Cultural competence education for practicing physicians: lessons in cultural humility, nonjudgmental behaviors, and health beliefs elicitation.

INTRODUCTION: Although numerous studies have examined cultural competence training, debate still exists about efficacious approaches to this training. Furthermore, little focus has been placed on training and evaluating practicing physicians. METHODS: A skills-based course on culturally competent diabetes care was developed and subsequently tested in a controlled trial of primary physicians caring for patients enrolled in one state's Medicaid program. We hypothesized that physicians completing the course would show higher levels of self-reported cultural competence as measured by a Cultural Competence Assessment Tool (CCAT) than those in the control group. Differences in CCAT subscale scores were also compared. RESULTS: Ninety physicians completed the study, with 41 in the control and 49 in the intervention group. Most were female (66%), with an average age of 44, and 12 years in practice. There were no significant differences on total CCAT score (212.7 ± 26.7 for control versus 217.2 ± 28.6 for intervention, p = .444) or subscales measuring cultural knowledge. There were significant positive differences on the subscales measuring physicians' nonjudgmental attitudes/behaviors (subscale score 2.38 ± 0.46 for control versus 2.69 ± 0.52 for intervention, p = .004) and future likelihood of eliciting patients' beliefs about diabetes and treatment preferences (3.11 ± 0.53 for control versus 3.37 ± 0.45 for intervention, p = .014). There was, however, a significant negative difference on the subscale measuring cultural self-awareness (3.48 ± 0.36 for control versus 3.26 ± 0.48 for intervention, p = .018). DISCUSSION: A predominantly skills-based approach to training physicians did not change aggregate measures of cultural competence, but did affect key attitudes and behaviors, which may better reflect the goals of cultural competence training.

Assessing culturally competent diabetes care with unannounced standardized patients.

BACKGROUND AND OBJECTIVES: More effective diabetes care is desperately needed, especially for ethnic minority populations. Provider cultural competence promises to be an important means for reducing disparities in outcomes for patients with diabetes. The objectives of this study were to understand the role of cultural competence in the diabetes office visit. METHODS: Unannounced standardized patients (SPs) were sent to the offices of 29 family and internal medicine residents and practicing physicians. The SPs portrayed a Mexican American woman newly diagnosed with type 2 diabetes. Using a checklist developed with the input of experts in Hispanic/Latino health care and cultural competence, the SPs evaluated physicians' cultural competence, diabetes care, and general communications skills. RESULTS: The average total SP Checklist score was 70.7-11.0%, with a range of 43.9% to 90.2%. Physicians scored highly on items that measured general communication skills (95.9%) but were less likely to ask about social history (ie, family and community support issues, 51.9% and 48.1%, respectively). Sixty-seven percent of physicians ordered a hemoglobin A1c, 44% referred to ophthalmology, and 15% performed a monofilament exam. Physicians' inquiry into SPs explanatory model of disease (ie, asking about the SPs' views regarding their disease and its treatment) correlated with the performance of several diabetes treatment-related behaviors, Spearman's rho=.466. CONCLUSIONS: The findings provide support for a relationship between inquiry into patients' explanatory models of disease and effective diabetes care. Social history and explanatory model elicitation skills are vital parts of cultural competence training programs and potentially valuable tools for mitigating health disparities.

Concurrent and longitudinal predictors of self-esteem in elementary and middle school girls.

BACKGROUND: The purpose of this study was to analyze the effects of factors related to self-esteem, both cross-sectionally and longitudinally, among 2 cohorts of girls over a period of 4 years, from elementary through middle school. METHODS: A multiethnic sample of 656 elementary school girls recruited from 13 schools in Hayward, CA, and Tucson, AZ, was evaluated annually over a 4-year period. The McKnight Risk Factor Survey IV was administered, which consists of 103 questions that assess self-esteem, appearance appraisal, effect of body changes, depressed mood, teasing, school performance, and other factors. In addition, participants' heights and weights were measured. RESULTS: The most important predictor of self-esteem in each grade was appearance appraisal, and, in all grades but the eighth, weight-related teasing by either boys or girls was also a predictor of self-esteem. Teasing about weight was more important than body weight itself in predicting self-esteem. Self-esteem was lower in girls who were teased about their weight, even if they believed that it had no effect on how they felt about themselves. School performance predicted self-esteem in grades 6 and 8. In longitudinal analyses, the participant's current perception of her appearance was more important than her previous level of self-esteem in predicting current self-esteem. CONCLUSIONS: The results of this study support the need to allocate funding to address the issue of teasing as 1 of the stressors in the school environment, and to explore further the important relationship between school performance and self-esteem.

Does dieting lead to weight gain? A four-year longitudinal study of middle school girls.

OBJECTIVE: A majority of the published longitudinal research on children has reported that dieting is related to weight gain at a later point in time. The purpose of this study was to look at weight control behaviors and patterns of weight gain and loss, specifically whether dieting is related to weight gain. RESEARCH METHODS AND PROCEDURES: Baseline data were collected from 1358 female students in grades 6 to 9 from schools in Hayward, CA, and Tucson, AZ. Data were obtained annually over a 4-year period. Paper-and-pencil questionnaires and height and weight were obtained during the students' regular classroom periods. Dieting was measured both with the single item, "In the past year, how often have you been on a diet to lose weight?" scored from "never" to "always," and with a Dieting Behavior Scale including five items on weight control behaviors. Changes in BMI z-scores were analyzed. RESULTS: On average, girls who reported "never" dieting were most likely to have an increased BMI z-score at the next measurement, and those who reported "always" dieting were most likely to have a decreased BMI z-score. The same pattern was true for the Dieting Behavior Scale. DISCUSSION: Our finding that dieting and weight gain were not related, independently of initial BMI, does not mean that dieting to lose weight is appropriate, especially among young girls. Additional research is needed both to examine this relationship and to determine exactly what behaviors children are engaging in when they report that they are dieting.

Eating and weight control behaviors among middle school girls in relationship to body weight and ethnicity.

This study examined the links among body mass index (BMI), weight control practices, binge eating, and eating disorders in 1164 middle school girls. Both the prevalence and frequency of weight control behaviors increased as BMI increased, but binge eating was reported approximately equally by girls across the BMI spectrum.

Gender differences in academic advancement: patterns, causes, and potential solutions in one US College of Medicine.

PURPOSE: The influx of women into academic medicine has not been accompanied by equality for male and female faculty. Women earn less than men in comparable positions, progress more slowly through academic ranks, and have not attained important leadership roles. This study tested hypotheses about why gender disparities exist in salary, rank, track, leadership, and perceptions of campus climate at one academic center, the University of Arizona College of Medicine, Tucson. METHOD: Salary, rank, and track data were obtained from institutional databases for the 1999-2000 fiscal year. A structured, online questionnaire was made available to 418 faculty members to collect information about their goals, attitudes, and experiences. RESULTS: A total of 198 faculty members completed the questionnaire. The data showed significant gender differences in faculty salaries, ranks, tracks, leadership positions, resources, and perceptions of academic climate. On average, women earned US dollars 12777 or 11% less than men, after adjusting for rank, track, degree, specialty, years in rank, and administrative positions (p <.0003). Of female faculty, 62% were assistant professors (49% of women were non-tenure-eligible assistant professors), while 55% of male faculty were promoted and tenured. Almost a third of women reported being discriminated against, compared with only 5% of men (p <.00001). CONCLUSION: Substantial gender differences in the rewards and opportunities of academic medicine remain, that can not be attributed to differences in productivity or commitment between women and men.

Ethnic differences in dieting, binge eating, and purging behaviors among American females: a review.

The research literature related to ethnic differences in dieting, binge eating, and purging behaviors among American females was reviewed. Relevant publications were located by means of computer searches utilizing MedLine and PsycInfo databases. The majority of the dieting studies that have been published thus far indicate that this behavior is more prevalent among White females while most studies of binge eating and purging behaviors indicate that these behaviors are as common among minority females as among White females. Factors that may influence the results of studies focusing on ethnic differences in eating-related behaviors are discussed. Recommendations for improving future research in this area are proposed.