results of a primary care program

8/9/2019 Results of a Primary Care Program

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Medical Students and Cultural Awareness

Refugees and Medical Student Training: Results of a Program in Primary Care

Frances G. Saad, MSW School of Social WorkFamily Medicine Research Institute

State University of New ork at !uffalo

"eader# $im Griswold, M%, M&'Family Medicine Research Institute


(oan !. $ernan, !SFamily Medicine Research InstituteState University of New ork at !uffalo

)imothy (. Servoss, M* Family Medicine Research Institute


+hristine M. Wa ner, MSWFamily Medicine Research Institute


"uis -. ayas, &h.%.Family Medicine Research Institute


Sally S/eed, %irector N S Medicaid )rainin Institute

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Abstract

!ack round1 Medical schools have 2een res/ondin to the increased diversity of the United

States /o/ulation 2y incor/oratin cultural com/etency trainin in their curriculum. )his /a/er

/resents results from a /re and /ost survey of medical students who /artici/ated in a trainin

/ro ram which included evenin clinical sessions for refu ee /atients and related educational

worksho/s.

Methods1 * self#assessment survey was administered at the 2e innin and at the end of theacademic year, to measure cultural awareness of /artici/atin medical students.

Results1 3ver the three years of the /ro ram, over 044 students /artici/ated and 56 7849:

com/leted /re and /ost surveys. &artici/ants rated themselves si nificantly hi her in all three

domains of the cultural awareness survey after com/letion of the /ro ram.

+onclusions1 )he o//ortunity for medical students to work with refu ees in the /rovision of

health care /resents many o//ortunities for the students, includin communications lessons,

learnin a2out other cultures, and /racticin 2asic health care skills. *n im/ortant issue to

consider is the /ower differential 2etween those in medicine and /atients who are refu ees. )o

avoid reinforcin stereoty/es, medical /ro rams and medical school curricula can incor/orate

efforts to /romote reflection on /rovider attitudes, 2eliefs and 2iases.

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Overview Box:

What is already known on this su2 own cultural awareness.

Su estions for further research1

)rackin of students who /artici/ate in similar

/ro rams to study whether there are lon #term chan es in attitude and knowled e.

+onduct future studies with com/arison rou/s to

determine /ro ram effectiveness, and lon er#term outcomes. Investi ate the role of /ower in doctor#/atient

relationshi/s that involve vulnera2le /o/ulations.

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Bac ground

&hysicians are increasin ly attuned to the cultural differences in the /o/ulations they

serve. Medical schools have res/onded to this increasin diversity 2y incor/oratin different

methods of cultural awareness trainin into their curricula. )he "iaison +ommittee on Medical

-ducation 7"+M-:, which sets accreditation standards for medical schools, re?uires that @faculty

and students must demonstrate an understandin of the manner in which /eo/le of diverse

cultures and 2elief systems /erceive health and illness and res/ond to various sym/toms,

diseases, and treatments. A B0C

Whether didactic teachin and curriculum enhancements make an im/act on medicalstudents> awareness of cultural nuance, /articularly in the early sta es of medical trainin , may

2e difficult to discern. %evelo/in insi ht and cultural awareness has 2een descri2ed as a

self ratin s of the im/ortance of measurin /atient o/inions and determinin health

2eliefs were si nificantly im/roved followin com/letion of the curriculum.B4C In another study,

medical students /artici/ated in a EGlo2al Multicultural )rackE elective in Family Medicine and

+ommunity 'ealth. *fter takin the curriculum, the /artici/ants demonstrated a hi her level of

cultural com/etence, more tolerance of /eo/le with different cultural 2ack rounds and more


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acce/tance of /ersons who did not s/eak -n lish.B C *t another university, a more in#de/th

year#lon course, @+ulture and %iversityA, was desi ned around core com/etencies outlined 2y

the *merican Medical Student *ssociation>s &romotin , Reinforcin and Im/rovin Medical

-ducation /ros own ethnicity and culture, ;.: understandin and

a//reciation for cultural diversity in the health care settin , 4.: communication skills includin

a2ility to utiliHe inter/retive services, and .: skills for esta2lishin colla2orative /artnershi/s

2etween /roviders and /atients. )his elective /ro ram is offered to 0 st# th year medical students.

)his /a/er re/orts findin s from three years of student involvement, for /artici/ants from

all four years of medical school.

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3ur evaluation ?uestion was1 0: %oes an e=/eriential learnin format im/rove medical students>

/erce/tions of their cultural awareness )his study was a//roved 2y our institutional IR!.

Met!ods

Medical Students

* total of 044 medical students /artici/ated in this voluntary elective over three academic

years, ;JJ;#;JJ6. )his convenient sam/le of first throu h fourth year medical students involved

a /re and /ost /ro ram self#assessment evaluation. )he student 2reakdown was1 869 first year,

0 9 second year and 59 third or fourth year. )he ma


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Medical students attended two evenin clinics where newly arrived refu ees were seen

2y the family /hysicians at the two desi nated clinical sites. -ach of the /hysician /rece/tors

had e=/erience in international medical settin s, and /rovided the full sco/e of /rimary care,

includin /renatal and delivery care, to a diverse, multi#lin ual /o/ulation in inner#city

University#2ased clinics.

*n initial re?uirement of the /ro ram was attendance at an introductory lecture where

students com/leted a /re#assessment cultural com/etency survey and were /rovided information

on refu ee status and health. Students were re?uired to /artici/ate in at least two refu ee clinic

sessions durin the academic year.&rior to the clinical encounter, a cultural lesson was iven 2y a case mana er em/loyed

2y a refu ee resettlement a ency. )he cultural lesson consisted of a 4J# 6 minute review of the

2ack round and history of the /articular refu ee rou/ the student would encounter that session.

Students received instruction on inter/retation methods 7tele/honic andLor in#/erson:, and the

im/ortance of matchin ender for inter/retation was em/hasiHed. )hen students met with the

/hysician /rece/tors for a//ro=imately hour, while refu ee /atients were 2ein screened 2y

office staff. &hysicians discussed with students how to a//roach the interview, and make

sensitive in?uiry a2out the individual>s life story and


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office they attended for this first visit.

Immediately followin the clinical session, students were de2riefed 2y the case mana er

and a social worker, on their e=/erience, either individually or with another medical student.

Students were asked a2out their e=/erience with the refu ee /atients, in terms of communication,

cultural, clinical or /sychosocial issues, and emotional content of the interview. Students were

then asked to offer su estions andLor im/rovements for the /ro ram. *t the end of the

academic year students were re?uired to attend an end of trainin /ro ram luncheon where they

com/lete the /ost assessment ?uestionnaire.

Other Activities*s a result of feed2ack from our students, we incor/orated more activities for the medical

students to meet with refu ees. Story#tellin sessions were held at lunch time at the medical

school so that more students could attend and where refu ees told their life stories. We

incor/orated monthly 2rown#2a lunches where2y different lectures were iven on refu ee

issues includin le al as/ects of immi ration, and health care issues of refu ees such as mental

health, female circumcision, lead /oisonin , and tu2erculosis. &ro ram activities offered durin

the academic year are listed in )a2le 0.

Analysis of the Self-Assessment Questionnaire

)he Cultural Awareness Self-Assessment Questionnaire is a self#re/ort 6#/oint 70

-=cellent, ; Good, 4 Fair, &oor, 6 None: "ikert scale survey ada/ted 2y the authors

from a ?uestionnaire develo/ed at &ortland State University. B5C *n e=/loratory /rinci/al

com/onents analysis with varima= rotation was used to e=amine the measurement structure of

the instrument. *s a result of this analysis, three of the ori inal 08 items were dro//ed, leavin

0 items loadin on three /rinci/al com/onents which accounted for a//ro=imately 89 of the

K


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variance amon the items. )he three domains measured 2y the instrument corres/ond to

knowled e of /sychosocial issues affectin refu ees 7seven items, +ron2ach>s al/ha .KKD 569

+I .K6##.50:, knowled e of cultural issues 7four items, +ron2ach>s al/ha .K8, 569 +I .

K4##.5J:, and communication skills 7three items, +ron2ach>s al/ha .8K, 569 +I .8J##.K :.

+om/onent loadin s, communalities and more s/ecifics from the /rinci/al com/onents analysis

are located in )a2le ;.

ata Analysis

Scores for the three com/onents of the self#assessment survey 7/sycho#social issues,

cultural issues, and communication: were com/uted as the avera e of the items corres/ondin toeach com/onent. In the case of item non#res/onse, a /erson#s/ecific estimate was calculated for

missin items within a iven com/onent /rovided at least 6J9 of the items within that scale

were non#missin . )he avera e score within that scale across the com/leted items was used as

this estimate. For e=am/le, if someone only answered si= of the seven items within the /sycho#

social issues scale, the avera e across the si= com/leted items would 2e su2stituted for the

missin seventh item. )his eneral a//roach to item non#res/onse has 2een su//orted 2y other

research.B0JC +om/arisons of /re# and /ost#test scores on the three com/onents were made

usin /aired#sam/les t#tests. -ffect siHes were calculated as /re#test means minus /ost#test

means divided 2y /re#test standard deviations. Multi/le re ression was used to e=amine the

influence of several covariates on /ost#test scores while controllin for /re#test levels of cultural

awareness. +ovariates to 2e e=amined included student characteristics such as a e, se=,

nationality, num2er of lan ua es s/oken, and num2er of forei n countries visited.

Results

+om/leters vs. non#com/leters

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that were .4 K /oints 7.;8; standard deviation units: hi her than their male counter/arts, / .

JJ;. In the communication domain, similar findin s emer ed. +ontrollin for /re#test levels,

females had /ost#test scores in the communication domain that were .;8J /oints 7.;J standard

deviation units: hi her than their male counter/arts, / .J K.

"iscussion

)his Refu ee 'ealth and +ultural *wareness )rainin &ro ram /resented an o//ortunity

for medical students at our university to learn a2out diverse cultures 2y /rovidin an immediate

e=/erience of interactin with /atients from other cultures. )he oal of our study was to offer

e=/osure to /rovidin culturally com/etent care in a /rimary care settin . Results from the /reand /ost survey ?uestions indicated that after an academic year of /artici/atin in the /ro ram,

students re/orted increased knowled e of /sycho#social and cultural issues that had an effect on

refu ee health. Students also re/orted im/roved communication skills. Some im/rovements

a//eared to 2e sli htly more /ronounced for female /artici/ants, /articularly in the knowled e of

cultural issues and communication skills domainsD this findin may reflect 2ias of this

convenience sam/le. )hou h we ada/ted our tool from a validated ?uestionnaire, the survey

we used has not 2een further validated. )he instrument did show a trend in terms of measurement

structure and internal consistency amon the 0 ?uestions.

)he use of a self#re/ort survey and self#selection in volunteerin for this /ro ram

/resents limitations in analysis of these outcomes. !ecause of the elective nature of the /ro ram,

it is /ossi2le that students who volunteered to /artici/ate may 2e /redis/osed to learnin a2out

other cultures, and therefore may have contri2uted to a 2iased sam/le. )hus, differences in

student res/onses /re and /ost /ro ram may have 2een due to characteristics of this /articular

sam/le. *dditionally, this /ro ram did not have the sco/e or resources availa2le to track lon er#

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then heLshe will use such skills in all their encounters with /atients, re ardless of 2ack round.

)his trainin /ro ram may offer a /otential model for other medical schools to link with refu ee

communities to offer medical students o//ortunities to e=/and their communications skills, and

/rovide health care for those newly arrived in our country.

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Ac nowledgements

We are inde2ted to *n ela 'enke for her invalua2le assistance on this manuscri/t.

We thank all the medical students who /artici/ated in the /ro ram, and /articularly the refu ee

adults and children for teachin us.

)he authors ratefully acknowled e the New ork State %e/artment of 'ealth for /rovidin

trainin /ro ram fundin , and the University at !uffalo>s %e/artment of Family Medicine for its

institutional su//ort. We also wish to reco niHe the International Institute of !uffalo, (ourney>s

-nd Refu ee Services, (ericho Road Family &ractice, and Nia ara Family 'ealth +enter of

!uffalo for their su/er2 colla2oration.

New ork State %e/artment of 'ealth. Fundin for this research /ro


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References

0. "iaison +ommittee on Medical -ducation. Functions and Structure of a Medical School1

Standards for *ccreditation of Medical -ducation &ro rams "eadin to the M.%. %e ree.

Washin ton, %+. 3cto2er, ;JJ .

;. "ike R+. +ulturally com/etent mana ed health care1 a family /hysician s /ers/ective ! "

#ranscult $urs 0555. #$7 :1 /. ;KK#5.

4. +rosson (, %en W, !raHeau +, !oyd ", Soto#Greene M. -valuatin the effect of cultural

com/etency trainin on medical student attitudes. %am Med ;JJ . %&74:1 /. 055#;J4.

. Godkin M., Sava eau (. )he effect of a lo2al multiculturalism track on culturalcom/etence of /reclinical medical students ! %am Med ;JJ0. %%74:1 /. 08K#K .

6. +randall S, Geor e G, Marion G, %avis S. *//lyin theory to the desi n of cultural

com/etency trainin for medical students1 a case study ! Acad Med ;JJ4. '( 7 :1 /. 6KK#

5 .

. !ea an !". )eachin social and cultural awareness to medical students1 Eit s all very

nice to talk a2out it in theory, 2ut ultimately it makes no differenceE ! Acad Med ;JJ4.

'( 7 :1 /. J6#0 .

8. Griswold $S ! Refugee health and medical student training! %am Med ;JJ4. %)75:1 /.

5#6 .

K. U.S. %e/artment of 'ealth and 'uman Services, *dministration for +hildren and

Families, 3ffice of Refu ee Resettlement. Retrieved *u ust 0, ;JJ6 from 3ffice of

Refu ee Resettlement we2site1 htt/1LLwww.acf.dhhs. ovL/ro ramsLorrLmissionLinde=.htm

06
http://www.acf.dhhs.gov/programs/orr/mission/index.htmhttp://www.acf.dhhs.gov/programs/orr/mission/index.htmhttp://www.acf.dhhs.gov/programs/orr/mission/index.htm


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5. Mason (". +ultural com/etence self#assessment ?uestionnaire1 a manual for users.

&ortland, 3R1 &ortland State University, Research and )rainin +enter on Family

Su//ort and +hildren>s Mental 'ealth. 0556.

0J. Ware (-, %avies#*very *, !rook R'. 705KJ:. +once/tualiHation and measurement of

health for adults in the 'ealth Insurance Study. Tolume TI1 *nalysis of relationshi/s

amon health status measures. Santa Monica, +*1 )he R*N% +or/oration 7/u2lication

no. R#05K8L #'-W:.

00. +andi2 "M, Gel2er ". 'ow will family /hysicians care for the /atient in the conte=t of

family and community %am Med! */r ;JJ0D447 :1;5K#40J.0;. Ro2ins "S, Fantone (+, 'ermann (, *le=ander G", weifler *(. Im/rovin cultural

awareness and sensitivity trainin in medical school. Acad Med! 3ct 055KD8470J

Su//l:1S40#4 .

04. )an )S, Fantone (+, !oHynski M-*., *dams !S. Im/lementation and evaluation of an

under raduate Sociocultural Medicine &ro ram ! Acad Med ;JJ;. '' 7 :1 /. 68K#K6.

0 . $ern %-, !ranch W), (ackson (", !rady %W, Feldman M%, "evinson W, "i/kin M.

)eachin the /sychosocial as/ects of care in the clinical settin 1 /ractical

recommendations. Acad Med ;JJ6. ($ 70:1 /. K#;J.

06. Smits &!, (' Ter2eek, and +% de !uison


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Table #: Additional Com,onents of Refugee -ealt! and Cultural AwarenessTraining Program

*ctivity %escri/tionStorytellin 0#hour evenin session where

refu ees tell their life stories.i.e. Ira?i, "i2erian, Sudan.

Mini#+linical ;#hour clinical sessions entailinimmuniHationsinitials screenin s#la2L&&%,

2lood /ressure screenin .

'ealth -ducation Sessions 0 hour educational sessions /resented 2y medical students that includehealth to/ics related to refu ees i.e.nutrition, hy iene, smokin .

!rown !a 0#hour educational sessions /resentedon various refu ee to/ics i.e. le alissues, mental health, female healthcare, 2irth control, %ia2etes, 'eart%isease

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Table *: Com,onent .oadings/ Communalities 0 h *1/ and Percents of 2ariance for Princi,alCom,onents 3xtraction and 2arimax Rotation on #+ Cultural Awareness 4tems5

Items&sycho#Social

Issues

+ulturalIssues

+ommuni#cation h

;

#Rate your familiarity with the ty/es of trauma thatrefu ee rou/s may e=hi2it comin into the U.S. .KJ0 .;6K .J0 .80

#Rate your knowled e of 2asic mental health careissues /resented 2y refu ee rou/s .85; .;J .;86 .8

#Rate your awareness of 2asic non#medical needs of refu ee for a successful inte ration into their newhost society

.8 ; .0J4 .0K . 4

#Rate your awareness of the factors that force /eo/le from other countries to seek refu e in U.S. . 58 .4 .0JK . 4

#Rate your familiarity with the challen es that

refu ee rou/s /ose in the /rimary care settin. .4;0 .4K4 . 5

#Rate your awareness of the le al ri hts of refu eesand other immi rant rou/s when interfacin withthe U.S. health care system

.650 .; ; .;K5 . 5

#'ow knowled ea2le are you re ardin refu eeissues overall .6J; .4K .04J . ;

#Rate your knowled e of the relationshi/ 2etweenculture and ender issues .;K6 .K6 .J;5 .K0

#Rate your knowled e of the /artnershi/ 2etweenculture and /ower issues .406 .K 6 .J65 .K;

#Rate your knowled e of the influence of reli ion in

health care 2ehaviors.00K .864 .;48 .

#Rate your knowled e of the relationshi/ 2etweenculture and social classLstatus .4K0 .8 K .JK8 .80

#Rate your familiarity with translation andinter/retation services in the health care settin .;06 #.J;J .K ; .85

#Rate your understandin of the difference 2etweentranslation and inter/retation .048 .J 5 .8K5 . 6

#Rate your knowled e of strate ies for effectivehealth education amon refu ee /atients .;;; .4;J .8;8 . K

SS" 4.K4 4.;45 ;.440 &ercent of Tariance ;8.45 ;4.0 0 . 6

0K

results of a primary care program

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