be coded into the existing categories of the Non-Teaching Methods/Delivery matrix. One COE reached out to its URM students to increase their participation in the masters of science program in community health. Another COE that is not located on the mainland facilitated a student exchange program with other medical schools in the mainland United States. Another COE created a community ambassador program, in which students received training in how to disseminate information successfully to the community surrounding the COE, which is predominantly Hispanic/Latino and/or rural.

One COE cited the development of partnerships as a promising practice. The COE reported that its university hospital received funding from New Jersey to develop a medical interpreter curriculum that could serve as a best practice model in health care institutions throughout the state. The Cross-Cultural Medical Interpreter Curriculum Pilot Program represented a first step by the state, in collaboration with a university hospital, toward ensuring that every New Jersey resident receives high quality health care by making trained medical interpreters available to limited English proficient patients. As a result, the state published a detailed curriculum for the training of medical interpreters. The university hospital now funds the Center for Multicultural Health care Communications, a direct result of its Cross-Cultural Medical Interpreter Curriculum Pilot Program.

Evaluation

This matrix is intended to catalog the evaluation activities the COEs are currently doing for their curriculum, students’ clinical experience, impact evaluations, and other evaluations. The evaluations were further categorized into formative, summative, and immediate evaluations. Formative evaluation is designed to strengthen or improve programs by examining their delivery, implementation, and the assessment of the organizational context, personnel, procedures, and inputs. Summative evaluations, however, examine the effects or outcomes of programs. That is, they summarize it by describing what happens subsequent to delivery, assessing whether it is responsible for the outcome, determining the overall effect of the causal factor beyond only the immediate target outcomes, and estimating the relative costs associated with the object (Trochim, 2000). Finally, immediate evaluations measure the mastery of knowledge and skills at or near the end of specific activities.

The curriculum category catalogued the curriculum evaluation activities of the COEs. Only a few COEs conducted any kind of curriculum evaluation. Two COEs conducted formative evaluations to assist in developing cultural and linguistic competence curriculum. One COE had faculty and students complete a questionnaire to assess the presence of cultural and linguistic competence concepts in existing curriculum. Another COE is attempting to establish a procedure by which every course is evaluated on its ability to address issues relating to minorities and women, including cultural and linguistic competence. Currently, cultural and linguistic competency working groups are in place to ensure that the cultural and linguistic competence objectives are met.

Another COE conducted an immediate assessment of the effect of the program by having students evaluate a medical Spanish class after completing the course.

The clinical evaluation category catalogued the clinical evaluation of the students. One COE developed and implemented a standardized patient case to assess students’ level of cultural and linguistic competence. Another COE completed a formative and summative evaluation of each student’s clinical ability.

One COE’s promising practice evaluation activity involves the evaluation of resident cultural and linguistic competency using standardized patients. Standardized patients were trained and subsequently treated in resident clinics. Although the residents agreed via informed consent forms to be visited by a standardized patient, they did not know when the patient would visit. The activity was evaluated by comparing the results of the standardized patient’s ratings across each resident group (first and third years) and the results for those residents tested as both first and third years will be compared to determine if their ratings improved after a cultural and linguistic competency workshop, computer module, and seminar.

Other evaluation. COEs performed evaluations for other programs. One COE designed a survey to determine faculty perceptions of the need for diversity training, the issues that such a program would address, the preferred method of delivery, and the potential participation of faculty. Another COE had faculty development program participants complete pre- and post-training questionnaires. This evaluation was both formative and immediate impact.

The impact evaluation category tracks the long-term effect of the programs. Different from summative evaluations, impact evaluations are broader and measure the overall effect, intended or otherwise, of the program as a whole (Trochim, 2000). Only one COE conducted a tracking survey for its Hispanic/Latino COE scholars who have completed their training and are now in academic positions.

Conclusion

The assessment results and the promising practices reveal that the COEs have been engaging in a broad array of activities consistent with their legislative mandate and as providers of cultural and linguistic competency training. As may be expected, the topic taught with the most frequency among the 29 COEs was “Different Population Groups.” This topic includes the general health-related and cultural beliefs of an ethnic group, as well as instruction on diversity and multiculturalism. In addition, the teaching method the COEs employed most was “Classroom-Directed Learning,” which includes activities that have been incorporated into the curriculum either as a required course, elective, or unit in an established course. And finally, the non-teaching method most frequently used was “Research Pertaining to People of Color.”

Although the assessment results and promising practices reveal that cultural and linguistic competence has yet to be fully incorporated in the educational process, focus group participants had wanted to see COEs progress to this level. As participants remarked, however, resources are often sparse for cultural and linguistic competency initiatives. Focus group participants also expressed a desire for the dissemination of the efforts of the various COEs. The inclusion of this COE Assessment and Promising Practices Report within the cultural and linguistic competency curriculum guide would be part of achieving that goal and a way to overcome the competitiveness that hinders the sharing of information between COEs.

The promising practice highlights the degree to which COEs have been able to develop their curricula. The vast majority of reported practices reveal the variety of approaches COEs have employed in teaching cultural and linguistic competency. Community based research and practice, immersion activities, raising awareness of disparities, and other such practices represent promising models, which, if properly adopted, can greatly enhance a school’s curriculum.