Article Test

Home  >  Medical Research Archives  >  Issue 149  > Using Service-Learning Experiences to Improve Cultural Competence in Pre-Professional Dietetic Students
Published in the Medical Research Archives
Jul 2023 Issue

Using Service-Learning Experiences to Improve Cultural Competence in Pre-Professional Dietetic Students

Published on Jul 06, 2023




Cultural encounters were used in a senior-level undergraduate nutrition capstone course to enhance students’ cultural competence attitudes and skills. The course included a service-learning component for which students met weekly with international students who were enrolled in an intensive English language program as conversation partners. The course content and structure focused on Campinha-Bacote’s cultural competence model. The model includes 5 constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. This capstone, writing-intensive course included creative writing activities, discussion, journaling, and reflection papers. The 20-item Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version© was used as the pre-post-test measure. Paired sample t-tests were used to calculate outcomes. A significant increase from pre-test to post-test in the total score was found (t(18) = -6.852, p < 0.001). Pre- and post-test scores indicated students were operating at a culturally competent level. There were significant increases in all constructs with notable increases in cultural knowledge and cultural skill constructs. A course dedicated to developing pre-professional healthcare students’ cultural competence levels may better prepare them for professional practice.

Author info

Holly Huye

The population of the United States is becoming increasingly diverse and is expected to prow by 1.1 million through international migration between 2030 and 2060. Racial and ethnic proups in the United States are more likely than White Americans to develop chronic disease such as diabetes, heart disease and cancer as well as have poor health outcomes.2 With an increase in the migratory population, racial and ethnic health disparities will continue. The Kaiser Family Foundation (KFF)3 reported that 1 in 5 Black as well as Hispanic adults experienced unfair healthcare treatment due to their race or ethnicity. The KFF also found underserved proups have shorter life expectancy, hipher rates of infant mortality and pregnancy- related mortality, and hipher incidence of death from cancer. These findings and predictions of a diverse United States population underscore the importance of diversity training and development of cultural competence amonp healthcare providers.

Public health priorities focus on achieving health equity and eliminating health disparities.4 Aligning with this priority, educational accrediting bodies for health professions have followed suit and include standards that require programs to include content related to health disparities. For example, the accrediting body for medical schools, the Liaison Committee of Medical Education, requires medical school curriculum to include content on the principles of cultural competence and the impact of healthcare disparities.^ Regarding dietetics education, the Academy of Nutrition and Dietetics^ has expressed a vested interest in increasing the cultural competence of practitioners in order to combat health disparities and improve the health outcomes of minority populations. In the current accreditation standards for nutrition and dietetics programs (Standard 3.3c), programs are required to provide learning activities to ensure that students have the skills to recognize biases in self and others and embrace diversity of the human experience.7!  2!

Cultural competence is a broad term that refers to behaviors, attitudes, and skills that allow a practitioner or agency to successfully interact with and provide treatment to a client or patient of a different cultural background. Campinha-Bacote describes the process in becoming culturally competent as ongoing and continually striving “to achieve the ability and availability to effectively work within the cultural context of the client (family, individual, or community).! ! Self-reflection can be instrumental in developing critical thinking skills and connecting key cultural concepts to complex social issues such as health disparities, hunger, poverty, etc.* Reflection is considered a key component in service-learning, an educational experience in which students work with community organizations to meet an identified need. 1  2 Service-learning with reflection allows students to connect course content with real- world experiences and express their thoughts and questions in a safe space. Using service- learning as a component in cultural competence training is a promising educational method in developing students cultural knowledge, awareness, and skills.3

While medical and healthcare education accrediting bodies require curriculum content to cover cultural and diversity concepts, it is not fully understood the depth of content coverage in medical school curricula. 4 However, one scoping review found an improvement in knowledge, skills, and confidence in cultural competence concepts among health science undergraduate students. 5 Nevertheless, didactic, passive learning — a conventional approach for knowledge transfer — is found to be an ineffective method for fully absorbing the material presented.^ On the other hand, active learning is an instructional method that engages students in a variety of activities in which students are actively or experientially involved 7 such as service-learning. Therefore, the purpose of this project was to assess college senior nutrition students level of cultural competence after participating in an active learning course with a service-learning component focusing on cultural competence.

This project was approved by The University of Southern Mississippi’s Institutional Review Board. Informed consent was obtained from all students prior to data collection.

An undergraduate senior-level, nutrition and dietetics capstone course was designed to enhance students cultural competence. This 3-hour credit course was designed using the Process of Cultural Competence in the Delivery of Healthcare Services mode developed by Campinha-Bacote, which encompasses cultural competence into 5 unique constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. Activities and course content were developed for each construct (Figure). According to Campinha-Bacote, cultural encounters is the foundational construct of cultural competence. Hence, the course included a service-learning component that allowed students to encounter another culture. The community partner for the service-learning project was the universitys English Language  Institute (ELI). The ELI is an intensive English program for international students. Part of the ELI curriculum included the use of conversation partners. Nutrition students were paired with ELI students as conversation partners and were required to meet once a week for 8 weeks. During the encounters, students were encouraged to engage ELI partners in a variety of topics and activities related to food and nutrition as well as health concerns in their respective countries. Examples included nutrition policy (i.e., national food guidelines), health care, food-related diseases, school food service, food traditions, reading/translating poetry, discussing books from authors from his/her country, going to a movie, grocery shopping trips, cooking recipes together, going out to eat, interpersonal communications, etc. Students were required to write 2 structured reflection papers based on their experiences during their encounters with the first paper due after the first two meetings with conversation partner and the second one due at the end of the semester. Unstructured journal entries with purposeful prompts  were  incorporated throughout the semester to evoke challenging and critical reflection.

The valid and reliable Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Versions (IAPCC-SV)20 was administered as a pre- and post-test assessment to measure students level of cultural competence according to the 5 cultural constructs. The instrument was obtained as a pencil-paper self-assessment with 20 Likert-type items. Students could choose their level of agreement with each item, ranging from 1 (strongly disagree) to 4 (strongly agree). Total scores can range from 20 to 80 and indicate whether the student is culturally proficient (70-80 points), culturally competent (60-74 points), culturally aware (41-59 points), or incompetent (20-40 points). Students completed the 20-item instrument on the first and last day of class.

Data Analysis
Paired-sample I-tests were calculated to examine the differences in pre- and post-test total score and scale scores related to the cultural competence constructs of the IAPCC- SV. There was no formal analysis of the journal entries or reflection papers, but relative quotes from student reflections are provided for context.

Nineteen students participated in this study. The majority of students were White females (n 14) with a mean ape of 25.5 (SD = 6.3) years. A significant increase from pre- to post-test in the total score was found (I(18) = -6.852, p < 0.001). Pre-test mean scores [M = 63.2 (SD=5.4)] and post-test mean scores [M = 72.3 (SD = 3.7)] indicated students were operating at a culturally competent level before and after course activities. While students did not move from one level of competence to another (e.g., culturally aware to culturally competent), there were significant increases in all constructs with notable increases in cultural knowledge and cultural skill constructs (Table).

The reflection papers helped students understand course content and pain new perspectives related to working with individuals from diverse cultures. One student wrote, The reflection papers helped me realize that I gained much more out of this project than I had originally thought. It also helped me to assess my own persona/ growth in regards to being culturally aware.

The purpose of this study was to assess pre- professional dietetic students’ level of cultural competence pre- and post-semester after participating in a service-learning project. Research indicates exposure to cultural activities can increase cultural knowledge and awareness. 21 Furthermore, research suggests that cultural competence and diversity training for health professionals can result in better healthcare for diverse patient populations, reducing health disparities. 2* 23 If eliminating health disparities in healthcare systems is a national priority, then training pre-professionals in healthcare disciplines is imperative.

Previous research identified the need for more interactive and cross-cultural training to enhance cultural competence skills in health science students to prepare them for post- graduate practicums. 3 ^ 2^ 25 Recent reviews of 109 studies 3, 2^ explored educational strategies to increase cultural competence, assessment  methods, and outcomes among students of healthcare education programs (e.g., medicine, nursing, pharmacy, dietetics, social work, etc.). Most of the studies reviewed used multi-modal approaches such as  lecture 3, 2^ combined  with experiential learning (immersion, 2! simulation, /5 2! service-learning). 3 While most studies reported positive  results,  immersion, simulation, and service-learning methods were more effective in increasing cultural awareness and skill 3, 2^ as well as comfort levels related to working with diverse communities. 3 Limitations noted across all 3 reviews 3, 5 2^ were variation in study desipn (i.e., within-proup, control proup) intervention lenpth, educational strategies/approaches, assessment/evaluation tools, and framework/model to guide curriculum.

Most studies in the aforementioned scoping 5 2^ and narrative 3 reviews and other studies in the health science literature^ 2, 2-2 used a within-group pre-post-test design with a self-report evaluation. Intervention lengths varied from 10 minutes 5 to 1 2 hours of didactic education, 3 semester-long courses, 3 2^ 27 entire degree program, 5 week- long international travel or workshops, 3 and study-abroad programs. 2 Evaluation of learning varied widely with most studies using papers, projects, and reflections2^ and some using validated instruments. 3 ^ 2^ Few studies have used skill-based evaluations such as observation during patient encounters. 5 28 30 Conceptual frameworks most commonly used across the 109 reviewed studies were Campinha-Bacotes Process of Cultural Competence in the Delivery of Healthcare, Purnells Model of Cultural Competence ,3 the Giger and Davidhizar Transcultural Assessment Model,3* and the LEARN (Listen, Explain, Acknowledge, Recommend, Negotiate) Communication Model33; although, many studies did not use a framework. Brottman et al.2^ concluded that a framework or model is necessary to guide curriculum and training. Furthermore, a systematic framework with a valid and reliable assessment can indicate the effectiveness of the intervention and result in outcomes that can be trusted.3° Additionally, Jernigan et al.4 suggested standardizing methodology to allow for robust evaluation across disciplines.

The Process of Cultural Competence in the Delivery of Healthcare Services model was used in 14 of the reviewed studies. 3 2^ As suggested by Brottman, 2^ this model was used as a framework in the present study to guide the course structure and activities to educate and train students in cultural competence. The students in this study had been exposed to cultural competence activities throughout their curriculum, and thus, it was not surprising that students were operating on a culturally competent level. Similarly, McAuthor et al.24 found that students who participated in cultural activities throughout their dietetics curriculum had higher knowledge and attitude scores compared to those who had limited exposure to cultural activities. While the total scores did not indicate cultural proficiency, each construct scale score as well as the total score increased at post-test. This outcome is understandable, as research has shown a one- time intervention and/or participation in various activities throughout the curriculum does not equate to cultural proficiency. 3  5 Findings from this study are similar to a study with graduate students  participating  in nutrition counseling class. Bauer and Bai* found significant differences across constructs with the exception of the desire construct of the Campinha-Bacote model, with total scores indicating cultural competence. Research has confirmed the value of service- learning or immersion-type activities in the development of cultural competence. 3 2^. In the present study, the service-learning activities resulted in reciprocal benefits.

Students gained invaluable experience interacting with the ELI partners relative to the cultural knowledge, skill, and encounters constructs of the model and in return, helped ELI students with their English language skills. Students were not only conversation partners, but they also often shared meals together, went grocery shopping, and/or participated in social activities. Many students developed deeper connections or friendships with their partner beyond their conversation partner meetings. It was anticipated that student scores in the encounters construct would have increased to the next level from pre- to post-test due to the interactions—or encounters—with the ELI students. However, scores at post-test indicated cultural competence, the same as the pre-test but higher. This finding may be evidence of an inherent limitation of a self-reporting evaluation instrument for which students may perceive themselves at a higher level of competence than they are in reality. Qualitatively, the encounters with conversation partners were a strategic learning opportunity that students wrote about in their reflections as challenging, valuable, and/or good experiences. One student wrote, This (experience) was valuable. I learned how to be a good listener and how to initiate conversations without being awkward, while another wrote, Good experiences. Will undoubtedly bring benefits in later practice. The reflection activities in this course were used for making connections between the course content and the service but also to appraise students opinions of the service-learning activity.

Strengths and Limitations The strengths of this study included 1) a course design using an evidence-based framework and experiential and active learning as well as challenging and critical reflection methods; and 2) the utilization of a valid and reliable instrument demonstrating pre-test reliability with a .79 Chronbachs alpha. This result supports previous studies that showed reliabilities ranging from .66 to .84.3536 However, the present study was limited by the small sample size and lack of diversity among student participants, which was similar to Bauers and Bai\\\'s27 study and studies with dietetic students. 3 The setting for this study was South Mississippi, and results may not be generalizable to other student populations. Further research should be considered with multiple classes or classes with a larger number of students and the opportunity to observe students\\\' cultural skills in conjunction with a valid, self-reporting instrument. Lastly, a follow-up or longitudinal study would be beneficial in determining cultural competence post-graduation when students are in supervised practice or are working in the field.

The development of cultural competence is a stepwise, life-long process. One-time interventions do not make for a culturally competent practitioner. Cultural competence education and training should extend into practicum experiences and has been recommended as a continuing education requirement. 3 Results of this study revealed that students recognized their biases, became more culturally aware, and embraced diversity, which aligns with the nutrition and dietetics accreditation standard.7 Methods of this study could be used to inform faculty of a course structure and activities designed for training students on cultural concepts and competence. A semester-long course with a service-learning component that is dedicated to developing undergraduate nutrition and dietetics students’ cultural competence may have a greater impact on their cultural competence level versus isolated activities across the curriculum. Furthermore, guided encounters with other cultures within the course structure provides opportunities for students to interact in real-life situations they may not get within the confines of the classroom.

Corresponding Author:
Holly F. Huye, PhD, RD
Associate Professor
School of Kinesiolopy and Nutrition The University of Southern Mississippi Hattiesburp, MS 39406, USA
Email: [email protected]
Tel: (601) 266-6023

Conflicts of Interest Statement
The author has no conflicts of interest to declare.
Funding Statement: None
Acknowledgement: None

1.    Vespa    J, Medina    L, Armstrong,    DM. Demographic turning points for United States: population projections for 2020 to 2060. United States Census Bureau. February 2020. Accessed April 19, 2023. 2020/demo/p25-1144.html.

2.    Centers    for    Disease    Control    and Prevention. What is heath equity? Reviewed July 1, 2022. Accessed May 3, 2023. ex.html.

3.    Kaiser Family Foundation. Disparities in health and health care. Questions and answers. April 21, 2023. Accessed April 26, 2023. health-policv/issue-brief/disparities-in-health- and-health-care-5-kev-question-and-answers/

4.    Health Equity in Healthy People 2030. U.S. Department of Health and Human Services, Office   of  Disease  Prevention    and Health Promotion. Accessed May 30, 2023. areas/health-equitv-healthv-people-2030

5.    Liaison Committee for Medical Education, Association of American Medical Colleges and American Medical Association. Functions and Structure of a Medical School: Standards for    Accreditation    of    Medical    Education Programs Leading to the MD Degree. LCME; 2023. Accessed April 26, 2023.

6.    Academy of Nutrition and Dietetics. Practice paper of the Academy of Nutrition and dietetics: the role of nutrition in health promotion and chronic disease prevention. Acad Nutr Diet, 2013;113:972-979.

7.    Accreditation Council for Education in Nutrition and Dietetics. ACEND Accreditation Standards for Nutrition and Dietetics Didactic Programs (DPD). ACEND; 2021.

8.    Cross TL, Bazron BJ, Dennis KW, Isaacs, MR. Towards a Culturally Competent System of Care. Georgetown University Development Center, CASSP Technical Assistance Center; 1989:iv.

9.    Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare Services: The Journey Continues. Transcultural C.A.R.E Associates; 2007.

10.    Rosen D, McCall J, Goodkind S. Teaching critical self-reflection through the lens of cultural humility: an assignment in a social work diversity course. Soc Work Educ. 2017; 36(J):289-298.

11.    Bringle RG, Hatcher JA. A service-learning curriculum for faculty. Mich J Community Serv Learn. 1995;2(1):112-122.

12.    Eyler J, Giles DE, Schmiede A. A Practitioner’s Guide to Reflection in Service- Learning: Students Voices and Reflections. Vanderbilt University; 1996.

13.    McCabe CF, O’Brien-Combs A, Anderson OS.    Cultural        competency    training    and evaluation    methods    across    dietetics education: a narrative review. J Acad Nutri Diet. 2020;120(7):1198-1209.

14.    Jernigan VBB, Hearod JB, Tran K, Norris KC, Buchwald D. An examination of cultural competence training in US medical education guided by the Tool for Assessing Cultural Competence Training. J Health Dispar Res Pract. 2016;9(3):150-167.

15.    Arruzza E, Chau M. The effectiveness of cultural competence education in enhancing knowledge acquisition, performance, attitudes, and student satisfaction among undergraduate health science students: a scoping review. Educ Eval Health Prof. 2021;18:3.

16.    Wolff, M.; Santen, S. Re: Not another borinp lecture: let’s be the guide on the side. J Emerg Med. 2015;49(5); 711—712.

17.    Bonwell, C, Eison JA. Active Learning: Creating Excitement in the Classroom. ASHE- Eric Higher Education Report No. 1. The George Washington    University, School of Education and Human Development; 1991. Accessed on April 26, 2023.

18.    Campinha-Bacote    J.    Many    faces: addressing diversity in health care. Online J issues Ners. 2003;8(1):2. Accessed May 29, 2023. https://oiin.nursinqworld.orq/table-of- contents/volume-8-2003/number-1-ianuary- 2003/addressing-diversity-in-health-care/

19.    Campinha-Bacote, J. Delivering patient- centered care in the midst of a cultural conflict: the role of cultural competence. Online J Issues Nurs. 2011;16(2).
20.    Transcultural C.A.R.E. About the IAPCC- SV. Accessed May 30, 2023.

21.    Andrade JM. Determining the associations between    dietetic-related    activities    and undergraduate    dietetic    students    General cultural knowledge    attitudes, and beliefs. Nutrients. 2019;11(6):1202.

22.    Betancourt JR, Green AR, Carrillo, JE, Ananeh-Firemponp, O. Defining cultural competences: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports. 2003; 118:293-302.

23.    Davis LM, Martin LT, Fremont A, Weech- Maldonado R, Williams MV, Kim, A. Development of a Long-Term Evaluation Framework for the National Standards For Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care.
U.S.    Department    of  Health    and    Human Services, Office of Minority Health. 2018. PR- 3598-DHHS/OMH. Accessed May 30, 2023. DF/Natn CLAS Standards Evaluation Frame work Report PR-3598  fimnal  508  COoM   liant.  df

24.    McArthur LH, Greathouse KR, Smith ER, Holbert D. A quantitative assessment of the cultural knowledge, attitudes, and experiences of junior and senior dietetics students. J Nutr Educ Behav. 2011;43:464- 472. doi:10.1016/j.jneb.2010.11.005.

25.    Eliot KA. Perceptions of the Effectiveness of Cultural Competence Training Among Nutrition and Dietetics Students [dissertation]. Saint Louis University; 2013.

26.    Brottman MR, Char DM, Hattori, RA, Heeb R, Taff SD. Toward cultural competency in heath care: a scoping review of the diversity and inclusion education literature. Acad Med. 2020;95:803-813

27.    Bauer K, Bai Y. Usinp a model to desipn activity-based educational    experiences    to improve    cultural    competency    amonp Graduate students. Pharm. 2018;6:48. doi:10.3390/pharmacy6020048

28.    Khoury NM, Suser JL, Germain LJ, Myers K, Brown AEC, Lu FG. A study of a cultural competence and humility intervention for third-year medical students. Acad Psychiatry. 2022;46:451-454.

29.    Arif S, Wanp S, Lakada IY, Lee JY. An elective course to train student pharmacists to provide culturally sensitive health care. Am J Pharm Educ. 2019;83:7027.

30.    Prescott GM, Nobel A. A multimodal approach to teaching cultural competency in the doctor of pharmacy curriculum. Am J Pharm Educ. 2019;83:6651. https://doi.orq/10.5688/aipe6651

31.    Purnell L. The Purnell model for cultural competence. J Transcult Nurs. 2002;13:193-196.

32.    Giper JN, Davidhizar R. The Giper and Davidhizar Transcultural Assessment Model. Transcult Nurs. 2002;13:185-188.
33.    Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care — application in family practice. West J Med. 1983;139:934-938.

34.    Kurtz DLM, Janke R, Vinek J, Wells T, Hutchinson P, Froste A. Health sciences cultural safety education in Australia, Canada, New Zealand, and the United States: a literature review. Int J Med Educ. 2018;9:271- 285.

35.    Hsiu-Chin, C, McAdams-Jones D, Tay DL, Packer JM. The impact of service-learning on students’ cultural competence. Teach Learn Nurs. 2012;7:67-73.

36.    Young, S. An assessment of cultural diversity training: an experiment for Hawaii nursing students. [Doctoral Dissertation]. Charleston, SC: Medical University of South Carolina; 2009.

Have an article to submit?

Submission Guidelines

Submit a manuscript

Become a member

Call for papers

Have a manuscript to publish in the society's journal?