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

Chapter 4: Establishing a Multi-Dimensional Framework for Cultural and Linguistic Competence Curriculum

In this chapter, we highlight several multi-dimensional models for teaching the concepts underlying cultural and linguistic competency, and for designing, modifying, and delivering cultural and linguistic competency curricula. The topics covered in this chapter are: 1. the dimensions of multicultural education when designing and modifying curricula, 2. incorporating the process of cultural competence in the delivery of health care services model, and 3. adhering to standard principles of instructional systems development (ISD).

The basic challenge is: How can we successfully “talk the talk” and “walk the walk.” Although curriculum content obviously will need to be adjusted depending on the focus of each institution, this chapter includes some of the basic knowledge, skills, and attitudes that should be addressed in any curriculum related to cultural and linguistic competency.

As one COE director commented, “A COE should demonstrate how cultural and linguistic competency will be integrated into the matrix of what all students receive.” Educational content is embedded in what Elliot Eisner (http://www.teachersmind.com/eisner.htm) has termed the explicit (formal and co-) curriculum and the implicit (“hidden”) curriculum. In addition, there is a “null curriculum” of topics that are not taught on campus. Ignoring cultural and linguistic competence makes it part of the null curriculum, meaning that if a school does not teach it, it is ignoring it.

Cultural and linguistic competency content is best presented in both stand-alone cultural and linguistic competence courses and as components of general or core courses. The programming will vary according to the unique needs and capabilities of each COE’s student and faculty. The content, however, should reach all students.

When designing a cultural and linguistic competence curriculum, the sequencing of cultural and linguistic competency knowledge and skills is vital. For example, while it is possible to discuss communicating with patients of diverse languages and cultures at any time, students will retain the lessons much more easily when they are actually experiencing difficulties in communicating with culturally and linguistically diverse patients in community clinics. At one time, students were not exposed to patients until their third year of medical school, but today students are seeing patients in their second year in some schools and in their first year in other schools. As a result, each school should carefully consider sequencing and when to integrate specific aspects of cultural competence into the curriculum. Curriculum designers should view cultural and linguistic competence education as proceeding on a developmental trajectory with each step building on the prior one, moving from the purely informational to the actual practice of competencies in hands-on patient care.

An effective way to introduce cultural and linguistic competence, for example, might be to invite representatives of the community to speak with students about the cultures and beliefs that are present in the community at large and to invite the students to question these representatives about the attitudes and beliefs they are likely to encounter among patients in community clinics.

I. Consider the Dimensions of Multicultural Education When Designing and Modifying Curricula

The National Association for Multicultural Education (NAME), at www.nameorg.org, in Washington, D.C., defines multicultural education as a philosophical concept built on the ideals of freedom, justice, equality, equity, and human dignity. NAME says multicultural education:

• Affirms our need to prepare students for their responsibilities in an interdependent world
  
• Recognizes the role schools can play in developing the attitudes and values necessary for a democratic society
  
• Values cultural differences and affirms the pluralism that students, their communities, and teachers reflect
  
• Challenges all forms of discrimination in schools and society through the promotion of democratic principles of social justice.

Those charged with developing such a curriculum should consider the following recommended processes for including elements on cultural and linguistic competence. However, since each curriculum must serve its own particular audience, not all of these processes may meet all needs. Many educators have a narrow understanding of multicultural education as one that involves merely content integration or including content about ethnic groups into the curriculum. Professor James A. Banks, the Russell F. Stark University Professor and Director of the Center for Multicultural Education at the University of Washington, in Seattle, has developed a model that he calls The Dimensions of Multicultural Education, which depicts a broad and progressive concept of multicultural education. Banks is also the editor of the Handbook of Research on Multicultural Education, second edition, 2004, Jossey-Bass, San Francisco. Banks defines the dimensions of multicultural education as:

• Content integration, which deals with the extent to which teachers use examples, data, and information from a variety of cultures and groups to illustrate key concepts, principles, generalizations, and theories in their subject area or discipline
  
• The knowledge construction process, which describes the procedures by which social, behavioral, and natural scientists create knowledge and how the implicit cultural assumptions, frames or references, perspectives, and biases within a culture influence the ways that knowledge is constructed
  
• The prejudice reduction dimension describes the characteristics of racial attitudes and suggests strategies that can be used to help students to develop more democratic attitudes and values
  
• An equity pedagogy that exists when teachers modify their teaching in ways that facilitate the academic achievement of students from diverse racial, cultural, and social-class groups
  
• An empowering school culture and social structure which describes the process of restructuring the culture and organization of the school so that students from diverse racial, ethnic, and social-class groups will experience educational equity and empowerment

II. Incorporating The Process of Cultural Competence in the Delivery of Health care Services Model (Campinha-Bacote)

This cultural competence model developed for health care professionals by Dr. Josepha Campinha-Bacote is defined as the process by which the health care professional continuously strives to achieve the ability to effectively work within the cultural context of a client, individual, family, or community. This model has broad applicability for health care professionals in a variety of disciplines. “This process requires health care professionals to see themselves as becoming culturally competent, rather than being culturally competent. It includes the integration of cultural desire, cultural awareness, cultural knowledge, cultural skill (conducting culturally sensitive assessments) and cultural encounters” (Campinha-Bacote, 2002). These constructs of Dr. Campinha-Bacote’s model are summarized below:

a.) Cultural awareness is the examination and in-depth exploration of one’s own cultural background. This process involves the recognition of one’s biases, prejudices, and assumptions about individuals who are different from oneself. In seeking cultural awareness there must be a commitment to “cultural humility,” a life-long commitment to self-evaluation and self-critique, redressing the power imbalances in the relationship between the patient and the health care professional, and developing mutually beneficial partnerships with communities on behalf of individuals and defined populations (Tervalon and Murray-Garcia, 1998).

b.) Cultural knowledge is the process of seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. In the acquisition of cultural knowledge, the health care professional must focus on the integration of three specific issues: health-related beliefs, practices, and cultural values; disease incidence and prevalence; and treatment efficacy (Lavizzo-Mourey, 1996).

c.) Cultural skill is the ability to collect relevant cultural data regarding the patient’s presenting problem as well as accurately performing a culturally based physical assessment. This process involves learning the skills involved in conducting a cultural assessment and performing physical assessments on ethnically diverse clients.

d.) Cultural encounter is the process in which the health care professional is directly engaged in face-to-face and other types, of interactions with patients from culturally diverse backgrounds. Interacting with patients from diverse cultural groups will refine or modify one’s existing beliefs about a cultural group and prevent stereotyping.

e.) Cultural desire is defined as the motivation of the health care professional to want to engage in the process of becoming culturally aware, culturally knowledgeable, culturally skillful, and seek cultural encounters. It stands in contrast to the feeling of having to participate in this process. Cultural desire is the pivotal and key construct of cultural and linguistic competence.

Encounters between patients and health care practitioners are fraught with cultural biases, some seen and others unseen. Recognizing these biases, obstetrician-gynecologists, for example, often will discuss cross-cultural perceptions about the birthing process with their patients. Such discussions help ob-gyns who have the desire to elicit their patients’ cultural biases and beliefs, and thus help them to better understand their patients’ needs.

Likewise, cardiologists may understand that the heart is a symbol of the life force in many cultures, so that they can begin to understand their patients’ emotional response to the cardiac disease they are experiencing.

Cultural perceptions about organs and bodily functions often strongly affect patients’ perceptions about the etiology and appropriate treatment of a disease or disorder. When discussing high blood pressure with the patient, for example, a provider may elicit an unexpected response from an African-American since the term “high blood” has a meaning among some African-Americans that is quite different from the biomedical concept of high blood pressure. Accordingly, there is a very different perception of correct treatment.

Religious perceptions among patients also are important for clinicians to understand. Some patients may believe that their illness is a result of a punishment from God, for example, or that all results of care are “in God’s hands” regardless of the efforts of health care practitioners. Or they may believe an illness is a result of a punishment from ancestors beyond the grave.

The existence of such widely varying understandings and beliefs about bodily processes, etiology, treatment, and expected outcomes, in addition to differences in expectations about the behavior and attitude of health care providers, makes it necessary for health care professionals to be acquainted with the scope and breadth of such beliefs in their communities of practice. In order to create a plan of care that ensures patient adherence, the provider will often need to negotiate an approach that respects the patients’ beliefs while incorporating a biomedically correct treatment.

For clinicians seeking to understand their own biases, the mnemonic “ASKED” is useful in helping them to work with patients from a variety of cultures. The mnemonic summarizes The Process of Cultural Competence in the Delivery of Health care Services Model (Campinha-Bacote, 2003):

While we have included all five dimensions of the ASKED mnemonic, it is possible to adapt this mnemonic to focus on the first three elements only, ASK. In many ways, these three are the most important components of the ASKED mnemonic. Also, it should be noted that in addition to ASKED, there are other mnemonics that could be used in health care settings. Mnemonics are useful memory tools in medicine and other fields to assist practitioners in recalling concepts, steps, or ideas that might not easily come to mind otherwise. When conducting the research for this guide, the Expert Team found a number of useful mnemonics in the field of cultural diversity and these memory tools will be introduced in later chapters and are referenced in the Resources Chapter, Section IIA.

III. Adhere to Standard Principles of Instructional Systems Development (ISD)

Any initiative to design and implement a culturally and linguistically competent curriculum should take into consideration the principles for adult learning and well accepted curriculum development processes. An instructional systems development (ISD) process involves analyzing, designing, developing, implementing, and evaluating as follows:

a.) Analyze: The first phase of the ISD process involves data gathering and assessment. Curriculum developers analyze the organization or institution where people work and learn; the people whose performance is to be affected; and the environment in which they perform or will perform in the future. Through this data gathering and assessment process, curriculum developers must first determine whether there is a need for education or training. This determination can best be confirmed with a thorough needs assessment. Various methods can be used to conduct an effective needs assessment, including interviews, focus groups, surveys or questionnaires, observation, and document analysis.

b.) Design: A learning design specifies the behavioral objectives to be met by focusing attention on the objectives and not on extraneous or peripheral content. It also helps the instructor develop a logical, sequential, step-by-step learning experience. A functional learning design helps the instructor become more effective and efficient. Design takes into account what is likely to happen in the learning session and allows for contingencies.

c.) Develop: During the development phase, curriculum developers focus on the identification and selection of methods of instruction, instructional aids, media, activities, and equipment. Based on their knowledge of the learning objectives, the audience, and the time and resources available, curriculum developers create learning events and activities. When selecting instructional methods it is important to consider that individuals have a variety of different learning styles.

d.) Implement: In the implementation phase, the transfer or incorporation of knowledge, skills, and attitudes takes place. Ideally, this interaction is not a one-way transfer from an instructor to students, but rather a process that enables students to learn from the instructor, from one another, and from their larger community and environment. Instructors will need to develop a plan to ensure the successful implementation of their education program. This plan should include administrative details, a clear description of the audience to be educated, schedules and venues, logistics, test and evaluation procedures, instructor assignments, and a budget.

e.) Evaluate: The evaluation component of the ISD process focuses on the development of methods for tracking student performance and for evaluating the effectiveness of the education program. As outlined by Kirkpatrick (Kirkpatrick, 1994), the evaluation of training programs can be conducted on four distinct levels, as follows:

f.) Level 1 – Reaction: An assessment by learners of the value and effectiveness of the program.

g.) Level 2 – Learning: An assessment of the learners’ achievement of the program’s learning objectives. This assessment is usually conducted through pre- and post-tests.

h.) Level 3 – Behavior: An assessment of behavior change among learners in work or other performance situations resulting from the program. This assessment can be conducted via observations, surveys, interviews, or focus groups with learners and supervisors.

i.) Level 4 – Results: An assessment of the effect of the learning program in the larger environment. This assessment is usually carried out as part of a formal research program.

As is the case when incorporating any new and significant set of educational skills and knowledge into a preexisting curriculum, the work of incorporating a carefully constructed cultural and linguistic competency component into the education of health care professionals may require consultation with experts from both within and outside the school itself. Fortunately, many COEs have developed expertise in specific areas of cultural and linguistic competency education and could be asked to share their experience. Additionally, the field of cultural and linguistic competency education has matured sufficiently in the past decade so that there are many experts working in the various facets of the field. Curriculum designers are encouraged to review the many resources in Chapter 10, Resources, in which specific educational strategies have been described by those who have had success in implementing them. (In particular, see Betancourt, et al, 2002, and Culhane-Pera, et al, 2004.)