International Service Learning and Changes in Cultural Competence in Dental Students

1. International Service Learning and Changes in Cultural Competence in Dental Students EA Martinez-Mier, T Carlson, AE Soto-Rojas, KM YODER, MJ WILLIAMS, JA Hatcher Indiana University School of Dentistry, IU Center for Health Policy, IUPUI Center for Service and Learning

2. IUSD International Service-Learning Programs Programs that aim at connecting meaningful community service experiences with academic learning, personal growth, and civic responsibility

3. Where do the IUSD programs go?

4. IUSD Service-Learning Programs • As part of the Comprehensive Care/Patient Management & Rounds course (T840/850 ), fourth year dental students provide clinical treatment of patients applying the knowledge and skills developed in earlier dental sciences and clinical sciences courses. • Additionally, students are exposed, through intramural classes, to topics of interest to them which they pursue in greater depth. The International Service-Learning (ISL) course is one of these intramural classes (T840/850 – E 292). • Service learning is integrated into curriculum which provides structured time for reflection, enhances teaching and fosters civic responsibility

5. IUSD Service-Learning Programs • This international service-learning course has been designed to provide: • Background information on disparities in health care access and outcomes and recent efforts at eliminating these disparities • Information on core cultural issues relating to authority, physical contact communication styles, gender, sexuality and family that have potential for cross cultural misunderstanding; and, on attitudes that are fundamental to successful cross-cultural encounters: empathy, curiosity and respect • A set of practical methods to employ in cross-cultural encounters such as how to elicit patient information and negotiate within a patient • A set of practical methods adapt triage and treatment planning skills to meet community needs and clinical setting • A “hands on”, interactive, international service-learning (ISL) experience

6. What do students do? •  Register for a semester long class • Attend preparatory sessions • Multidisciplinary lecture sessions • Case studies • Small group discussions • Review of literature • Prepare assignments • Fill a pre and post participation survey to asses progress towards achieving competencies and meeting class objectives • Participate in “hands on”, interactive international service-learning experience where they provide dental services (in collaboration with community members) that include: • Education and dental screenings • Fluoride treatments • Sealants and prophylaxis • Restorations • Extractions • Participate in reflection sessions • Evaluate their participation and the program

7. Research Question • This study aimed at determining if participation in an ISL experience allowed dental students at IUSD to progress towards achieving American Dental Association (ADA) and IUSD established competencies.

8. Background • Competencies are outlined by the ADA Accreditation Standards for Dental Education Programs and the IUSD’s Competencies for the Dental Graduate and Standards of Care.

9. Health Professions Competencies American Dental Association and IUSD targeted competencies • Managing a diverse patient population • Having the interpersonal and communication skills to function successfully in a multicultural work environment

10. Theoretical Framework • A model that best fitted the research question was identified and a modification of validated questionnaires was used to assess students’ progress towards competencies. • We based our approach on Cross’s Cultural Competency Continuum Model. The model uses a continuum to assess cultural competency.

11. Research design • Students who participated in an ISL experience were invited to participate in the study which also included two control groups. • The positive control group consisted of students who had participated in a local service learning program, and the negative control group consisted of students who had not had similar experiences.

12. Research design • The rationale for this approach was to compare if both the international and the service learning components of the experience had an effect when compared to local or no experiences. • Our working hypothesis was that students who participate in ISL experiences progressed faster towards achievement competency in communication and cultural professionalism skills than those who don’t participate in such experiences.

13. Materials and Methods • The study assessed the impact of participation in ISL on three domains: • knowledge of the impact of values and belief systems on health case access and utilization • knowledge of cultural competency relates to health care quality • cross-cultural communication

14. Materials and Methods • For the values and belief systems domain, questions were included from a subscale from an instrument modified by Crosson et al. and developed by Dobbie et al. The Health Beliefs Attitudes Survey (HBAS) were used. • This subscale concerns students' knowledge of the values and belief systems of diverse cultural groups and their impact on health care access and utilization

15. Materials and Methods • For the Cross Cultural Communication domain, questions from a subscale from a self assessment tool Cultural Competence Health Practitioner Assessment (CCPHA) developed by the National Center for Cultural Competence were used. • The subscale explores capacity for cross-cultural communication, utilization of different modes of communication, and the provision of interpretation/translation services.

16. Materials and Methods • To assess the reliability of the HBAS and CCPHA, we computed Cronbach’s alphas for students’ survey responses both before and after the intervention. • Only those subscales that had alphas > 0.80 were included in the analysis. • Before and after participation responses were compared using ANOVA.

17. Results 180 students answered pre and post experience questionnaires. • 67 in the ISL group, • 58 in the Seal Indiana (SI) group and, • 55 in the Negative Control (NS) group.

18. Results • After the experience, a significant difference was found for group membership on the HBAS scale, with the ISL group having the highest Cultural Competency, followed by the NS group and the SI group

19. Results • There was a significant difference in the scores for pre (mean = 2.37, SD = 0.44) and post-test (mean = 2.52, SD = 0.47), p < 0.001, indicating that cultural competency increased between pre and post for the ISL group.

20. IUSD Service-Learning Programs Reflection • “…..I believe a major intent of this program is to provide students (and faculty) with an experience that brings to life the reality from which many of our Hispanic patients come from. After traveling in the back of pick-up trucks to small villages in the mountains of Mexico, hours away from the nearest health clinic or hospital, I have a much better understanding of the background of the people, their struggles as well as their impressive need….” • Student Participant, 2004

21. IUSD Service-Learning Programs Reflection • “…..I have learned so much in this program!!! I was so surprised to see how different children behave in the villages. The way they talk to their parents and grandparents, the respect, the obedience, the silence. I even started to pick up on the non-verbal ques. No wonder we cannot get our oral health education messages across. We expect them to behave like American children when many of our expectations require behaviors that are not acceptable in their culture.” • Student Participant, 2009

22. Interpretation of Findings • Participation in ISL experiences in this sample of students appears to have increased their knowledge of the impact of values and beliefs on access to care and facilitated culturally appropriate clinical decision making.

23. Relevance • This study provides evidence supporting the impact of service learning in advancing specific discipline based competencies.

24. Clinics

25. Clinics

26. Our Partners in Crime Dr. Steven B. Blanchard Dr. Lawrence P. Garetto Dr. Amul H. Singh Dr. Armando E. Soto-Rojas Dr. Karen M. Yoder Dr. Andrea Ferreira Zandona

27. Questions?