This is the published version of a paper published in Health & Social Care in the Community.
Citation for the original published paper (version of record):
Pettersson, S., Holstein, J., Jirwe, M., Jaarsma, T., Klompstra, L. (2021)
Cultural competence in healthcare professionals, specialised in diabetes, working in
primary healthcare — A descriptive study
Health & Social Care in the Community
https://doi.org/10.1111/hsc.13442
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Health Soc Care Community. 2021;00:1–10.
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1
Received: 9 December 2020
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Revised: 23 March 2021|
Accepted: 15 April 2021 DOI: 10.1111/hsc.13442O R I G I N A L A R T I C L E
Cultural competence in healthcare professionals, specialised in
diabetes, working in primary healthcare—A descriptive study
Sara Pettersson RN, PhD student
1| Jane Holstein OTR
1| Maria Jirwe RN, PhD
2|
Tiny Jaarsma RN, PhD
1| Leonie Klompstra PhD
11Department of Health, Medicine and Caring
Sciences, Linkoping University, Linkoping, Sweden
2Department of Health Sciences, Red Cross
University College, Huddinge, Sweden
Correspondence
Sara Pettersson, Department of Health, Medicine and Caring Sciences, Linköping University, SE 601 74, Norrköping, Sweden. Email: sara.pettersson@liu.se
Abstract
Self-care is the most important cornerstone of diabetes treatment. As self-care is affected by cultural beliefs, it is important for healthcare professionals to be able to adapt their educational approach and to be culturally competent. The aim of this study was to describe the cultural competence in Swedish healthcare professionals, specialised in diabetes care and to examine related factors for cultural competence. The healthcare professionals’ perceived level of cultural competence was measured across three domains—Openness and awareness, Workplace support and Interaction skills—in 279 Swedish healthcare professionals from all 21 regions of Sweden, using the Cultural Competence Assessment Instrument (Swedish version—CCAI-S). Descriptive statistics were used to describe cultural competence in healthcare pro-fessionals, and linear regression was conducted to examine factors related to cul-tural competence. Of the healthcare professionals studied, 58% perceived that they had a high level of Openness and awareness, 35% perceived that they had a high level of Interaction skills and 6% perceived that they had a high level of Workplace support. Two factors were found to be related to cultural competence, namely, high percentage of migrant clients at the healthcare clinic and whether the healthcare professionals previously had developed cultural competence through practical expe-rience, education and/or by themselves. In conclusion, most healthcare professionals perceived that they had cultural openness and awareness but need more support from their workplace to improve their interaction skills. Cultural competence-related education could support the healthcare professionals to develop interaction skills.
K E Y W O R D S
cultural background, cultural competence, diabetes mellitus, healthcare professionals, primary healthcare, self-care
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2021 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.
1 | INTRODUCTION
Type 2 diabetes constitutes a global public health problem that is rapidly increasing. Today, over 463 million people are affected by type 2 diabetes representing 9.3% of the world's population. It is predicted that, by 2045, the number will have risen to 700 million people (IDF, 2019; Saeedi et al., 2019). Type 2 diabetes particularly affects vulnerable populations, such as migrants living in developed countries (Guariguata et al., 2014; IDF, 2019; Testa et al., 2016). Migrants include foreign-born people who have moved to another country, either voluntarily as immigrants or involuntarily as refu-gees (IOM, 2017). In addition, migrants with type 2 diabetes have been shown to have limited knowledge about diabetes (Pettersson et al., 2019) and to be at increased risk of high blood glucose lev-els (Chambre et al., 2017). Furthermore, migrants find that diabetes care is not tailored to their expectations and cultural needs (Jager et al., 2019).
Type 2 diabetes is a progressive condition that can involve micro and macrovascular complications. These can have an adverse effect on health and possibly lead to high healthcare costs and suffering for the individual (IDF, 2019). Although serious complications can develop, the condition can be managed, complications can be pre-vented and the deterioration can be delayed by practicing adequate self-care (Cefalu et al., 2016; IDF, 2019; Saeedi et al., 2019).
Self-care is of great importance in improving the health of persons with a chronic condition and can be seen as a process of maintaining health through health-promoting practices, symptom monitoring and the managing of symptoms when they occur (Riegel et al., 2009). Active participation in self-care, based on knowledge of the condition, is the most important cornerstone of treatment for type 2 diabetes (IDF, 2019). Self-care for chronic illness is directly affected by several factors, such as knowledge of the condition, experience, skills, motivation, habits, cultural beliefs and values, functional and cognitive abilities, support and access (Jaarsma et al., 2017). The way in which an individual responds to health-care advice is partly based on their cultural backgrounds, and so it is important to consider a person's cultural beliefs in healthcare (Hjelm & Bard, 2013). Culture consists of knowledge, values, be-liefs, assumptions, perspectives, attitudes, norms and the customs people inherit when participating in a society or a certain group (Hammell, 2013). It may include people of the same religion or origin and it influences attitudes and behaviours in relation to lifestyle and activities to promote health, which may subsequently lead to differ-ences in self-care performance (Becker et al., 2004). Good commu-nication between clients and healthcare professionals is important and the knowledge obtained by a person with diabetes influenced by the way the professional responds to the person with diabetes during a consultation or clinical interview (Capone, 2016; Foronda et al., 2016).
Due to global migration, different cultural backgrounds in soci-ety have increased and healthcare professionals interact with a great number of clients from different cultural backgrounds and with dif-ferent cultural needs (Alizadeh & Chavan, 2016). Cultural diversity
What is known about the topic
• The cultural background in persons with diabetes may constitute a barrier for healthcare professionals when providing optimal diabetes care.
• Cultural competence is an important skill for healthcare professionals.
• In order to optimise the quality of healthcare, there is a need for further knowledge about the cultural compe-tence of healthcare professionals.
What this paper adds
• Healthcare professionals perceive a lack of feedback from managers on how to improve their interactive skills to be culturally competent when working with persons with diabetes with different cultural background. • Healthcare professionals perceive high levels of cultural
openness and awareness.
• The cultural openness and awareness in the clinic is high among the healthcare professionals when there is a high percentage of migrant clients with diabetes receiving care in a primary healthcare clinic.
can constitute a major barrier to effective healthcare, and so cultural competence and cultural awareness are becoming important skills for healthcare professionals (Alizadeh & Chavan, 2016; Leininger & McFarland, 2006) to enable them to provide effective and cul-turally responsive healthcare services (Campinha-Bacote, 2002; Papadopoulos et al., 2004). Cultural competence can be defined as healthcare professionals’ understanding on how culture affects an individual's beliefs and behaviours and adapts their strategies to meet clients’ individual needs, thus increasing the possibility of effective healthcare for people from various cultural backgrounds (Balcazar et al., 2010). Cultural awareness is an important aspect of cultural competence and involves the recognition of one's biases, prejudices and assumptions about individuals who are different (Balcazar et al., 2010; Jirwe et al., 2009). Cultural competence and cultural humility support health educators and professionals when working with diverse individuals, groups and communities (Greene-Moton & Minkler, 2020). Cultural humility is an integrated part of cultural competence when the health professionals question the assumptions, beliefs and biases they have and in the interaction with the client respect differences and reduce power disparities (Danso, 2018).
Previously, cultural competence has been measured at primary healthcare services to identify barriers in diabetes care. The re-sult reported cultural diversity related to languages and strong cultural traditions around food were the most common cultural barriers to culturally competent healthcare service (Domenech Rodríguez et al., 2019; Zeh et al., 2018). In order to enhance the quality of healthcare, there is a need for further knowledge
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3 PETTERSSON ETal.about the cultural competence of healthcare professionals (Berlin
et al., 2010) The aim of this study, therefore, is to describe the cultural competence of primary healthcare professionals that spe-cialise in diabetes care and to examine related factors that affect cultural competence.
2 | METHODS
2.1 | Design
This was a cross-sectional study involving a questionnaire measuring the cultural competence in healthcare professionals specialised in diabetes, working in primary healthcare.
2.2 | Sample selection and procedure
Data were collected between January 2020 and July 2020. All 21 re-gions in Sweden were contacted and informed about the study and e-mail addresses were obtained for all managers of primary health-care clinics (n = 957). Every region has healthhealth-care clinics, responsible for the care of persons with diabetes. Most healthcare clinics have special diabetes teams. Included in a diabetes team are, e.g., nurses, general practitioners, podiatrists, physiotherapists, social workers and dieticians.
Each manager was given information about the study and asked to provide contact details for healthcare professionals working with diabetes care. The healthcare professionals (n = 500) were con-tacted by e-mail including an encrypted web-based survey provided by Linköping University. The participants were informed that con-sent was implied through completion of the survey. A paper survey was provided for any professional that requested one. If there was no response approximately 2 weeks after the survey had been sent out, a reminder was sent. A second reminder was sent after approx-imately 4 weeks. During the Covid-19 pandemic, we realised that non-respondence was not due to an unwillingness to participate but to a lack of time, and we sent a third and a fourth request for responses. We aimed to include healthcare professionals from all regions as we wanted the results to be representative for the whole of Sweden. The 21 Swedish counties/regions are quite large by area and differ with regard to population density. There are differences in the rural or metropolitan lay out of each county and the composition of the population, e.g., related to economy, age of the population and number of immigrants (SCB, 2020).
The sample size calculated using the rule of thumb of Pedhazur and Schmelkin (1991) that states that good power to study rela-tionships requires 50 participants for each factor measured. We, therefore, aimed to include over 150 healthcare professionals (three domains in the cultural competence instrument).
The study was conducted in accordance with the Helsinki Declaration (WMA, 2013). However, the regional ethical committee waived the requirement for this study to gain ethical approval since
no sensitive personal data were collected nor information from med-ical records (registration no./decision no. 2019-05093).
2.3 | Measurement
Cultural competence was measured using the Swedish version of the Cultural Competence Assessment Instrument (CCAI-S; Holstein et al., , 2020). The CCAI-S is a self-report instrument aiming to meas-ure perceived cultural competence in healthcare professionals. As cultural competence is not a commonly used concept, we provided the healthcare professionals with a description of cultural compe-tence (Balcazar et al., 2010) before filling in the instrument. The in-strument includes13 items and response options on a 6-point scale, where 6 corresponds to “strongly agree” and 1 to “strongly disagree”. It contains three domains: Openness and awareness (measured by six items including respect for differences in cultural background) Workplace support (including four items measuring learn from peers) and Interaction skills (measured by three items including effective verbal and non-verbal communication). In this study, for each domain, a mean score lower than 3 was treated as low, 3–4 was treated as medium and a mean score higher than 4 was treated as high. For every item in the domains, response options 1 and 2 were recoded as strongly disagree/disagree, 3 and 4 as neutral and 5 and 6 as agree/strongly agree. The reliability of CCAI-S has been tested in a previous study (Holstein et al., 2020); Cronbach's alpha for the instrument as a whole was 0.81, and for the domains was: Openness and awareness 0.79; Workplace support 0.64; Interaction skills 0.69. In our study, the Cronbach's alpha was 0.82 for the total scale and for the three domains was: Openness and awareness 0.72; Workplace support 0.73; and Interaction skills 0.59. In addition, de-mographic information was collected on gender, education, place of birth, profession, length of practice in healthcare and diabetes care in particular, self-reporting of attitudes towards working with vari-ous cultures and varivari-ous types of disabilities and previvari-ous experi-ence of cultural competexperi-ence training. We also asked participants to estimate the percentage of migrants registered with their practice.
2.4 | Data analysis
Data were analysed using SPSS version 26. To describe the data, we used numbers and percentage, mean (SD) and median (range). It was only possible to submit fully completed questionnaires meaning that we did not need to address missing data in our analysis. For the as-sociations among the three domains of cultural competence, we per-formed correlation analyses. In order to analyse sociodemographic factors associated with the three domains, we performed univariate analyses with bivariate correlations, independent Student's t test or one-way ANOVA, where appropriate. When conducting linear re-gression analyses, with the three domains as dependent variables, it is common to observe a change in several predictive variables’ signif-icance level, and therefore, we included sociodemographic factors in
the linear regression analyses when a p-value < 0.15 was observed in
the univariate analyses.
3 | RESULTS
Of the 500 healthcare professionals invited, a total of 279 responded to the questionnaire (response rate 56%). Healthcare professionals from all 21 regions in Sweden were represented in the results. The majority of the healthcare professionals were female (91%) with a mean age of 50 years (SD 10). Most of them were born in Sweden (80%). In terms of academic achievement, 91% of the healthcare professionals had a university bachelor's degree or higher. The healthcare professionals were mainly registered nurses (74%); other professions represented were, in descending order, general practi-tioners (GPs), podiatrists and dieticians. The healthcare profession-als reported widely differing lengths of practice, from 2 to 48 years with a median of 23 years of practice (Table 1).
3.1 | Development of cultural competence
Healthcare professionals stated that they had developed their cul-tural competence through practical experience in their professional practice (78%, n = 218), by obtaining information for themselves (37%, n = 103) and through basic education (21% n = 58). Eight per cent stated that they had not developed any cultural competence (Table 2).
3.2 | Cultural competence
The mean score in the Openness and awareness domain was 4.98 (0.70), in the Workplace support domain 3.30 (1.07) and in the Interaction skills domain 4.40 (0.85). The majority of the healthcare professionals (n = 162, 58%) reported high perceived Openness and awareness (>4) while 35% (n = 98) had high perceived Interaction skills and 6% (n = 17) had high perceived Workplace support in re-lation to cultural competence (Table 3; Figure 1). The lowest score was found in the Workplace support domain, where 37% of the healthcare professionals reported low perceived Workplace support (n = 104), 4% reported low perceived Interaction skills (n = 10) and 2 (1%) reported low perceived Openness and awareness (Table 3; Figure 2).
Considering the responses at item level (Table 3), the items showing the lowest score referred to feedback from supervisors on how to improve practice skills with clients from different cultural backgrounds, where 56% (n = 156) of the healthcare professionals reported that they did not receive feedback about cultural compe-tence from their workplace. A total of 61% (n = 170) reported that their verbal communication with clients whose culture is different from theirs was effective, while 9% of the healthcare profession-als (n = 24) found effective non-verbal communication difficult.
TA B L E 1 Sociodemographic characteristics for the healthcare
professionals
n = 279
Age (years; mean ± SD) 50 (±10)
Female gender (n%) 254 (91%)
Place of birth (n%; order of frequency)
Sweden 224 (80%)
Scandinavia (not Sweden) 12 (4%)
Rest of Europe 21 (7%) Asia 10 (4%) Africa 4 (1%) South America 3 (1%) North America 1 (0.4%) Australia 1 (0.4%) Education (n %) Primary school 1 (0.4%) Secondary school 17 (6%) Universitya 261 (94%) Profession (n %) Nurse 207 (74%) General practitioner 37 (13%) Podiatrist 22 (8%) Dietician 8 (3%) Other 4 (2%)
Years working in healthcare (median Q1–Q3) 23 (15–34) Years working in diabetes care (median Q1–Q3) 9 (5–16)
aIn Sweden, both general practitioners and nurses are trained at
university.
Difficulties in working competently with minority ethnic clients were reported by 10% (n = 27) of the healthcare professionals, and 9% (n = 26) did not openly discuss issues about multicultural awareness or examine their own biases around ethnicity. None of the health-care professionals reported that they were not sensitive to the need to value and respect differences between their own cultural back-ground and their clients’ cultural heritage (Table 3; Figure 3).
3.3 | Sociodemographic factors related to
cultural competence
Univariate analysis showed that neither age (Openness and aware-ness r = −0.04 p = 0.55, Workplace support r = −0.01 p = 0.83, Interaction skills r = 0.04 p = 0.48) nor length of practice of the healthcare professionals (Openness and awareness r = −0.06 p = 0.30, Workplace support r = −0.01 p = 0.81, Interaction skills r = 0.03 p = 0.66) were significantly related to any of the three domains in cultural competence. Neither was there a statistically significant relationship between if the healthcare professionals themselves being a migrant and any of the three domains (Openness
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5 PETTERSSON ETal.TA B L E 2 Healthcare professionals’ development of cultural
competence
N = 279a
n (%) Through practical experience in professional practice 218 (78) Obtained information by themselves
Through basic education Through teamwork
Through education at advanced level Through internship as part of basic education Ongoing education
Workplace tutorial Not developed
aMore than one answer possible.
103 (37) 58 (21) 47 (17) 45 (16) 39 (14) 28 (10) 15 (5) 23 (8)
and awareness; F = 1.22 p = 0.22), Workplace support (F = 4.13 p = 0.20) and Interaction skills (F = 1.53 p = 0.66; Table 4).
In the univariateanalyses p-values < 0.15 were marked bold. In multivariate analyses p-values< 0.05 were marked bold.
The Openness and awareness (F = 2.65, p < 0.05) and Interaction skills (F = 3.85, p = 0.01) differed between professions. Nurses scored higher than GPs in Openness and awareness (5.03 ± 0.66 vs. 4.69 ± 0.82, p = 0.01) and Interaction skills (4.43 ± 0.83 vs. 4.03 ± 0.78, p = 0.01) while no significant differences between professions in Workplace support were found (F = 0.53, p = 0.67). The self-estimated percentage of migrants in the healthcare clinic correlated significantly with Openness and awareness (r = 0.26, p = 0.01) and with Workplace support (r = 0.26, p = 0.01) but not with Interaction skills (r = 0.11, p = 0.10). Cultural competence devel-oped through education, practical experience or personal learning
TA B L E 3 Mean and standard deviation (SD) for domains and items in the CCAI-S. Number and percentage for each item where the
respondents responded “Strongly disagreed/disagreed” or “Strongly agree/agreed”
Domain Item Mean (SD)
Strongly disagree/ disagree n (%)
Strongly agree/ agree n (%)
Openness and 4.98 (0.7)
awareness I am sensitive to valuing and respecting differences between my cultural background and my clients’ cultural heritage
5.62 (0.6) 0 (0) 265 (94)
I actively strive for an atmosphere that promotes risk-taking and self-exploration
5.18 (0.9) 5 (2) 235 (84)
I feel that I can learn from my ethnic minority clients. 5.12 (1.1) 10 (4) 215 (77) I learn about different ethnic cultures through
educational methods and/or life experiences.
4.86 (1.1) 8 (3) 203 (73)
I openly discuss with others issues I have in developing multicultural awareness.
4.56 (1.3) 26 (9) 160 (57)
I examine my own biases related to ethnicity and culture that may influence my behaviour as a service provider.
4.54 (1.3) 26 (9) 174 (62)
Workplace support 3.3 (1.1)
I have opportunities to learn culturally responsive behaviours from peers
3.89 (1.5) 64 (23) 115 (41)
At work, pictures, posters, printed materials and toys reflect the culture and ethnic backgrounds of ethnic-minority clients
3.42 (1.4) 76 (27) 59 (21)
Cultural competence is included in my workplace's
mission statement, policies and procedures 3.39 (1.5) 90 (32) 69 (25) I receive feedback from supervisors on how to
improve my practice skills with clients from different ethnic-minority backgrounds
2.51 (1.4) 156 (56) 26 (9)
Interaction skills 4.4 (0.9)
I am effective in my verbal communication with clients whose culture is different from mine
4.64 (0.9) 5 (2) 170 (61)
I am effective in my non-verbal communication with clients whose culture is different from mine
4.29 (1.2) 24 (89) 130 (47)
I would find it easy to work competently with
ethnic-minority clients 4.28 (1.3) 27(10) 126 (45)
Primary health care clinics included (n = 188)
Health care professionals contacted (n = 500)
Declined to participate (n=10) No response (n = 211)
Health care professionals included (n =279)
F I G U R E 1 Participant flow
F I G U R E 2 Mean score, measured as a percentage, for each
of the three domains Openness and awareness, Workplace support and Interaction skills
0 10 20 30 40 50 60 70 80 90 100 sl li k s n o it c a r e t n I t r o p p u s e c a l p k r o W s s e n e r a w a & s s e n n e p O
Low Medium High
F I G U R E 3 Health care professionals’ responses for each item,
within the three domains Openness and awareness, Workplace support and Interaction skills, measured as a percentage
was associated with Openness and awareness (F = 0.63, p = 0.03) but not with Workplace support (F = 4.75, p = 0.13) or Interaction skills (F = 1.11, p = 0.30; Table 4).
Only the percentage of migrant clients at the healthcare clinic was independently related to Openness and awareness in relation to developed cultural competence (ß = 0.26 p > 0.01), explaining 7% of the variance. Percentage of migrant clients at the healthcare clinic (ß = 0.26 p > 0.01) and developed cultural competence (ß = 0.14 p = 0.03) were significant predictors of Workplace support, explaining 8% of the variance in Workplace support in relation to cultural com-petence. No predictors were found for Interaction skills. Although profession and percentage of migrant clients in the healthcare clinic were associated with Interaction skills in the univariate analyses, these
were not found to be related factors in the linear regression analysis of Interaction skills (ß: 0.023, p: 0.718 and ß: 0.005, p: 0.099; Table 4).
3.4 | Correlation between the domains
All three domains were positively correlated to each other, with the strongest correlation between Openness and awareness and Interaction skills (r = 0.47, p-value □0.01; Table 5).
4 | DISCUSSION
To our knowledge, this is the first study to measure, and report per-ceived cultural competence in healthcare professionals working in diabetes care within primary healthcare. It certainly exists studies measuring cultural competence in primary healthcare but with a focus on the general practise teams (Balcazar et al., 2010; Kirk et al., 2014; Zeh et al., 2018). Our main finding is that a considerable proportion of healthcare professionals (58%) perceived themselves to be open and aware in regard to clients with other cultural backgrounds and a third (36%) of the healthcare professionals perceived that they had good Interaction skills in relation to cultural competence. Further, fewer than 10% (6%) reported having received support from their workplace in relation to cultural competence. Another important finding was that only two factors were identified affecting self-assessed cultural competence among the healthcare professionals. The first factor was that healthcare professionals working at health-care clinics with a high percentage of migrants showed significantly higher levels of Openness and awareness and Workplace support. The second factor positively affecting self-assessed cultural com-petence was whether the healthcare professionals had developed cultural competence through practical experience, obtained infor-mation themselves and/or through education.
In this study, the healthcare professionals were rated as having a high level of Openness and awareness, indicating that they rec-ognise their biases, prejudices and assumptions about individuals with various cultural backgrounds (Balcazar et al., 2009; Campinha-Bacote, 2002), which is an important aspect in cultural competence. None of the healthcare professionals reported that they were not sensitive to the need to value and respect differences between their cultural background and the cultural heritage of their clients. These findings strengthen previous research findings that have showed high self-rated levels of cultural awareness among healthcare pro-fessionals (McElroy et al., 2016; Suarez-Balcazar et al., 2009). To achieve cultural competence in practice, it is essential to be cultur-ally aware and have an open attitude and a respect for cultural dif-ferences (Darawsheh et al., 2015).
A major finding was the reported lack of support for cultural competence at the workplace. Only 9% of all healthcare profession-als perceived that they received input from supervisors on how to improve their practice skills with clients from different culturally backgrounds. Workplace support has been found to be important
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7 PETTERSSON ETal.TA B L E 4 Univariate and multivariate analyses for sociodemographic factors related to Openness and awareness, Workplace support and
Interaction skills
Univariate Multivariate
p-value p-value Standardised
Domain Variable ß CI (95%) F Openness and awareness Age Length of practice Migrant or not
Developed cultural competence or not Profession
Percentage of migrant clients at the clinic 0.55 0.30 0.22 0.03 <0.05 <0.01 0.08 0.58 0.00 0.11 −0.04 0.26 −0.59 to 0.03 −0.14 to 0.08 0.01 to 0.01 7.15 Workplace support Age Length of practice Migrant or not
Developed cultural competence Profession
Percentage of migrant clients at the clinic 0.83 0.81 0.20 0.13 0.67 <0.01 0.03 0.48 0.00 0.14 0.04 0.26 −1.03 to 0.05 −0.11 to 0.23 0.01 to 0.02 7.62 Interaction skills Age Length of practice Migrant or not
Developed cultural competence Profession
Percentage of migrant clients at the clinic 0.48 0.66 0.66 0.30 0.01 0.10 0.19 0.81 0.12 0.09 −0.02 0.10 −0.67 to 0.14 −0.16 to 0.12 −0.00 to 0.01 1.48
In the univariate analyses p-values < 0.15 were marked bold. In multivariate analyses p-values < 0.05 were marked bold.
TA B L E 5 Correlations of cultural competence domains
Cultural
competence Openness and Workplace Interaction
domain awareness support skills
Openness and —
awareness
Workplace support 0.42a —
Interaction skills 0.47a 0.42a —
aSignificant at the 0.01 level (2-tailed).
in improving cultural competence. One way to feel supported by the workplace is by being given opportunities to learn and to ob-tain feedback from colleagues about cultural skills (Holstein et al., 2019). Support from the organisation is also important when de-fining the capacity of individual healthcare professionals to supply culturally relevant services (Anderson et al., 2003). Further, cultural competence training seems to be essential for developing these skills. The cultural competence of general practices providing di-abetes services depends mostly on cultural awareness of practice staff, general practices’ understanding with staff ethnicity and the language skills (Zeh et al., 2018). In the current study, there was low Workplace support in relation to materials that reflected the culture
of the clients. Healthcare organisations should provide patient in-formation materials that meet clients’ needs, for instance, on health literacy and language during assessment, treatment and discharge (Seeleman et al., 2015).
There seems to be a need of studies comparing cultural com-petence between different healthcare professionals. This study re-ported significantly higher scores in the Openness and awareness and Interaction skills in nurses compared to GPs, while other re-search has reported no significant difference in cultural competence between professionals; however, sensitivity and knowledge regard-ing cultural competence were found to be higher in GPs compared to nurses (Pedrero et al., 2020).
We were unable to identify any factors that were strongly re-lated to the three domains. Neither age nor length of practice af-fected cultural competence in any of the three domains, while other studies have shown that length of practice is a related factor for cultural competence (Leininger & McFarland, 2006; Lin et al., 2015; Suarez-Balcazar et al., 2009). This may be partly explained by the fact that the healthcare professionals included in our study had quite extensive practical experience, with a median of 23 years of practice. Further, there was no significant difference in self-assessed cultural competence if the healthcare professionals were migrants themselves, in any of the three domains, although in previous
research cultural competence has been found to be positively
as-sociated with healthcare professionals from minority backgrounds (Repo et al., 2017). Diversity among staff members is desirable for furthering responsiveness to client diversity (Seeleman et al., 2015). However, the percentage of migrant clients at the healthcare clinic and if the healthcare professionals stated that they had de-veloped cultural competence, particularly by practical experiences but also by education, were found to be related to perceived cultural competence assessed with CCAI-S. This result strengthens previous studies showing that frequency of caring for clients from different culturally backgrounds improves cultural competence in cultural en-counters (Chen et al., 2018; Lin et al., 2015; Repo et al., 2017). The result is also in line with studies reporting that the experience of cul-tural education is a predictor of culcul-tural competence in healthcare professionals (Holstein et al., 2019) and that there is a need to high-light the importance of cultural competency education in healthcare (Abrishami, 2018; Chae et al., 2020). Thus, it is essential to provide cultural competence training to healthcare professionals at differ-ent levels in the healthcare system to increase their awareness of cultural differences (Kaihlanen et al., 2019). Future research needs to examine other factors to identify additional related factors in re-spect of cultural competence in healthcare professionals. Teaching and learning methods of cultural competence can, for instance, com-prise cultural self-awareness and intercultural communication skills, understandings of socio-cultural barriers in professional–patient en-counter and in leadership and workforce at the organisational level (Horvat et al., 2014).
However, even if the healthcare professionals in this study per-ceived that they had developed cultural openness and awareness, they did not necessarily have Interaction skills relating to cultural competence when working with clients. Thus, healthcare profes-sionals might need more support from their workplace to improve their cultural competence in Interaction skills when working with clients from a cultural background different to their own.
4.1 | Strengths and limitations
One of the limitations of this study was that out of the 957 health-care clinics that were contacted, only 188 approved participation in this study. Although we were able to include healthcare profession-als from all regions, this low response rate (20%) may have affected the results. On the other hand, the results are based on healthcare clinics from every region of Sweden, giving a good spread. Another limitation of this study is that most of the healthcare professionals included were nurses (80%) and 91% were female. Although this is representative of a diabetes healthcare team (Socialstyrelsen, 2019), the results cannot be generalised to all healthcare professionals working with persons with diabetes or to male healthcare profes-sionals. Future studies should aim to include a greater variety of healthcare professionals. Although we included all the regions of Sweden and the results reflect Sweden as a whole, the sample size included in this study has not enough power to make comparisons
between the regions and therefore we could not make comparison in, for example, differences in rural or metropolitan areas in Sweden according to the cultural competence in healthcare professionals.
The result showed a high score for cultural Openness and awareness which might be indicative of a selective sample (e.g. only those with cultural competence responded to the question-naire) but it also reflects a high rating of Openness and awareness in those who did respond. A person rating themselves as very con-fident may possess real qualities of Openness and awareness, but they could also be lacking awareness of their limitations, which might suggest overconfidence (Gozu et al., 2007). However, cul-tural awareness includes the ability to reflect on culcul-tural interac-tions. This involves self-exploration and the ability to recognise when the judgemental self affects the capacity to be open-minded (Wells et al., 2016).
4.2 | Conclusion
Although most healthcare professionals had practical experiences with cultural diversity in caring for persons with diabetes, only one-third of healthcare professionals perceived to have interaction skills needed to be culturally competent. The healthcare professionals felt that they did not receive support from their workplace to improve their interaction skills. Cultural competence-related education could support the healthcare professionals to develop interaction skills. Most healthcare professionals perceived that they had developed cultural openness and awareness.
ACKNOWLEDGEMENT
We thank primary healthcare professionals who participated in this study. This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
CONFLIC T OF INTERESTS
The authors declare that they have no conflict of interest.
AUTHOR CONTRIBUTIONS
SP, LK, TJ were involved in study design, data collection, analysis, drafting and re-drafting of the article. JH was involved in analysis, drafting and re-drafting of the article. MJ was involved in drafting and re-drafting of the article.
Data Availabilit y Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
ORCID
Sara Pettersson https://orcid.org/0000-0003-1406-0349
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How to cite this article: Pettersson S, Holstein J, Jirwe M,
Jaarsma T, Klompstra L. Cultural competence in healthcare professionals, specialised in diabetes, working in primary healthcare—A descriptive study. Health Soc Care Community. 2021;00:1–10. https://doi.org/10.1111/hsc.13442
