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Introduction
Today’s healthcare professionals provide Services to diverse populations whose cultures, languages, and experiences must be taken into account in order to assure compliance with medical treatments. Moreover, the literature suggests medical professionals are often ill-prepared to deal with cultural diversity among their patients, providing a clear call for the incorporation of intercultural training to medical school curricula 1-3.
Given the increasing diversity in the patient population, it is vital for medical professionals to address the needs of individuals in a culturally competent manner. The professional literature provides ample evidence for the need to incorporate culture as we work within and across groups in order to improve human relations, reduce intolerance, promote greater inclusion, and takes culture into account in the delivery of health care services 3-4.
Culture is a theoretical abstraction based on the beliefs, behavior, and practice of people and is defined as dynamic interactions, set of beliefs, knowledge, values and behaviors learned and transmitted between people through language and their life in society. In that context, culture is understood as a dynamic process that is acquired, transformed and reproduced through continuous learning and socialization"5-6.
Culture, like language, is a place of expression and interaction between oneself and the other and it dictates behaviors in different settings including health related decisions. It is for this reason that understanding the nature of culture requires the understanding of related concepts such as multiculturalism, interculturality and intercultural competence that are important in educational systems.
Multiculturalism refers to the diversity of cultures that exist within a certain geographic region regardless of their relationships. This concept can also be understood as a collection of singular cultures often with often juxtaposed social organizations and can be defined as the presence in a territory of different cultures that are limited to coexist. By definition multiculturalism is a static concept that leads to a situation of segregation and denial of coexistence and social transformation due to the adoption of paternalistic positions towards present cultural minorities 8-9.
The related concept of pluriculturality refers to several cultures coexisting in a territorial space coming together to create a national totality 9-11. A fundamental characteristic of pluriculturality is its emphasis on the differences between and within cultures. Cultural pluralism is fundamental in all democratic societies because it emphasizes intercultural equality especially as it relates to the delivery of health care services.
The more expansive term of interculturality helps us grow, promote and maintain bioethical principles that involve actions to maintain autonomy and beneficence since it helps us understand that there should not be any hierarchies among individuals and groups. Intercultural competences are considered to be cognitive, affective and practical skills needed to function effectively in an intercultural environment. They should be promoted to create an educational climate where people feel accepted and supported by their own skills and input and to allow effective and fair interaction between all members of the group. The dimensions of intercultural competence revolve around knowledge, skills or attitudes which must be possessed by the pedagogue, complemented by the values that are part of a society 12.
In relation to interculturality the literature suggests that there are three stages:
Decentralization or the perspective in which we move away from ourselves through self-reflection, for example working in the classroom with elements of critical thinking is a pedagogically necessary strategy given that the empathic orientation in medical students require important inputs to promote it.
Penetration or the process of empathy development by leaving one’s point of view and developing an understanding the reality from another person’s perspective.
Negotiation which refers to the symbiosis or the understanding and experiences necessary to avoid confrontation between different cultures.
Some authors suggest that in addition to the three concepts described above, there must be reciprocity, good will and horizontality for the establishment of safe harbors where negotiations can take place and where parties are assured respect. The application of the concepts of multiculturalism, pluriculturality, and interculturality invariably result in improving the health status of populations as health care providers are able to not only improve provider-patient communication, but also improve health outcomes from improve patient compliance.
The exploration of interculturality in health requires commitment from all aspects of society and it could be argued that it should be an integral part of the training of medical students13-15. This training would not only generate increased sensitivity and awareness of the differences with and between their patients, but also would allow future medical providers to develop as individuals and gain a better recognition of themselves and the other with a critical stance and the ability to engage in productive and open dialogue. Better health outcomes are but one expected outcome from better patient-doctor interactions as a result of intercultural sensitivity.
The classroom is a time of important interactions that merit intercultural work and where students become aware of the plurality of patient origins and how those differences require respect for diversity. The classroom is also a venue to explore the negative results of ignorance or under value of people’s cultural experiences and expressions. Scientifically sound educational experiences assist in the development of capacities related to intercultural dialogue and the removal of cultural blinders which may result in discrimination 16. The purpose of this study was to evaluate an inter-cultural competence training program among first and sixth semester medical students at a university in Colombia.
Materials and methods
The Intercultural Experience in the Classroom program (IEC) was implemented in two classes taken by first and sixth semester medical students at the Universidad del Norte in Barranquilla, Colombia. The program was implemented in the "Family, Society and Health" class taken by first semester students and in the "Family Medicine Rotations" class taken by sixth semester students.
The steps for intervention in the subjects were as follows:
Agreement of teachers of the area of family medicine, public health.
Agreements on the type of study and the pedagogical methodology to be used. It was decided to work in areas related to critical thinking incorporating universal questions related to the purpose of the promotion of interculturality, its assumptions, its implications, and their arguments in today's society.
Obtain Support from the CEDU (Center for Teaching Excellence of the University, since most of the researchers had participated in a CAD (Teaching Learning Community) whose special topic was related to the promotion of work by cultural differences in the classroom.
Planning of dynamics related to curricular contents that allow to explore the perceptions that have the sixth semester students, about the way in which the culture of their patients influences the behaviors related to the health and in the health-disease process.
Planning activities related to raising awareness of self- recognition and of the other.
Feedback activities with students about the intercultural elements found in classroom discussions.
Program Implementation
Two classes were selected for first year students and two classes were selected for six year students, one class was assigned to the control group and one class was assigned to the experimental group in each of the grade levels.
Students in the control group received the regular classroom topics without any special mention of cultural issues. Students in the experimental group, participated in activities related to the recognition of their culture and that of their families as part of the intercultural training. The trainings consisted of dialogue and interaction with their peers and with guides based on the principles of critical thinking (see Appendix A). In addition, videos and introspective peer discussions leading to the creation of drawings that showed their representations about Colombian families were utilized.
A pre-post test (Appendix B) using the “Survey for the analysis of intercultural competences of higher education students” (16) was used to measure the level of development of the intercultural competence of higher education students. This instrument consists of 23 questions, the first 17 questions are focused on the first competence “Intercultural Efficacy” and the last 6 questions are focused on the competence “Respect and understanding of the differences and the diversity”. The instrument has been used in assessing intercultural issues among college students in the region.
Results
Quantitative data were analyzed using the Wilcoxon rank test for related samples for the analysis of median differences. Over 97% of the students were Colombian, mostly from the Atlantic region, and the remaining students were from the US and Brazil.
Significant differences were found in the first semester experimental group when comparing their pre- and post test results, no such differences were observed in the control group (see Table 1). Students in the experimental
Tabla 1 Findings from experimental and control group 1 semester students
Source: Authors * Wilconson 0.016 p=<.05
group reported higher level of intercultural understanding and empathy at the end of their training.
Significant differences were found in the sixth semester experimental group when comparing their pre- and post test results, no such differences were observed in the control group (see Table 2). Students in the experimental group reported higher level of intercultural understanding and empathy at the end of their training.
Discussion
In addition results from this study suggest certain weaknesses manifested in the form of stereotypes which are exacerbated by the lack of communication among members of diverse groups Further work, however, is necessary to expand the dialogue related to these topics in the classroom and in to institutionalize curriculum changes designed to address attitudes, values and norms that promote intercultural.
Conclusión
Results from this study show that the intervention resulted in positive changes in student attitudes toward interculturality. Results also suggest that the intervention was successful in increasing intercultural sensitivity, empathy and recognition of cultural values and resulted in the first acknowledgment of prejudices held by some program participants, which were also transformed into higher levels of respect of others, increased tolerance and coexistence, and values the lessons they can learn from people from diverse backgrounds.
Results from the study support the notion that intercultural training is not only necessary at the individual level, but that the intercultural dynamics that are institutionalized in the universities should incorporate activities that start from the cultural sensibility to the development of projects designed to create intercultural competences among future health professionals17.
Multiculturalism, pulticulrurality, and interculturality are part of an ever changing paradigms facing current and future health care professionals. Given its more expansive definition, this training focused on the latest concept and its inclusion in medical education. Activities in this program were designed to promote interculturality and promoted the understanding of the self as well as the other especially as it related to the health-disease process. This process is vital since the Colombia Comprehensive Health Model (MIAS), proposes respect for cultural differences and establishes cultural competence as a priority for healthcare professionals, this experience demonstrates that one way to address this mandate could include cultural sensitivity training of medical students. By better preparing their students to address the needs of diverse populations, educational institutions would show their commitment to international declarations establishing interculturality is a priority and assure better health outcomes.
