Health educators and cultural competence: implications for the profession.

Abstract: The purpose of the study was to assess levels of cultural competency among health educators. Four hundred and fifty-five participants completed the Inventory for Assessing the Process of Cultural Competence-Revised. Results of the study showed that most participants were operating at a level of cultural awareness. Degree in health education, levels of exposure to diverse groups, health education settings, and the number of cultural education programs participants' attended were associated with their level of cultural competence. Findings from this survey support the need for more research in this area to develop discipline-specific guidelines for cultural competency among health educators.

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In 2000, the U.S. population reached its most diverse composition in the last decade. According to the U.S. Census Bureau, non-Hispanic whites experienced a 6% decrease in their share of the population from 75% in 1990 to 69% in 2000 (U.S. Census Bureau, 2000). In addition, population projections suggest that the number of Hispanic, African American, Asian/Pacific Islander, Native American/Alaskan Native and other racial and ethnic groups will continue to grow in the next few decades. In fact, the U.S. Census Bureau (2004) estimates that the White non-Hispanic population will decrease 8% from 69% in the year 2000 to 61% by the year 2020. This racial and ethnic diversification of the U.S. population demonstrates the need to incorporate the concept of cultural competence into every aspect of the planning, implementation, and evaluation process of health education and promotion programs. Further, this diversification demonstrates the need to develop culturally and linguistically appropriate programs designed to train the next generation of health educators (Luquis & Perez, 2003).

Luquis and Perez (2003) propose that the issues surrounding cultural competence and health education present both challenges and opportunities for health educators as they strive to reach the culturally and ethnically diverse U.S. population. Health educators provide services to individuals from diverse cultural, ethnic, and socio-economic backgrounds, and in many cases, they may be the first point of contact within the U.S. health care system. Given their prominent role, it is imperative that health educators possess culturally appropriate skills that will enable them to better interact with their target groups. Hence, the preparation of culturally competent health educators is fundamental to this endeavor. The concept of cultural competence among health educators has evolved from the cultural sensitivity role advocated by the Association for the Advancement of Health Education, currently the American Association for Health Education, (AAHE, 1994) to the current definition by the Joint Terminology Committee (2002). In that report, cultural competence was defined as:

   The ability of an individual to understand
   and respect values, attitudes, beliefs, and
   mores that differ across cultures, and to
   consider and respond appropriately to
   these differences in planning, implementing,
   and evaluating health education and
   promotion programs and interventions
   (pp. 5).

Luquis and Perez further argued that the concept of cultural competence goes beyond an individual's capacity to respect and tolerate values and practices different from their own. Cultural competence also involves organizational practices and policies governing the development, implementation, and evaluation of health education and promotion programs. These recommendations are similar to those contained in the Standards for Cultural Competence for Health Professionals advocated by the Office of Minority Health.

Throughout the last decade, several studies have addressed the areas of culture and health, multicultural issues in health education, and the development of cultural sensitivity and competence among health professionals (Airhihenbuwa, 1995a, 1995b; Garcia & Bregoli, 2000; Pinzon & Perez, 1997; Redican, Stewart, Johnson, & Frazee, 1994; Stoy, 2000). However, few studies have assessed the preparation of health educators in the area of cultural sensitivity and competence. Some studies have focused on the professional preparation of health educators as a way to address cultural sensitivity and competence (Beatty & Doyle, 2000; Doyle, Liu, & Ancona, 1996; Redican et al., 1994). Results of these studies showed that, while many health educators are expected to address the needs of multicultural groups, most professional preparation programs (i.e., college or university) do not provide adequate training in this area. The limited focus of their research, however, fails to provide a complete assessment of cultural competence among health educators. For instance, one might assume that many health educators have obtained mandatory job-related training (i.e., workshops or conferences) in the area of culture and health, multicultural health, and cultural competence in order to address the needs of the diverse populations they serve. In addition, one would presume that professional preparation programs are doing a better job of addressing cultural competence in the preparation of health educators regardless of health education settings. Finally, one might assume that an individual who has earned an advanced degree in health education would possibly attain more training in this area. There is a dearth of investigations that specifically address the degree to which health educators have achieved cultural competence; the levels of cultural competence among health educators; and which variables might have an impact on cultural competency in this group. The purpose of the current study is to assess the levels of cultural competency among professional health educators and to assess the relationship between demographic characteristics, professional experiences, health education settings, cultural diversity training, and the level of cultural competency in this group.

METHOD

SAMPLE

Study participants were selected from the 2003 active membership list provided by AAHE. As one of the largest professional organizations for health educators, AAHE membership represents a wide cross-section employed in healthcare, community and public agencies, businesses, schools (Pre-K-12th) and institutions of higher education (AAHE, 2003). The diversity in the organization's membership represents a good, albeit not ideal, population of professional health educators nationwide. One thousand current AAHE members were randomly selected to participate in the study. Four hundred and fifty participants returned a completed survey for a 46% response rate.

The sample was mostly white (87%), female (71%), between the ages of 40-59 years (73%), working in a school (45%) or college/university (36%) setting. In addition, 79% possessed a degree in health education. Of this number, 55% of the sample had at least one degree in health education and 35% had two degrees. Fifty-seven percent of these health educators reported that up to 25% of the people (i.e., students, clients, etc.) that they work with were from different cultural backgrounds. Similarly, 56% reported that they had attended 1-3 cultural or diversity education programs within the last three years (see Table 1).

INSTRUMENT

Data was collected using a modified version of the Inventory for Assessing the Process of Cultural Competence among Healthcare Professionals--Revised (IAPCC-R) developed by Campinha-Bacote (2002). This instrument is based on a theoretical model of cultural competence and contains five constructs: cultural desire, cultural awareness, cultural knowledge, cultural skills, and cultural encounters (Campinha-Bacote, 1999, 2001, 2002). The IAPCC-R is a self-administered tool consisting of 25 items (5 items for each construct) designed to measure the level of cultural competence among healthcare professionals. The IAPCC-R uses a 4-point Likert scale reflecting the response categories of strongly agree to strongly disagree, very aware to not aware, very knowledgeable to not knowledgeable, very comfortable to not comfortable, and very involved to not involved. A sum of the scores from the five subscales demonstrates whether a health professional is operating at a level of cultural proficiency (91-100), cultural competence (75-90), cultural awareness (51-74), or cultural incompetence (25-50). Higher scores represent a higher level of competence.

The author of the instrument failed to describe the different levels of cultural competency. Based on the literature review, we propose the following definitions to be utilized by the field of health education. Culturally incompetent individuals can be described as those who lack an understanding of the difference among ethnic and cultural groups. They are at the lowest level of the cultural competence process. As they move through this process, the individual develops cultural awareness, or sensitivity to the values, beliefs and practices of different ethic and cultural groups. Culturally competent individuals are not only culturally sensitive to the different groups, but are also able to respond appropriately to the needs of these groups. Finally, cultural proficiency can be described as the endpoint of cultural competence. An individual who is culturally competent has developed the ability to respond appropriately to groups of diverse ethnic and cultural backgrounds.

While the IAPCC-R is intended for healthcare professionals (i.e. physicians, nurses, etc.), we modified the scale with permission from the author to assess the level of cultural competency among health educators (The instrument is copyrighted, and thus, formal permission to use this tool is required.). We revised 7 of the 25 items to correspond to the field of health education and multicultural health. For example, we rephrased the statements, "I have a personal commitment to care for clients from ethnically/culturally groups" to state "I have a personal commitment to provide health education and health promotion programs for clients from ethnically/ culturally groups." The statement "I am knowledgeable in the area of ethnic pharmacology" was rephrased to state "I am knowledgeable about healing practices among different ethnic/racial groups."

The original instrument's construct and content validity was addressed by linking the instrument with the Campinha-Bacote (1999, 2001, 2002) conceptual model of cultural competence. The instrument was also reviewed by national experts in the field of transcultural health care. A study using the IAPCC-R calculated a reliability coefficient Cronbach's alpha of .8399 and a Guttman split-half of .8214. For the current study, we established the content validity of the modified instrument using a panel of three health educators who had knowledge and experiences in the area of cultural competency and multicultural health. In addition, the principal investigator (PI) solicited comments from 12 health education graduate students pertaining to the clarity and wording of each of the statements. Reliability coefficient calculated with the current data resulted in a Cronbach's alpha of .849 and a Guttman split-half of .829. The final instrument used in this study included 10 questions dealing with participants' demographic characteristics, professional experience, work setting, and cultural training.

DATA COLLECTION AND ANALYSIS

The current study followed a descriptive research design over a four-month period. Each of the randomly selected study participants received a package that included the survey, a cover letter, and a business reply envelope via regular first class mail. The cover letter, addressed to each participant, explained the purpose of the investigation, issues regarding anonymity, and contact information for the PI. Implied informed consent was obtained from all study participants.

The PI also informed the participants that they could receive a copy of study results as an incentive for their participation. Three hundred and seventy-one individuals completed and returned the survey within four weeks of the initial mailing. In order to increase response rate, a follow-up package, including another copy of the survey, was sent only to non-respondents within four weeks of the initial mailing. Only those who did not respond to the initial mailing (n=629) received the second mailing. After four more weeks, an additional 84 individuals completed the survey. Ten surveys were returned to the researcher that were incomplete due to wrong mailing address or participants no longer employed in the field of health education. One survey was returned well after the closing date of the study; hence, it was not included in data analysis.

The Statistical Package for the Social Sciences (SPSS) was used for data analysis. In order to ensure the anonymity of the participants, responses to the survey were entered into a database without identification codes. Descriptive statistics were calculated to examine participants' responses. Some of the categories within the independent variables contained small observations (e.g. race, number of college degree, etc.). As a result, several categories within specific variables were combined before further analysis was conducted. For example, race categories were combined into white and non-white. Given the descriptive nature of the study, a series of Mann-Whitney test analyses and Kruskal-Wallis tests were used to compare the level of cultural competence (dependent variable) and the demographic characteristics, professional experience and training, and health education settings (independent variables).

RESULTS

Results from the study indicate that the majority of study participants fall under the cultural competency classification (M= 71.36). Moreover, the sum of the subscales scores showed that 62% of participants were operating at a level of cultural awareness, 34% at a level of cultural competence, 2% at the level of cultural proficiency, and 2% at a level of cultural incompetence.

The Mann-Whitney analysis showed a statistically significant difference on cultural competency mean scores based on racial groups, having a degree in health education, number of college degrees in health education and estimated number of diverse clients served by participants. As seen in Table 2, the analysis showed that non-white participants had a higher mean rank score on cultural competence than white participants (z = 4.409, p < .001). Moreover, those participants with a college degree in health education had a higher mean rank score than those without a degree in health education (z = 2.475, p = .013). Participants who had two or more college degrees in health education had a higher mean rank score than those with only one degree in health education (z = 4.086, p < .001). Finally, those participants with more diverse clients had higher mean scores than their counterpart (z = 6.274, p < .001; see Table 2).

In addition, Kruskal-Wallis analysis were conducted to determine any difference in the level of cultural competency based on years of experience in health education, health education settings, and number of cultural or diversity programs attended within the past three years. A Kruskal-Wallis analysis showed no statistically significant difference on cultural competency mean scores and years of experience in health education. A series of Kruskal-Wallis showed a statistically significant difference on cultural competency mean scores among health education settings ([sup.~2](2)= 67.094, p < .001) and number of cultural or diversity education programs attended in the last three years ([sup.~2](2)= 81.160, p < .001). As shown in Table 3, participants who work in a school setting had a lower mean rank score than participants who work at a college/university or other settings. Similarly, participants who did not attended cultural or diversity education programs had a lower mean rank score than participants who attended 1-3 and four or more cultural or diversity education programs in the past three years (see Table 3).

DISCUSSION

The purpose of this investigation was to assess the levels of cultural competency among professional health educators. In general, it seems that most participants were operating at a level of cultural awareness. Moreover, a third of the participants were operating at a level of cultural competency. Overall this group of health educators can be described as individuals who are sensitive to the values, beliefs and practices of different ethic or cultural groups and who would be able to respond appropriately to the needs of these groups.

The results also showed that there were several variables including race, degree in health education, contact with a diverse population, health education setting, and participating in cultural or diversity educational program that might influence the level of cultural competency among health educators. First, it is important to recognize that the number participants in the independent variable categories were uneven and might have accounted for the significant difference in the dependent variable. For example, the number of white participants versus the number of non-white participants might have accounted for the significant difference in cultural competency. However, it might be possible that the difference in cultural competency between white and non-white participants is the result of differences in cultural experiences faced by members of non-white populations during their lifetime. For example, non-white participants might have encountered and experienced incidents of discrimination, prejudice, and racism that white participants may not have experienced. More studies are necessary to understand the relationship between race and cultural competency.

Similarly, there was a significant difference in cultural competency between health educators working with populations that are more diverse and those working with a homogenous population. According to Campinha-Bacote (1999, 2001, 2002), the cultural encounter (i.e. interaction with different racial or ethnic groups) is one of the key constructs of cultural competence. Health educators working with different ethnic or racial groups might have more opportunities to interact with members of those groups, which can result in a better understanding of these groups' values, beliefs, practices and experiences. As a result of these interactions, health educators working with more diverse populations be more likely to operate at a higher level of cultural competency than health educators working with homogenous groups.

Results also showed that health educators with a degree in health education and those with more than one degree in health education were operating at a higher level of cultural competency than their counterparts. While receiving a degree in health education does not assure that one would become culturally competent, this result might imply that the health education professional preparation programs are providing their students with more opportunities to acquire the knowledge, awareness, and skill needed to deal appropriately with group of diverse ethnic or racial backgrounds. This result is evident among individuals with more than one degree in health education. Similarly, health educators working in college/university settings are generally required to obtain an advanced degree before they work in this setting. These health educators were operating at a higher level of cultural competency than those working in school settings. Likewise, health educators who have attended cultural or diversity education programs in the past three years were operating at a higher level of cultural competency than those who have not attended a similar program. Thus, the type of college degree, number of years of postgraduate education, and cultural or diversity-focused education significantly influences the level of cultural competency among health educators. Nonetheless, more studies are necessary to assess how professional preparation programs are preparing health educators in the area of cultural competency and to understand which educational strategies work best in this endeavor.

Finally, the results of this study should be carefully examined as these are subject to several limitations. First, as with any survey, there could be bias in responses given the participants' interest in the area of cultural competency. Second, the return rate was less than optimal; hence, bias in the responses might be expected. In addition, a description of the AAHE membership was not available at the time of the study, therefore, it is difficult to compare respondents to non-respondents. Future studies should utilize strategies such as a third follow-up mailing or postcard to increase the survey's return rate to higher than 60% to allow for generalization of the results (Price, Murnan, Dake, Dimming, & Hayes, 2004). Third, it is also important to note that the sample was selected from AAHE members. Future studies should target health educators in other national or local professional organizations in order to compare results with others who are not affiliated with this organization. Finally, a causal relationship should not be inferred from the findings because this study used a cross-sectional survey design. Despite these limitations, the results provide insight into the level of cultural competency among health educators and factors that might contribute to cultural competency among this group. In addition, the study provides a starting point to conduct more research in this area.

IMPLICATIONS

In 1994, the Association for the Advancement of Health Education (currently the American Association of Health Education) released a pioneering report entitled Cultural Awareness and sensitivity: Guidelines for Health Educators. In its foreword, the association's President-elect, W.P. Pat Buckner, wrote, "these guidelines are intended to help the reader develop a more comprehensive understanding of the relationship between culture and health" (AAHE, p. v). In the past ten years, several studies have paid attention to the professional preparation of health educators as a way to address cultural sensitivity and competence (Beatty & Doyle, 2000; Doyle et al., 1996; Redican et al., 1994). Still, those studies fail to provide a complete assessment of cultural competence among health educators. The current study attempted to address the degree to which health educators have achieved cultural competence, assess the levels of cultural competence among health educators, and determine which variables might have an impact on cultural competency among professional health educators. While limited, the results from this study present some encouraging results. Health educators are attending trainings designed to enhance their ability to become culturally competent and to communicate across cultures. Results also indicate that professional preparation programs are making strides in educating the future workforce. Despite these gains, however, results from this study also indicate an urgent need to assist health educators to enhance their ability to reach across cultural and racial or ethnic divides. Results from the study showed that the majority of study participants could be classified as culturally aware, leaving a vast area to cover in attaining cultural competence.

Finally, the authors would do the profession and their peers a disservice if they did not acknowledge a significant concern. Currently, the health education profession lacks discipline-specific guidelines that address cultural and linguistically competent health education programs. Findings from this study exemplify the need for more research in this area in order to develop these guidelines and to better ascertain the cultural competence accomplishments and needs for improvement for health educators. Until those guidelines are developed, we will continue to do ourselves a disservice by borrowing from other disciplines and comparing ourselves in areas that do not necessarily apply to health educators.

REFERENCES

Airhihenbuwa, C. O. (1995a). Health and culture: Beyond the western paradigm. Thousand Oaks, CA: Sage Publications.

Airhihenbuwa, C. O. (1995b). Culture, health education, and critical consciousness. Journal of Health Education, 26(5), 317-319.

American Association for Health Education. (2003). General overview. Retrieved August 16, 2004 from http://www.aahperd.org/aahe/

Association for the Advancement of Health Education. (1994). Cultural awareness and sensitivity: Guidelines for health educators. Reston, VA: Author.

Beatty, C. E, & Doyle, E. I. (2000). Multicultural curriculum evaluation of a professional preparation program. American Journal of Health Studies, 16(3), 124-132.

Campinha-Bacote, J. (1999). A model and instrument for addressing cultural competence in health care. Journal of Nursing Education, 38(5), 203-209.

Campinha-Bacote, J. (2001). A model of practice to address cultural competence in rehabilitation nursing. Rehabilitation Nursing, 26(1), 8-12.

Campinha-Bacote, J. (2002). Inventory for assessing the process of cultural competence among healthcare professionals--revised (IAPCC-R). Retrieved September 30, 2005, from http://www.transculturalcare.net/

Doyle, E. I., Liu, Y., & Ancona, L. (1996). Cultural competence development in university health education courses. Journal of Health Education, 27(4), 206-213.

Garcia, B., & Bregoli, M. (2000). The use of literary sources in the preparation of clinicians for multicultural practice. Journal of Teaching in Social Work, 20(1/2), 77-102.

Joint Terminology Committee. (2002). Report of the 2000 Joint Committee on Health Education and Promotion Terminology. Journal of School Health, 72(1), 3-7.

Luquis, R., & Perez, M. (2003). Achieving cultural competence: The challenges for health educators. American Journal of Health Education, 34(3), 131-138.

Pinzon, H. L., & Perez, M. A. (1997). Multicultural issues in health education programs for Hispanic/ Latino populations in the U.S. Journal of Health Education, 28(5), 314-316.

Price, J. H., Murnan, J., Dake, J. A., Dimmig, J., & Hayes, M. (2004). Mail survey return rates published in health education journals: An issue of external validity. American Journal of Health Education, 35(1), 19-23.

Redican, K., Steward, S. H., Johnson, L., E., & Frazee, A. (1994). Professional preparation in cultural awareness and sensitivity in health education: A national survey. Journal of Health Education, 25(4), 215-218.

Stoy, D. B. (2000). Developing intercultural competence: An action plan for health educators. Journal of Health Education, 31(1), 16-19.

U.S. Census Bureau. (2004). U.S. interim projections by age, sex, race, and Hispanic origin. Retrieved August 16, 2004 from http://www.census.gov/ipc/www/usinterimproj/

U.S. Census Bureau. (2000). United States census 2000. Retrieved August 16, 2004 from http://www.census.gov/

CHES AREAS

Responsibility VIII: Applying Appropriate Research Principles and Methods in Health Education

Competency A. Conduct thorough review of literature. Subcompetencies:

5. Synthesize key information from the literature. Competency B. Use appropriate qualitative and quantitative research methods. Subcompetencies:

1. Assess the merits and limitations of qualitative and quantitative research methods.

2. Apply qualitative and/or quantitative research in research designs. Competency C. Apply research to health education practice. Subcompetencies:

7. Use protocol for dissemination of research findings.

Responsibility X: Advancing the Profession of Health Education

Competency A: Provide a critical analysis of current and future needs in health education. Subcompetencies:

1. Relate health education issues to larger social issues.

Raffy R. Luquis, PhD, CHES is an Associate Professor of Health Education for the School of Behavioral Sciences and Education at Penn State Harrisburg. Miguel A. Perez, MS, PhD, CHES is an Associate Professor for the Department of Health Sciences at California State University. Address all correspondence to Raffy R. Luquis, MS, PhD, CHES, School of Behavioral Sciences and Education, W331 Olmsted, Penn State Harrisburg, 777 West Harrisburg Pike, Middletown, PA 17057; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Demographics Characteristics of Respondents

Category                                  N     %

Gender
  Female                                  321   71
  Male                                    133   29

Race/Ethnicity
  White                                   397   87
  African American                         16    4
  Hispanic                                 15    3
  American Indian                          14    3
  Asian                                     2   <1
  Other                                    11    2

Age (years)
  20-29                                    14    3
  30-39                                    71   16
  40-49                                   128   28
  50-59                                   205   45
  60 or more                               36    8

Education Level
  Bachelor's                               58   13
  Master's                                227   50
  Doctoral                                156   34
  Other                                    14    3

Health Education Degree
  Yes                                     357   79
  No                                       97   21

Number of Health Education Degrees
  One                                     196   55
  Two                                     125   35
  Three                                    31    9
  More than three                          35    1

Years of Experience in Health Education
  0-5                                      41    9
  6-10                                     88   20
  11-15                                    77   17
  16-20                                    81   18
  More than 20                            163   36

Health Education Setting
  School                                  203   45
  College                                 164   36
  Community                                27    6
  Public Health Dept.                      16    4
  Other                                    45    9

Percentage of Diverse Clients
  0-25                                    255   56
  26-50                                    99   22
  51-75                                    46   10
  76-100                                   40    9
  Other                                    13    3

Cultural Education Program
  None                                    123   27
  1-3                                     255   56
  4-6                                      52   12
  7 or more                                24    5

Note: Frequency and percentage does not include missing values.

Table 2. Cultural competency mean rank scores comparison between race,
college degree, number of college degrees, and percent of diverse
clients.

Category                             Mean Rank    N     Z-value

Race                                                    4.409 **
  White                              217.62       397
  Non-White                          299.06        58

College Degree in Health Education                      2.475 *
  Yes                                235.44       357
  No                                 198.28        97

Number of College Degree in
    Health Education                                    4.086 **
  One degree                         158.79       196
  Two or more degree                 203.61       161

Percentage of Diverse Clients          6.274 **
  0-25%                              190.61       259
  25-100%                            268.10       186

* Significant at p < .05

Table 3. Cultural competency mean rank scores comparison among years
of experience, health education settings, and number of cultural or
diversity programs attended

Category                                   Mean Rank   N     Chi-Square

Years of Experiences in Health Education                      3.718
  10 years or less                         208.43      129
  11 to 20 years                           226.66      158
  More than 20 years                       237.89      163

Health Education Setting                                     67.094 *
  School                                   172.13      203
  College/University                       278.54      164
  Other                                    262.70       88

Number of Cultural/Diversity Program
    Attended in Past 3 Years                                 81.160 *
  None                                     150.48      123
  1-3                                      237.28      255
  4 or more                                319.35       76

* Significant at p < .001