Cultural Competence: Evaluating Free Online Courses for Pharmacy Students

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1 XULAneXUS: Xavier University of Louisiana s Undergraduate Research Journal. Scholarly Note. Vol. 7, No. 2, April Cultural Competence: Evaluating Free Online Courses for Pharmacy Students LaKeisha George Williams, Pharmacy Faculty Mentor: Margarita Echeverri, Pharmacy Abstract This study is the second part of a project that examines various online courses in health disparities and cultural competence that are freely accessible on the internet and recommends the one most suitable for students at Xavier University of Louisiana, College of Pharmacy (XULA/COP). The purpose of this study is to complete nine previously selected online courses and pilot test an evaluation framework specifically designed to identify the main characteristics of the courses and difficulties in completing them. Results will be used to extend the project to a third phase where more students will be invited to complete and evaluate the courses prior to final selection of the one to be recommended as a mandatory activity in a current core course in the XULA/COP curriculum. After completion of this study, it was concluded that although the evaluation framework is very useful to record the information required to evaluate the different courses, an additional table is needed to report other information that the evaluators consider of special interest. This study found that there are several online courses that could be embedded into the curriculum of existing pharmacy courses. Although the author identified online course Unified Health Communication 101 (CO8) as the best one, more evaluations are needed to make the final recommendation of the course to be implemented into the XULA/COP curriculum. Key Terms: Health Disparities, Cultural Competence, Curriculum, Online Training Introduction Despite advances in health care and technology, disparities among ethnic and racial minorities occur every day because of a healthcare system that fails to provide equal service to all individuals, regardless of race, gender, ethnic background, socioeconomic status or geographic location (AMSA, 2008). African Americans, Hispanics, Native Americans, and Asian/Pacific Islanders, who represent 34 percent of the U.S. population (CBS, 2009), continue to experience striking health disparities, including shorter life expectancy and higher rates of diabetes, cancer, heart disease, stroke, substance abuse, infant mortality and low birth weight (NIH, 2006). Taking into account that many of these disparities are linked to discrimination, stereotypes, and cultural and language barriers between the patient and healthcare professional, training in cultural competence has been recognized as an important strategy to decrease health disparities (ASHP, 2008; IOM, 2004). According to the Health and Human Services Office of Minority Health, cultural competency is one of the main ingredients in closing the disparities gap in health care (2005). Therefore, it is imperative that pharmacy students and practicing pharmacists gain knowledge in health disparities and develop skills in cultural competence so that medication

2 60 L. Williams therapy will be more effective and optimal health outcomes are attainable (Bole, 2007). When the characteristics of a culturally competent pharmacist or health care professional (such as effective communication, increased awareness, respect and overall knowledge of other cultures) are combined with greater patient satisfaction, then the elimination of health disparities will be achieved. Currently, many accreditation agencies are making mandatory recommendations to include training in cultural competence and health disparities in different health professions. Specifically, in pharmacy, the Accreditation Council for Pharmacy Education (ACPE) includes Guideline 9.1 in its revised standards: The college or school must ensure that the curriculum addresses patient safety, cultural competence, health literacy, health care disparities, and competencies needed to work as a member of or on an interprofessional team. In order to satisfy this academic standard, pharmacy schools are providing students with cultural competence training through workshops, lectures or elective courses (Lang, 2008). According to Margarita Echeverri, XULA/COP Educational Coordinator in Health Disparities, Cultural Competence, and Diversity (2010), one of the main difficulties in implementing a cultural competence curriculum in pharmacy schools is the heavy course load that already exists in a four-year academic program. When elective courses in health disparities and cultural competence are implemented, they have to compete for the enrollment of students. Therefore, only a small percentage of students are exposed to the new content. Although XULA/COP provides cultural competence training in seminars and courses, including Introduction to Pharmacy, Pharmacy Practice, and Behavioral Pharmacy & Communications, students do not receive enough instruction on cultural competence. Echeverri is thus analyzing the use of online training in cultural competence and health disparities that could be completed by XULA/COP students in their own time and location. She is also developing assessment strategies to measure the competencies required by both the ACPE and XULA/COP s program outcomes. The first part of Echeverri s project was a literature review and environmental scan on online training freely available on the Web, which resulted in the selection of nine different courses targeted to specific populations including physicians, nurses, medical students and residents. Although very few web courses give information specific to pharmacists and other health care professionals, the nine selected courses were determined to be adaptable to the specific needs of pharmacy students. The present study is the second part of Echeverri s project. The purpose is to complete the nine previously selected courses and pilot test an evaluation framework specifically designed to identify the main characteristics of the courses and difficulties in completing them. Results will be used to extend the project to a third phase where more students will be invited to complete and evaluate the courses prior to final selection of the one to be recommended as a mandatory activity in a current core course in the XULA/COP curriculum. Methods The author completed nine online courses in cultural competence and health disparities that were freely accessible on the Internet (Appendix A) and evaluated them using a given framework that considered the following characteristics (Appendix B): (1) duration of training, (2) registration requirements, (3) accessibility, (4) assessment strategies and feedback, (5) teaching resources used, (6) organization of content, (7) enjoyability, and (8) effort to complete

3 Cultural Competence 61 the course. The duration of the training was specified according to the overall time (minutes) taken to complete the entire program, including pre- and post-assessment tests. Registration requirements were measured using a 3-point scale (0 =no registration required, 1 = only name and required and 2 = more than name and required). Responses to accessibility, assessment and teaching resources used dichotomous categories (1 = yes and 2 = no). The organization of the content consisted of a brief description of the structure of the course: modules, sections, lessons, and the total number of screens and or pages included. Level of course enjoyment was measured with a 5-point scale (0 = not at all, 1 = a little, 2 = somewhat, 3 = quite a bit, and 4 = very), and student s effort was evaluated by considering the training as a course assignment or as a one-hour course, and was measured using a 4-point scale (0= easy, 1 = fair, 2 = a lot and 3 = too much). According to Renninger, Studies of student effort suggest that the more difficult a task appears in the sense of the task's difficulty and the likelihood that the student can complete it successfully the less likely it is that the student will be motivated to take the task on. Remaining characteristics and additional comments were described through open-ended responses. Overall, the online training programs were evaluated on the basis of implementing an online cultural competence course for pharmacy students. Informed consent was obtained before evaluating the courses. Once the courses were completed, they were ranked from 1 to 9 (1 = lowest, 9 = highest) as an overall evaluation. This rank was interpreted as the evaluator s recommendation of the order in which courses should be considered for implementation into the XULA/COP curriculum. Results The nine courses were numbered consecutively for easy identification and the evaluation framework was completed for each. The duration of the courses ranged from 45 to 270 minutes, which was based on the comprehensiveness of a given course s content. For example, the shortest time, 45 minutes, was needed to complete the course, Introduction to Health Disparities (C07). It consisted of a limited number of characteristics, such as no pre- or postassessments and the use of interactive graphics only. In addition, the course included only three modules compared to the eight modules of C01, which had the longest duration (270 minutes). Unlike other courses, Provider s Guide to Quality and Culture (C01), contained comprehensive information about health disparities and cultural competence and included numerous interactive graphics, videos, links to other sources, assessment tests and feedback, and other evaluative characteristics. However, the time taken to complete a course would vary depending on the student s interest and knowledge of the material and if the course was completed in one attempt or several. The majority of the training programs did not require registration; however, C05 required the participant s name and , and C08 required additional registration information. Another important characteristic in the evaluation involved the quantity and quality of content information. Most of the online courses gave detailed information about health disparities and cultural competence. They included numerous facts and reflective questions and displayed an array of surveys, interactive graphics, video, audio, case studies and assessments (Table 1). Some featured a glossary to research terms and a reference page that listed its sources. Several online courses even compared participant s responses to questions to the responses of

4 62 L. Williams previous participants. Furthermore, many web courses were visually appealing and displayed bold colors, text, and graphics that attracted the participant s attention. One online course was entirely a video (C06), yet it was very interesting. However, it may be a disadvantage to visual and hearing impaired students. Numerous online courses gave assessment tests that were posted in either the beginning or end of the learning modules. A few even posted several questions during the online course instead of posting one pre- or post-assessment test. In addition, a majority of the assessments were listed in multiple-choice form, while others contained case studies and short-answer type questions. Every training program covered various aspects of cultural competence through various modules and lessons. Table 1 Characteristics of Online Courses in Cultural Competence Access, Assessment and Content Information Characteristics: Yes No Access Requires Username/Password? 4 5 Assessment Pre-Assessment Test? 3 6 Post-Assessment Test? 6 3 Feedback on assessment test(s)? 4 5 Content Information Has Videos? 4 5 Has Audio? 4 5 Has Case Studies? 7 2 Has Interactive Graphics? 4 5 Has PowerPoint Presentations? 0 9 An additional aspect of the evaluation involved the student s level of enjoyment (Table 2) and effort in completing the online course as an assignment or as a one-credit course (Table 3). The level of enjoyment correlates to the student s interest in some extent. It is assumed that the greater the level of enjoyment, the more interested the student would be in taking the course. This also has a relationship to the student s effort in completing the online course as an assignment or for 1-credit hour. Table 2 Characteristics of Online Courses in Cultural Competence Student s Level of Enjoyment Enjoyment Level Not at All A Little Somewhat Quite a bit Very Enjoyable Evaluator Responses (%): 0 (0%) 2 (22%) 3 (33%) 2 (22%) 2 (22%)

5 Cultural Competence 63 Table 3 Characteristics of Online Course in Cultural Competence Student s Effort as an Assignment or 1-Hour Credit Course Evaluator Responses (%) Easy Fair A lot Too Much Student s Effort as an Assignment in a Course 0 (0%) 7 (78%) 0 (0%) 2 (22%) Student s Effort as a 1-hour Credit Course 1 (11%) 6 (67%) 1 (11%) 1 (11%) As a complement to the evaluation framework, additional comments were also noted about each online course (Appendix C). Some online courses integrated overall information about health disparities and cultural competence, whereas others focused on specific disparities, such as cardiovascular disease and African Americans. In other courses, feedback or an assessment response was also given if a question was answered correctly or incorrectly. If the question was answered correctly, then it was possible to proceed to the next question. However, several attempts were allowed after an incorrect response. Another characteristic evaluated was the total number of pages per module, section or lesson. A majority of the online courses targeted various health care professionals. However, Provider s Guide to Quality and Culture (C01) and Unified Health Communication 101 (C08) were found to be excellent candidates for an online course in the pharmacy curriculum. Not only did these two courses give interesting information about cultural competence and health disparities, but they also displayed high student interest, pharmaceutical knowledge, medication examples, case study scenarios and questions that are applicable to pharmacy. Discussion In this evaluation of online training in cultural competence, it was found that several online courses are available for pharmacists and other healthcare professionals. Using the given evaluation framework, the author completed, evaluated, and ranked each online course as though it was an actual credit course and added personal perceptions of the courses. The author s final ranks suggest that two of the courses, C01 and C08, or even the combination of two courses, such as C02 and C09 based on modules covered and duration of course, could be implemented as a one-hour online credit course in the XULA/COP curriculum. Although the implementation of an existing online course that is freely available on the Internet would save money for the university and time for the course instructor, it would be the instructor s decision to compose additional assessments such as exams and quizzes. Papers or projects could be assigned to test students knowledge in cultural competence after completing the online course. During this study, it was observed that there is a lack of online courses that are designed specifically for pharmacists and pharmacy students. Limitations to the study included a restriction to the previously selected nine online courses and the short time available for this

6 64 L. Williams study, which did not allow the identification of other courses that could be included in the list. An increased number of web courses selected would give a greater representation of the types of courses on cultural competence available. Another limitation was that the courses were evaluated using a previously designed framework. Assessing more characteristics would give better content descriptions of the information covered in the courses. However, the evaluator s comments found in Appendix C include additional information that could be used to update the framework for the next phase of the project. Furthermore, the scope of this study was limited to pilot testing the methodology used in the evaluation of the online courses, and the study used only one evaluator. The addition of evaluators in future studies would provide different opinions about the course characteristics and varying insight about a course s implementation into the curriculum. Depending on the student s level of pharmacy school, the courses may receive a different evaluation. As a fourth year pharmacy student, the evaluator has experienced various courses in the pharmacy curriculum and has witnessed the level of cultural competence training covered throughout the XULA/COP program. Therefore, the evaluator s opinion may be different from the opinion of a first year pharmacy student. Due to the impact of health disparities in health care, accreditation agencies are requiring colleges and schools of pharmacy to ensure that students are knowledgeable about cultural care and communication through cultural competence. Moreover, it is vital that pharmacy students of all levels (P1 P4) gain this knowledge so that they will be able to apply it in their current and future pharmacy settings. Incorporating new courses into a compact curriculum is very challenging, yet vital towards effective learning. Therefore, implementing online training is considered an important strategy to overcome these barriers and increase the opportunity for pharmacy students to gain knowledge in health disparities and cultural competence. During this study, no significant difficulties were found in completing any of the nine online trainings or using the evaluation framework to register the main characteristics of each. However, during the completion of each course, additional information was identified that was not assessed in the framework but considered important to the evaluation of the courses. As this study is a part of an ongoing project, it is recommended that this new form is added to the evaluation framework for the next phase. Additionally, due to an increased awareness of health disparities and cultural competence, it is expected that more websites and online training will be available in the future, and a regular update of the courses available for evaluation is recommended.

7 Cultural Competence 65 References Accreditation Council for Pharmacy Education (ACPE). (2006). Accreditation Standards and Guidelines for the Professional Program in Pharmacy Leading to the Doctor of Pharmacy Degree. Retrieved from 06.pdf. American Society of Health-System Pharmacist (ASHP). (2008, April 14). New ASHP Statement Point to Pharmacists Role in Eliminating Health Disparities. Retrieved from American Medical Student Association (AMSA). (2008). What are Health Disparities? (2008). Retrieved from Assemi, Mitra and Chris Cullander. (2003). Cultural Competency in Pharmaceutical Care Delivery: A Training Template for a One-Day Pharmacy Student Elective Course. Regents of the University of California. Retrieved from Bole, Kristen. (2007, August 15). Health Care Disparities Start at the Local Pharmacy, Study Shows. Retrieved from CBS News. (2009, May 19). Census: Minority Population Growth Slow. Retrieved from Echeverri, Margarita. (March 2010). Personal communication. Health and Human Services Office of Minority Health. (2005, October 19). What is Cultural Competency? Retrieved from Institute of Medicine (IOM). (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. Lang, Will. (2008). Academic Pharmacy: Working Towards Health Equity. American Association of Colleges of Pharmacy (AACP). Retrieved from ebrief2008.pdf. National Institute of Health. (2006, October). Health Disparities. Retrieved from Renninger, K. Ann. (2010). Effort and Interest Effort, Interest, Effort and Interest. Retrieved from

8 66 L. Williams Acknowledgments I would like to acknowledge and extend my deepest gratitude and warmest appreciation to the following persons, who have contributed and inspired me to the overall success of the undertaking: To Dr. Kathleen Kennedy, Interim Dean of Xavier University of Louisiana, College of Pharmacy for the opportunity and approval of enrolling in the pharmacy independent research course, Research Clinical Pharmacy. To my mentor, Dr. Margarita Echeverri, for her research, development of the framework and list of websites that were evaluated in the study and revision of the manuscript. Most importantly, for her guidance, patience, motivation, constant reminders and support in the duration of the course, study and submission of the paper. I am truly appreciative of her passion for research and I hope to emulate that same passion in future research studies. To God, most especially, who makes all things possible!

9 Cultural Competence 67 Appendix A: Course Identification C01 - Provider s Guide to Quality and Culture, HRSA roup=&mgroup= C02 - A Clinician s Guide to Reduce Cardiovascular Disparities, Cultural Competence Online for Medical Practice (CCOMP) C03 - The Texas Health Steps Cultural Competency Web Based Long Distance Learning Program, Department of State Health Services C04 - Healthcare Disparities, Talaria Inc &btn=back C05 - Physician's Guide to Culturally Competent Health Care, Office of Minority Health C06 - Educating Physicians on Controversies and Challenges in Health: Health Care Disparities among Racial-Ethnic Minority Patients, AMA C07 - Intro to Health Disparities, CHERP C08 - Unified Health Communication 101: Addressing Health Literacy, Cultural Competency, and Limited English Proficiency, HRSA C09 - Learning Module Cultural and Spiritual Sensitivity: A Quick Guide to Cultures and Spiritual Traditions, Sue Wintz