Development of an instrument to measure the cultural competence of health care workers

Pedrero, Victor; Bernales, Margarita; Chepo, Macarena; Manzi, Jorge; Pérez, Miguel; Fernández, Paulina

doi:10.11606/s1518-8787.2020054001695

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Original Articles • Rev. Saúde Pública 54 • 2020 • https://doi.org/10.11606/s1518-8787.2020054001695 copy

Development of an instrument to measure the cultural competence of health care workers

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

OBJECTIVE

To validate an instrument measuring the cultural competence in health care workers from Chile.

METHODS

Using Sue & Sue’s theoretical model of cultural competence, we designed a scale, which was assessed by health care workers and experts. Subsequently, the scale was applied to a sample of 483 different health care workers, during 2018 in Santiago de Chile. The analysis included: exploratory and confirmatory factor analysis, estimation of reliability, and analysis of measurement bias. Finally, the level of cultural competence was calculated for every professional who participated in this study.

RESULTS

The final scale include 14 items that are grouped into three dimensions concordant with the theoretical model: sensitivity to own prejudices, cultural knowledge, and skills to work in culturally diverse environments. This scale showed good fit in factor models, adequate reliability and lack of evidence of measurement bias. Regarding the performance of health care workers, sensitivity showed a lower level compared with the other dimensions evaluated.

CONCLUSION

The scale for measuring the level of cultural competence in health care workers (EMCC-14) is a reliable instrument, with initial support for its validity, which can be used in the Chilean context. Additionally, the results of this study could guide some possible interventions in the health sector to strengthen the level of cultural competence.

Cultural Competency; Culturally Competent Care; Health Knowledge, Attitudes, Practice; Validation Studies

Thinking about your usual clinical practice, for each question, indicate how much you agree or disagree.	Totally disagree	Disagree	Neither agree nor disagree	Agree	Totally Agree
	(1 point) (%)	(2 points) (%)	(3 points) (%)	(4 points) (%)	(5 points) (%)
1. I believe patients with different beliefs and customs have different expectations and/or needs in health care ^a .	7.1	10.2	9.6	38.1	35.0
2. I believe patients’ beliefs, values and customs affect their health ^b .	8.3	10.6	17.0	37.6	26.6
3. I believe my cultural context influences my attitudes and beliefs about other cultural groups ^c .	18.9	21.8	15.6	30.9	12.9
4. I am aware that my beliefs about patients influence the therapeutic recommendations I make to them.	20.8	23.1	18.3	28.5	9.2
5. Patient beliefs, values and customs should be appreciated in health care.	0.2	0.6	2.9	33.2	63.1
6. I believe that knowing more about patients’ beliefs and habits helps me to plan a more appropriate treatment.	0.8	1.0	7.9	36.4	53.8
7. I believe that each patient has his or her own concept of health and illness.	0.2	1.9	7.1	45.0	45.9
8. I believe the patient’s health problems must be understood within their cultural context (beliefs, values and customs) ^d .	0.2	1.1	6.6	48.2	44.0
9. I ask the patient and his/her family to express their expectations regarding health care ^b .	1.0	6.6	18.0	46.7	27.6
10. I am able to recognize potential barriers that different patients may face to accessing health services ^b .	0.4	2.1	7.0	61.9	28.5
11. I am able to set therapeutic goals and/or objectives considering the cultural context (beliefs and customs) of my patients and their needs ^c .	0.6	1.5	14.9	51.0	32.0
12. I record in the clinical file the data about beliefs and customs collected in the evaluation of the patient.	4.9	11.1	21.1	38.9	24.0
13. I make an effort to explain to the patient his/her medical treatment, even if he/she believes that the cause of his/her illness is supernatural.	0.2	1.1	5.9	44.4	48.4
14. I am aware of possible difficulties that may arise during health care due to cultural differences between the patient and me.	0.2	1.1	4.5	49.9	44.3

	Qualitative phase		Sample Factor Analysis					Sample bias analysis
	Focus groups		Confirmatory		Exploratory		p	Nurses		Physicians		p
	(n=29)		(n=247)		(n=236)			(n=116)		(n=217)
	%	n	%	n	%	n		%	n	%	n
Sex							0.18					< 0.01
Male	28	8	24	60	30	70		54.3	63	17.5	8
Female	72	21	76	187	70	166		45.7	53	82.5	179
Age (average)	37.2		35		35			37		34
Occupation							0.92
Physician	17	5	25	61	23	54		-	-	-	-
Nurse	28	8	43	106	47	111		-	-	-	-
Kinesiologist	7	2	10	25	9	21		-	-	-	-
midwife	7	2	14	35	13	30		-	-	-	-
Nutritionist	14	4	8	20	8	19		-	-	-	-
Other	28	8		-		-		-	-	-	-
Contact with patients							0.78					0.38
All the time	-	-	90	221	91	211		94.4	201	96.6	112
Half or less	-	-	10	24	9	21		5.6	12	3.4	4
Level of care
Primary	-	-	24	58	31	72	0.09	17.8	38	27	31	0.05
Secondary	-	-	11	27	13	31	0.48	7	15	28.7	33	< 0.01
Tertiary	-	-	69	167	61	142	0.07	71.4	152	71.3	82	0.99
Graduate							0.63
Yes	-	-	64	157	61	145		46.1	100	79.3	92	< 0.01

	Factor Loads EFA (n = 236)			Factor Loads CFA(n = 247)
	Sensibility	Knowledge	Skills	Sensibility	Knowledge	Skills
Item 1	0.445	0.331	0.075	-
Item 2	0.400	0.100	0.321	0.649
Item 3	0.469	0.036	0.086	0.521
Item 4	0.793	0.005	0.025	0.69
Item 5	0.734	0.014	0.101	0.607
Item 6	0.583	0.369	0.164
Item 7	0.131	0.330	0.507		-
Item 8	0.090	0.121	0.894		0.831
Item 9	0.078	0.211	0.742		0.722
Item 10	0.123	0.378	0.524		0.614
Item 11	0.014	0.376	0.579		0.774
Item 12	0.034	0.574	0.278			0.637
Item 13	0.151	0.498	0.262			-
Item 14	0.054	0.572	0.121			0.566
Item 15	0.099	0.769	0.228			0.732
Item 16	0.077	0.569	0.093			-
Item 17	0.034	0.535	0.169			0.474
Item 18	0.066	0.476	0.084			0.516
Item 19	0.183	0.600	0.257			0.649

Level	χ ²	df	p	CFI	TLI	RMSEA	Δ CFI
Configural	186.1	148	0.00	0.98	0.975	0.039
Metric	188.5	159	0.05	0.984	0.982	0.033	0.004
Scale	196.6	170	0.08	0.986	0.985	0.031	0.002

	Sensitivity (sd)	p	Knowledge (sd)	p	Skills (sd)	p	Cultural competence total (sd)	p
Sex
Male	62.5 (20.9)	< 0.01	82.9 (13.2)	< 0.01	74.7 (11.9)	< 0.01	73.7 (9.6)	0.31
Female	56.3 (22.6)		86.6 (12.2)		78.8 (12.8)		74.9 (10.1)
Age (average)
Occupation
Physician	65.1 (21.5)	< 0.01	82.8 (13.2)	< 0.01	76.8 (11.5)	0.06	75.2 (9.7)	0.3
Nurse	57.4 (22.3)		86.2 (12.4)		76.8 (13.4)		74.3 (10.4)
Kinesiologist	60.1 (19.6)		84.7 (12.8)		79.5 (10.5)		75.5 (9.4)
midwife	49.2 (22.2)		85.8 (12.7)		78 (13.8)		72.4 (9.8)
Nutritionist	51.3 (21.5)		91.8 (8.6)		83 (10.9)		76.4 (9.2)
Contact with patients
All the time	58.3 (22.4)	0.2	85.3 (12.6)	0.04	77.8 (12.7)	0.65	74.6 (9.9)	0.78
Half or less	54.3 (21.2)		89.3 (11.8)		76.7 (12.2)		73.7 (11)
Level of care
Primary/ Secondary	58.8 (22.6)	0.54	86.7 (12.1)	0.23	78.9 (12.3)	0.14	75.5 (10.2)	0.08
Tertiary	57.8 (22.3)		85.2 (12.8)		77 (13.1)		74.2 (9.9)

Faculdade de Saúde Pública da Universidade de São Paulo Avenida Dr. Arnaldo, 715, 01246-904 São Paulo SP Brazil, Tel./Fax: +55 11 3061-7985 - São Paulo - SP - Brazil
E-mail: revsp@usp.br

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[1] Correspondence: Victor Pedrero Av Republica 217, Santiago, Chile E-mail: victor.pedrero@unab.cl