# data[].attributes.headline
Sexual orientation and gender identity within youth 

# data[].attributes.subject
Sexual orientation and gender identity within youth 

# data[].attributes.body
This, within a classroom setting, could affect how a child is perceived and potentially disrupt other students' understanding of someone else's orientation, which may lead to another student acting differently towards the child who identifies differently.

# data[].attributes.attachment_link.readable_text
Sexual orientation and gender identity/expression are important aspects of a young person's identity. Understanding and expressing sexual orientation and gender and developing related identities are typical development tasks that vary across children and youth. For example, some youth may be unsure of their sexual orientation, whereas others have been clear about it since childhood and have expressed it since a young age. Expressing and exploring gender identity and roles is a part of normal development. The process of understanding and expressing one's sexual orientation and gender identity is unique to each individual. It is not a one-time event and personal, cultural, and social factors may influence how one expresses their sexual orientation and gender identity.

There is currently no universally-accepted acronym inclusive of all youth who are not heterosexual and/or express their gender in diverse ways. The commonly-used acronym - LGBTQ+ (lesbian, gay, bisexual, transgender, queer or questioning, or another diverse gender identity) - refers to the communities included in the "LGBTTTQQIAA" acronym (see Figure 1). This youth topic primarily uses "LGBTQ+" as an inclusive term for simplicity, except when describing research studies explicitly focused on more narrowly-specific communities. See Key Terms and Concepts to learn more about each of these communities.
Figure 1: Communities included in the "strong LGBTTTQQIAA" acronym
Resiliency and Protective Factors

Research on LGBTQ+ youth has focused on the risk factors and disparities these young people experience compared with youth who are not LGBTQ+. However, more recently there has been research on resiliency and protective factors, which offers a strength-based focus on LGBTQ+ youth well-being. For instance, LGBTQ+ youth who have access to spaces that affirm their sexual orientation and gender identity report lower rates of attempting suicide and experiencing supportive environments.

Several factors that can help improve outcomes for LGBTQ+ young people include:

Addressing LGBTQ+-related stigma, discrimination, and violence

Building on the strengths of LGBTQ+ youth

Fostering supports such as family acceptance and safe, affirming environments in schools and other settings

Federal and local policies and practices increasingly acknowledge and focus on the experiences and needs of LGBTQ+ youth. Numerous national advocacy and other organizations are also giving greater attention to LGBTQ+ youth in their work. Fostering safe, affirming communities and youth-serving settings such as schools for all youth requires efforts to address the challenges described here. At the same time, it is also important to acknowledge and build on the strengths, resilience, and factors that protect LGBTQ+ youth from risk, such as connection to caring adults and peers and family acceptance. Parental support of sexual orientation and gender expression provide uniquely strong benefits to positive well-being and mental health in young adulthood and are related to higher levels of self-esteem and lower levels of depression, suicidal ideation, and suicide attempts.

Young people who identify as LGBTQ+ can experience various challenges because of how others respond to their sexual orientation or gender identity/expression. This is also true for youth who are questioning their sexual orientation or gender identity, or may be perceived as LGBTQ+ or gender variant by others. In a 2021 survey of nearly 35,000 LGBTQ+ youth, 75 percent reported having experienced discrimination based on their sexual orientation or gender identity at least once in their lifetime. These negative experiences include high rates of physical and emotional bias and violence; rejection by schools, employment, and communities because of their sexual orientation and/or gender identity/expression.

Research shows that due to these challenges and the associated stress, LGBTQ+ youth are at risk for negative health outcomes and are more likely to attempt suicide, experience homelessness, and use illegal drugs These issues may also contribute to anxiety, depressive symptoms, and feelings of isolation. Youth who express their gender in ways that vary from societal expectations for their perceived sex or gender are at risk for high levels of childhood physical, psychological, and sexual abuse. They are also at risk for school victimization. As a result, they may have poorer well-being than lesbian, gay, and bisexual peers whose gender expression is more closely aligned with societal expectations.

Resources

Health Considerations for LGBTQ Youth
This website provides information on protective factors and data related to health risks and sexual minority youth, as well as related resources.

Practice Brief 1: Providing Services and Supports for Youth Who Are Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex, or Two-Spirit (LGBTQI2-S)(PDF, 8 pages)
This practice brief outlines key information for working with and providing culturally and linguistically competent services to LGBTQI2-S youth.

References
1 Poirier, Fisher, Hunt, & Bearse, 2014
² Poirier, Fisher, Hunt, & Bearse, 2014
³ Poirier, Fisher, Hunt, & Bearse, 2014
⁴ The National Trevor Project, 2021
⁵ Day, Ioverno, & Russell, 2019
⁶ American Association of School Administrators et al., n.d.; National Association of School Nurses, 2003; National Association of School Psychologists, 2006
⁷ Shilo & Savaya, 2011; Sheets & Moor, 2009; Ryann et al., 2010; Snapp et al., 2015; Russell & Fish, 2016
⁸ Gender variant youth are not necessarily LGBT. In fact, any youth who does not fit typical social expectations for his or her mannerisms, behavior, or choice of clothing based on birth-assigned gender, for example, can be considered "gender variant." This does not mean the youth is lesbian, gay, or bisexual - or identifies as a gender different from what he or she was assigned at birth (i.e., transgender).
⁹ The National Trevor Project, 2021 (45 percent of this sample were youth of color, and 38 percent were transgender or nonbinary.
¹⁰ Hunter & Schaecher, 1987; Reis, 1999; Reis & Saewyc, 1999; Ray, 2006; Ryan, Huebner, Diaz, & Sanchez, 2009; SAMHSA, 2014
¹¹ Roberts, Rosario, Corliss, Koenen, & Austin, 2012
¹² Toomey, Ryan, Diaz, & Russell, 2010
¹³ Rieger & Savin-Williams, 2012

# data[].attributes.attachment_link.description
Sexual orientation and gender identity/expression are important aspects of a young person's identity. Understanding and expressing sexual orientation and gender and developing related identities are typical development tasks that vary across children and youth. For example, some youth may be unsure of their sexual orientation, whereas others have been clear about it since childhood and have expressed it since a young age.

# data[].attributes.headline
Religion can contribute to mental health within youth

# data[].attributes.subject
Religion can contribute to mental health within youth

# data[].attributes.body
This can be a challenge in the school aspect because so many students can come from different religious backgrounds, and confusing and mixing them can confuse others. This can also interfere with school, religious holidays, and everything else. Each religion teaches differently as well, so each student could learn at a much different rate than the rest.

# data[].attributes.attachment_link.provider_name
International Journal of Mental Health Systems

# data[].attributes.attachment_link.readable_text
International Journal of Mental Health Systems 13, Article number: 28 (2019) Cite this article

12k Accesses

3 Citations

9 Altmetric

Metrics

Abstract

Background

Mental disorders contribute substantial burden to the society due to their widespread occurrence and debilitating effects. A quarter of the world's population are children and adolescents, a significant number of whom experience mental disorders as early as the age of 14. Some interventions have been found to effectively reduce the risk factors and reinforce protective or preventive factors. However, there is still a need to put emphasis on mental health promotion strategies such as religious education. This paper aims to discuss the importance of religious education in promoting mental health.

Discussion

Religious education can be instrumental to improving adolescent mental health. Specifically, it can: (1) help develop healthier reaction to stimuli through the internalization of religious morality; (2) reinforce religious coping mechanisms which reduce the impact of stresses, enhance coping skills, and promote a less risky lifestyle; (3) increase awareness regarding religious beliefs and practices and their influence on the individual, the family, and the community; and finally, (4) promote connectedness which can enhance self-esteem and well-being. However, negative health outcomes such as discrimination and social isolation can also develop, especially among religious or gender minority groups.

Conclusion

It is important to reflect on the crucial role of religious education on adolescent mental health. School-based mental health education and promotion strategies can maximize the benefits of religious education by putting emphasis on effective implementation of religious education to positively influence adolescent mental health.

Background

Mental disorders are global public health concerns due to their widespread occurrences and debilitating effects. In 2010, mental, neurological, and substance abuse disorders accounted for 258 million disability-adjusted life years (DALYs), equivalent to 10.4% of global DALYs, 2.3% of global years of life lost (YLLs), and 28.5% of global years lived with disability (YLDs) [ 1]. The most recent estimates from the World Health Organization identified depressive disorders as the largest contributor to global YLD, accounting for 50 million or 7.5% of all YLDs [ 2].

Adolescence is a critical period of cognitive and behavioral human development. According to Erik Erikson's Social-Emotional Development Theory, it is during this stage when an individual urgently needs to search for a proper role model to answer the big question of who he/she is and his/her moral and spiritual aspects. This formation of identity is a major event in the development of personality and is associated with positive life outcomes [ 3]. Moreover, it is during this period when an individual develops the capacity to understand and internalize religion-its beliefs, values, and practices [ 4], which can lead to changes in the pattern of religious participation [ 5]. Furthermore, the emergence of mental disorders coincides with this developmental period, with an estimated half of mental disorders manifesting as early as 14 years old [ 6]. On a global scale, 10-20% of this population experience mental disorders, with depression contributing the largest burden of disease [ 3]. Poor mental health has been shown to affect the overall health and well-being of adolescents and is associated with adverse health and social outcomes like substance abuse, adolescent pregnancy, school drop-out, and delinquent behaviors, among others.

Mental disorders contribute substantial burden to the society. Given the magnitude of this public health problem, it is necessary to employ strategies which can effectively reduce its occurrence. Strategies which put emphasis on improving social determinants of health such as nutrition, housing, access to education, reductions in economic insecurity and harm from addictive substances, and strengthening of community networks have been found to reduce risks, reinforce protective factors, and decrease psychiatric symptoms and disability and the onset of some mental disorders [ 7]. School-based interventions are especially advantageous in addressing mental disorders, since children and adolescents spend more time in this setting than in any other formal institutions. Interventions implemented in schools which aim to improve adolescent mental health using strategies such as gatekeeper training and improving knowledge or mental health literacy among others are found to be effective in increasing knowledge, self-esteem, and social support thus reducing risk factors [ 8, 9, 10]; however, there is limited information on the integration of religious education in these interventions, which can be an effective approach in promoting mental health. This paper discusses religious education and how it can influence adolescent mental health.

Discussion

Defining religious education

Religious education aims to provide students with knowledge and understanding of, as well as to develop sensitivity to different religions [ 11]. Religious education has been traditionally categorized into: (a) confessional religious education, which seeks to promote obligation towards a specific religion, such as Islam [ 12], or Catholicism [ 13]; and (b) non- confessional religious education, which focuses on providing information about religion/religions for students to expand their understanding on the different worldviews and eventually result in the development of tolerance for other religions [ 14]. Confessional religious education is implemented in countries such Austria and Croatia, while non-confessional religious education is present in Slovenia [ 15]. Education is crucial to the development of a tolerant society. The education system in many countries have evolved from being secular to one that promotes pluralism, an understanding that people will have different conceptions of the good and understanding of the best way to live life morally [ 16]. In the United States, for example, public education was designed to teach Protestant values. However, the increase in the Catholic population has led to the instruction of religion as a subject matter without any intention of indoctrination. Religious education remains a topic for debate because of the inviolable separation of the Church and State in some countries [ 17]. Nevertheless, teaching religion in secular schools can provide a student with deeper understanding of different cultures around the world, enrich a student's understanding of human experiences, and allow the student to acquire values that they can integrate into their own lives [ 18].

Adolescence and religion

Adolescence is the stage of human development which Erik Erikson states as a transition period from childhood to adulthood. An integral component of this developmental stage is identity development, wherein an individual develops the ability to think about abstract concepts and the capacity to think about the consequences of decisions that they make. This developmental stage is also characterized by an increase in their sense of autonomy, leading to more interaction with peers and other individuals [ 3]. These changes that occur in adolescents affect their view about religion and its accompanying beliefs and practices. In their quest to develop their identity, they start searching for life's meaning and become critical of ideologies being taught in religion. Consequently, adolescents question or reject some religious ideas which were taught to them by adults during early age [ 19]. Experiences and interaction with others during this developmental period are also critical in the development of religiosity. For example, family structure and attachment influence how religious behaviors and attitudes are transmitted from parents to their children; adolescents who were raised by both parents and grew up in families with close relationships are more likely to adopt their parents' religious beliefs and practices [ 20]. Similarly, peers influence adolescent religiosity in the sense that religiosity fosters greater peer attachment; that is, religious adolescents tend to have more friends who foster the same religious belief and they are less likely to engage in delinquent behavior [ 21].

The role of religious education in adolescent mental health

Religion and its effect on health and well-being has been the subject of many previous studies [ 22]. Although the definitions for both religiosity and spirituality remains a point of debate among researchers, the two concepts are considered as related [ 23] and include several dimensions such as beliefs, attitudes, and behaviors, to name a few [ 24]. A recent systematic review and meta-analysis of randomized controlled trials which investigated the effects of religious and spiritual interventions showed positive effects on mental health outcomes such as significant decrease in stress, alcoholism, and depression [ 25]. However, the importance of religious education in the promotion of both physical and mental health in the school has not been given emphasis despite several religions teaching about overall health and well-being. For example, Islam teaches the importance of personal hygiene, stress management, and eating healthy [ 26]; Buddhism teaches avoidance of any drink or drug which can cloud the mind [ 27]; the Catholic Christian spiritual perspective puts emphasis on confession of sins for forgiveness by God to provide relief to a troubled mind; and Jewish beliefs emphasize that their bodies belong to God and should therefore take care of it by maintaining a proper diet, getting adequate exercise and sleep, maintaining good hygiene, and having a healthy mind [ 28].

One of the basic aims of religious education is to promote awareness about religious beliefs and practices and how these affect the individual, the family, and the community [ 29]. Previous studies have presented evidence of the positive effects of religious education against risky health behaviors such as alcohol use, drug use, violence [ 30], and suicidal ideation [ 31]. Religious education can be instrumental to improving adolescent mental health by developing religious morality, reinforcing religious coping, developing respect for religious diversity, and promoting connectedness.

Religious beliefs and practices contribute substantially to the development of personal morality and sound judgment, which influence decisions that shape one's life. Religious education strengthens the formation of moral consciousness through the internalization of religious morality [ 32]. Internalization, the process wherein an individual adopts the values or regulations prescribed by a religion as their own [ 33], can affect mental health [ 34]. Religious moral beliefs such as objections to suicide can also influence suicide rates and attitudes towards suicide [ 35].

Religious beliefs also affect how individuals deal with stressful situations, suffering, and life problems [ 36] as it enhances acceptance and one's ability to function competently in the face of stress and adversity [ 37]. Religious education reinforces religious coping, which is the use of cognitive behavioral techniques to manage stressful situations in light of one's spirituality or religious beliefs [ 38]. Previous studies have shown that people frequently count on religion to cope with stressful situations [ 35, 36, 39, 40]. Furthermore, meta-analyses have already indicated the positive impacts of religious coping on health wellbeing [ 41, 42, 43]. Positive religious coping involves engaging in religious practices, seeking social support through religious leaders and congregations, and reframing stressful events in reference to their relationship with God [ 43, 44, 45]. Some of these practices and religious involvement have been proven to help in dealing with stressful situations, anxiety, and isolation, displacement after natural disasters, among others [ 46]. For example, meditation and yoga have been demonstrated to relieve tension and anxiety and stabilize emotions. Traditionally, studies have examined religious coping among Christian populations. However, ethnic minorities living as long-term residents in Western countries have begun to receive attention. These findings suggest that disempowered and deprived groups, including women and ethnic minorities, resort to the use of religious coping and found great efficacy in it [ 43]. In addition, religious coping has been shown to be extensively used when situations are deemed uncontrollable [ 41, 47], thus providing an outlet for those at a social disadvantage and with limited access to external resources [ 48]. Based on these findings, it is apparent that religious coping serves as a resilience mechanism as it enhances a more stable and positive measures of wellbeing. The use of religious coping can enhance contentment with one's life, thus, potentially protecting against the long-term effects of distress [ 49].

Religious education can likewise serve as a vehicle to emphasize respect for diversity, by providing a venue for adolescents to understand the differences in religions and world views. Social skills are needed to live and work together harmoniously and to function effectively in a diverse society [ 50]. It is likewise vital to developing good relationships and values and respecting differences at a personal level [ 51]. By talking about other's beliefs and traditions, students are equipped with social skills and the ability to prevent prejudice and hatred towards others [ 52]. Exploring issues within and across faiths can teach children and adolescents how to understand and respect different religions, beliefs, values and traditions (including ethical life stances), and their influence on individuals, societies, communities and cultures [ 53]. Putting emphasis on religious diversity can eventually reduce, if not eliminate, cases of bullying, offensive behavior, and violence [ 54].

Schools exist not only to provide academic knowledge to students, but also to promote connectedness among its students and teachers. Through religious education, the learning atmosphere can be improved by connecting students regardless of their faith [ 50]. It has been found that receiving religious education provided students with a higher purpose in life and more social support from peers [ 55]. It can also be a means for teaching religious beliefs and practices which promote support and care for one another. The social support one receives from being part of religious communities and participating in religious practices contributes to positive mental health and well-being [ 56, 57]. This social support, which accounts largely to the impact of religiosity to well-being, can be credited to the concept of love and brotherhood being promoted by religious teachings [ 58]. Research has shown that participating in religious practices has positive effects on adolescents in terms of having higher self-esteem and lower incidence of substance abuse through engaging in religious practices, adolescents achieved a feeling of belongingness [ 22]. Furthermore, social relationships formed through religious involvement are likewise found to intervene with adolescent suicide ideation [ 59].

Previous studies have also reported some negative effects of religion and religious education on mental health. In some cases, religious beliefs and practices contributed to the development of certain disorders like obsession, anxiety, and depression [ 60]. In other cases, religiosity was cited as a deterrent in seeking professional help for mental health [ 61, 62, 63]. There are also conflicting findings regarding radicalism and extremism due to religious education. In the case of Pakistan and Indonesia, religious educational institutions were reported to be exploited by perpetrators of extremism [ 64, 65]. However, others argue that there is no sufficient evidence to conclude that Islamic education contributes to extremism; on the contrary it is reported to foster civic empowerment among students [ 66].

Additionally, students who are considered as religious minority are also at risk to developing negative mental health outcomes. For example, non-Christian students attending a school where majority of the population are Christians can experience religious discrimination or microaggressions [ 67]. A previous study has also found that a religious "mismatch" (i.e. students attending a school with religious education which is different from their religion) increased the risk of suicide attempts and self-harm significantly [ 68]. Other issues identified by previous studies include concerns about schools as being safe spaces [ 69].

Aside from negative effects experienced by religious minority, religious education can also negatively impact adolescents who belong to sexual minority groups. As discussed previously, adolescence is an important period of personal development and sexual identity development figures prominently during this stage. However, previous studies have reported negative effects of religious education on lesbian, gay, bisexual, transgender, and queer (or questioning) (LGBTQ) adolescents. Although gender discrimination is not unique to religious schools, hostile messages promoted by religious denominations and groups can foster victimization of LGBTQ adolescents [ 70, 71, 72]. These religiously-based messages of discrimination can contribute to social exclusion. Furthermore, non-acceptance of LGBTQ views (i.e. not accepted or permitted in school work) can also undermine academic achievement [ 72]. Despite, these unintended negative outcomes, religion remains an important aspect of human life, and if implemented properly, religious education can positively influence adolescent mental health.

Conclusion

Schools are an effective setting for gathering large populations of adolescents for mental health promotion and it is also important to reflect on the crucial role of religious education on mental health among this age group. School-based mental health education and promotion strategies can maximize the benefits of religious education by putting emphasis on effective implementation of religious education to influence adolescent mental health.

Abbreviations

DALY:

disability-adjusted life years

LGBTQ:

lesbian, gay, bisexual, transgender, and queer (or questioning)

YLD:

years of life lived with disability

YLL:

years of life lost

References

Download references

Authors' contributions

JK conceived the presented idea. CAME and MFTCL wrote the manuscript in consultation with EA, ERG, CRL, and RRQ. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Availability of data and materials

Not applicable.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Not applicable.

Funding

This paper was supported by the Research Grant for National Center for Global Health and Medicine (30-3, 30-4).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Author information

Affiliations

1. Department of Global Health, School of Health Sciences, University of the Ryukyus, Okinawa, Japan

Crystal Amiel M. Estrada & Jun Kobayashi

2. Department of Environmental and Occupational Health, College of Public Health, University of the Philippines Manila, Manila, Philippines

Marian Fe Theresa C. Lomboy & Romeo R. Quizon

3. Department of Health Promotion and Education, College of Public Health, University of the Philippines Manila, Manila, Philippines

Ernesto R. Gregorio Jr.

4. Faculty of Medicine, Mataram University, Mataram, Indonesia

Emmy Amalia

5. Department of Psychiatry and Behavioral Medicine, College of Medicine, University of the Philippines Manila, Manila, Philippines

Cynthia R. Leynes

6. Japanese Consortium for Global School Health Research, Nishihara, Japan

Jun Kobayashi

Corresponding authors

Correspondence to Crystal Amiel M. Estrada or Jun Kobayashi.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Reprints and Permissions

About this article

Cite this article

Estrada, C.A.M., Lomboy, M.F.T.C., Gregorio, E.R. et al. Religious education can contribute to adolescent mental health in school settings. Int J Ment Health Syst 13, 28 (2019). https://doi.org/10.1186/s13033-019-0286-7
Download citation
Keywords

Religious education

Adolescent mental health

Schools

# data[].attributes.attachment_link.title
Religious education can contribute to adolescent mental health in school settings

# data[].attributes.attachment_link.description
Background Mental disorders contribute substantial burden to the society due to their widespread occurrence and debilitating effects. A quarter of the world's population are children and adolescents, a significant number of whom experience mental disorders as early as the age of 14.

# data[].attributes.attachment_link.readable_text
Meaningful Family Engagement

Family engagement is essential in promoting healthy physical, cognitive and social-emotional development, and academic achievement of children and youth from pre-K to high school. Research shows that when families are meaningfully and continuously engaged in their children's learning and development, they can positively impact their child's health, development, academic, and well-being outcomes into adulthood.,

Description of Family Engagement

Strong family engagement happens when families have a primary and meaningful role in all decision-making that impacts every young person and their families. Meaningful family engagement is about improving outcomes for all youth and families and happens at the system level and at the service level.

At the system level, family engagement is evident when families routinely engage as equal partners with state and local leaders in planning, designing, and evaluating services, programs and policies that impact the lives of children, youth and families served.

Family engagement also happens at the individual service level where agency partners and a single family collaborate in making decisions that address their child's unique strengths and needs and considers the family's ideas of success. Meaningful family engagement requires that state and local leaders model and champion family partnership anchored by mutual respect, shared authority, two-way communication, and a commitment to a common vision and shared goals to improve outcomes for every young person and their family.,

Definition of "Family" in Family Engagement

Child and youth serving systems broadly define "family" in family engagement as including parents and other adult caregivers, acknowledging today's varied family units and their needs for extended supports. For example, early childhood education and juvenile justice programming describe family engagement as including biological, adoptive, and foster parents; grandparents; legal and informal guardians; and adult siblings.,

Some agencies have broadened this definition of family to include related and non-related members. As an example, transition-aged and foster youth work with their providers to identify and name their personal family system that includes peers, mentors, and service providers who they trust and can count on for support. Key service sectors that are implementing family engagement plans and strategies to increase and improve the engagement of families in their systems and services include education, child welfare, juvenile justice, mental health, and primary health care providers.

References

Weiss, Lopez, & Caspe, 2016
Henderson & Mapp, 2002
U.S. Departments of Health and Human Services and Education, 2016
Child Welfare Information Gateway, 2016
U.S. Departments of Health and Human Services and Education, 2016
Development Services Group, Inc., 2018

# data[].attributes.attachment_link.description
Family engagement is essential in promoting healthy physical, cognitive and social-emotional development, and academic achievement of children and youth from pre-K to high school.

# data[].attributes.body
Race can play a massive part in the education stance, because if a child is treated differently because of their skin color then the other children can start to get confused on why they aren't treated the same or even better.

# data[].attributes.attachment_link.readable_text
Maria Trent, Danielle G. Dooley, Jacqueline Dougé, SECTION ON ADOLESCENT HEALTH, COUNCIL ON COMMUNITY PEDIATRICS, COMMITTEE ON ADOLESCENCE, Robert M. Cavanaugh, Amy E. Lacroix, Jonathon Fanburg, Maria H. Rahmandar, Laurie L. Hornberger, Marcie B. Schneider, Sophia Yen, Lance Alix Chilton, Andrea E. Green, Kimberley Jo Dilley, Juan Raul Gutierrez, James H. Duffee, Virginia A. Keane, Scott Daniel Krugman, Carla Dawn McKelvey, Julie Michelle Linton, Jacqueline Lee Nelson, Gerri Mattson, Cora C. Breuner, Elizabeth M. Alderman, Laura K. Grubb, Janet Lee, Makia E. Powers, Maria H. Rahmandar, Krishna K. Upadhya, Stephenie B. Wallace; The Impact of Racism on Child and Adolescent Health. Pediatrics August 2019; 144 (2): e20191765. 10.1542/peds.2019-1765

Download citation file:

# data[].attributes.attachment_link.title
The Impact of Racism on Child and Adolescent Health

# data[].attributes.attachment_link.description
The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others. Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.

# data[].attributes.body
This could confuse children in the educational aspect because they may start to question why they cannot have certain things that other children can.

# data[].attributes.attachment_link.title
Socioeconomic status and health behavior in children and adolescents: a systematic literature review

# data[].attributes.attachment_link.description
Socioeconomic status affects individuals’ health behaviors and contributes to a complex relationship between health and development. Due to this complexity, the relationship between SES and health behaviors is not yet fully understood. This…

# data[].attributes.body
I would have to understand that each child comes from a different background, and then not take too many favorites based on how they were born or raised.

# data[].attributes.attachment_link.readable_text
An implicit bias is an unconscious association, belief, or attitude toward any social group. Implicit biases are one reason why people often attribute certain qualities or characteristics to all members of a particular group, a phenomenon known as stereotyping.

It is important to remember that implicit biases operate almost entirely on an unconscious level. While explicit biases and prejudices are intentional and controllable, implicit biases are less so.

A person may even express explicit disapproval of a certain attitude or belief while still harboring similar biases on a more unconscious level. Such biases do not necessarily align with our own sense of self and personal identity. People can also hold positive or negative associations about their own race, gender, religion, sexuality, or other personal characteristics.

Causes of Implicit Bias

While people might like to believe that they are not susceptible to these implicit biases and stereotypes, the reality is that everyone engages in them whether they like it or not. This reality, however, does not mean that you are necessarily prejudiced or inclined to discriminate against other people. It simply means that your brain is working in a way that makes associations and generalizations.

In addition to the fact that we are influenced by our environment and stereotypes that already exist in the society into which we were born, it is generally impossible to separate ourselves from the influence of society.

You can, however, become more aware of your unconscious thinking and the ways in which society influences you.

It is the natural tendency of the brain to sift, sort, and categorize information about the world that leads to the formation of these implicit biases. We're susceptible to bias because of these tendencies:

We tend to seek out patterns.Implicit bias occurs because of the brain's natural tendency to look for patterns and associations in the world. Social cognition, or our ability to store, process, and apply information about people in social situations, is dependent on this ability to form associations about the world.

We like to take shortcuts. Like other cognitive biases, implicit bias is a result of the brain's tendency to try to simplify the world. Because the brain is constantly inundated with more information than it could conceivably process, mental shortcuts make it faster and easier for the brain to sort through all of this data.

Our experiences and social conditioning play a role. Implicit biases are influenced by experiences, although these attitudes may not be the result of direct personal experience. Cultural conditioning, media portrayals, and upbringing can all contribute to the implicit associations that people form about the members of other social groups.

How Implicit Bias Is Measured

The term implicit bias was first coined by social psychologists Mahzarin Banaji and Tony Greenwald in 1995. In an influential paper introducing their theory of implicit social cognition, they proposed that social behavior was largely influenced by unconscious associations and judgments.

In 1998, Banaji and Greenwald published their now-famous Implicit Association Test (IAT) to support their hypothesis. The test utilizes a computer program to show respondents a series of images and words to determine how long it takes someone to choose between two things.

Subjects might be shown images of faces of different racial backgrounds, for example, in conjunction with either a positive word or a negative word. Subjects would then be asked to click on a positive word when they saw an image of someone from one race and to click on a negative word when they saw someone of another race.

Interpreting the Results

The researchers suggest that when someone clicks quickly, it means that they possess a stronger unconscious association.﻿﻿ If a person quickly clicks on a negative word every time they see a person of a particular race, the researchers suggest that this would indicate that they hold an implicit negative bias toward individuals of that race.

In addition to a test of implicit racial attitudes, the IAT has also been utilized to measure unconscious biases related to gender, weight, sexuality, disability, and other areas. The IAT has grown in popularity and use over the last decade, yet has recently come under fire.

Among the main criticisms are findings that the test results may lack reliability. Respondents may score high on racial bias on one test, and low the next time they are tested.

Also of concern is that scores on the test may not necessarily correlate with individual behavior. People may score high for a type of bias on the IAT, but those results may not accurately predict how they would relate to members of a specific social group.

Link Between Implicit Bias and Discrimination

It is important to understand that implicit bias is not the same thing as racism, although the two concepts are related. Overt racism involves conscious prejudice against members of a particular racial group and can be influenced by both explicit and implicit biases.

Other forms of discrimination that can be influenced by unconscious biases include ageism, sexism, homophobia, and ableism.

One of the benefits of being aware of the potential impact of implicit social biases is that you can take a more active role in overcoming social stereotypes, discrimination, and prejudice.

Effects of Implicit Bias

Implicit biases can influence how people behave toward the members of different social groups. Researchers have found that such bias can have effects in a number of settings, including in school, work, and legal proceedings.

Implicit Bias in School

Implicit bias can lead to a phenomenon known as stereotype threat in which people internalize negative stereotypes about themselves based upon group associations. Research has shown, for example, that young girls often internalize implicit attitudes related to gender and math performance.﻿﻿

By the age of 9, girls have been shown to exhibit the unconscious beliefs that females have a preference for language over math.﻿﻿ The stronger these implicit beliefs are, the less likely girls and women are to pursue math performance in school. Such unconscious beliefs are also believed to play a role in inhibiting women from pursuing careers in science, technology, engineering, and mathematics (STEM) fields.

Studies have also demonstrated that implicit attitudes can also influence how teachers respond to student behavior, suggesting that implicit bias can have a powerful impact on educational access and academic achievement.

One study, for example, found that Black children-and Black boys in particular-were more likely to be expelled from school for behavioral issues. When teachers were told to watch for challenging behaviors, they were more likely to focus on Black children than on White children.

Implicit Bias In the Workplace

While the Implicit Attitude Test itself may have pitfalls, these problems do not negate the existence of implicit bias. Or the existence and effects of bias, prejudice, and discrimination in the real world. Such prejudices can have very real and potentially devastating consequences.

One study, for example, found that when Black and White job seekers sent out similar resumes to employers, Black applicants were half as likely to be called in for interviews as White job seekers with equal qualifications.

Such discrimination is likely the result of both explicit and implicit biases toward racial groups.

Even when employers strive to eliminate potential bias in hiring, subtle implicit biases may still have an impact on how people are selected for jobs or promoted to advanced positions. Avoiding such biases entirely can be difficult, but being aware of their existence and striving to minimize them can help.

Implicit Bias in Healthcare Settings

Certainly, age, race, or health condition should not play a role in how patients get treated, however, implicit bias can influence quality healthcare and have long-term impacts including suboptimal care, adverse outcomes, and even death.

For example, one study published in the American Journal of Public Health found that physicians with high scores in implicit bias tended to dominate conversations with Black patients and, as a result, the Black patients had less confidence and trust in the provider and rated the quality of their care lower.﻿﻿

Researchers continue to investigate implicit bias in relation to other ethnic groups as well as specific health conditions, including type 2 diabetes, obesity, mental health, and substance use disorders.

Implicit Bias in Legal Settings

Implicit biases can also have troubling implications in legal proceedings, influencing everything from initial police contact all the way through sentencing. Research has found that there is an overwhelming racial disparity in how Black defendants are treated in criminal sentencing.﻿﻿

Not only are Black defendants less likely to be offered plea bargains than White defendants charged with similar crimes, but they are also more likely to receive longer and harsher sentences than White defendants.

Strategies to Reduce the Impact of Implict Bias

Implicit biases impact behavior, but there are things that you can do to reduce your own bias. Some ways that you can reduce the influence of implicit bias:

Focus on seeing people as individuals. Rather than focusing on stereotypes to define people, spend time considering them on a more personal, individual level.

Work on consciously changing your stereotypes. If you do recognize that your response to a person might be rooted in biases or stereotypes, make an effort to consciously adjust your response.

Take time to pause and reflect. In order to reduce reflexive reactions, take time to reflect on potential biases and replace them with positive examples of the stereotyped group.

Adjust your perspective. Try seeing things from another person's point of view. How would you respond if you were in the same position? What factors might contribute to how a person acts in a particular setting or situation?

Increase your exposure. Spend more time with people of different racial backgrounds. Learn about their culture by attending community events or exhibits.

Practice mindfulness. Try meditation, yoga, or focused breathing to increase mindfulness and become more aware of your thoughts and actions.

Recap

While implicit bias is difficult to eliminate altogether, there are strategies that you can utilize to reduce its impact. Taking steps such as actively working to overcome your biases, taking other people's perspectives, seeking greater diversity in your life, and building your awareness about your own thoughts are a few ways to reduce the impact of implicit bias.

A Word From Verywell

Implicit biases can be troubling, but they are also a pervasive part of life. Perhaps more troubling, your unconscious attitudes may not necessarily align with your declared beliefs. While people are more likely to hold implicit biases that favor their own in-group, it is not uncommon for people to hold biases against their own social group as well.

The good news is that these implicit biases are not set in stone. Even if you do hold unconscious biases against other groups of people, it is possible to adopt new attitudes, even on the unconscious level.﻿﻿ This process is not necessarily quick or easy, but being aware of the existence of these biases is a good place to start making a change.

# data[].attributes.attachment_link.title
Is It Possible to Overcome Implicit Bias?

# data[].attributes.attachment_link.description
An implicit bias is an unconscious belief about a group of people. Learn more about how these biases form and strategies to reduce their influence on behavior.

# data[].attributes.body
I do not have much cultural competence when it comes to how someone is presented, but I guess I would try to make it easy on each and every student.

# data[].attributes.attachment_link.readable_text
This article will help better understand cultural competence and its components. Adopted cross-cultural attitude strategies will help to develop and enhance the ability to practice effective communication in intercultural situations.

Working and living in a global society requires the ability to create interactions and relationships with people who are different from oneself. It is critical to know how to assess our cultural competency and evaluate our own cultural behaviors. Globalization and diversity lowered the barriers that once separated cultures both internationally and domestically (Garneau & Pepin, 2015). Cultural competency skills can help businesses run more productively, and efficiently. Practicing cultural competency skills can also elevate your customer service skills. Exceptional customer service gives you the ability to set your business apart from your competitors and keeps your customers returning to your business.

What is culture?

In 1951, Kluckhohn explained culture as sharing a pattern of thinking, feeling, reacting, and problem-solving. Culture is a dynamic relational process of shared meanings that originate in the interactions between individuals (Carpenter-Song, Schwallie, & Longhofer, 2007). In 2010, Gregory and colleagues emphasized that culture must be considered in historical, social, political, and economic contexts. Betancourt (2004) defined culture as a pattern of learned beliefs, values, and behavior that are shared within a group; it includes language, styles of communication, practices, customs, and views on roles and relationships. Edgar Schein (2010) described a culture as "shared beliefs, values, and assumptions of a group of people who learn from one another and teach to others that their behaviors, attitudes, and perspectives are the correct ways to think, act, and feel." Psychologists argue that unfamiliar culture negatively affects an individual's sensemaking mechanisms and determine their behavioral responses. As a result, individuals cannot accurately perceive, interpret, explain, and predict the behavior of people with different cultural background(s) (Muzychenko, 2008).

What is cultural intelligence?

Cultural intelligence is the ability to interpret the stranger's behavior the way the stranger's compatriots would (Muzychenko 2008). For example, if employees don't feel as if their manager understands or respects their culture, employees may find it hard to trust the leader or work as a team.

What is cultural competence?

Current research on cultural competence focuses on sensitivity to cross-cultural differences and the ability to adapt to other cultural environments (e.g., Hansen, Pepitone-Arreola-Rockwell, & Greene, 2000), or reflective awareness of cultural influences on one's thoughts and behaviors (Chao, Okazaki, & Hong, 2011). Muzychenko (2008) defined cultural competence as the appropriateness and effectiveness of one's behavior in an alien cultural environment. Wilson, Ward, and Fischer (2013) defined cultural competence as "the acquisition and maintenance of culture-specific skills" for very practical reasons:

function effectively within a new cultural context.

interact effectively with people from different cultural backgrounds.

Williams (2001) defined cultural competence as " the ability of individuals and systems to work or respond effectively across cultures in a way that acknowledges and respects the culture of the person or organization being served" p.1.

Why do we need to develop cultural competence?

Developing cultural competence helps us understand, communicate with, and effectively interact with people across cultures. It gives us the ability to compare different cultures with our own and better understand the differences. Unconsciously, we bring our own cultural frame of interpretation to any situation. This is not to say that culture alone determines how one interprets a situation. One's own unique history and personality also play an important role (Hofstede, 2002).

How do we develop an attitude and components of cultural competence?

Developing cross-cultural attitudes allows one to develop skills for better engaging with people from all kinds of cultures. Cross-cultural skills demonstrated through the ability to communicate with respect; recognize others' values, accept knowledge, skills, and talents; and tolerate, engage, and celebrate the success of others. Deardorff defined competence as " the ability to communicate effectively and appropriately in intercultural situations based on one's intercultural knowledge, skills, and attitudes" (Deardorff, 2006, pp. 247-248). We adopted Deardorff (2006) cross-cultural attitude strategies that help you to develop and enhance one's ability to practice effective communication in intercultural situations:

Practice openness by demonstrating acceptance of difference.

Be flexible by demonstrating acceptance of ambiguity.

Demonstrate humility through suspension of judgment and the ability to learn.

Be sensitive to others by appreciating cultural differences.

Show a spirit of adventure by showing curiosity and seeing opportunities in different situations.

Use a sense of humor through the ability to laugh at ourselves.

Practice positive change or action by demonstratinga successful interaction with the identified culture.

Borchum (2002) described cultural competence as " a non-linear dynamic process that is never-ending and ever expending. It is built on increases in knowledge and skill development related to its attributes" p. 5. We synthesized and adopted Williams's (2001) and Martin and Vaughn's (2007) studies that can assist in better understanding of components of cultural competency. These attributes will guide you in developing cultural competence:

Self-knowledge and awareness about one's own culture.

Awareness of one's own cultural worldview.

Experience and knowledge of different cultural practices.

Attitude toward cultural differences.

In conclusion, our global society necessitates interactions and relationships with people who are different from oneself. By developing one's own cultural competence, productivity and efficiency may increase and in turn improve one's customer service skills. Customers who feel valued and understood will return for repeat business.

Resources

Burchum, J. L. R. (2002, October). Cultural competence: An evolutionary perspective. In: Nursing Forum: (Vol. 37, No. 4, p. 5). Blackwell Publishing Ltd.

Carpenter-Song, E. A., Schwallie, M. N., & Longhofer, J. (2007). Cultural competence reexamined: critique and directions for the future. Psychiatric Services, 58(10), 1362-1365.

Betancourt, J. R. (2004). Cultural competence-marginal or mainstream movement? New England Journal of Medicine, 351(10), 953-955.

Chiu, C.-Y., Lonner, W. J., Matsumoto, D., & Ward, C. (2013). Cross-Cultural Competence: Theory, Research, and Application. Journal of Cross-Cultural Psychology, 44(6), 843-848.

Garneau, A. B., & Pepin, J. (2015). Cultural competence: A constructivist definition. Journal of Transcultural Nursing, 26(1), 9-15.

Gregory, D., Harrowing, J., Lee, B., Doolittle, L., & O'Sullivan, P. S. (2010). Pedagogy as influencing nursing students' essentialized understanding of culture. International Journal of Nursing Education Scholarship, 7(1), 30. doi:10.2202/1548-923X.2025

Hofstede, G. J., Hofstede, G., & Pedersen, P. B. (2012). Exploring culture: exercises, stories, and synthetic cultures. Boston: Intercultural Press.

Hofstede, G. J., Pedersen, P. B., & Hofstede, G. (2002). Exploring culture: Exercises, stories, and synthetic cultures. Nicholas Brealey.

Martin, M., & Vaughn, B. (2007). Cultural competence: The nuts and bolts of diversity and inclusion. Strategic Diversity & Inclusion Management, 1(1), 31-38.

Muzychenko, O. (2008). Cross-cultural entrepreneurial competence in identifying international business opportunities. European Management Journal, 26(6), 366-377.

Schein, E. H. (2010). Organizational culture and leadership (Vol. 2). John Wiley & Sons.

Williams, B. (2001). Accomplishing cross cultural competence in youth development programs. Journal of Extension, 39(6), 1-6.

Wilson, J., Ward, C., & Fischer, R. (2013). Beyond culture learning theory: What can personality tell us about cultural competence? Journal of cross-cultural psychology, 44(6), 900-927.

# data[].attributes.attachment_link.title
What is Cultural Competence and How to Develop It?

# data[].attributes.attachment_link.description
This article will help better understand cultural competence and its components. Adopted cross-cultural attitude strategies will help to develop and enhance the ability to practice effective communication in intercultural situations. Working and living i

# data[].attributes.body
There could be good and evil to cultural competence; everyone has their own opinion of everyone else, but trying to shield it from children would be for the better because having specific views in front of children could confuse them and make them think differently at a young age.

# data[].attributes.body
Everyone has their views on the world, but keeping a clean and appropriate environment for children could allow them to learn the beauty of the world just the way they want to without having so many biases to go off of while growing up.

# data[].attributes.attachment_link.title
How Implicit Bias & Cultural Competence Shape the Patient Healthcare Experience

# data[].attributes.attachment_link.description
Marin Gillis (she/her), PhD, LPh Professor and Interim Chair, department of Justice & Health Humanities Roseman University of Health Sciences, College of Medicine Summerlin, Nevada USA

# data[].attributes.attachment_link.title
NCCC: Curricula Enhancement Module Series

# data[].attributes.body
It would be good to know that each person can be different in many different ways and not be biased on how they act or are raised.

# data[].attributes.attachment_link.readable_text
Cultural Competency is a term we speak a great deal about in our Human Services program here at Ottawa University. When you are considering a career in Human Services, it is important to understand that different cultures have unique histories and experiences. Cultural competence in social work deals with understanding the cultural differences of people in need of social services. Displaying empathy and compassion by fostering mutual respect between the worker and the client is the foundation of any Human Services practice. As such, cultural competence is an integral component in this process.
Why is Cultural Competence Important?
Cultural competence encourages the acknowledgement and acceptance of differences in appearance, behavior and culture. In this field, you will encounter diverse clients from a wide range of backgrounds. Even students who come from diverse neighborhoods will likely come in contact with new cultures as they enter the Human Services field. As we develop our levels of cultural competence, we begin to have a greater appreciation for our clients' journeys.
How to Increase Cultural Competence
Those who who have a career in Human Services should make an ongoing effort to increase their cultural competence. Many who enter the field may feel they have a good grasp on these concepts. However, it is a skill that requires continuous development.

Some believe that cultural competence is practiced by merely showing respect to everyone we encounter without considering our own bias. However, it is impossible to be an expert of knowledge in every culture. Therefore, it is important to admit you are NOT an expert. Always be willing to ask questions with the understanding that you do not nor cannot fully understand the cultures of all the clients you will meet. It is through your willingness to ask questions and listen to your client's story that you demonstrate respect.

When you pursue a career in Human Services you will repeatedly hear the importance of listening. Cultural humility is achieved through listening rather than making assumptions about cultural identities and backgrounds. It is through admitting what we don't know and a willingness to listen that we move beyond cultural competence to what is known as cultural humility.

Social workers demonstrate an appreciation of their own cultural identities and those of others. Self-awareness includes "a lifelong commitment to self-evaluation and self-critique" (Tervalon and Murray-Garcia, 1998). The part about self-critique is where most of us stumble. Some of us find it challenging to recognize the privilege and power we hold. The Human Services classes at Ottawa University teach our students how to deepen their understanding of themselves in order to remain objective with clients. These skills are an essential component of working with the various ethnic populations within the United States.

It is crucial to be aware of our own biases. When interacting with others, it is important for those in the Human Services field to remember that we are looking through the lens of our own gender, race, economic background, religion, and sexual orientation and other lenses that color our perception of others. We must remember that our clients also have their own lenses from which they are looking through as well. If we remember this and are willing to acknowledge these lenses, we will be more empathetic and compassionate as we work with others.

One of the core standards of the National Association of Social Work (NASW) for developing cultural competence is making a commitment to ongoing professional education. Our students examine the framework, skills, analysis of issues, and current intervention strategies for working with individual clients and groups in diverse social services settings within the Human Services courses taken at Ottawa University.

We encourage our students to further their education in order to uphold this code of ethic, set in place by the NASW. After you earn your Bachelor of Arts degree in our Human and Social Services program, you can prepare for a lifelong career of making a positive impact in the lives of others by earning your counseling graduate degree online at Ottawa University.

The good news today is that there are many additional resources for Human Services students to utilize in the search for information on diversity as well as the pursuit of cultural humility. For example, there are podcasts with personalities who offer different perspectives on the topic of race and encourage us to have uncomfortable conversations.

As a student in the Human Services Program at Ottawa University, you will receive ongoing faculty support in your Human Services classes to prepare you for succeeding in your journey toward cultural humility. This field is surrounded by a world of diversity and the education you receive at Ottawa University will prepare you for the joys and challenges that come with that diversity.

When you have a greater understanding of other cultures you will be able to interact with people from a wide range of backgrounds and you will increase your abilities to help your clients receive the highest level of support. Contact us for further information about how we can help you begin your journey as a social worker.

Reference

Tervalon, M. & Murray-Garcia.J. (1998) Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117-125

# data[].attributes.attachment_link.title
Why is Cultural Competence Important| Human Services Blog Article | Ottawa University | Online Degree Programs | Ottawa University

# data[].attributes.attachment_link.description
Cultural Competency is a term we speak a great deal about in our Human Services program here at Ottawa University. When you are considering a career in Human Services, it is important to understand that different cultures have unique histories and experiences.

# data[].attributes.attachment_link.title
Cultural Competence vs. Cultural Humility: Key Differences

# data[].attributes.attachment_link.description
Cultural competence and cultural humility are key concepts in social work. Learn the difference between the two and how to apply it as a social worker.

# data[].attributes.attachment_link.readable_text
Show authors

BMC Health Services Research 19, Article number: 135 (2019) Cite this article

81k Accesses

52 Citations

19 Altmetric

Metrics

Abstract

Background

Cross-cultural educational initiatives for professionals are now commonplace across a variety of sectors including health care. A growing number of studies have attempted to explore the utility of such initiatives on workplace behaviors and client outcomes. Yet few studies have explored how professionals perceive cross-cultural educational models (e.g., cultural awareness, cultural competence) and the extent to which they (and their organizations) execute the principles in practice. In response, this study aimed to explore the general perspectives of health care professionals on culturally competent care, their experiences working with multi-cultural patients, their own levels of cultural competence and the extent to which they believe their workplaces address cross-cultural challenges.

Methods

The perspectives and experiences of a sample of 56 health care professionals across several health care systems from a Mid-Western state in the United States were sourced via a 19-item questionnaire. The questionnaire comprised both open-ended questions and multiple choice items. Percentages across participant responses were calculated for multiple choice items. A thematic analysis of open-ended responses was undertaken to identify dominant themes.

Results

Participants largely expressed confidence in their ability to meet the needs of multi-cultural clientele despite almost half the sample not having undergone formal cross-cultural training. The majority of the sample appeared to view cross-cultural education from a 'cultural awareness' perspective - effective cross-cultural care was often defined in terms of possessing useful cultural knowledge (e.g., norms and customs) and facilitating communication (the use of interpreters); in other words, from an immediate practical standpoint. The principles of systemic cross-cultural approaches (e.g., cultural competence, cultural safety) such as a recognition of racism, power imbalances, entrenched majority culture biases and the need for self-reflexivity (awareness of one's own prejudices) were scarcely acknowledged by study participants.

Conclusions

Findings indicate a need for interventions that acknowledge the value of cultural awareness-based approaches, while also exploring the utility of more comprehensive cultural competence and safety approaches.

Peer Review reports

Background

In recent decades, several key public health care reports and research studies on health care experiences have indicated that particular cultural groups are more likely to be underserved, perceive negative treatment, and receive differential treatment outcomes [ 1, 2, 3]. In response, health care systems in North America and other CANZUS nations, have endeavored to adapt their service delivery practices and policies to improve the quality and access of health care to culturally and linguistically diverse groups [ 4, 5, 6, 7]. Industry objectives in health care settings contemporaneously aspire to, i) improve cross-cultural communication ii) enhance responsiveness to the health care needs of diverse patients iii) reduce health care provider discrimination and iv) reduce health care disparities. Health care organizations have embraced and enlisted a variety of cross-cultural educational approaches (e.g., cultural awareness, cultural competence etc.) to achieve these objectives.

Cross-cultural education training for health care professionals is now commonplace and in some settings, mandated [ 8, 9]. Its principles are often embedded within the strategic plans of health organizations, and human resource departments will often oversee the advancement of such initiatives. Participating health care systems usually employ one, or a combination, of several popular cross-cultural models that have emerged over the past four decades. These include, but are not limited to, cultural awareness, cultural competence, cultural safety, cultural humility and cultural intelligence. There are also multiple off-shoots including anti-racism training and diversity training. The cross-cultural models overlap considerably though they have differing emphases. Cultural awareness focuses on learning about the norms and customs of multi-cultural groups [ 10]. Cultural safety is concerned with protecting the culture of vulnerable groups by identifying biases and power imbalances within organizational structures [ 11]. Cultural humility promotes openness and non-judgement while allowing the client to determine how their culture impacts their experiential reality and by extension, the clinical encounter [ 12]. Cultural intelligence focuses on an individual's capacity to first recognize and then successfully function in various cultural environments foreign to their own [ 13]. And cultural competence (though often used generically) is an institutional framework that expands an organization's internal and external capacity to support and implement protocols that improve worker attitudes, cross-cultural communication, staff diversity, and ongoing relationships with multi-cultural communities and stakeholders [ 14]. The adoption of these models, or aspects of the models, are believed to ultimately reduce the obstacles that still contribute to the poor health care experiences and unmet health needs of particular cultural minority groups [ 15].

While the uptake of cross-cultural education models has been widespread across health care systems, evidence for the models' ability to reduce cross-cultural health care disparities has been slim. There has been some confirmation of temporary improvements in practitioner attitudes and patient experiences post model implementation (usually in the form of a workshop), however the impact on patient treatment outcomes has been largely negligible [ 16, 17, 18]. While there are possible associated explanations for these findings (e.g., model implementation integrity, methodological rigor of validation studies, broader organizational factors) is it uncertain as to why current cross-cultural education strategies have not had stronger effects. In fact, there is evidence indicating that certain delivery styles (e.g., coercive, shame-and-blame) of cross-cultural education may have unintended contrary outcomes for participating staff [ 8, 19]. Other literature has offered some speculation as to why such trainings and associated initiatives may fall short in achieving anticipated outcomes in health care settings [ 20, 21, 22, 23]. Shepherd [ 9] points to the impracticality of retaining and then utilizing 'quickly-learned' cultural knowledges, customs and interaction styles beyond cross-cultural workshops. The potential for essentializing and/or homogenizing cultural groups leading to stereotypical pre-conceptions has also been referred to [ 22, 24, 25, 26]. Moreover, numerous factors may impact a cross-cultural clinical encounter beyond cultural differences (e.g., personality, temperament, cognitive ability, level of education, socio-economic status, mental health, universally poor service delivery). It is clear that further research efforts are required to explore how cross-cultural education is typically delivered, received and implemented in various health care settings.

One way to acquire this information is to ascertain the views and experiences of health care professionals themselves. Cross-cultural training workshops are often validated by health care professionals via pre-post intervention surveys. However, the insights and perceptions of health care professionals are infrequently sought when attempting to develop, define or refine effective cross-cultural practice. Few studies globally, have explored the perceptions of professionals on cross-cultural education initiatives in health care. A number of studies from Australia (samples < n = 20) explored the barriers to effective cross-cultural communication as identified by health workers and the importance they afforded to cultural competence [ 27, 28, 29, 30]. Similar studies were conducted with small samples of nurses in Scotland [ 31] and Ireland [ 32]. In North America, a study from Canada assessed attitudes towards cultural competence for 170 registered nurses [ 33] and a study from USA explored how 31 public health nurses gauged their own levels of cultural competence and experiences of culturally competent care [ 34]. The opinions of both health care providers and medical staff on some of the challenges faced when working with diverse clientele, were obtained in the context of broader studies on cross-cultural health care in the USA [ 35] and Sweden [ 36]. Furthermore, health care professionals' perceptions of their own cultural competence has been examined across professions (i.e., physicians compared to nurses) [ 37] and in relation to their alignment with patient observations [ 38]. Overall, the above literature illustrates that health care professionals, despite possessing varying levels of cross-cultural knowledge, largely acknowledge the importance of cross-cultural awareness and demonstrate a willingness to improve their cross-cultural communication skills. Language barriers, low client health literacy and bureaucratic constraints are regularly offered as barriers to effective cross-cultural service delivery [ 27, 28, 29, 30]. It is clear however, that further research is warranted in this space to acquire a more nuanced understanding of how health care providers and professionals view and experience intercultural encounters, and the educational initiatives implemented to enhance such encounters. In response, this study aims to gather and explore i) the general perspectives of health care professionals on culturally competent care, ii) their experiences working with multi-cultural patients, iii) their perceptions of their own levels of cultural competence and iv) the extent to which they believe their respective organizations address cross-cultural challenges in the workplace. Professionals were recruited from health care systems in a Mid-Western region of the USA where no prior research of this nature has been conducted. We anticipated that the majority of professionals will value the importance of cross-cultural education and training but may differ with regards to both their own and their organization's perceived knowledge, and which aspects of cross-cultural education they believe are relevant to their practice.

Methods

Participants

Participants were recruited across three major health care systems and one university student health center from a Mid-Western state in America. The first health system, a major university medical training facility comprises a network of two hospitals and 40 clinics. The second health system, is a state-run network of over 30 major hospitals and clinics. The third, is a regional faith-based network of 14 hospitals and over 400 clinics. The university student health center provides a range of medical services on a major university campus. Combined, the three health systems and university student health center, operate the majority of medical facilities in the state.

Materials

Participants completed a 19-item questionnaire ascertaining their general perspectives on culturally competent care, their experiences working with multi-cultural patients, their own levels of cultural competence and the extent to which they believe their organizations addressed cultural competence in the workplace. The questions were both multiple choice ( n = 15) and open-ended ( n  = 4). For the multiple choice questions, participants were asked the extent to which they agree or disagree with various general statements (e.g., Do you think health service providers should consider a patient's cultural background when treating them?), to reflect on how often their own skills align with best practice cross-cultural care (e.g., Do you feel that you attend to the cultural needs of patients from difference cultural backgrounds?) and the importance they afford to various skillsets (Do you think it is important to learn about different cultures as part of your practice?). Open ended questions prompted participants to elaborate on their perceptions and experiences (e.g., What areas of cultural awareness/competence do you feel that you and/or your organisation perform well?). The combination of both closed and open-ended questions allowed for a baseline understanding of participant views across key ideas, which could then elucidated through nuanced personal narratives.

The questionnaire was developed by the study authors through their own expertise and after reviewing the relevant public health and cross-cultural health care literature. Questions were selected based on their relevance to the study (e.g., health care environments) and their alignment with the expectations and principles of cross-cultural communication philosophies (e.g., cultural competence, cultural awareness, cultural safety). No previous validated questionnaire specifically tailored to the cross-cultural experiences of health care professionals was located for use.

Procedure

Researchers contacted participating health care networks in mid-2016 to ascertain their interest in being involved in the study. After receiving support from their respective internal review boards, the organizations distributed an online link to the study survey to clinical and professional staff via email. The link was accompanied with a short passage enquiring if staff were interested in participating in an anonymous online research study survey on cross-cultural health care service delivery experiences.

Individuals who opted to click on the study link were presented with a digital consent form outlining the requirements and their involvement in the study. After consenting, participants then completed the anonymous online health care provider cross-cultural experiences survey. The questionnaire was conducted on an online research survey software program. The duration of participation ranged from 10 to 30 min. All participants received a $10 online gift voucher for their contribution. Data was collected across the months of August and September in 2016. It is unknown as to exactly how many staff at each organization received the study recruitment email.

Data analyses

A mixed methods study design was employed. First, percentages across participant responses were calculated for all multiple choice items. Second, the four open-ended questions were then qualitatively analysed. After extracting the data from the online research survey program, a thematic analysis was undertaken by a primary coder (author DN) using a progressive process of classifying, comparing, grouping and refining groups of text segments to create and then clarify the definition of categories, or themes, within the data [ 39]. For the purposes of reliability, another coder (author SS) independently coded a subsection of interview notes and cross-checked these with the findings of the primary coder. Following coding, dominant themes were cross-checked between raters until a consensus was reached. Participant percentages across categories for the 19 multiple choice questions were calculated and tabled.

Results

Data were collected from a total of 56 health care workers. Four additional individuals elected not to consent to participate in the study after viewing the information statement and consent form page. Due to the anonymous nature of the study, the distribution of participants across the four health care organizations was unknown. The mean age of the sample was 38.66 (SD: 12.03, range 20-65) years. The majority were female ( n = 52, 92.9%). Over 85% ( n = 48) of the sample identified as White/Caucasian, with 8.9% ( n = 5) identifying as Hispanic/Latino, 3.6% ( n = 2) identifying as Middle Eastern and 1.8% ( n = 1) identifying as African-American. The self-described professions of the participants included Nurse/Nurse Practitioner ( n = 18, 32.1%), Mental Health Professionals ( n = 9, 16.1%), Medical Assistants ( n = 7, 12.5%), Hospital/Clinic Administrators (n = 7, 12.5%), Medical Receptionist (n = 5, 8.9%), Physicians ( n = 3, 5.4%), Physiotherapists ( n = 2, 3.6%), Interpreters (n = 2, 3.6%), Pharmacist (n = 1, 1.8%), Community Support Worker (n = 1, 1.8%), Medical Lab Technician (n = 1, 1.8%). Regarding years of experience in their current profession, 26.8% ( n = 15) of the sample reported more than 20 years of experience, 23.2% ( n = 13) reported between 11 and 20 years of experience, 21.4% ( n = 12) reported between 5 and 10 years of experience, and 28.6% ( n  = 16) reported less than 5 years of experience.

Participant perceptions on the importance of cross-cultural education and communication in health care settings are presented in Table 1. The vast majority of participants clearly believed that cultural considerations are an important component of best practice health care and that professionals should be learning about different cultural groups. Responses varied as to whether one's organization should be making improved efforts to meet the needs of diverse clientele and whether cultural-specific approaches to health (e.g., traditional/spiritual healers) should be accommodated.

Table 1 Cross-cultural perceptions of health care professionals (Agree - Disagree)

Participants were also asked to designate the level of perceived importance they afforded to having staff from diverse cultural backgrounds represented at their workplace. Almost three-fifths (39.3%, n = 22) of the sample believed staff diversity to be 'extremely important', 28.6% ( n = 16) believed staff diversity to be 'important' and a further 12.5% ( n = 7), 17.9% ( n = 10), 1.8% ( n = 1), believed staff diversity to be moderately, slightly, or not at all important, respectively. Most participants (91.1%, n = 51) acknowledged that bi-lingual staff worked at their organization. Three participants (5.4%) did not provide an answer to this question.

Participant perceptions of their own cross-cultural awareness experiences and capabilities are presented in Table 2. Health care providers acknowledged that they regularly treat patients of color and that they would commonly attend to their needs. The majority also noted that sometimes, and for some, often, it was more challenging to treat or engage with patients from a different cultural background to their own. Over 40% ( n = 23) of participants believed that their cultural background often makes patients from other cultural backgrounds uncomfortable. Moreover one-fifth ( n = 12) of the sample thought that their cultural background sometimes made patients of color feel anxious or nervous. Participants were also asked to describe how satisfied they were with their own perceived level of cross-cultural knowledge. Under 15% ( n = 8) reported that they were 'extremely satisfied' with their level of knowledge, 64.3% ( n = 36) were 'satisfied' with their level of knowledge, 16.1% ( n = 9) were neither dissatisfied or satisfied, and 3.6% ( n  = 2) were 'dissatisfied'. No participant reported 'extreme dissatisfaction' with their level of cross-cultural knowledge.

Table 2 Cross-cultural perceptions of health care professionals (Always - Never)

Thematic analysis

Participants responded to four open-ended questions on cross-cultural health care delivery. They were asked to reflect on ways to improve cross-cultural health care and the extent to which they perceived their organizations to be suitably performing in this area. Each question and the associated response themes are presented below.

What factors/skills do you think could improve cross-cultural health care?

Education/training

Many ( n  = 31) participants believed that formal cross-cultural education and training would indeed improve their organization's capacity to provide cross-cultural health care. Most of the suggestions were oriented to learning about multi-cultural customs.

Some felt that this education should be mandatory or at least regularly provided to staff.

Two participants felt that education and training should have a particular focus on systemic issues experienced by patients from minority backgrounds.

Interpreter services

The second most common response theme was having interpreter services available and accessible to all patients.

Some participants also suggested that that there should be more bi-lingual professionals.

Diversification of staff

One participant expressed that organizations should aim for cultural diversity when recruiting staff.

What areas of cultural awareness/cultural competence do you feel that you or your organization perform well?

Access to interpreters

Cultural awareness/sensitivity

Education/training

Culturally diverse staff members

Five participants believed that their organization benefitted from hiring diverse staff members. This was viewed as being of great value to the multi-cultural patients attending their organization. "Our organization does an excellent job of hiring diverse staff members, for the most part, especially in our refugee services and support staff positions" (Mental Health Professional). "Having providers and staff with different cultural backgrounds has been useful" (Hospital/Clinic Administrator).

Assessment of needs/rapport development

Resources

Four participants commented positively on their organization's provision of cross-cultural educational resources for both patients - "We have information printed in different languages for communication of medical information" (Physician), and staff - "Education and resources related to all cultures available to staff" (Registered Nurse).

What was the nature of the training?

This open-ended question followed the initial yes/no question, "Did your health care training include a cultural awareness/competence component", to which 57.1% ( n  = 32) participants affirmed that they had received some form of cultural training as part of their professional education. The thematic responses from these 32 participants are illustrated below.

Format

Content

Participants described the content of the training as primarily focused on "cultural norms and differences" (Nurse Practitioner, Physiotherapist).

How would you improve the cultural competence of your organization?

Further education/training

Most participants believed that cultural competence training should be "regular" (Interpreter) and "mandatory" (Registered Nurse). More specifically, several participants suggested that training should involve "speakers from different cultural backgrounds" (Hospital/Clinic Administrator). "It would be helpful to have training/discussions with people from different cultures/ethnic backgrounds who are willing to meet with health care staff in order to learn about their cultures/norms and how health care providers would be most effective in helping those clients" (Nurse Practitioner). Some participants advocated for regular organizational-wide meetings for staff to have discussions about cultural competence. "Talking about the problems we may encounter based on culture" (Interpreter). Others felt that any cultural education should only focus on the cultural groups within the organization's catchment area. "Education in regards to the geographical location of the patients we provide health service to" (Hospital/Clinic Administrator). "More detailed training on the specific cultures that are prevalent in the area rather than presenting it as more global" (Registered Nurse). Only one participant referred to discriminatory behaviors. "Increase accountability for micro-aggressions, institutional inequality, racism, sexism etc. with the understanding that we all have these issues and the most important thing is to be aware of them and work to challenge them within ourselves" (Mental Health Professional).

Staff diversity

Although few participants commented on staff diversity, disagreement was evident. Three participants believed that their organization would be more culturally competent if there was greater cultural diversity among staff members. "Increase the number of staff members of color and staff members who are multi-lingual" (Mental Health Professional). In contrast, two participants stated that cultural background was not the main priority when hiring new staff members. "I hire the best person for the job, not for their cultural background" (Hospital/Clinic Administrator).

Already competent

Discussion

Cross-cultural educational initiatives for professionals are now commonplace across a variety of sectors including health care. A growing number of studies have attempted to explore the utility of such initiatives on workplace behaviors and client outcomes. Yet few studies have explored how professionals perceive cross-cultural educational models (e.g., cultural awareness, cultural competence) and the extent to which they (and their organizations) execute the principles in practice. This study aimed to address this gap in the literature by gathering the perspectives of a sample of health care workers from a Mid-Western state in the United States of America. The insights gained from the research provide a useful contribution to the practical literature on cross-cultural professional training. It is important to ascertain the attitudes and professional experiences of health workers when working cross-culturally, to assist in developing functional and effective trainings that are endorsed by the very professionals that they are designed for.

Like prior research [ 29, 31, 33, 35], the vast majority of the sample acknowledged that a consideration of a client's culture was of importance. Possessing cultural knowledge was widely perceived to be 'best practice' and necessary for effective cross-cultural communication and service delivery. Half the sample agreed that alternative cultural models of health would augment existing approaches to care. There is a wide body of literature illustrating culturally bound models of health and symptom expression styles that are believed to deviate from, or partially overlap with western diagnostic categories [ 40, 41]. Other participants may have been unaware of the differing concepts of health and wellbeing possessed by particular cultural groups. Some may also have perceived that certain cultural or 'folk' health beliefs clash with conventional methods to the detriment of their patient, a view documented in prior research with health professionals [ 27, 28, 29, 42]. Nonetheless, approximately 95% of the sample believed that they always or often attend to the cultural needs of their patients. This near consensus arose despite over 80% of participants sharing that they often or sometimes found it more difficult to engage with or treat patients from cultures different to their own. Additionally, almost 60% acknowledged that their own culture may make some patients uncomfortable. The sample's apparent confidence in their own abilities to work effectively cross-culturally despite obvious challenges may reflect workplaces committed to cultural competence initiatives and diversity. Some participants in this study may also genuinely be equipped with cultural knowledge and the facility to recognize the limitations of their own knowledge when working with different cultures as per the cultural humility model. However, there is also a possible incongruity between the assumption that one is commonly addressing cultural needs and the frequent experiencing of challenges when working with minority patients, which may signal an over-confidence and/or unawareness. This is often referred to in the cultural safety literature as a failure to interrogate one's own cultural beliefs, and how a vocation may have built-in entrenched dominant culture norms and standards that impact cross-cultural clinical encounters [ 43]. It was unknown as to how participants discerned that their cultural background had made their patients uncomfortable. They may have been acutely aware of how the dominant culture is viewed through the lens of historically oppressed minority patients. Alternatively, they may have received negative feedback or complaints from patients because of their actions.

In a similar pattern to the above findings, just over half of the sample (57%) had received some form of cross-cultural training as part of their overall health care education, yet almost 80% were satisfied with their level cultural knowledge. The cross-cultural training undertaken, was largely described as learning about the norms and customs of other cultural groups (either online or through presentations) which is reminiscent of the cultural awareness model. Alternative cross-cultural models (cultural humility, cultural safety) critique the cultural awareness approach for homogenizing cultural groups, and effectively 'trading in stereotypes' [ 12, 44]. A possible discrepancy between real and perceived cross-cultural knowledge is conceivable here.

Participants were asked to outline what areas of cross-cultural care they believed that they (or their organization) perform well. Answers here, would perhaps illuminate the apparent confidence many participants possessed when working cross-culturally despite a significant minority not having undertaken formal cross-cultural training. The availability of interpreters was the most common example of effective cross-cultural care as denoted by participants. A lack of interpreter services has been identified as a common obstacle for cross-cultural service delivery in prior studies [ 27, 29, 30, 34]. There was also a belief from numerous participants, that their respective organizations were culturally respectful and attentive to the cultural needs of clients. Several participants stated that their organizations offer cultural training (some on a regular basis), employ multi-cultural staff, and provide educational resources for staff and patients. Staff diversity was emphasized as beneficial for multi-cultural patients. Perhaps this was in regard to their capacity to speak languages other than English - over 90% of participants indicated that they work alongside bi-lingual staff. It is possible from the above testimony that many participants work in organizations that possess some of the attributes allied with the cultural competence model. Cultural competence is an organizational-wide approach to enhancing effective cross-cultural communication which includes a number of interconnecting initiatives (e.g., staff diversity, staff training, interpreter services, improving staff attitudes to cross-cultural care) [ 15]. Such a framework could potentially engender a safe multi-cultural working environment despite staff not having undergone direct cultural training themselves. In contrast, it is perhaps more likely that participants viewed effective cross-cultural care as essentially a communication matter as opposed to a multi-faceted institutional framework. Rather than perceiving cross-cultural care as a broader phenomenon encompassing power imbalances, dominant culture biases and contrasting worldviews (interpretations seldom articulated by the sample), most participants may have simply regarded cross-cultural care from an immediate practical standpoint whereby interactive/informational barriers require alleviation; hence the highlighting of interpreter services, staff bi-linguicism and assessment rapport development. Starr and Wallace [ 34] found that the availability (or lack of) interpreters and gender-specific providers were some of the most commonly raised themes in a sample of American public health nurses when discussing culturally competent care. Only a small number of participants referred to diversity hiring strategies directly. A tension between affirmative action and colour-blind approaches was evident among some of the responders.

Participants were asked to identify which factors/attributes improve cross-cultural care, and more pointedly, to offer recommendations to improve the cultural competence of their own organizations. Two main themes were canvassed in relation to the first question. Participants cited the need for ongoing cross-cultural education and training in the workplace. Responses again appeared to denote the cultural awareness approach - a focus on cultural norms, customs and health beliefs - which is the most common form of cross-cultural education universally, yet the most criticized in the literature. Only two participants described the need for training to encompass themes of systemic bias and privilege which reflect the cultural safety approach. Cross-cultural education was the leading recommendation among the sample for improving organizational cultural care. A desire for regular staff meetings on cross-cultural issues was posited. There was also a preference among several respondents to focus attention on the cultural needs of clientele within the organization's catchment area, a recommendation proffered in previous research. No participants referred to any bureaucratic procedures that constrained their ability to work effectively cross-culturally, a finding noted in several prior studies [ 27, 29, 30]. Somewhat surprisingly, several participants disclosed that their organizations were already culturally competent and as such, did not offer any recommendations to improve cross-cultural care. Cultural competence is often described by its proponents as an evolving process rather than a 'clear-cut' actuality [ 45]. There is some evidence however from the same mid-western region that multi-cultural patients are generally satisfied with their treatment from health care providers. Shepherd et al. [ 46] found that racial minorities from a mid-Western state reported that they had good access to health care services, were not afraid to visit mainstream medical services and experienced low levels of racism and poor treatment.

Implications

Findings from the study should be considered in light of several limitations. First, caution is advised when generalizing results beyond Mid-Western health care settings. Second, the sample, like previous cohorts in the extant literature, was predominantly female and white/Caucasian. Prior research has suggested that female health care staff are more likely to possess patient-centered communication styles [ 47, 48] which may be more conducive to cross-cultural care. Ohana & Mash [ 38] discovered that discrepancies between physicians' perceptions of their own cultural competence and their patients' perceptions are reduced if the physician is female. Moreover, few cultural minorities participated, which may reflect the demographics of health care professionals in the region, and more broadly, the state population. Health professionals from cultural minority backgrounds may be more cognisant of the systemic and/or historical challenges faced by minority patients and may therefore be inclined to support broader cross-cultural educational approaches that address explicit/implicit discrimination, power structures and historical injustices [ 11, 12, 49, 50, 51]. Furthermore, the exact response rate in the study was unknown - health systems were unable to disclose how many study invitations were distributed across their respective networks. Third, no direct patient data was collected to corroborate the cohort's generally optimistic assertions that they and their organizations provide care that is meeting the needs of their multi-cultural clientele. Prior research has found a weak relationship between medical professionals' perceptions of their own cultural competence and their patient's perceptions of their cultural competence [ 38]. Last, the terminology on the questionnaire (i.e., 'diverse cultures', 'cultural background' etc.) was left open to interpretation. It is possible that these broad descriptors may have influenced responses.

The health workers in our sample appeared to view cross-cultural education from a 'cultural awareness' perspective. Effective cross-cultural care was often defined in terms of cultural knowledge (e.g., norms and customs) and facilitating communication (the use of interpreters). A dearth of respondents referred to broader, systemic components of cross-cultural care such as a recognition of racism (explicit and implicit), power imbalances, entrenched majority culture biases and the need for self-reflexivity (awareness of one's own prejudices). Although a number of participants supported workplace diversity, this appeared to be in the course of improved communication with minority patients rather than advocating for diversity per se, or for cultural diversity at the executive, or 'decision-making' levels. As speculated earlier, cross-cultural education was perhaps viewed as an immediately applied or 'hands on' phenomenon rather than a holistic, structural approach. Prior research has found that clinicians have a preference for 'active behavioural simulations' as a cross-cultural training method [ 52].

While most models of cross-cultural education encompass learning about the 'other' to some degree, simply absorbing the health beliefs, idiosyncrasies and traditions of particular cultural groups is somewhat superficial and as such, unlikely to advance cross-cultural communication [ 9, 44]. Advocates of later cross-cultural models (cultural competence, cultural humility, cultural safety) would indeed stress the need to augment the cultural awareness styled training undertaken and demanded by participants in the study. The compelled awareness of one's own biases and their institutions' potential to marginalize patients from non-mainstream cultural groups would be likely additions to teachings. In fact proponents of later models may argue that the over-confidence displayed by some participants in our study could be a reflection of their inability to recognize their own limitations and prejudices - and as such, underscoring the need for participants to undergo broader, holistic training. Intuitively, there is merit to multi-faceted models that incorporate socio-historical and political factors. At the same time, robust evidence for cross-cultural educational models, regardless of their content, is meagre [ 9, 44, 53, 54, 55]. Interpreter and bi-lingual health worker services possess some empirical support [ 56, 57, 58] though further research is warranted [ 17]. Thus, a conundrum unfolds whereby participants appear to be content with a limited model (in cultural awareness) yet the more expansive, recommended alternatives (cultural safety etc.) have yet to demonstrate rigorous utility beyond anecdotal evidence. The potential consequences of politically charged 'blame and shame' approaches (which are more likely to occur within cultural safety-styled trainings) have also been documented [ 8, 19]. Further research is required to rigorously test the validity of the various models and their specific assumptions. It is also important to ensure that cross-cultural models are relevant to specific workplaces, flexible enough to address immediate challenges identified by frontline staff, and seek realistic, practical goals that are clear, quantifiable and have evidence for their utility.

Conclusions

This study finds that health care professionals from a Mid-Western region of the USA value the possession and pursuit of cultural knowledge when working with multi-cultural populations. Practical cross-cultural approaches endorsed by staff (e.g., interpreter services) appeared to be enthusiastically supported and were thought to be associated with effectual cross-cultural care. However, the principles of systemic cross-cultural approaches (e.g., cultural competence, cultural safety) were scarcely acknowledged by study participants. The findings indicate a need for interventions that acknowledge the value of cultural awareness-based approaches, while also exploring the utility of more comprehensive cultural competence and safety approaches.

Abbreviations

CANZUS:

Canada, Australia, New Zealand, United States

USA:

United States of America

References

Download references

Acknowledgements

Not applicable.

Funding

The research was partially funded by a Swinburne University of Technology 2016 Research Development Grant.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Author information

Authors and Affiliations

1. Centre for Forensic Behavioural Science, Swinburne University of Technology, 1/582 Heidelberg Rd, Alphington, Melbourne, Victoria, Australia

Stephane M. Shepherd

2. Department of Psychology, University of Nebraska-Lincoln, Burnett Hall, Lincoln, NE, USA

Cynthia Willis-Esqueda

3. School of Social & Political Sciences, The University of Melbourne, Gratton Street, Melbourne, Victoria, Australia

Danielle Newton

4. School of Psychological Sciences, Swinburne University of Technology, John St, Hawthorn, Melbourne, Victoria, Australia

Diane Sivasubramaniam

5. Alfred Deakin Research Institute for Citizenship and Globalisation, Deakin University, Burwood, Melbourne, Victoria, Australia

Yin Paradies

Contributions

SS designed the study, performed the analyses and wrote the manuscript. CWE co-designed the study and assisted with manuscript preparation. DN performed the qualitative analysis and reviewed the manuscript. YP and DS assisted in conceptualising the study and made substantial revisions to the manuscript. All authors have read and approved the submitted manuscript.

Corresponding author

Correspondence to Stephane M. Shepherd.

Ethics declarations

Ethics approval and consent to participate

Informed consent was obtained from participants via the following process. After receiving support from their respective internal review boards, health care organizations distributed an online link to the study survey to clinical and professional staff via email. The link was accompanied with a short passage enquiring if staff were interested in participating in an anonymous online research study survey on cross-cultural health care service delivery experiences.

Individuals who opted to click on the study link were presented with a digital consent form outlining the requirements and their involvement in the study.

Ethical permission for this research was obtained by a mid-Western university Institutional Review Board (IRB Number: 20160716266 EX).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Reprints and Permissions

About this article

Cite this article

Shepherd, S.M., Willis-Esqueda, C., Newton, D. et al. The challenge of cultural competence in the workplace: perspectives of healthcare providers. BMC Health Serv Res 19, 135 (2019). https://doi.org/10.1186/s12913-019-3959-7
Download citation

Received:

Accepted:

Published:

DOI: https://doi.org/10.1186/s12913-019-3959-7

Keywords

Cultural competence

Cultural safety

Cultural humility

Diversity training

Public health

# data[].attributes.attachment_link.title
The challenge of cultural competence in the workplace: perspectives of healthcare providers - BMC Health Services Research

# data[].attributes.attachment_link.description
Background Cross-cultural educational initiatives for professionals are now commonplace across a variety of sectors including health care. A growing number of studies have attempted to explore the utility of such initiatives on workplace behaviors and client outcomes.

# data[].attributes.attachment_link.title
Embracing Cultural Diversity In The Workplace: Respecting Culture Differences

# data[].attributes.attachment_link.description
Embracing cultural diversity in the workplace means to recognize and respect the cultures and belief systems of different people for harmonious teamwork.

# data[].attributes.attachment_link.readable_text
An implicit bias is an unconscious association, belief, or attitude toward any social group. Implicit biases are one reason why people often attribute certain qualities or characteristics to all members of a particular group, a phenomenon known as stereotyping.

It is important to remember that implicit biases operate almost entirely on an unconscious level. While explicit biases and prejudices are intentional and controllable, implicit biases are less so.

A person may even express explicit disapproval of a certain attitude or belief while still harboring similar biases on a more unconscious level. Such biases do not necessarily align with our own sense of self and personal identity. People can also hold positive or negative associations about their own race, gender, religion, sexuality, or other personal characteristics.

Causes of Implicit Bias

While people might like to believe that they are not susceptible to these implicit biases and stereotypes, the reality is that everyone engages in them whether they like it or not. This reality, however, does not mean that you are necessarily prejudiced or inclined to discriminate against other people. It simply means that your brain is working in a way that makes associations and generalizations.

In addition to the fact that we are influenced by our environment and stereotypes that already exist in the society into which we were born, it is generally impossible to separate ourselves from the influence of society.

You can, however, become more aware of your unconscious thinking and the ways in which society influences you.

It is the natural tendency of the brain to sift, sort, and categorize information about the world that leads to the formation of these implicit biases. We're susceptible to bias because of these tendencies:

We tend to seek out patterns.Implicit bias occurs because of the brain's natural tendency to look for patterns and associations in the world. Social cognition, or our ability to store, process, and apply information about people in social situations, is dependent on this ability to form associations about the world.

We like to take shortcuts. Like other cognitive biases, implicit bias is a result of the brain's tendency to try to simplify the world. Because the brain is constantly inundated with more information than it could conceivably process, mental shortcuts make it faster and easier for the brain to sort through all of this data.

Our experiences and social conditioning play a role. Implicit biases are influenced by experiences, although these attitudes may not be the result of direct personal experience. Cultural conditioning, media portrayals, and upbringing can all contribute to the implicit associations that people form about the members of other social groups.

How Implicit Bias Is Measured

The term implicit bias was first coined by social psychologists Mahzarin Banaji and Tony Greenwald in 1995. In an influential paper introducing their theory of implicit social cognition, they proposed that social behavior was largely influenced by unconscious associations and judgments.

In 1998, Banaji and Greenwald published their now-famous Implicit Association Test (IAT) to support their hypothesis. The test utilizes a computer program to show respondents a series of images and words to determine how long it takes someone to choose between two things.

Subjects might be shown images of faces of different racial backgrounds, for example, in conjunction with either a positive word or a negative word. Subjects would then be asked to click on a positive word when they saw an image of someone from one race and to click on a negative word when they saw someone of another race.

Interpreting the Results

The researchers suggest that when someone clicks quickly, it means that they possess a stronger unconscious association.﻿﻿ If a person quickly clicks on a negative word every time they see a person of a particular race, the researchers suggest that this would indicate that they hold an implicit negative bias toward individuals of that race.

In addition to a test of implicit racial attitudes, the IAT has also been utilized to measure unconscious biases related to gender, weight, sexuality, disability, and other areas. The IAT has grown in popularity and use over the last decade, yet has recently come under fire.

Among the main criticisms are findings that the test results may lack reliability. Respondents may score high on racial bias on one test, and low the next time they are tested.

Also of concern is that scores on the test may not necessarily correlate with individual behavior. People may score high for a type of bias on the IAT, but those results may not accurately predict how they would relate to members of a specific social group.

Link Between Implicit Bias and Discrimination

It is important to understand that implicit bias is not the same thing as racism, although the two concepts are related. Overt racism involves conscious prejudice against members of a particular racial group and can be influenced by both explicit and implicit biases.

Other forms of discrimination that can be influenced by unconscious biases include ageism, sexism, homophobia, and ableism.

One of the benefits of being aware of the potential impact of implicit social biases is that you can take a more active role in overcoming social stereotypes, discrimination, and prejudice.

Effects of Implicit Bias

Implicit biases can influence how people behave toward the members of different social groups. Researchers have found that such bias can have effects in a number of settings, including in school, work, and legal proceedings.

Implicit Bias in School

Implicit bias can lead to a phenomenon known as stereotype threat in which people internalize negative stereotypes about themselves based upon group associations. Research has shown, for example, that young girls often internalize implicit attitudes related to gender and math performance.﻿﻿

By the age of 9, girls have been shown to exhibit the unconscious beliefs that females have a preference for language over math.﻿﻿ The stronger these implicit beliefs are, the less likely girls and women are to pursue math performance in school. Such unconscious beliefs are also believed to play a role in inhibiting women from pursuing careers in science, technology, engineering, and mathematics (STEM) fields.

Studies have also demonstrated that implicit attitudes can also influence how teachers respond to student behavior, suggesting that implicit bias can have a powerful impact on educational access and academic achievement.

One study, for example, found that Black children-and Black boys in particular-were more likely to be expelled from school for behavioral issues. When teachers were told to watch for challenging behaviors, they were more likely to focus on Black children than on White children.

Implicit Bias In the Workplace

While the Implicit Attitude Test itself may have pitfalls, these problems do not negate the existence of implicit bias. Or the existence and effects of bias, prejudice, and discrimination in the real world. Such prejudices can have very real and potentially devastating consequences.

One study, for example, found that when Black and White job seekers sent out similar resumes to employers, Black applicants were half as likely to be called in for interviews as White job seekers with equal qualifications.

Such discrimination is likely the result of both explicit and implicit biases toward racial groups.

Even when employers strive to eliminate potential bias in hiring, subtle implicit biases may still have an impact on how people are selected for jobs or promoted to advanced positions. Avoiding such biases entirely can be difficult, but being aware of their existence and striving to minimize them can help.

Implicit Bias in Healthcare Settings

Certainly, age, race, or health condition should not play a role in how patients get treated, however, implicit bias can influence quality healthcare and have long-term impacts including suboptimal care, adverse outcomes, and even death.

For example, one study published in the American Journal of Public Health found that physicians with high scores in implicit bias tended to dominate conversations with Black patients and, as a result, the Black patients had less confidence and trust in the provider and rated the quality of their care lower.﻿﻿

Researchers continue to investigate implicit bias in relation to other ethnic groups as well as specific health conditions, including type 2 diabetes, obesity, mental health, and substance use disorders.

Implicit Bias in Legal Settings

Implicit biases can also have troubling implications in legal proceedings, influencing everything from initial police contact all the way through sentencing. Research has found that there is an overwhelming racial disparity in how Black defendants are treated in criminal sentencing.﻿﻿

Not only are Black defendants less likely to be offered plea bargains than White defendants charged with similar crimes, but they are also more likely to receive longer and harsher sentences than White defendants.

Strategies to Reduce the Impact of Implict Bias

Implicit biases impact behavior, but there are things that you can do to reduce your own bias. Some ways that you can reduce the influence of implicit bias:

Focus on seeing people as individuals. Rather than focusing on stereotypes to define people, spend time considering them on a more personal, individual level.

Work on consciously changing your stereotypes. If you do recognize that your response to a person might be rooted in biases or stereotypes, make an effort to consciously adjust your response.

Take time to pause and reflect. In order to reduce reflexive reactions, take time to reflect on potential biases and replace them with positive examples of the stereotyped group.

Adjust your perspective. Try seeing things from another person's point of view. How would you respond if you were in the same position? What factors might contribute to how a person acts in a particular setting or situation?

Increase your exposure. Spend more time with people of different racial backgrounds. Learn about their culture by attending community events or exhibits.

Practice mindfulness. Try meditation, yoga, or focused breathing to increase mindfulness and become more aware of your thoughts and actions.

Recap

While implicit bias is difficult to eliminate altogether, there are strategies that you can utilize to reduce its impact. Taking steps such as actively working to overcome your biases, taking other people's perspectives, seeking greater diversity in your life, and building your awareness about your own thoughts are a few ways to reduce the impact of implicit bias.

A Word From Verywell

Implicit biases can be troubling, but they are also a pervasive part of life. Perhaps more troubling, your unconscious attitudes may not necessarily align with your declared beliefs. While people are more likely to hold implicit biases that favor their own in-group, it is not uncommon for people to hold biases against their own social group as well.

The good news is that these implicit biases are not set in stone. Even if you do hold unconscious biases against other groups of people, it is possible to adopt new attitudes, even on the unconscious level.﻿﻿ This process is not necessarily quick or easy, but being aware of the existence of these biases is a good place to start making a change.

# data[].attributes.attachment_link.title
Is It Possible to Overcome Implicit Bias?

# data[].attributes.attachment_link.description
An implicit bias is an unconscious belief about a group of people. Learn more about how these biases form and strategies to reduce their influence on behavior.

# data[].attributes.body
In a scenario, a teacher may be faced with the challenge of creating an assignment where they may be swayed to make it more difficult on one race than another rather than just making the assignment easy across the board.

# data[].attributes.attachment_link.readable_text
During these summer months away from the classroom, we teachers are readying ourselves to embrace our next opportunity to make a difference. We're attending workshops and writing curriculum (and of course binge-watching Netflix).

The beauty of teaching is that each year we get another chance to do things better, to get things right. So each year we eagerly prepare our classrooms and our lesson plans to ensure that they're better than the previous year.

We post rules, hang a "welcome" greeting on the door, write a neatly color-coded agenda on the board-and we're ready. When the greatly anticipated first day of school arrives, we stand by our doors smiling and greeting students as they enter the classroom.

That's when it starts to happen. In these moments, as students mingle and shyly interact with one another, we the teachers begin to make the very crucial observations that will affect our perceptions, and thus inform our expectations, of each student that school year.

Research has shown that before teachers even have a conversation with a student, they have already formulated a number of opinions based on that student's race, appearance, and other factors -and begun to form a certain set of expectations. How is this possible, why does it happen, and what does this mean for our teaching?

Underestimating Students' Potential

Regardless of how much we may like to think of ourselves as progressive educators, the reality is that our subconscious is at work. We, too, are studying the every move of our students: their dress, their personal grooming, their hair style, their use of language, and their mannerisms. Admitting it may be uncomfortable, but almost all of us have looked at a student at one time or another and thought, solely based on their appearance, "That kid is going to be someone," or "that kid is going to make my life miserable," or "that kid should pick up his pants; that's so disrespectful."

These subconscious thoughts and feelings are known as implicit biases. Whether our perceptions are positive or negative, they have an impact; they determine expectations, and these expectations dictate how we teach. Studies show that teacher expectations are closely linked to student achievement and success.

In my 15 years of teaching, I have been flooded with implicit biases; after all, that is not something we can control. We can, however, control how we deal with and respond to our biases. Our implicit biases, then, should only be a source of shame if we choose to ignore them.

One time when I struggled with implicit bias has especially stuck with me. I first met Anthony in mid-October of last year. He walked into my classroom three minutes late wearing an oversized shirt, slicked-back longish hair, and baggy jeans that hung well below the waist, revealing his underpants if not for his shirt. I greeted Anthony, feigned a smile, and asked what class he had been in last year.

Inwardly, I only half-listened to his response as the other part of me was already making assumptions: He must be behind, he'll never catch up, he's probably a troublemaker. Anthony had not even taken a seat in my classroom, yet already I had assigned him a set of not-so-high expectations simply because of his tardiness and his appearance.

But after a lesson on figurative language, he began to rap complex and beautiful lyrics in English and Spanish as he picked up his backpack and began walking out of my classroom. I asked about the artist, and he smiled proudly and responded that the lyrics were his own. Then he quickly added, "I surprised you, didn't I?"

He was right; he did surprise me. I had let my implicit biases go unchecked. Fortunately, Anthony reminded me to check myself. That single interaction was an indication that I had clearly underestimated his intelligence, potential, and his own academic expectations.

Ignoring Bias Furthers Inequity

Not all kids are as confident or as vocal as Anthony; actually, most students will not call you out. Most students will instead internalize your low or lowered expectations and your lack of confidence in them or their academic ability. Over time, this internalization results in low academic performance and apathy. More often than not, if we raise expectations, students will rise to the occasion; the opposite is true as well.

I was wrong about Anthony. He wasn't behind, and he was no troublemaker. He made daily contributions to the class, and his creativity fueled that of his peers while it inspired me. I was fortunate enough in Anthony's case to minimize the damage, but how many other times have I unwittingly allowed my implicit biases to inform my teaching and my relationships with students?

These biases are ever-present, and as such they require constant monitoring. Ignoring our implicit biases guarantees that we further impoverish the already poor or marginalized student. As educators, we must be mindful of not just how we teach students, but how we approach them, how we talk to them, and how we convey our academic expectations for each of them.

# data[].attributes.attachment_link.title
Why Teachers Must Fight Their Own Implicit Biases (Opinion)

# data[].attributes.attachment_link.description
During these summer months away from the classroom, we teachers are readying ourselves to embrace our next opportunity to make a difference. We're attending workshops and writing curriculum (and of course binge-watching Netflix). The beauty of teaching is that each year we get another chance to do things better, to get things right.

# data[].attributes.attachment_link.title
Confronting Implicit Bias: How Are We Showing Up For ALL Students?

# data[].attributes.attachment_link.description
What do you see when you look at your students? It should come as no surprise that perception dictates the way we see and interact with others. In fact, the perception of others too frequently becomes an inequitable reality for students of color. The implicit bias of educators can impact a student’s academic, social, and behavioral achievement. Implicit bias refers to the unconscious beliefs, attitudes, and stereotypes that influence our perception as well as the expectations we have for student