Article Test

Introduction
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.

Methods
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.

Measure
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.

Results
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.

Discussion
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.

Conclusion
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

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