Introduction: There is a critical need for qualified health care workers to care for this increasingly diverse generation of older adults. This cultural competency training module was developed for health care professional students, trainees, and practitioners to explore personal health beliefs, attitudes towards older adults, and strategies to facilitate cross-cultural communication in this vulnerable patient population. Methods: The activity incorporates a combination of instructional strategies including self-reflection, video vignettes, and role plays for participants to practice using cross-cultural communication skills and tools. The activity is designed to be a stand-alone 2-hour session, with an additional 15-20 minutes of individual self-reflection before and evaluation after the session. It may be used as an introductory module for a didactic course, clinical rotation, or continuing education activity for health care providers. Results: Based on participant evaluations from two sessions, the majority (94%) of respondents agreed or strongly agreed that they were able to describe similarities and differences between major health belief systems in the world. All participants reported high self-efficacy in the ability to describe the source of one personal cultural health belief. Two-thirds of respondents (71%) believed that this module improved their cross-cultural communication skills and would result in better patient–provider relationships with older adults. Discussion: Based on participant evaluations of the module, the session has consistently been able to increase participant awareness of the influence that personal health beliefs have on patient–provider communication and perspectives on health, disease, and methods of healing. activity.
- Summarize at least two similarities and differences between the major culturally based health belief systems in the world.
- Identify and provide an example of at least one personal cultural health belief.
- Describe how the concept of illness explanatory model may be used to facilitate cross-cultural interviewing.
- Recommend and demonstrate at least two strategies to facilitate cross-cultural interviewing and therapeutic planning with older adults.
According to Census Bureau statistics, the United States is experiencing the largest increase of the older adult population in history.1,2 The biggest surge will occur between 2012 and 2050. This is largely attributed to increasing longevity and aging baby boomers. Within this time frame, the population 65 and over will nearly double from 43.1 million to over 80 million.1 These projections surpass population estimates of older adults in all other developed countries. Japan is projected to be a distant second, at approximately 43 million older adults by 2050. In addition to an increasing number and proportion of older adults in the US, there will be a significant shift in the racial and ethnic composition. The percentage of non-Hispanic whites will decrease by 18%, while racial and ethnic minority groups will increase at a similar rate. By 2050, the older adult population will be at its most diverse in history, with racial and ethnic minorities comprising 39.1% of the population.1
Recognizing the critical need for qualified health care workers to care for this increasingly diverse generation of older adults, the Institutes of Medicine developed recommendations in the Retooling for an Aging America report.2 In one coordinated response to the report, 10 health professions formed the Partnership for Health in Aging Coalition to develop standardized multidisciplinary competencies in geriatrics that may be applied across all health professions.3 The workgroup outlined guiding principles that serve as stepping stones towards mastering the geriatric competencies. Two of these guiding principles relate to a need for providing person-centered and culturally competent care and read as follows:
- “Each competency should be considered in the context of the unique characteristics and needs of older adults, with an emphasis on ensuring person-centered and directed care that supports the dignity, autonomy, and rights of each older person.”
- “These competencies must also take into account the individual preferences, ethnic backgrounds, culture, spiritual beliefs, and levels of health literacy of older adults and their caregivers. . . .”
These guiding principles suggest that entry-level health care professionals need to possess knowledge, skills, and attitudes in cultural competency and patient-centered care towards achieving optimal health outcomes.4-6 Within the context of interpersonal interactions, this means having the ability to traverse the gap between patient–provider cultural differences. This provides a foundation for building effective communication and relationships with patients while recognizing and respecting the patient as a unique individual.4 For the culturally competent health care professional, this translates into having an awareness of personal beliefs and biases, being knowledgeable of other cultures, understanding the influence of culture on patient health, showing empathy and respect towards patients’ health beliefs and preferences, and being able to negotiate a therapeutic plan. These cross-cultural skills have been linked to improved communication, patient satisfaction, adherence, and overall health outcomes.7,8
Cultural competency training is an effective vehicle that may be used to equip providers with the knowledge, skills, and attitudes to care for the needs of diverse older adults.5,8,9 There is a wide range of methods that may be used to facilitate cultural competency training, but the most effective approach is a combination of improving cross-cultural knowledge and communication skills throughout didactic and experiential training.5,8 The Stanford Geriatric Education Center has developed the Curriculum in Ethnogeriatrics, which highlights many evidence-based cultural competency instructional activities.10 Several of their tools and strategies have been referenced or incorporated into this activity.
MedEdPORTAL contains a wealth of resources to enrich health professions curricula in all domains of cultural competency. This resource both complements and builds on previously published work in the area of cross-cultural communication. A resource created by Elliott, St. George, Signorelli, and Trial incorporates self-reflection and small-group activities to increase awareness of personal bias and stereotyping towards psychiatric patients into a third-year medical clerkship.11 Another resource by Elliott uses a workshop for students to reflect on culturally based health beliefs.12 The Stanford Gap Cases13 use culturally diverse pediatric standardized patients to evaluate students’ ability to facilitate cross-cultural interviews using the LEARN14 and Kleinman-Stewart tools.15 Other resources highlight other aspects of cross-cultural communication skills and tools in various ethnic groups, disease states, and spiritual beliefs.16-24
This resource uses self-reflection, discussion groups, and role-play exercises to practice using cross-cultural skills and tools. The self-reflection survey explores attitudes towards older adults and personal health belief systems. The resource also discusses unique challenges of and useful strategies for facilitating communication with diverse older adults. While currently available resources draw from similar cultural competency domains, there is a paucity of resources highlighting cross-cultural communication in older adults. The resource focuses on several domains of cultural competency as defined in the revised Tool for Assessing Cultural Competency Training.24
The primary target audience for this resource includes health care professional students, postgraduate trainees, and practicing health care professionals.
Facilitators should notify participants at least 1 week in advance to complete presession activities. Activities completed during the session, including the presentation, discussion, and role-play exercises, may be completed in 90-120 minutes. This depends on whether the faculty facilitator elects to use all or only select exercises (e.g., vignettes or role play). The guide (Appendix A) provides detailed timing of each exercise. Faculty facilitators should review the PowerPoint presentation, video vignettes, and role-play exercises (Appendices C-G) prior to the session to decide which activities best suit their session and the allotted time frame.
The live session is a combination of small- and large-group interactions, which requires the use of audiovisual equipment. Therefore, facilitators should be thoughtful about selecting the appropriate space for the activity. At a minimum, the room should have a computer with Internet access and projector. Participants should be able to view the video and fully participate in the group discussions from where they are seated. For maximal participation, there should be at least 10 and no more than 30 participants.
One week prior to the session, disseminate the Cultural Self-Assessment Survey (Appendix B). This is an anonymous self-reflection that should be completed individually prior to the session. The survey is used to explore the participant’s cultural background as well as reflect on his/her personal health beliefs, cultural values, and attitudes towards older adults. The survey should take 15-20 minutes to complete. Participants should print or save their completed surveys for personal reflection and in preparation for the session discussion. The facilitator may view, but not collect, the participant surveys to confirm completion if this activity will be used for grading purposes. A non-peer-reviewed version of the survey is available at https://www.surveymonkey.com/s/agingculturehealth.
Students should also receive instructions for accessing the optional online prereading.25 Once on the Ethnogeriatrics Overview, Fund of Knowledge page users must click download this module as a pdf in order to access the summary reading that provides a review of the major systems of health beliefs in the world. While this content is briefly discussed during the live session, facilitators may use it as a recommended preclass or postclass reading for a more in-depth review.
The live session should run according to the Aging, Culture, and Health Communication Presentation (Appendix C). This is a guided presentation that incorporates all of the session activities (including presession activities), small-group discussions, and role-play exercises. Throughout the presentation, there are speaker’s notes, which should be used together with the guide for more detailed guidance on facilitating activities and discussion. The video vignettes (Appendices D & E) provide examples of cross-cultural communication for the large-group exercise during which participants compare and contrast less effective and more effective cross-cultural communication strategies during a patient encounter. During the role-play exercise (Appendices F & G) a common patient–provider scenario is used to allow participants to practice additional cross-cultural skills discussed throughout the module. This includes tools to facilitate cross-cultural communication and elicit a patient’s perception of illness, show empathy, and negotiate a treatment plan. After completing the module, participants complete a session evaluation (Appendix H) to measure progress towards achieving the learning objectives and assess changes in perceptions and attitudes towards culturally diverse older adults.
For this activity to be successful, the facilitator needs to create a safe environment. Some participants may not feel comfortable with sharing their cultural background and experiences with others. Major points for the facilitator include using a good balance of small-group and self-reflection techniques to create a safe environment for students to share openly without fear of being critiqued or graded on their responses.
The facilitator should choose a space that encourages small-group interaction (e.g., small tables vs. lecture hall). However, based on experience using various rooms from large lecture halls to small classrooms, the activity will be successful as long as participants are divided into small groups. This creates a safer environment for discussion, regardless of the size of the room.
The cultural self-assessment small-group discussion was one of the most beneficial parts of the module as it required students to examine their perceptions and beliefs. The discussion helped students recognize that all health beliefs are culturally based and that none can be considered superior as they are all different. Students expressed increased empathy towards older adults with differing health beliefs and a plan to use negotiating skills to arrive at a mutual therapeutic plan in the future.
Implementing the video vignettes and role-play exercises towards the end of the session is very effective with helping participants practice navigating an interview when working with a patient with an unfamiliar health belief system. Directly following the exercises, it is important for groups to share their challenges and areas of discomfort during the interactions. This allows other participants and/or the facilitator to share useful strategies for overcoming the barriers.
Lastly, it is important that the facilitator allots time at the end of the session for participants to complete the final evaluation. It is difficult to quantify changes in perceptions and attitudes, so the evaluation allows participants to state in their own words how their attitudes and perceptions have changed as a result of the activity. Timing is also important as completing the evaluation while the experience is fresh in participants’ minds makes the comments most informative.
This resource has been facilitated with more than 150 participants over the last 4 years. The audience has primarily been pharmacy students, but the session was recently incorporated into a third-year dental geriatrics elective, and there are plans to continue the session every year based on student feedback. Additionally, the module was facilitated as part of a training session for social workers who work with older adults in the community.
Evaluation data were collected from pharmacy students using Likert-scale questions about perceived progress towards achieving the module learning objectives. The majority (94%) of student respondents agreed or strongly agreed that after completing the module they were able to summarize the similarities and differences between major health belief systems in the world. All students reported high self-efficacy in the ability to identify and describe the source of one personal cultural health belief. Students reported feeling more prepared to communicate with culturally diverse older adults in a health care setting. Finally, all students reported being able to describe at least two strategies to facilitate cross-cultural communication with older adults.
Approximately half of the students (51%) stated that the module increased their understanding of cultural differences and diverse health beliefs. This is an appropriate response after this module as it only provided the students with an introductory overview. The response also emphasizes the need for more activities throughout their training to develop their proficiency in this area. Over two-thirds of the class (71%) believed that this module helped them improve their communication skills and would consequently lead to better relationships with older adults.
Students reported that the videos helped them realize the importance of effective communication strategies to overcome cultural differences. Students recognized the benefits of conducting a cross-cultural interview to learn more about older adult health belief systems before suggesting any new treatment plans. Additionally, students commented that the videos demonstrated the benefits of establishing a relationship of trust with older adults to learn more about their concerns.
Students agreed that being compassionate, being respectful, and actively listening are required to have a successful conversation with older adults. Most students agreed that preserving the patient’s autonomy was essential to the acceptance of their care plan. In addition, students reported that readings provided more in-depth understanding of the impact of individual cultural beliefs, an important factor to take into consideration when designing an effective treatment plan. In a survey conducted between 2012 and 2013, several students commented that participating in a role-play exercise would be helpful to practice the communication techniques. As a result, the 2014 revision of the activity incorporated the role-play exercise Mr./Mrs. Wei (Appendices F & G) into the session to allow participants to practice cross-cultural communication skills with their colleagues.
Comments from the various session participants over the past 4 years suggest that the activities were successful in changing attitudes and perceptions towards working with culturally diverse older adults and facilitating a cross-cultural interview:
- “I learned two essential ways to conduct a successful cross-cultural interview with patients—listening and summarizing. It is important to be an active listener without imposing my own opinions. It is also crucial to summarize patients' complaints and reflect back to make sure that I understand all of their concerns.”
- “There is so much more to understanding how to treat a person, not just their disease but their beliefs.”
- “I learned a more detailed definition of the major systems of culturally-based health beliefs and how to integrate beliefs into patient encounters.”
- “How to ask a question in a patient-centered way, as compared to a disease-centered way in order to better connect with the patient.”
- “Culture is a very important part of working with elderly patients. They are many different views, lifestyles, dietary differences that needs to be taken into consideration.”
- “I have learned to appreciate the great diversity that exists . . . and that those of the geriatric population will likely be just as culturally diverse. It is important to be a good listener to patients and respectful of their beliefs. I liked the advice given that we should allow our patients to remain autonomous but provide the education they need to make an informed decision about their health.”
Based on participant evaluations of the module, the session has consistently been able to increase participant awareness of the influence that personal health beliefs have on patient–provider communication and perspectives on health, disease, and methods of healing. The session has been particularly successfully at changing participants’ attitudes and perceptions toward working with culturally diverse older adults. The combination of self-reflection, discussion, video vignettes, and role-play exercises allows participants with various learning styles to benefit from the session. It also encourages personal self-reflection and discussion of health beliefs in a shame-free environment.
The format of the activity does not require the audience to have any specific knowledge prerequisites and therefore serves as an excellent introductory module for an entry-level didactic course, clinical rotation, or skill-building continuing education activity for health care providers currently in practice. It allows for flexibility and may be used with a range of learners (e.g., students to seasoned practitioners) and professions. Having a diverse group of participants with different levels of experience and cultural backgrounds enhances the learning opportunity for both the participants and the facilitators.
None to report.
None to report.
Reported as not applicable.
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- Committee on the Future Health Care Workforce for Older Americans, Board on Health Care Services. Retooling for an Aging America: Building the Health Care Workforce. Washington, DC: National Academies Press; 2008.
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This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial-Share Alike license.
Received: June 8, 2015
Accepted: February 25, 2016