Cultural Competence among Healthcare Professional Educators: A Mixed-Methods Study

Round 1

Reviewer 1 Report

This nice manuscript by Mukhalalati and colleagues is aimed at investigating the Healthcare Professional Educators' (HPEs) perceptions of the cultural competence at QU-HC and the influence of cultural diversity of HPEs and students on teaching and learning process. 

This is relevant and well written, and I congratulate the authors with the methods section, which is well explained. However, I suggest taking care of a number of issues before considering its publication: 

INTRODUCTION: 

- The manuscript's main topic is cultural competence among healthcare professional educators, as stated by the title. Although inequities are certainly related to it (and relevant in healthcare processes) I find a bit misleading/confusing the fact that the introduction of the manuscript starts defining inequities (instead of cultural competence, which is the main topic). I suggest reorganizing the text in a more coherent way. 

- In the introduction, the Authors state that "there is still a lack of expertise in cultural competence for the majority of healthcare practitioners [...]". This is a quite strong affirmation that the authors support with a 20-years old reference (8). Many things may have changed since 2002, considering the progresses that have been made in this field. Also, this sounds very general: is this referred to a specific area, or is it a generalised fact? I suggest either finding a consistent, more recent reference, or rephrase the statement. 

- In the introduction, the Authors state that Qatar is an attractive destination for migrants due to many reasons, including the healthcare system, which is one of the best in the world. The reference mentioned by the authors does not seem to support this statement. Are there non-national assessments that support this statement? (e.g. WHO or other non-governative institutions studies). 

METHODS: 

- In "Sample": the approach is correct, but i would not say that it is done to maximize the response rate, but to maximize the number of responses (you can't be sure the rate will be higher if you only increase the denominator) and to avoid a rather useless complication, in case you sampled only some of them. 

- Data collection instrument: Although you have used a validated questionnaire (MTCS), you decided to to reduce it from a six to a five-point scale. Technically speaking, this affects the validation and you should re-evaluate the tool since you are NOT using the validated version. At least, this needs to be added to the limitations of this manuscript. 

- Data collection instrument: please explain whether the score ranges for the MTCS were decided a priori or after conducting the study, and how the consenus was reached. 

- Data analysis: Assuming your data have no normal distribution, I suggest recalculating and presenting frequencies as median + Interquartile range, instead of mean + SD. It would be more informative in this case. 

RESULTS: 

- in the tables, you added a footnote reporting "#indicates missing data". I suspect this is not enough for a reader to understand the results and the tables, as many items report different numerosity/total. E.g. in Table 1 the total seems to be 69/71 (NA=2), while in table 3 the number of participants is 52 or 53 depending on the item, and in table 4 the subtotals are again different (less than 50 sometimes). I might have missed some explanation, but I suggest 1. adding totals and NAs to all items and all tables (e.g. table 1, gender, total = 69 and NAs = 2). I also suggest explaining in the text the reason why, out of 71 included individuals, you have no 71 responses for all items. Were some questions optional? Did you apply filters? Please explain

DISCUSSION

I have no major comments as i find the results nicely discussed. The limitation section should include what highlighted above. 

 Minor editing of English language required

Author Response

Authors reply:

The author would like to thank the reviewer for his/her comprehensive review of our manuscript. These thoughtful insights and suggestions are invaluable to us, and we are committed to addressing each of them to enhance the quality of this piece of work.

 

Here is our response to the reviewer comments:

INTRODUCTION: 

- The manuscript's main topic is cultural competence among healthcare professional educators, as stated by the title. Although inequities are certainly related to it (and relevant in healthcare processes) I find a bit misleading/confusing the fact that the introduction of the manuscript starts defining inequities (instead of cultural competence, which is the main topic). I suggest reorganizing the text in a more coherent way. 

The author would like to thank the reviewer for this valid point. The authors concur with the reviewer on this point, and therefore the introduction section has been modified, as follows, to present ‘cultural competence’ as a central theme of this paper:

“Cultural competence is defined as “the ongoing process in which the healthcare provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)”[5]. Cultural competence promotes the questioning of one’s own preconceptions and prejudices, as well as other cultural humility and anti-oppressive principles like respecting differences, minimizing power disparities, forming alliances, and learning from patients [6]. Campinha-Bacote (1999) in her conceptual model of cultural competence, ‘The Process of Cultural Competence in the Delivery of Healthcare Services’, suggested five constructs of cultural competency that could be used to develop and implement culturally responsive healthcare services: cultural awareness; cultural knowledge; cultural skill; cultural encounter; and cultural desire [6]. In this model, there is an interdependence and an intersection between the constructs; the stronger the intersection, the greater the integration of cultural competence constructs in the healthcare provided to people from diverse races, ethnicities, genders, religions, and countries of origin [6].

Cultural competence is widely recognized as a way of minimizing health inequities in the medical and public health field. Healthcare inequities are systematic disparities due to discrimination, bias, and prejudice faced by different groups in attaining optimal health resulting in inequitable and preventable differences in health outcomes [1, 2]. One of the causes of healthcare inequities is differences based on social groups (e.g., race, religion, and culture) [3]. In the clinical literature, differences in referrals and in treatment practices by providers have been linked to patients’ cultural, racial, or ethnic backgrounds [4].

Several scholars view cultural competence as a practical tool providing healthcare providers and educators with crucial skills for dealing with various individuals, groups, and communities in today’s complicated world [7]. Despite the recognition of healthcare practitioners to the significance of cultural competence, there is still a lack of expertise for the majority of healthcare practitioners, which might prevent them from effectively providing culturally sensitive and acceptable care [8]. ….. ”

- In the introduction, the Authors state that "there is still a lack of expertise in cultural competence for the majority of healthcare practitioners [...]". This is a quite strong affirmation that the authors support with a 20-years old reference (8). Many things may have changed since 2002, considering the progresses that have been made in this field. Also, this sounds very general: is this referred to a specific area, or is it a generalised fact? I suggest either finding a consistent, more recent reference, or rephrase the statement. 

The authors are grateful to the reviewer for highlighting this important point. After a thorough examination of the paragraph and further investigation into this matter, the authors have determined that the assertion is too broad in scope. While there is some recent evidence support for it, its applicability remains context-dependent, and divergent evidence can be argued in varying settings. As a result, the authors have opted to omit this sentence from the paragraph, ensuring that the structural coherence and flow of ideas remain intact.

- In the introduction, the Authors state that Qatar is an attractive destination for migrants due to many reasons, including the healthcare system, which is one of the best in the world. The reference mentioned by the authors does not seem to support this statement. Are there non-national assessments that support this statement? (e.g. WHO or other non-governative institutions studies). 

The authors concur with the reviewer on the importance of including a non-national/unbiased evaluation of the healthcare system in Qatar. The following sentence and reference is now edited on the revised version, as follows:

“Qatar provides an attractive destination for individuals to immigrate, live and work in (14), because of a high gross national income (15)and one of the good healthcare systems in the world as being the second in the MENA region, and 39th out of 167 countries according to 2021 Legatum Prosperity Index (16).”

METHODS: 

- In "Sample": the approach is correct, but i would not say that it is done to maximize the response rate, but to maximize the number of responses (you can't be sure the rate will be higher if you only increase the denominator) and to avoid a rather useless complication, in case you sampled only some of them. 

Thank you very much for this insightful remark which the authors totally agree with. The authors clarified the description under the "Sample" section as suggested.

“The total population sampling approach was followed because the population was relatively small, and this attempt was made to maximize the number of responses.”

- Data collection instrument: Although you have used a validated questionnaire (MTCS), you decided to to reduce it from a six to a five-point scale. Technically speaking, this affects the validation and you should re-evaluate the tool since you are NOT using the validated version. At least, this needs to be added to the limitations of this manuscript. 

The authors greatly appreciate this valuable comment, with which the authors are in complete agreement. However, the above point was already addressed as a limitation in the original version of the manuscript, submitted previously, as follows:

 

“Nevertheless, the findings of this study should be interpreted with caution because of the relatively small sample of participants, and the lack of validity and reliability assessments of the adapted questionnaire.”

- Data collection instrument: please explain whether the score ranges for the MTCS were decided a priori or after conducting the study, and how the consenus was reached. 

The authors thank the reviewer for this remark and the authors agree that further details are needed. The following sentence is now edited in the manuscript.

 

“Because of the absence of a reference point in the initial scale, a consensus among the research team was reached prior to the conduction of the study by discussing the different approaches to score categorization. A consensus was reached on considering the total MTCS score between 59–80 as high, 37–58 as moderate, and 16–36 as low.”

 

- Data analysis: Assuming your data have no normal distribution, I suggest recalculating and presenting frequencies as median + Interquartile range, instead of mean + SD. It would be more informative in this case. 

The authors would like to thank the reviewer for raising this important point. The authors would like to bring to the reviewer’s kind attention that the data of the current study is normally distributed, besides the fact that parametric analyses are used for higher-rank Likert scales. Hence mean+SD and other parametric tests are used in this study. To improve clarity, the following sentence is added to the manuscript:

 

“The distribution of data was tested and showed normality.”

 

RESULTS: 

- In the tables, you added a footnote reporting "#indicates missing data". I suspect this is not enough for a reader to understand the results and the tables, as many items report different numerosity/total. E.g. in Table 1 the total seems to be 69/71 (NA=2), while in table 3 the number of participants is 52 or 53 depending on the item, and in table 4 the subtotals are again different (less than 50 sometimes). I might have missed some explanation, but I suggest 1. adding totals and NAs to all items and all tables (e.g. table 1, gender, total = 69 and NAs = 2). I also suggest explaining in the text the reason why, out of 71 included individuals, you have no 71 responses for all items. Were some questions optional? Did you apply filters? Please explain

The authors would like to thank the reviewers for this valuable remark. After a careful review of the results section, the authors made the following edits:

 

• The total number of participants and missing are now added in all tables and items if applicable.
• In Table 2, the authors initially (in the original previous submission) reported the demographics of anyone who responded to the survey, even those who did not reach the assessment of the outcome of the interest (MTCS) in order to understand the demographics of non-responders. However, because of potential confusion that might be created, the authors have now decided to report the demographics of only those who participated in the MTCS, even if is a partial completion. Hence, only Table 2 was modified, because all remaining analysis (in the other tables) involved participants who completed the MTCS.

 

The following paragraph is edited to clarify the reporting of response rate and usable rate:

 

“Seventy-one educators responded (the response rate was 60.2%); however, the usable rate was 81.7% (n = 58 of 71), after removing respondents who filled the demographic section only. The demographic characteristics of educators who participated in the study are presented in Table 2. The majority of HPEs were male (33 [57.9]), with the majority (19 [33.3%]) being ≥ 50 years of age. HPEs were predominantly from Canada (10 [18.2%]), the UK (7 [12.7%]), the US (5 [9.1%]), and Palestine (5 [9.1%]).”

• It is also worth mentioning that the participants were informed that they have the right not to respond to any question/item if they do not feel comfortable doing so. Therefore, not all participants completed the questionnaire fully.

 

The following paragraph is edited to clarify the point of having different numbers of responses:

 

“Participation in the survey was voluntary, no identifiable information was gathered, and participants were assured of anonymity and their right to abstain from answering any questions that they preferred not to answer.”

DISCUSSION

I have no major comments as i find the results nicely discussed. The limitation section should include what highlighted above. 

The authors appreciate the reviewer's positive feedback on the discussion section. As indicated, the limitation related to the absence of validity and reliability assessments of the adapted questionnaire is included in the paper, as follows:

 

“Nevertheless, the findings of this study should be interpreted with caution because of the relatively small sample of participants, and the lack of validity and reliability assessments of the adapted questionnaire.”

 

 

Comments on the Quality of English Language

Minor editing of English language required

The authors carefully reviewed and edited the manuscript to address minor language issues as suggested.

 

 

Once again, the authors would like to thank the reviewer for his/her thorough review and valuable comments. The authors believe that these inputs contributed significantly to the refinement of the manuscript. The authors committed to making the necessary revisions and ensured the highest quality of our work.

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

This is a well conducted study and well written manuscript

Author Response

Authors reply:

The authors would like to thank the reviewer for his/her positive feedback. We greatly appreciate your recognition of our efforts in conducting the study and preparing the manuscript.

 

Author Response File: Author Response.docx

Reviewer 3 Report

Thank you for submitting this review entitled  “cultural competence of health professional educators: A mixed-Methods Study”

I am going to comment on some doubts, suggestions that the authors must take into account to facilitate reading for the reader.

In table 2 they should put the missing values.

In the frequency section (table 2), prior to this they should be able to “n”

Below table 4, you should comment on the abbreviations.

Citations in the bibliography must follow the same format.

It is an interesting topic that I believe may be of interest to the university community, both for teachers and professors.

Thanks for the work, I hope you can resolve these issues.

Author Response

Authors reply:

The authors would like to express gratitude for this review and constructive feedback on our manuscript. The reviewer's input was invaluable in helping us improve the quality of our work.

The authors have carefully considered the reviewer's comments and have made the following revisions to address his/her concerns:

 

• In Table 2, we have included the number of participants who responded to each item and the missing values.
• In the frequency section of Table 2, we have added the "n" before presenting the data.
• We have added a comment on the abbreviations below Table 4 for clarity, as follows:

“Abbreviation: MTCS, Multicultural Teaching Competence Scale”

• The authors have reviewed and standardized the citation format in the bibliography to ensure consistency.

The authors hope these revisions meet the reviewer’s expectations, and they remain committed to resolving any remaining issues to enhance the manuscript's quality. The reviewer’s recognition of the importance of our research to the university community is greatly appreciated.

 

Author Response File: Author Response.docx

Reviewer 4 Report

In the modern healthcare system around the world, medical professionals (HPEs) are expected to have a high level of cultural competence in education. Therefore, the subject of the study is legitimate, and its results are needed for national and foreign health care systems.

The aim of this study was to assess the perception of cultural competences by HPEs. This study was conducted to examine cultural competences in education in healthcare professions in light of the multicultural nature of the Qatari population, healthcare professionals and teaching staff.

The Authors used a convergent mixed-method design. Quantitative research concerned the analysis of the responses of 71 medical workers on the Multicultural Teaching Competence Scale (MTCS). The qualitative research involved three focus groups (FGs) consisting of 22 HPEs. In the summary of the results, it was found that HPE showed a moderate level of cultural awareness (mean MTCS = 57±7.8). In contrast, the FG study revealed that HPE have awareness and teaching ability, but some individual and institutional factors need improvement.

The Authors also reviewed the scientific literature (Cochrane Review) on cultural diversity and its impact on teaching and learning in healthcare professions, particularly in the context of the Middle East.

The abstract contains all the elements analyzed in the thesis. The choice of keywords is correct.

In the introduction, the Authors emphasize that one of the causes of inequalities in health care is differences based on social groups, i.e. race, religion and culture. Cultural competence, on the other hand, is widely recognized as a means of minimizing health inequalities in medicine and public health. The WHO also emphasizes the importance of cultural awareness in supporting the development of adaptive, equitable and sustainable health systems. The Authors provided a definition of cultural competence. They presented a five-stage model of implementing interrelated cultural competences (Campinha-Bacote's, 1999; Table 1), which was then used to analyze their own research. Despite the recognition by healthcare professionals of the importance of cultural competence, most healthcare professionals still lack expertise, which may prevent them from effectively delivering culturally sensitive care.

In the introduction, I suggest leaving item 12 only in the last paragraph, there is no need to repeat it twice in the previous paragraphs.

All references from the reference list (43 items) are included in the text of the article.

The study design for quantitative and qualitative analysis was properly described. The results are presented in tables 2 to 7, in a careful and very readable way for the recipient.

In conclusion, the Authors note the need for formal and informal training of health professionals and strengthening their ability to deliver to diverse populations by implementing well-designed cultural competence training programs as a way to reduce health disparities and improve patient quality, health and sustainability of care.

The Authors did not show significant differences in the results, so conclusions were drawn through discussion and comparison. This may be due to the small group of surveyed medical workers. However, the group of respondents was recruited mostly from experienced employees, while people at a younger age in the range of 20-29 years constituted a definite minority (5.5%).

In the discussion, in the absence of research using the MTCS tool in the context of health care professional education, the results were compared with research conducted in an educational context.

The strengths and limitations of the study are well-founded. Particularly valuable was the use of mixed methods among survey participants who were culturally diverse, which facilitated the emergence of stronger views on cultural competence. In addition, this study is the first in which the authors decided to use MTCS in the context of professional health care education.

I rate this study and the presentation of the results very highly. The work is also written in a language understandable to the recipient.

 

Author Response

Authors reply:

The authors thank the reviewer for his/her thorough and positive assessment of our manuscript. The feedback is both encouraging and insightful.

 

The authors critically reviewed the manuscript to address the following reviewer's comment:

“In the introduction, I suggest leaving item 12 only in the last paragraph, there is no need to repeat it twice in the previous paragraphs.”

 

The authors now put reference 12 only at the end of the sentence describing the study and eliminated it from other sentences. Reference 12 (in the previous submission) has been changed to 11 after incorporating the edits made for this review.

 

Once again, the authors would like to thank the reviewer for his/her positive remarks on its presentation and language clarity. The reviewer's constructive feedback will undoubtedly contribute to the improvement of our manuscript, and we are committed to addressing any remaining issues to ensure the quality and impact of our research.

 

 

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

The Authors revised their manuscript very carefully. Congratulations. 

Minor editing of English language required