Development of a curriculum in cultural determinants of health and health disparities

Abstract

Introduction:

Current sociopolitical events coupled with requirement modifications by the Liaison Committee on Medical Education have reinvigorated a need for training in cultural awareness and health disparities in undergraduate medical education. Many institutions, however, have not established longitudinal courses designed to address this content. Additionally, little is known about the change in learners’ awareness of cultural determinants of health and health disparities after enrollment in such curricula. In 2016, the authors developed a yearlong required course entitled Cultural Determinants of Health and Health Disparities for first year medical students at a large university medical school in the United States. The course launched in the 2017 academic year.

Methods:

Two cohorts participated in twelve 2.5 to 3-hour multi-modal sessions focused on various aspects of healthcare delivery for marginalized populations and factors that contribute to health disparities. The Multicultural Assessment Questionnaire was used pre and post course to assess students’ self-evaluated changes in knowledge, skills, and awareness related to cultural competency in healthcare.

Results:

Students’ self-reported knowledge, skills, and awareness scores regarding cultural competence in health care increased from pre to post-course assessment. On the knowledge scale, students’ mean score increased from 2.63 to 2.97 (P < .001), with 16% reporting a decreased score, 30% reporting no change, and 54% reporting growth. On the skills scale, students’ mean score increased from 2.64 to 3.38 (P < .001), with 11% reporting a decreased score, 17% reporting no change, and 72% reporting growth. On the awareness scale, students’ overall score increased from 3.76 to 3.97 (P < .05), with 16% reporting a decreased score, 50% reporting no change, and 34% reporting growth. There were no changes in KSA scores across cohorts pre and post course.

Conclusion:

Perceived knowledge, skills, and awareness related to the importance of cultural competence in healthcare delivery increased at the end of the academic year. This type of longitudinal course model could be broadly adopted at other institutions to enhance patient, peer, and future provider awareness regarding cultural impacts on care and health disparities among vulnerable populations.

1. INTRODUCTION

In the last 20 years, extensive research has documented the importance of social, cultural, and historical inequities in driving disparate health outcomes for marginalized groups in the United States.^1–8 This research has prompted accreditation and regulatory bodies, such as the Liaison Committee on Medical Education (LCME), to encourage instruction in medical education institutions on cultural sensitivity and the delivery of medical care to patients from diverse populations.⁹ Despite this call for action, curricula to address this need are not ubiquitous in medical education.^10–12 Furthermore, when curricula are present, they vary widely in structure, content, and evaluation. The impact, therefore, of existing interventions and evidence-based best practices has not been well established.

Moreover, undergraduate medical education institutions have yet to fully embrace these concepts or determine how to best integrate content into already demanding, time-stretched curricula. A 2019 American Association of Medical Colleges (AAMC) Curriculum in Context report revealed that only 40.2% of medical education institutions documented racial disparity curricular content.¹³ The 2019 AAMC Graduation Questionnaire (GQ) revealed that 21% of students reported no curricular experience related to health disparities, and 25.1% reported no experience related to cultural awareness and cultural competence.¹⁴ At the large university medical school where the study took place, students learned about concepts related to inequity, cultural competency, and bias only sporadically during their 4 years of education. Internal GQ data from 2014 revealed that over a third of medical students who were surveyed felt that training in culturally appropriate care for diverse populations was inadequate, a rate three times higher than combined data from all GQ participating schools. On the same survey, 37.5% of the school’s medical students reported no experience in health disparities training compared with 25.1% of students at other institutions.

Experts in cultural humility and disparities education suggest that delivery of health disparities training must move beyond awareness and be integrated throughout the curriculum with an emphasis on practical skill instruction, interactivity, and scientific rigor.¹⁵ The Cultural Determinants of Health and Health Disparities (CDHD) course was created as the first-ever required curricular element tasked with exploring health disparities and the impact of sociocultural influences on a spectrum of health outcomes observed in the area local to the large university medical school and beyond. The curriculum was designed as a longitudinal course that explores a broad range of topics, including local history, mistrust, implicit bias, social determinants of health, care of gender and sexual minorities, social constructions of race, impact of racism on health, ableism, mental health disparities, and immigrant health.

2. MATERIALS & METHODS

2.1. Curriculum design and participants

In 2016, we developed a twelve-session, yearlong, mandatory curriculum based on focus group data, stakeholder consultations, and planning sessions coupled with a targeted review of published literature on health disparities curricula.^16–20

Two cohorts (2017–2018 and 2018–2019) of first year medical students participated in twelve 2.5 to 3-hour course sessions (lectures, small group discussions, and experiences). Prior to each session date, students were provided with required readings and/or videos chosen by course faculty. Most sessions began with a large group audiovisual presentation led by School of Medicine faculty followed by case based small group discussion and self-reflection exercises. Some of the large group sessions included panels of providers and patients when appropriate. Small groups were co-facilitated by an interprofessional group of School of Medicine faculty and clinical or research phase medical students. Table 1 outlines the sessions, learning objectives, and instructional strategies used in the course.

Table 1.

Cultural Determinants of Health and Health Disparities (CDHD) course sessions, learning objectives, and Instructional strategies (2017–2019).

Session/Topic	Key Learning Objectives	Instructional strategies
Introduction to the local city, University, & Health Disparities	• Describe how race and class have shaped the history of the local city. • Explore historical analysis as a critical tool to understanding the development of health disparities.	• Audiovisual presentation • Small group discussion
Local city Cultural Heritage and History Experience	• Review key historical local and University locations. • Stimulate discussion and reflection on how history and culture contribute to the well-being of a community.	• Facilitated walking and bus riding experience
Structural Competency, Cultural Competency, & Health	• Define concepts of culture, structural competency, cultural competency, and critical consciousness, specifically in the context of healthcare. • Explore how biases affect clinical and professional encounters. • Explore the concept of microaggressions. • Recognize how provider bias can perpetuate health disparities. • Develop personal strategies to combat bias.	• Audiovisual presentation • Small group discussion • Implicit • Association Test (IAT)
Poverty, Housing, and Health*	• Describe historical and current disparities in wealth, housing, and health in the United States, local state and city. • Explore the impact of housing and wealth on health. • Discuss how clinicians/health systems might mitigate the impact of substandard housing and poverty on health.	• Audiovisual presentation • Small group activity
Supporting and Affirming People with Marginalized Sexual Orientations, Gender Identities, and Gender Expressions	• Define and differentiate common terminology for: gender, sex, and sexual orientation, with an emphasis on non-normative identities. • Discuss Cissexism and Heterosexism. • Explore cisgender and heterosexual privileges broadly and in the healthcare context. • Identify social and behavioral determinants of health for LGBTQIA individuals.	• Audiovisual presentation • Large group interactive discussion
Gender Diverse Populations: Strategies for Communication and Care	• Discuss health disparities unique to gender diverse populations and what role the health care system has in reducing them. • Explore assumptions and misconceptions involving transgender populations and gender diverse children and youth. • Discuss methods to sensitively approach history taking and physical examination in transgender and gender diverse patients. • Explore strategies to enhance future practice and provide an inclusive safe space for gender diverse patients.	• Audiovisual presentation • Panel of transgender teenagers
Race, Racism, and Racial/Ethnic Disparities Part 1	• Explore and define concepts of race, ethnicity, ancestry, evolution, genetic drift, and genetic variation. • Explore misconceptions about race that lead to invalid and discriminatory practices. • Review specific examples of health and healthcare disparities related to race/ethnicity. • Explore resources to critically examine culture, race, and ethnicity within medical education.	• Audiovisual presentation • Small group discussion
Race, Racism, and Racial/Ethnic Disparities Part 2	• Review the racial/ethnic demographic data of the University medical center, local city, and state patient and provider communities. • Define the terms stereotype, prejudice and discrimination while identifying distinctions and exploring interrelationships. • Describe examples of best practices that can facilitate the elimination of racial/ethnic biases in patient interactions and potentially reduce health disparities.	• Audiovisual presentation • Small group discussion
Ableism/Persons with Disabilities	• Explore appropriate terminology and considerations for providing care to individuals with disabilities. • Review health disparities that exist across the continuum of disability. • Identify stigmas associated with disabilities and explore the impact on health care delivery. • Discuss the basic principles of the American with Disabilities Act (ADA) and their implications for healthcare delivery.	• Audiovisual presentation • Small group discussion
Mental Health Disparities	• Discuss health disparities in the United States across the domains of mood disorders & thought disorders. • Explore access to mental health care with a focus on recent legislative changes in the state and impacts of these changes on mental health care.	• Audiovisual presentation • Small group discussion
Immigrant Health	• Review the major immigrant populations in the US, local city and state. • Review the common immigrant health inequalities in the United States and locally and compare mortality rates among US born and foreign-born populations. • Provide guidance for clinical interactions with immigrant populations and resources to get involved in immigrant and refugee health care locally.	• Audiovisual presentation • Small group discussion

^*Session not offered in 2017–2018 cohort; replaced a mid-year evaluation day with no content.

2.2. Evaluation

To evaluate student perceptions of learning associated with completing the curriculum, the local Institutional Review Board-approved (Pro00085828) pre and post-course survey of first-year medical students (n = 161; cohorts 2017–2018 and 2018–2019) was used to assess change in knowledge, skills, and awareness (KSA) centered on cultural competence in health care. The knowledge domain pertains to the understanding of key terms and concepts; skills domain to implementation of these concepts in patient care and interprofessional interactions; and awareness domain to the perception of issues related to cultural competency in the environment. The Multicultural Assessment Questionnaire (MAQ), a validated survey tool, was administered before and after the course. The MAQ consists of 16 Likert questions mapped to the three KSA domains.²¹ Students also provided a self-rating of their cultural competency before and after the course, information on their exposure to cultural competency education, attitudes towards content covered in medical school, and self-reported race/ethnicity and gender.

2.3. Data sources

Students completed the survey in Qualtrics before (in August 2017 or August 2018) and after (in May 2018 or May 2019) the course. Survey responses were tracked at the individual level allowing for an assessment of within-person change. Across the two cohorts, a combined 51% of first-year medical students (83 of n = 161) completed both the pre and post-course surveys. We used this data from students who completed both surveys for the present study.

2.4. Statistical analysis

In this study, we examined pre and post-course changes in students’ KSA scores related to cultural competency in healthcare delivery. We reported descriptive statistics for the sample, including students’ demographic characteristics (gender, race/ethnicity, and cohort) and exposure to cultural competency education prior to medical school. Next, we created three scaled outcome domains from the separate averages of responses to knowledge, skills, and awareness survey items, and report Cronbach’s alpha statistics for each scale. Scores range from 1 to 5, with higher values indicating greater perceived knowledge, skills, or awareness. Given the non-parametric distributions of the outcomes, we used two-tailed Kruskal-Wallis tests to conduct bivariate comparisons in the outcomes by prior cultural competency education and demographics. We used two-tailed Wilcoxon signed rank tests to assess change between pre and post-course KSA scores. For the main models, we used linear mixed models which are appropriate for repeated measures analysis to account for correlation in individual response. To assess change, we adjusted the models for prior cultural competency education and demographics, and identified random effects at the level of individual response. Estimated means and 95% confidence intervals are reported to illustrate KSA score changes and to show patterns by prior cultural competency education and demographics for the estimated KSA scores averaged across both surveys. For all statistical significance tests, we set the threshold for significance at P≥.05. All analyses were performed in Stata SE 16 for Windows (StataCorp, College Station, Texas).

3. RESULTS & DISCUSSION

3.1. Participants

Students’ demographic characteristics, cultural competency exposure prior to medical school, and bivariate analyses of the outcomes are presented in Table 2. Students’ exposure to cultural competency education prior to medical school varied, with some notable patterns. Data show that 48% of students had formal education in cultural competency prior to medical school. Of this group, the majority received their education during college.

Table 2.

Student self-reported demographics and bivariate associations with KSA scores from baseline and follow-up surveys (n = 83).

	Knowledge scale			Skills scale			Awareness scale
	Pre	Post	Δ P-value	Pre	Post	Δ P-value	Pre	Post	Δ P-value
Overall score	2.63	2.97	.000	2.64	3.38	.000	3.76	3.97	.008
Prior Education a
Yes (n = 40, 48%)	2.77	2.97	.144	2.66	3.34	.001	3.81	3.92	.312
No (n = 43, 52%)	2.51	2.97	.000	2.62	3.42	.000	3.70	4.02	.006
Group comparison P-value	.155	.923	–	.780	.976	–	.232	.833	–
Gender
Women/another gender (n = 53, 64%)	2.65	2.99	.001	2.68	3.50	.000	3.89	4.04	.029
Men (n = 30, 36%)	2.61	2.93	.031	2.57	3.15	.011	3.55	3.85	.118
Group comparison P-value	.751	.628	–	.318	.009	–	.101	.279	–
Race/ethnicity b
Asian (n = 26, 31%)	2.70	2.99	.073	2.59	3.39	.000	3.71	4.01	.112
URE/Multiple race/other (n = 13, 15%)	2.74	3.24	.049	2.63	3.56	.016	3.67	4.06	.076
White (n = 44, 53%)	2.56	2.88	.004	2.67	3.32	.000	3.81	3.93	.161
Group comparison P-value	.597	.268	–	.958	.614	–	.336	.914	–
Cohort
2017–18 (n = 54, 65%)	2.57	2.88	.008	2.56	3.28	.000	3.72	3.88	.096
2018–19 (n = 29, 35%)	2.76	3.15	.002	2.79	3.55	.000	3.83	4.15	.029
Group comparison P-value	.202	.130	–	.126	.049	–	.325	.073	–

URE, underrepresented.

^aPrior education in cultural competency.

^bAsian = 17% (n = 14) Asian only; 6% (n = 5) Indian only; and 8% (n = 7) combined Asian/Indian; Underrepresented (URE)= 2% (n = 2) Black/African American; 1% (n = 1) American Indian/Alaska Native, Native Hawaiian and other Pacific Islander (AIAN/NHPI); 3.5% (n = 3) Hispanic/Latinx only; 5% (n = 4) Hispanic/Latinx and White; 1% (n = 1) Black and AIAN/NHPI; 2% (n = 2) reported more than one race/ethnicity; and 53% (n = 44) identified as White.

3.2. Multicultural assessment questionnaire

3.2.1. KSA demographic bivariate analysis.

Comparisons of pre and post-course KSA scores show growth in each of the three domains, with increased scores within and across most demographic groups (Table 2). Few bivariate associations emerge, with no demographic group differences in knowledge or awareness. In post-course skills, women report greater skills compared with men, and the 2018–2019 cohort shows greater skills compared with the 2017–2018 cohort. Bivariate analysis stratified by individual questions in the MAQ can be found in Supplemental Tables 1–3.

3.2.2. Unadjusted analysis.

Students’ self-reported knowledge, skills, and awareness regarding cultural competency in health care were all enhanced upon completion of the course (Fig. 1). Change in KSA scores was summarized by students’ average scores on each scale as well as movement from one scale value to another (e.g., from Good to Excellent, Good to Fair, etc.).

Fig. 1.

Results of Pre and Post-Course Multicultural Assessment Questionnaire (MAQ). CDHD MS1 Students from 2017 to 2018 and 2018 to 2019 (n = 83). MAQ scores are the average of scores for each scale (range 1 to 5), with higher scores indicating greater perceived knowledge, skills, or awareness (KSA). Wilcoxon signed rank tests used to compare pre-course and post-course scores. * P < .05; ** P < .01; *** P < .001. α=Cronbach’s alpha.

In unadjusted analyses, students’ mean knowledge score increased from 2.63 to 2.97, with 16% reporting a decreased score, 30% reporting minimal to no change, and 54% reporting growth over the course. Students’ mean skills score increased from 2.64 to 3.38, with 11% reporting a decreased score, 17% reporting minimal to no change, and 72% indicating perceived skills growth. Students’ mean awareness score increased slightly from 3.76 to 3.97, with 16% reporting decreased scores, 50% reporting minimal to no change, and 34% reporting positive growth in awareness.

3.2.3. Linear mixed model analysis.

Results from the repeated measures linear mixed models of KSA scores (Table 3) pre and post course, confirm findings from bivariate analyses showing significant growth among students across each of the three domains. Average knowledge scores increased by a modest 0.34 points on the scale pre-course (mean 2.63, 95% CI 2.49–2.78) and post-course (mean 2.97, 95% CI 2.82–3.11). While awareness scores were greater compared with the other domains, growth from pre-course (mean 3.76, 95% CI 3.60–3.92) to post-course (mean 3.94, 95% CI 3.78–4.10) was similarly modest at 0.18 on the scale. The greatest growth was in the skills domain, with average skills scores increasing by 0.72 on the scale from pre-course (mean 2.64, 95% CI 2.49–2.80) to post-course (mean 3.36, 95% CI 3.20–3.52). Although we anticipated some associations between change in knowledge, skills, and awareness and covariates, none emerged in the multivariable models. There were no changes in KSA scores across cohorts pre and post course.

Table 3.

Linear mixed models of change in students’ knowledge, skills, and awareness pre and post-curriculum (n = 83).

	Knowledge scale		Skills scale		Awareness scale
	Est Mean (CI)	P-value	Est Mean (CI)	P-value	Est Mean (CI)	P-value
Time
Pre-course	2.63 (2.49–2.78)	.000	2.64 (2.49–2.80)	.000	3.76 (3.60–3.92)	.033
Post-course	2.97 (2.82–3.11)		3.36 (3.20–3.52)		3.94 (3.78–4.10)
Prior Educationa
Yes	2.85 (2.67–3.03)	.436	2.98 (2.80–3.16)	.754	3.84 (3.64–4.04)	.938
No	2.75 (2.58–2.92)		3.02 (2.84–3.19)		3.85 (3.66–4.05)
Gender
Women/another gender	2.80 (2.65–2.96)	.907	3.07 (2.92–3.23)	.110	3.94 (3.77–4.12)	.069
Men	2.79 (2.58–3.00)		2.86 (2.65–3.07)		3.67 (3.44–3.90)
Race/ethnicity
Asian	2.82 (2.59–3.05)	.564	2.93 (2.70–3.16)	.794	3.79 (3.54–4.04)	.813
URE/Multiple race/other	2.94 (2.62–3.26)		3.02 (2.70–3.34)		3.80 (3.45–4.16)
White	2.74 (2.57–2.92)		3.03 (2.85–3.20)		3.89 (3.70–4.08)
Cohort
2017–18	2.73 (2.58–2.89)	.187	2.92 (2.76–3.07)	.106	3.79 (3.62–3.96)	.296
2018–19	2.92 (2.70–3.13)		3.14 (2.93–3.36)		3.95 (3.71–4.19)

CI, confidence interval; EST, estimated; URE, underrepresented.

Mean and confidence intervals reported. aPrior education in cultural competency.

Our findings illustrate that over the course of a year of instruction in cultural competency in health care and health disparities, students showed growth in their skills and, to a lesser extent, in awareness and knowledge.

4. DISCUSSION

Data from this yearlong, longitudinal course demonstrate the ability to increase students’ perceived knowledge and skills in cultural humility through didactic teaching combined with small group discussion and experiences. Our data also suggest that training in cultural determinants of health and health disparities can influence students’ awareness of this content, particularly increasing awareness of sociocultural factors that influence interactions within the healthcare setting and awareness of practices that respect patients’ behaviors and values.

This study is one of the first to utilize a validated assessment tool to analyze a required, longitudinal curriculum delivered to medical students and also evaluate student exposure to and perceptions about the course content pre and post-course. Our study builds on previous work recommending required longitudinal curricula on heath disparities and cultural competency in medical education, which typically have consisted of elective and/or intensive short-term courses or one-time only lectures.

4.1. Limitations

This curriculum assessment has several limitations. First, we did not evaluate student behavioral change and its impact on patient care. While we do believe that the gains in knowledge, skills, and awareness observed have direct implications for students’ behaviors towards patients, healthcare staff, and one another, the scale of such a detailed longitudinal study was beyond the scope of this curriculum assessment. Second, based on student feedback, the course was adjusted from year 1 to year 2, which may have impacted outcomes between cohorts. One salient piece of feedback was the need for more small-group time and less didactic lecture. We speculate that increased small group time in cohort 2 enabled deeper engagement with the material and fostered discussion of different perspectives, which may be crucial for changes in awareness moving forward.

A third limitation is the sample size, particularly under-represented (URE) participants. Although the total number of URE participants was 13% of the study sample, which is similar to national percentages of medical school graduates, and no statistically significant differences emerged pre and post-course, theoretically, the low URE participation may have impacted conclusions. Fourth, since this curriculum was small group focused, there was variability in instruction from faculty facilitators. Each faculty member did attend a course coordinated training, and while most faculty entered the course knowledgeable about issues of health equity, no two small groups were identical in instruction.

Lastly, students are not learning this content in a vacuum, so while we believe the course had positive impacts on KSA scores, causality is difficult to assess as many contextual and cultural factors contribute to growth in these areas.

4.2. Future directions

Future directions for this course include integrating additional health professions students, expanding the curriculum into the clinical years of medical school training, synergizing our content with biomedical courses, and implementing optional lectures and sessions on special topics that are open to residents, faculty, and other members of the community. We also aim to collaborate with local organizations to create opportunities for students to gain experience working on health equity initiatives in our local area.

5. IMPLICATIONS

In summary, this longitudinal, required curriculum for first year medical students was associated with increased knowledge and skills, and to a lesser degree awareness, of healthcare disparities and cultural competency in the healthcare setting. Importantly, less measurable but equally impactful change has come from the inclusion of this course in the first-year curriculum. Making the curriculum mandatory, training faculty as facilitators, and providing space and time for small group discussion around these topics has prompted other courses to incorporate similar content, thereby bolstering the institutional commitment to include cultural humility and health disparities education as an essential component in the training of future physicians.

Abbreviations

AAMC

American Association of Medical Colleges

CDHD

Cultural Determinants of Health and Health Disparities

GQ

Graduation Questionnaire

KSA

knowledge, skills, and awareness

LCME

Liaison Committee on Medical Education

MAQ

Multicultural Assessment Questionnaire

URE

underrepresented