Table 1.

Development of the questionnaire

The cultural competence framework
Competencies defined in the framework (Seeleman et al. 2009)	Knowledge	Attitudes	Skills
	1. Knowledge of epidemiology and manifestation of diseases in various ethnic groups	3. Awareness of how culture shapes individual behaviour and thinking	6. Ability to transfer information in a way the patient can understand and to know when to seek external help with communication
		4. Awareness of the social contexts in which specific ethnic groups live
	2. Knowledge of differential effects of treatment in various ethnic groups	5. Awareness of one’s own prejudices and tendency to stereotype
Operationalisation for questionnaire
What we want to measure (the numbers between brackets refer to the competencies defined in the framework)	Knowledge of:	Ability to reflect on how a care provider’s own frame of reference (e.g. cultural), and prejudice and stereotypes, influences his practice (3,5).	Behaviour showing that the care provider effectively takes patients’ social context and culture into account (3,4), and applies the appropriate communication strategies in diverse contexts (6).
	- the context and processes that influence health and health care of minority patients (such as ethnic inequalities in health, ethnic composition of the population) (1,2);
	- interpretation services (e.g. when and how to use professional interpreters in medical practice) (6)
What we measure
Domain	Knowledge	Reflection ability	Culturally competent consultation behaviour
	a) general knowledge of ethnic minority care provision
	b) knowledge of interpretation services
Type of assessment	Multiple choice items	GRAS (Groningen Reflection Ability Scale)	- Case based questions with ‘correct’ (culturally competent) and ‘incorrect’ (culturally incompetent) response options (2 items)
	a) 8 items on general knowledge of ethnic minority care provision (4 response options, including ‘do not know’)	Self-assessment measure: 23 statements with 5 point Likert scale (Aukes et al. 2007)
	b) 6 statements on knowledge of interpretation services (true/false/do not know)		- 11-item scale on knowledge of patients’ individual social context
			- asking preference for (students) or actual use in past months of (YHC respondents) different types of interpreters (1 item)
Examples	- General knowledge of ethnic minority care provision	- Statements from the GRAS	- Culturally competent consultation behaviour
		To what extent do the following statements apply to you?
	1. In 2010, 20% of the Dutch population had a migrant (non-Dutch) background. What was the proportion of Western vs. non-Western migrants?	• I take a closer look at my own habits of thinking	1. Which communication techniques do you apply in a consultation with a migrant patient that only has finished primary education? (there is no language barrier)(maximum of 4 answers)
		• I am aware of the emotions that influence my thinking
	a) 30/70 (Western/non-Western)	• I can see an experience from different standpoints
	b) 50/50 (Western/non-Western)*
	c) 70/30 (Western/non-Western)	• I am aware of the cultural influences on my opinions	• I am concise in my information
	d) Do not know		• I use laymen’s language*
			• I check the patients’ knowledge level before I start my information*
	2. During Ramadan, religious Muslims are not allowed to eat and drink between sunrise and sunset. Do Muslims in the Netherlands apply these fasting rules to medication as well (i.e., they will not use medication between sunrise and sunset)?	• I am able to understand people with a different cultural/religious background	• I start a next consultation repeating the information
			• I provide written information as much as possible
		Answers on 5-point scale (1 meaning ‘totally disagree’ until 5 ‘totally agree’)	• I limit the number of new subjects I introduce*
	a) Yes: many Muslims in the Netherlands apply these fasting rules to medication use.*		*scored as culturally competent answers
	b) No: Muslims in the Netherlands seldom apply these fasting rules to medication use.		2. Take in mind the newly registered migrant patients of the past two months. Of which part of these patients you know the following background characteristics:
	c) Partly: these fasting rules are applied to alternative medication, but not to medication that is prescribed by physicians.
			• country of origin
			• composition of family
	d) Do not know		• patient’s social network
			• work/daily routine
	- Knowledge about interpretation services		• years education
	1. Patients are responsible to take care for an interpreter (true/false*/do not know)		Answers on 4-point scale (<25%; 25-50%; 50-75%; >75%)
	2. A professional interpreter (in the Netherlands) is trained to explain cultural issues, in addition to translation (true/false*/do not know)

*reflect correct answers.