MULTICULTURAL CURRICULUM EVALUATION OF A PROFESSIONAL PREPARATION PROGRAM.

Abstract: Multicultural competencies for the seven responsibility areas of health education were applied to evaluate the multicultural curriculum of a health education professional preparation program. Faculty, students' and practicum supervisors' perceptions were assessed, course content was evaluated, and students' multicultural sensitivity was measured. Competencies were addressed at varying levels, and some courses had a greater multicultural focus. Students perceived that the multicultural portion of the curriculum could be enhanced by requiring a separate multicultural health education issues course, incorporating cultural sensitivity and competence into every health education course, and requiring varied multicultural field experiences. Students' high level of cultural sensitivity did not increase significantly during the program.

The U.S. population mix is fast becoming a "majority of minorities" who co-exist in a diverse society where a pluralistic, salad-bowl perspective has replaced assimilation and melting-pot paradigms (Airhihenbuwa, 1995; Salimbene, 1999). Health educators need to focus their efforts on these growing, yet marginalized, cultural and ethnic groups (Denboba, Bragdon, Epstein, Garthright, & Goldman, 1998). Traditional health education approaches are not as effective with some groups as with others. Culture-specific intervention strategies are needed that reflect subjective cultural characteristics and group expectations; involve culturally competent intervenors; and have a culturally relevant theoretical framework (Marin et al., 1995).

The AAHE and SOPHE ethical codes reflect the importance of cultural sensitivity and competence among health educators (AAHE, 1994a). These abilities are critical to the skillful conduct of health education practice (AAHE, 1994b; Stoy, 2000). Professional preparation programs need a strong multicultural focus to meet the expectation of providing multicultural training for health educators (Redican, Stewart, Johnson, & Frazee, 1994).

Two recent studies found that multicultural content is not adequately addressed across health education professional preparation programs. In a survey of institutions offering such programs (Redican et al., 1994) faculty rated their programs low in terms of including cultural awareness and sensitivity in the educational experience. Another survey of the same population (Doyle, Liu, and Ancona, 1996) revealed that course-based cultural diversity education was lacking, and training in cultural competence was weak. Efforts toward a solution should involve the development of multicultural health education criteria and a program evaluation framework. The purpose of this study was to evaluate the multicultural content of an existing health education professional preparation program.

METHODS

Multicultural content of an undergraduate community health program was evaluated in 1996 using a multimethod approach that blended qualitative and quantitative methods (Doyle, Woods, & Deming, 1995). The program was housed in a department that offered doctorate, masters, and bachelors degrees in health education at a mid-sized urban university. The program had an enrollment of 88 undergraduate health education majors and a faculty that consisted of one part time and six full time professors and six graduate student assistants. The self-evaluation process (SABPAC, 1990) involved students, practicum preceptors, and instructors in individual interviews, focus groups, and written surveys to provide multivalidation of self-reported data. The researcher examined the multicultural content reflected on course syllabi for comparison to instructor evaluations.

Study instruments were developed based on multicultural competencies (see Figure 1) identified from a qualitative analysis of the multicultural health education literature (AAHE, 1994b; Acosta-Deprez, 1994; Bensley, 1994; Fortune, 1994; Orlandi, 1992; Pahnos & Butt, 1994; Taylor, 1F998). The competencies were submitted to eight multicultural health education experts for content validity, organized in relation to the seven areas of responsibility of an entry-level health education specialist (National Task Force, 1985), and incorporated into parallel student, instructor, practicum preceptor, and syllabus evaluation instruments. Terms were defined on each instrument, and study participants had the opportunity to ask questions to clarify terms during focus groups and interviews. Instrument scoring was patterned after scoring used to self-evaluate professional preparation programs for approval (SABPAC, 1990).

Figure 1. Competency Items Included in the Various Evaluation Instruments

Skill-level competencies

* Area of responsibility. Assessing individual and community needs for health education

Competency: Assess the needs of ethnic/cultural groups

* Area of responsibility. Planning effective health education programs

Competency: Plan a health education program for an ethnic/cultural group

* Area of responsibility: Implementing health education programs

Competency: Select/develop teaching strategies specific to an ethnic/cultural group

Competency: Select/develop culturally appropriate educational materials

Competency: Identify biases in existing health education programs and curricula

* Area of responsibility. Evaluating effectiveness of health education programs

Competency: Provide non-biased and culturally sensitive program evaluation

* Area of responsibility. Coordinating provision of health education services

Competency: Identify health agencies and organizations that are responsive to the needs of multicultural groups

* Area of responsibility. Acting as a resource person in health education

Competency: Be a resource for information on health needs of ethnic/cultural groups

* Area of responsibility. Communicating health and health education needs, concerns, and resources

Competency: Interact with other ethnic/cultural groups in a culturally competent manner

Cognitive competencies: Knowledge of:

* The existence of many cultures

* The influence of culture on health behavior, health decisions, and health status

* The differences among cultures in terms of health beliefs and values

* The effects of the history of specific cultural groups on their contemporary health behavior, decisions, and status

* The effects of the history of specific cultural groups on their relationships and interactions with members of the dominant American culture

* The fact that cultural groups have different communication styles

* The fact that cultural groups have different learning styles

* Definition of culturally sensitive health education

* The fact that culturally sensitive health education is important

* Multicultural demography and demographic projections

* Culture and acculturation 

* Health problems of ethnic/cultural groups

* Stereotypes, biases, and discrimination

* Cultural norms and capabilities of ethnic/cultural groups

STUDENTS' PERCEPTION OF MULTICULTURAL CONTENT OF THE PROGRAM

Thirty-six students in the capstone course completed a 3-point Likert scale program evaluation instrument (1=no emphasis, 2=minor emphasis, 3=major emphasis) to assess their perceptions of how well the program addressed multicultural content and the emphasis placed on each of the competencies in program core courses. Thirty-eight students in the same course completed the Multicultural Sensitivity Scale (Jibaja-Rusth, Kingery, Holcomb, Buckner, & Pruitt, 1994), a 21-item instrument that measures cultural sensitivity levels (a=.90, r=.92). In a pretest posttest design, these scores were matched to the students' previous Multicultural Sensitivity Scale scores collected in the introductory community health course.

Thirty students participated in a focus group to evaluate the program's multicultural component and recommend changes. Students individually wrote three prioritized responses to the question, "What could the program do to better equip you for cultural sensitivity and competence?" In groups of six or seven, they then discussed their answers to reach group consensus. The class as a whole then listed and prioritized the groups' highest priority responses.

PRACTICUM PRECEPTORS' PERCEPTION OF STUDENTS' MULTICULTURAL COMPETENCE

A questionnaire and stamped self-addressed return envelope were mailed to 21 current preceptors of community health practicum students. A follow-up mailing was accomplished three weeks later. The questionnaire measured preceptors' perceptions of the students' demonstrated knowledge or abilities in relation to the same multicultural competencies (1=excellent, 2=good, 3=fair, 4=poor, 5=unknown). Two open-ended questions asked for the three most important ways that the student was and was not culturally sensitive and competent.

EVALUATION OF MULTICULTURAL CONTENT OF THE CURRICULUM

The researcher evaluated the seven core courses and two group-specific courses (women and older adults) through syllabus review. For each syllabus, the researcher highlighted course objectives, topics of study, and activity descriptors that reflected cultural content. The researcher then critically analyzed the content to determine which of the multicultural competencies were reflected. The emphasis placed on each one was rated using a 3-point Likert scale (0=no emphasis, 1=minor emphasis, 2=major emphasis). The resulting scores were entered on a grid that matched the seven areas of responsibility and corresponding program certification competencies.

Also, each course instructor evaluated the level of multicultural emphasis in that course. A similar grid was used to allow comparisons between instructor and researcher perceptions. The researcher individually interviewed the instructors to clarify course evaluation results, identify possible reasons for any disagreement between the researcher's and instructor's course evaluations, and determine instructors' perceptions of the multicultural content of the curriculum.

RESULTS

STUDENT EVALUATION OF THE PROGRAM

Student Evaluation Questionnaire. Mean competency scores on the student evaluation scale (Cronbach Alpha=.94) ranged from 2.11 (SD=0.71) to 2.69 (SD=0.47). This indicated that students perceived that multicultural content was moderately to well addressed in the program. A Friedman two-way analysis of variance and a post-hoc test yielded a statistically significant difference between the lowest and highest mean ranks, [chi square] (22, N=36)=53.37, p [is less than] .001. The students rated four competencies as having significantly greater emphasis. Those were (a) program communication that culture influences health behavior, health decisions, and health status; (b) program communication that there are differences among cultures in terms of beliefs and values; (c) preparation to value diversity in our society; and (d) program communication that many cultures exist. Two content areas that received significantly lower ratings were (a) culture and acculturation and (b) multicultural demography and demographic projections.

Student Cultural Sensitivity. The students' mean Multicultural Sensitivity Scale score in the capstone course (Cronbach Alpha=.91) was 50.16 (SD=16.76). The possible range of scores was 21-126, with a lower score representing greater cultural sensitivity. This finding indicated a high level of cultural sensitivity. There was no statistically significant difference (t(21) =-.02, p=.99, N=20) in students' cultural sensitivity levels at the time of the introductory course (M=47.68, SD-16.02), compared to the time of the capstone course (M=47.64, SD=19.17).

The relationship between the student evaluation questionnaire responses and the students' Multicultural Sensitivity Scale scores was analyzed with a Spearman correlation coefficient. The resulting r of -.16 (p=.38) demonstrates no relationship between the students' multicultural evaluation of the curriculum and their cultural sensitivity, indicating that the two instruments measured different constructs and that students discriminated among responses.

Focus Group. Thirty students provided individual written responses to the question of how the program could better equip them for cultural sensitivity and competence. Table 1 lists six response categories that emerged. The class consensus was that the two most important suggestions were to (a) have a separate required multicultural course and (b) incorporate cultural sensitivity into other courses, especially if a separate course were not required. One student exhorted that cultural sensitivity should be addressed by every professor in every course.

Table 1. Categories of student responses to question of how program could equip them better for cultural sensitivity and competence (N=30)

* Include a separate required ethnic and cultural issues course in the curriculum (N=19)

* Spend more time on cultural sensitivity in existing courses (N=18)

* Utilize guest speakers from different cultures (N=13)

* Provide field experiences in varied cultural areas (N=9)

* Provide more information about different cultures' unique characteristics, issues, and beliefs (N=7)

* Focus less on cultural sensitivity (N=2)

Suggested methods of multicultural instruction were to use guest speakers from different cultures, assign student group presentations on different cultural health issues, form culturally diverse student groups for class activities and assignments, study existing community programs that targeted culturally diverse groups, assign presentations on health issues related to a cultural group other than one's own, require field experience rather than just observation, and offer culturally diverse practicum sites. One student summed up the feelings of the group by stating, "[Field experience] puts you ahead in the long run and gives you the background you need."

PRACTICUM PRECEPTOR EVALUATION

Six of the 25 practicum preceptors responded "unknown" to varied questionnaire items (Cronbach Alpha=.95). With these "unknown" responses deleted, the N for the various analyses ranged from 7 to 13. Mean competency scores ranged from 1.58 (SD=0.67) to 2.67 (SD=0.71), indicating that the preceptors rated the students as moderately knowledgeable about multicultural health education and capable of culturally competent practice. A Friedman analysis of variance revealed statistically insignificant differences in the mean item ranks, [chi square] (24,n=6)=29.54, p=.20.

Five of the 14 respondents listed ways the student was and was not culturally sensitive and competent. They generally perceived the students to be culturally sensitive and competent and believed that this was influenced by their prior experience in interacting with other cultures. One preceptor commented that this experience resulted from ethnic group membership.

EVALUATION OF MULTICULTURAL CONTENT OF CURRICULUM

Researcher Evaluation of Course Syllabi. The mean course syllabus multicultural score was 10 (SD=15.75; possible range=0-46). The total multicultural score for all competencies across all syllabi was 90 (possible range=0-414). These results indicate minimum reflection of multicultural content in syllabi and great variability across syllabi. A Friedman analysis of variance revealed no statistically significant difference in mean ranks of competencies identified on the course syllabi, [chi square] (22, N=9)=9.69, p=.99. A statistically significant difference was detected in mean ranks of course syllabi multicultural content scores, [chi square](8, N=23)=67.68, p [is less than] .0001. Higher ranked courses were more experiential and had a broader focus in relation to responsibility areas.

Instructor Course Evaluation Questionnaires. The total emphasis score for each competency across the nine courses ranged from 5 to 13 (possible range=0-18). The mean total course score for all competencies was 21.6 (SD=8.45; possible range=0-46). Multicultural content was moderately addressed in the curriculum with varied breadth of coverage across courses and competencies.

A Friedman two-way analysis of variance revealed significant differences in mean ranks of competencies in the courses, [chi square] (22, N=9)=35.63, p [is less than] .05. Six competencies were rated as receiving significantly greater emphasis. In rank order, beginning with the highest, they were (a) knowledge of the existence of many cultures; (b) knowledge of the influence of culture on health behavior, health decisions, and health status; (c) knowledge of stereotypes, biases, and discrimination; (d) ability to be an information resource for health needs of ethnic and cultural groups; (e) knowledge of health belief and value differences among cultures; and (f) knowledge of health problems of ethnic and cultural groups. Three competencies were rated as receiving significantly less emphasis in the courses. In rank order, beginning with the lowest, they were (a) ability to provide non-biased and culturally sensitive program evaluation, (b) knowledge of multicultural demography and demographic projections, and (c) understanding of culture and acculturation.

A Friedman analysis of variance also revealed statistically significant differences in mean ranks of courses which addressed multicultural content, [chi square] (8, N=23)=28.58, p [is less than] .001. The courses that scored significantly higher taught interaction with the community, were experiential in nature, and contained content that broadly reflected the breadth of the seven responsibility areas.

The proportion of agreement between instructor and researcher multicultural content evaluation of courses was .36. The z test of proportions of agreement (z=-7.122, p [is less than].0001) suggested significant disagreement between the content of the syllabi and the actual course content, particularly regarding skill-level competencies.

Instructor Interviews. Table 2 presents nine trends in the data that emerged from the qualitative analysis of the instructor interviews. Several suggestions related to curriculum considerations. A separate multicultural health education course should be required to overcome the lack of focus on multicultural topics in current courses. Such a course should be broad-based to reflect ethnic cultural groups and non-ethnic cultural groups, such as religious, age-specific, and gender groups. Pertinent multicultural content and issues should also be addressed within each course to the degree that they are relevant. Students should develop cultural sensitivity in their coursework prior to their field experience. Students should spend an adequate amount of time in the field to resolve multicultural issues and frustrations related to the site and population.

Table 2. Trends that emerged from instructor interview data

* Instructors held differing opinions and philosophies about their role in relation to multicultural education in a health education professional preparation program.

* Opinions varied about the relationship between cognitive and skill-level competencies and between cultural sensitivity and competence.

* None of the courses had a focus on multicultural health education, but most instructors addressed it as it related to other topics that were the focus of their courses.

* Certain factors limited or enhanced addressing multicultural content in the courses.

* In general, instructors willingly and creatively taught multicultural health education in their courses.

* Pedagogical and curriculum considerations influenced how well multicultural education was addressed.

* Instructors believed that students appreciated it when they confronted and addressed multicultural issues in their courses.

* Instructors agreed that multicultural content was not reflected in their syllabi although it was covered in the courses.

* Instructors believed that multicultural content should be addressed in the course syllabi.

Factors which emerged as possible enhancers of multicultural education were the professors' multicultural knowledge, experience, and sensitivity; the students' receptivity to multicultural topics and issues; diversity within the student body; a culturally diverse faculty; and written policies of expected culturally sensitive behaviors for students. The presence of non-health education majors in the classroom was perceived as a barrier to training in multicultural health education. The cultural mix of the students in this program was perceived as having the greatest positive influence. Student diversity provided culturally diverse presentations of topics and populations by students in the various courses, created an atmosphere rich in shared learning, and enhanced their receptivity to multicultural topics.

Pedagogical suggestions included needs assessment to determine students' multicultural educational needs; use of experiential activities and projects to provide opportunities to apply knowledge; provision for choices of topics, populations, settings, and sites of projects, research papers, field experience, and other assignments; instructor guidance of projects to assure that multicultural issues are addressed; presentation of projects and papers in class to provide further exposure to various cultures; and role modeling of culturally sensitive and competent behavior.

The qualitative analysis mirrored the quantitative result of the lack of reflection of content on the syllabus, and instructors agreed that it should be reflected. Reasons given were to stress the importance of multicultural health education, monitor content taught by graduate teaching assistants, and document multicultural teaching for program certification and other university reviews. The assumed multicultural nature of the health education profession was suggested as a possible justification for the absence of specific multicultural objectives and content on the syllabi.

DISCUSSION

Based on input from students and faculty, all multicultural competencies were addressed at various levels within the curriculum. The concepts of culture, acculturation, and multicultural demography received less emphasis. Greater emphasis was placed on developing an awareness of and value for a culturally diverse society, and an understanding of how culture influences health. This cultural awareness and sensitivity focus is congruent with recommendations from multicultural education experts who target these as the first steps in cultural competence development (Salimbene, 1999; Smith, 1998). In that regard, the curriculum may be adequately addressing these important components. However, it also seems logical that an introduction to culture, acculturation, and demographics could be readily infused into the learning experience.

No significant difference was found between student cultural sensitivity pretest and posttest scores, and the mean score was high at both times. The university where this study was conducted is noted for its diversity-embracing atmosphere and attracts students who value diversity. This may have played an important role in the high sensitivity scores of incoming students.

The results of this study validate the argument that cultural awareness and sensitivity do not automatically translate into high levels of skills-based competence (Smith, 1998). The preceptors' moderate ratings of student intern competence could be interpreted in several ways. It may be that more culture-based experiential experiences should be infused into preparatory courses so that students are better equipped for culturally competent internship performance. Yet, a moderate performance rating is not particularly alarming in light of the purpose and nature of undergraduate-level professional preparation. Students graduating from baccalaureate programs are rarely expected to be seasoned experts in the competencies of their chosen field. More research is needed to further explore competence evaluation.

Students suggested specific teaching methods and activities, including cultural classroom activities, guest speakers, student group presentations, culturally diverse student groups for assignments and activities, required study of a cultural group other than one's own, rotation among several ethnic or cultural field sites, required volunteer work within an ethnic or cultural community, and a foreign exchange health education program. These ideas paralleled faculty practices and suggestions for increasing multicultural content in their courses. The literature substantiates these means of incorporating multicultural health education into professional preparation programs (Doyle et al., 1996, Redican et al., 1994).

Recommendations resulting from student focus groups and instructor interviews reflect multicultural education literature debate about whether multicultural education should be infused across all courses or contained in a single course. As is often espoused by multicultural education experts (Banks, 1995; Gay, 1997; Gillette & Chinn, 1997), students and faculty suggested a need for both. The opinion prevailed that a separate required ethnic and cultural health issues course is needed to help students focus on the importance of the topic and gain in-depth understanding about sensitivity and competence in health education settings. Such a course could provide the recommended overview of culture, acculturation, and demographics; an in-depth emphasis upon the development of cultural sensitivity and competence; and more ethnic and cultural field experiences to prepare students for an even better internship experience. Other topic- and group-specific health courses could support those efforts by providing a topic- and group-specific multicultural perspective.

Barriers to introducing a new course exist on most university campuses. However, most health education programs offer a course designed to introduce students to the health education profession. The introductory course is a logical course in which to introduce cultural sensitivity and competence because the course prepares students for the development of established professional competencies and overviews health issues among various U.S. subpopulations.

Several sampling issues could limit the study results. Although a small sample is appropriate for qualitative research (Stainback & Stainback, 1988), the small samples used in this study could limit interpretation of quantitative results. Some students who were enrolled in the capstone course were still one semester away from graduation and had not yet completed all their core courses. Also, students had varied practicum experiences at the time of their participation in the study. Although the focus group method can place limitations on a study, no reservations were observed in students' willingness to share thoughts and suggestions, and qualitative analysis revealed that individual written responses paralleled focus group results. The small number of preceptors responding and the possible variability in their ability to assess cultural competence may limit the results of that part of the evaluation. However, preceptors' perceptions are important because they have the opportunity to observe students in the community settings.

CONCLUSIONS AND RECOMMENDATIONS

In summary, the program evaluated in this study addressed multicultural competencies, some competencies were addressed significantly more than others, and some courses addressed them more than others. Multicultural content was included in all courses, was not the primary focus of any course, and was not adequately reflected on course syllabi even when it was adequately addressed in the course. Suggestions to increase multicultural competence included requiring a separate multicultural health education issues course, incorporating cultural sensitivity and competence into every course, requiring varied and extensive multicultural field experiences, and addressing cognitive competencies prior to providing field experiences.

Several recommendations for health education professional preparation programs are based on the results of this study:

* Multicultural program evaluation should be broad-based and employ multiple methods.

* Multicultural evaluation of the curriculum should include student and faculty assessments.

* Practicum preceptors should be included in the evaluation process only if they are able to observe students' cultural sensitivity and competence, and should evaluate only skill-level competencies.

* Syllabi should reflect multicultural content of courses.

* Future studies should identify and test factors that influence development of students' cultural sensitivity and competence.

* Programs should explore the advantages of combining a requirement for a separate course in multicultural health education issues with the infusion approach of including appropriate multicultural content in all health education courses.

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Chris French Beatty, R.D.H., Ph.D., Associate Professor & Department Chair, Department of Dental Hygiene, Texas Woman's University, P.O. Box 425796, Denton, Texas 76204, (Ph) 940-898-2870, (Fax) 940-898-2869, [e-mail]. Eva I. Doyle, Ph.D., M.S.Ed., C.H.R.S., Associate Professor, Department of Health Studies, Texas Woman's University.