Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
The data presented in this study are available on request from the corresponding author.
Current research often refers to cultural competence to improve health care delivery. In addition, it focuses on the cultural uniqueness of each health service user for optimal personalized care. This study aimed to collect self-assessment data from health professionals regarding their cultural competence and to identify their development needs. A mixed methods design was adopted using the Cultural Competence Self-assessment Checklist of the Central Vancouver Island Multicultural Society. This was translated into Greek, validated, and then shared with health professionals in Cyprus. Subsequently, a semi-structured interview guide was designed and utilized. This was structured in exactly the same question categories as the questionnaire. Data collection took place between October 2021 and May 2022, and convenience sampling was used to recruit 499 health scientists in Cyprus. The sample comprised doctors, nurses, psychologists, midwives, social workers, and physiotherapists. Subsequently, 62 interviews were conducted with participants from the same specialties. The results showed that (compared to other health professionals) nurses and psychologists are more sensitive to issues of cultural competence. It would appear that the more socially oriented sciences had better-prepared healthcare staff to manage diversity in context. However, there is a gap between knowledge and skills when comparing doctors to nurses; they seem to be more skilled and willing to intervene actively in cases of racist behavior or problem-solving. In conclusion, participants identified the importance of their cultural competence; they also realized the importance of optimal planning of personalized health care. There is a significant need for continuous and specialized cultural competence training for all health professions.
Keywords: cultural competence, personalized care, self-assessment, quality health care, optimal care, mental health, diversity
Research that aims to enhance the quality of personalized health care delivery has recently focused on the cultural competence of health professionals. Cultural competence is referred to as the process by which the health care provider constantly strives to work effectively according to the patient’s cultural context [1]. This ability includes characteristics such as respect, adapting care to the values, needs, practices, and expectations of individuals, as well as providing fair and ethical care and understanding [2]. The characteristics of cultural competence, according to Zarzycka et al., are cultural awareness, knowledge, sensitivity, skills, competence, and dynamics [3]. These variables affect the health literacy of members of the same ethnic group, health behaviors, perceived risk, attitudes, and beliefs towards health care [4]. Therefore, several studies argue that to ensure effective and culturally adequate care and to develop culturally competent health care practices, properly educated providers are required [3,5]. These practices are directly related to the mental health characteristics of professionals necessary for effective cooperation between those involved in health services. In this context, cultural competence assessment tools, such as the “Cultural Self-Efficacy Scale (CSES),” for the self-efficacy of nurses caring for specific groups of people, including colored, Hispanic, and Asian patients, have been developed [6]. The Cultural Competence Assessment Scale-CCAS assesses the cultural awareness, sensitivity, and behavior of physicians [7], Self-Efficacy Scale-CSES, assesses cultural knowledge and skills [8]. Other tools that have been used successfully are the Transcultural Assessment of Self-Efficacy Scale, which measures cultural awareness, knowledge, and skills; the Cultural Capacity Scale-CCS, for the assessment of cultural sensitivity, knowledge, and skills; Nurses ‘Cultural Competence Scale-NCCS; the Scale of Cultural Competence for nurses-SCC; and Scale of Community Health Nurses’ Cultural Sensitivity-SCS [1,9].
Recent research and the tools used, however, show a significant lack of using mixed methods and self-assessment scales. In particular, in Cyprus, there are no recent systematic reviews regarding cultural competence in the healthcare sector, nor has this issue been studied at a national level. In Greece and Cyprus, the importance of this has not been prioritized, nor have specific training programs been implemented appropriately and in accordance with the local needs of the communities. This is a particular issue within Cyprus as the geographical position of the country and the financial opportunities that it offers attract people from Europe, Asia, and Africa, making it more multicultural. In addition, the population heterogeneity of Cyprus includes (apart from refugee minorities) every other community within the spectrum of diversity and has its own cultural identity. At the same time, there is an evident lack of governmental, educational, and social emphasis on cultural competence, knowledge, and skills [10]. There are also no data related to intervention programs to promote cultural competence, nor are there relevant topics in the curricula of medical and nursing schools. The lack of cultural capacity in health professionals, constant social changes, and the intense development of multiculturalism leads to the growing and intense inequality and marginalization of minorities or vulnerable groups receiving quality and effective health care services [11,12]. In addition, the number of systematic international reviews is low, and there are several studies that focus primarily on nurses but not other health professionals. Thus, the rights of vulnerable communities, diversity, multiculturalism, culture, beliefs, values, attitudes, views, experiences, patterns of thought, rules of conduct, and forms of communication are often overlooked. However, they continue, are transmitted from generation to generation, and are subject to change and evolution [13]. As a result, there is a reduced quality in the personalized provision of health services [14].
This study aimed to measure the level of knowledge and skills of cultural competence that the participants consider themselves to possess through the collection of self-assessment cultural competence data from health professionals. For this reason, this study used mixed methods, combining the quantitative and qualitative methodology.
The Cultural Competence Self-assessment Checklist of the Central Vancouver Island Multicultural Society was used to collect data after it had been translated into the Greek language and validated [10]. Next, a semi-structured interview guide was designed for the study, structured in exactly the same categories as the questionnaire but using different questions. In this way, it was possible to cross-check the answers and collect additional data as well as non-verbal information.
The following research questions emerged from the review of the literature and the identification of gaps in the research:
How do health professionals evaluate their knowledge of transcultural communication? How do health professionals perceive their transcultural communication skills?What is the relationship between the self-assessment of health professionals and the analysis of their qualitative interview responses?
Data Collection and Sample of the Study
Data collection took place between October 2021 and May 2022 from 499 health scientists who live and work in Cyprus. Convenience sampling was used. The Northern part of Cyprus (which is occupied by Turkey and is not recognized internationally as an independent country) was excluded from this study due to access difficulties. The sample comprised doctors, nurses, psychologists, midwives, social workers, and physiotherapists. Subsequently, 62 interviews were conducted with participants from the same specialties (Table 2).
The questionnaire
The Self-Assessment tool was developed by the Central Vancouver Island Multicultural Society with the ultimate goal of helping people to consider their skills and knowledge in their interactions with others. Its goal was to assist communities in recognizing what they can do to become more effective in working and living in a diverse environment. It comprises a Likert rating scale to help respondents identify areas of strength and areas that need further development to reach cultural competence. The response categories were set as Never/Not at all, Sometimes/Good, Often/Fairly good, and Always/Excellent, with the score being respectively totaled at the end of each section. The questions used deal with cultural knowledge, about learning from mistakes, the assessment of the knowledge, the questions an individual asks themself in terms of cultural difference, and the importance that this difference has to the individual. It also includes questions about knowledge of history, understanding the impact of culture, interest in lifelong learning, and understanding the consequences of racism, sexism, homophobia, etc. Finally, this section includes questions about the participant’s knowledge of the history of diversity. The section listing skills has questions about adaptability to diversity, active support for people on the diversity spectrum, and transcultural communication skills. It also records the search for opportunities to acquire skills and the active involvement of the individual in processes that promote cultural experiences. Respect for diversity and the implementation of cultural practices in combination with allied strategies and flexibility are some of the necessary elements that are recorded to develop a more complete picture of the cultural ability of the individual.
The semi-structured interview guide
To capture the cultural competence of health professionals more fully, it was also felt necessary to use a qualitative methodology to explore the experiences of the participants from their collaboration with diverse communities. A semi-structured interview guide was designed, which included nine questions grouped into two main categories: (a) questions about how the participants acquired knowledge about cultural diversity and best practices, the management of transcultural communication, previous studies, and the role of the social environment, and (b) questions about experiences of active involvement of health professionals in cases they had to intervene in or deal with.
The Procedure
The study was part of the research program entitled: QR-CCC Building Cultural Competence for Health Professionals, funded by Frederick University between September 2021 and June 2022. After the research was designed, the quantitative research instrument was translated into Greek and validated following international guidelines for the validation of research tools published in a reputable journal [10]. It was then applied to the Cypriot health care professional population following an invitation to also participate in the qualitative research. After expressing their interest, the participants were asked to answer the questionnaire in a personal interview. All interviews were conducted by the research team members who were qualified in qualitative research methods. The duration of the quantitative element of the interview was 20 minutes, and this was then followed by the semi-structured interview process, which took another 30 minutes. In all instances, the procedure was performed in a quiet place within the working environment of health professionals. Analysis of quantitative data used the statistical program SPSS v.25 (Chicago, IL, USA). Qualitative data were analyzed using thematic content analysis. Using content analysis, the researchers quantified and analyzed the presence, meanings, and relationships of certain words, themes, or concepts. The researchers were, thus, able to evaluate the language used and to search for bias or partiality. After familiarizing themselves with the data, the researchers coded and generated themes. After reviewing the aforementioned steps, the research team defined theoretical models leading to the writing up and their theoretical analysis.
Ethical Issues
The written approval of the Central Vancouver Island Multicultural Society was obtained by the scientific director of the organization for its use in this study. Approval was also obtained from the Frederick University Bioethics Committee, as well as written consent from participants. Throughout the process, anyone was able to withdraw their participation, and everyone was made aware of their rights. No names were recorded on the gathered data and participants were aware that no individual data would be identifiable in any reports/publications.
Validity and Reliability
The English language version of the Cultural Competence Self-assessment Checklist of the Central Vancouver Island Multicultural Society has been tested for validity and reliability. The reliability has been tested using Cronbach’s α method. In addition, the internal structure was tested by a confirmatory factor analysis-CFA, and the validity analysis has also been taken into account. The measurements of the Cronbach alpha values were, on average, 0.80, so it is considered to be a reliable tool ( Table 1 ).
Internal Consistency Validity.