OPEN ACCESS This is the English version.

Cultural Competence/Global Health The German version starts at p. 9. position paper

Cultural Competence and Global Health: Perspectives for

MedicalEducation– PositionpaperoftheGMA Committee
on Cultural Competence and Global Health
Abstract
Introduction: Routine medical care in Germany, Austria and SwitzerlandClaudia
Mews1 is being increasingly impacted by the cultural and linguistic diversity of2
Sylvie Schuster an ever more complex world. Both at home and as part of international
student exchanges, medical students are confronted with different waysChristian Vajda3
of thinking and acting in relation to health and disease. Despite an in-Heide creasing number of courses
on cultural competence and global health Lindtner-Rudolph4 at German- speaking medical schools,
systematic approaches are lacking
Luise E. Schmidt5,6 on how to integrate this topic into medical curricula.
Methodological approach: This paper is based on a structured con-Stefan Bösner7
sensus-building process by a multidisciplinary committee composed ofLeyla Güzelsoy8 faculty and
students. In a first step, a qualitative online survey was
Frank Kressing9 carried out in order to establish an inventory of definitions and
concepts.
After the second step, in which a literature search was conducted and Houda Hallal10
definitions of global health and transcultural and intercultural compet-Tim Peters11 ence were
clarified, recommendations were formulated regarding con-
Margarita Gestmann12 tent, teaching and institutional infrastructure. Based on small-
group
work and large-group discussions, different perspectives and critical Linn Hempel13
issues were compiled using multiple feedback loops that served to en- Tatjana Grützmann14 sure
quality.15
Erika Sievers
Results: An inventory on the national and international level showed
that great heterogeneity exists in regard to definitions, teaching Michael Knipper16
strategies, teaching formats and faculty qualification. Definitions and practical realization to qualification of t
central aspects considered essential to medical education were thus research.
established for the use of the terms “cultural competence” and “global Outlook: High-quality healthcare as a g
health”. Recommendations are given for implementation, ranging from internationalization of undergraduate m
to offering specific courses on cultural co
synergies would be created through
competence and global health content
existing subject areas. The NKLM (the
catalogue of learning objectives for unde
would serve as a basis for this.
Keywords: cultural competence, global h
education, teaching, curriculum
1 University Medical Center
Hamburg-Eppendor,f

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

Department of General
Practice/Primary Care , Hamburg, Germany
2 University Hospital Basel,
Head of Program on
Diversity Management, Basel, Switzerland
3 Medical University of Graz,
Department of Medical
Psychology and
Psychotherapy, Graz, Austria
4 University Medical Center Hamburg-Eppendorf, Center for Psychosocial
Medicine, Institute and Outpatients
Clinic Medical Psychology,
Research Group on
Migration and Psychosocial
Health (MiPH), Hamburg, Germany
5 University of Greifswald, Department of Psychiatry and Psychotherapy,
Greifswald, Germany

1. Introduction
Routine medical care in hospitals, medical practices and other
healthcare institutions has increasingly been affected by cultural and
linguistic diversity for years. The profound significance of cultural
aspects, as well as of the social, legal and political framework for
patient

6 Heli
os
Han
sekl
inik
um
Stralsu
nd,

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

Department of Embedding these topics in

Psychiatry and medical education is a
Psychotherapy, Stralsund, Germany basic prerequisite in order
7 University of Marburg, Department of General to ensure high-quality,
Practice/Family Medicine, Marburg, Germany individualized healthcare
for all patients in times of
8 Paracelsus Medical Private
globalization. Furthermore,
University, Nuremberg
Hospital, Department of Psychosomatic Medicine and it is essential to prevent
Psychotherapy, Psychosomatic Consultation and misunderstandings and
Liaison Service, Nuremberg, Germany avoid inappropriate care.
Systematically structured
9 Ulm University, Institute of the History, Philosophy
and sustainable
and
Ethics of Medicine, Ulm, Germany institutionalized
approaches are currently
10 University of Cologne, lacking.
Faculty of Medicine, Cologne, Germany
Already in 2009, the
11 Ruhr-University Bochum, Bundesvertretung der
Medical Faculty, Center for Medizinstudierenden in
Medical Education, Bochum, Germany Deutschland bvmd (the
12 University of DuisburgEssen, Medical Faculty, national association of
Dean's office for student affairs, Essen, Germany medical students in
Germany) pointed out the
13 University of Dusseldorf,
Medical Faculty, need to pay stronger
Psychosomatic and attention to global health in
Psychotherapy, Dusseldorf, Germany medical education [2]. In
2014, the Lancet
14 RWTH Aachen University, Dean's office for student
Commission on Culture and
affairs, Aachen, Germany
Health emphasized the
15 Academy of Public Health importance of a broad and
Services, Düsseldorf, Germany nuanced understanding of
16 Justus Liebig University culture in medicine and
Giessen, Institute for the fostering the development
History of Medicine, Giessen, Germany of cultural competence
during medical education
[3]. In 2015, the Leopoldina
and other scientific
academies took a stand on
strengthening public health
health and medical practice have become increasingly conspicuous in
and global health in
Germany, Austria and Switzerland following the development of
Germany. They therein
globalization and migration processes. Current challenges related to
articulated a clear
the reception of large numbers of refugees from war zones and regions
recommendation for the
of conflict [1] dramatically testify to this. Medical students are not only
exhaustive inclusion of this
confronted with different and sometimes foreign ways of thinking and
issue in medical education
acting as relates to disease and health in the context of international
[4]. Most recently, in 2017,
student exchanges. Students also experience many different and
the
sometimes unexpected forms of doctor-patient relationships in their
Hochschulrektorenkonfere
native countries.
nz (the association of
It must be taken into consideration, for instance, that wide diversity in
German universities and
as much regards as the understanding of hierarchies, communication
higher education
styles, the inclusion of family members, or the value of religion and
institutions) issued
spirituality is not limited solely to contact with patients with migration
recommendations for the
background. In consequence, cultural competence and global health
internationalization of
are indeed relevant to medical practice and decision-making both at
curricula, calling for the
home and abroad.
systematic integration of

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

courses on cultural competence and global health into medical are optional, offered
curricula [5], [6]. voluntarily by committed
Through this position paper, the Committee on Cultural Competence teaching faculty and
and Global Health of the Gesellschaft für Medizinische Ausbildung particularly motivated
(GMA) intends to contribute to the systematic development of courses students. Structural
and programs dealing with the tightly interconnected topics of cultural integration into official
competence and global health in medical education. In addition to an curricula is rare [11], [17]. A
overview of the current situation in Germanspeaking countries and recent publication on
internationally, the committee presents definitions, theoretical Germany’s increasing role
considerations and recommendations regarding teaching and faculty in global health criticized
qualification. German medical schools
for placing low priority on
this particular topic [18],
2. Methodological approach [19]. With the introduction
in 2015 of the NKLM (the
This paper is the product of a structured consensusbuilding process national competence-
[7] which was undertaken from 2013 to 2016. A multidisciplinary based catalogue of learning
committee strategically composed of highly experienced faculty objectives for
participated in this process. The members represented the diverse undergraduate medical
academic and professional contexts of clinical medicine, public health, education) learning
cultural and social sciences and other disciplines relevant to the topic objectives covering the
in question. Undergraduate medical students were actively involved central aspects of cultural
alongside faculty. The aim was to compile well-balanced and competence and global
meaningful results and reach a consensus whilst drawing on the health now exist for
multidisciplinary nature of the committee and following a structured Germany [http://
process (see Attachment 1). www.nklm.de]. The 2008
As initial step, a qualitative online survey was carried out in order to Swiss Catalogue of
assess pre-existing understandings, definitions and concepts related Learning Objectives has
to the subject area among the 16 original committee members with been revised and replaced
expertise in teaching intercultural and transcultural competence by the Profiles Framework
and/or global health. Based on the results, priorities were set for the (PROFILES 2017) which
next steps in the process. Divided into two working groups, definitions also contains learning
for the terms “global health” and “transcultural/intercultural objectives on this topic
competence” were elicited based on targeted literature search and [http://www.profilesmed.c
extensive deliberations. Recommendations were compiled in an h/doc/ Profiles_2017.pdf].
ongoing process concerning content, didactics and structures. The use In Austria, there is no
of different settings such as small-group work, large-group discussions national catalogue of
and teleconferences served to identify and discuss different learning objectives yet. A
perspectives and critical standpoints while providing feedback loops profile required for faculty
for quality assurance. A major goal was to develop integrated teaching cultural
perspectives regarding topics that are usually viewed separately, such competence and/or global
as, for example, transcultural and intercultural competence or cultural health does not exist in any
competence and global health in medical education. of the three countries,
because there are no
binding requirements
3. Situation in German-speaking countries regarding content and/or
structures for course
and internationally planning.
In German-speaking countries, there exists a wide variety of initiatives By contrast, there has been
and programs fostering cultural competence and teaching global a decades-long tradition of
health in medical education [2], [8], [9], [10], [11], [12], [13], [14], offering courses and
[15], [16]. At some universities, individual aspects are addressed (e.g. employing elaborate
cultural competence or topics regarding the global health spectrum), concepts to impart cultural
at others, integrated formats are offered. At many universities, courses competence during medical
education in conjunction

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

with far-reaching academic debates and research in education at relationships [15], [54].
some Anglo-American universities [20], [21], [22], [23], [24], [25], The isolated view of
[26], [27], [28]. Cultural competence in healthcare has become more medicine and healthcare
important in Europe in recent years as a response to different in terms of the North-
initiatives, as are, for instance, the EU project on MigrantFriendly South divide, implying
Hospitals (2002-2004) [29] and the national strategy addressing supposedly developed
migration and health on the part of the Federal Swiss Health Agency and underdeveloped
(2002-2017). This increased importance is reflected in the growing countries, is
numbers of related courses or discussions about course content, inappropriate from a
structure, teaching methods and faculty qualification [30], [31], [32], global health
[33], [34], [35]. There are also publications about courses and perspective.
programs on other continents [36], [37]. This likewise applies to the • Interdisciplinarity:
somewhat more recent topic of global health, which is also receiving Global health is an
growing attention in medical education, accompanied by related interdisciplinary field
discussions regarding content, objectives, structure and teaching [48], [49], [55].
strategies [14], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47]. Alongside scientific and
However, a general statement about the type of courses or their mere clinical concerns, there
existence in different countries cannot be made, since no are also epidemiological,
comprehensive data has been collected and there are no universal socio-cultural, economic,
definitions, nor is there uniformity among course titles. ecological, ethnic,
political and legal
contexts relevant to
4. Definitions and central aspects healthcare and the
practice of medicine.
Many different ideas and assumptions are associated with the terms
“cultural competence” and “global health”, resulting in a diverse range Cultural competence
of possible interpretations and understandings. In the course of the
consensusbuilding process, the following points have been identified Against the backdrop of
as central to medical education: socio-cultural diversity of
populations, culture is an
Global health ambivalent and complex
term, even in the context of
The term “global health” designates a broad and heterogeneous medicine and healthcare
subject area characterized by a general interest in the various [10], [21], [22], [23], [25],
challenges and potentials of medicine and healthcare in an [56], [57]: Careless use of
increasingly complex world [12], [14], [17], [44], [48], [49]. In the term can lead to
conjunction, the following three core elements form a working stereotyping and
definition of global health and constitute an innovative and necessary misunderstandings, while
perspective for medical education. deeper reflection on the
• Health as a human right: The normative basis for global health lies term’s meaning offers the
in the individual human right to the highest attainable standard of chance for better
health, as stated in Article 12 of the International Covenant on understanding and
Economic, Social and Cultural Rights adopted by the United Nations improved interaction with
[49], [50], [51]. Global health is explicitly based on the human rights all patients. A more
concept of equity [48]: All people are equal in regard to dignity and differentiated and culturally
rights, regardless of their origin and all biological, social or other aware view places the focus
specific differences. The promotion and guarantee of equal rights on patients’ reality and the
requires leveling the field in terms of disadvantages and protection concrete significance of
against preventable health risks and all forms of discrimination social, cultural and
[50], [52]. structural aspects of
• Global perspective: Global health perspective focuses on the entire health, medicine and
world, meaning that it is not limited to specific areas or regions [48], healthcare [20], [21], [58],
[53]. This involves consideration of local situations within a global [59], [60].
context, including migration, climate change, and global economic This complexity has led to a
wide variety of theoretical

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

views, concepts and terms in the academic debate. For instance, there didactically useful
are numerous definitions of the terms “interculturality” and interaction as regards
“transculturality” [8], [25], [59], [61], [62], [63], [64]. The aims and cultural competence.
main aspects of intercultural and transcultural competence derived While teaching skills
from these terms are not contradictory, but rather exhibit large overlap related to cultural
and can mutually supplement each other. Based on the consensus competence is crucial to
reached, the term “cultural competence” is recommended, as it is to courses on global
be understood in a comprehensive, overarching manner and is defined health, aspects of
for use in medical education by the following aspects: global health are not
absolutely necessary in
• An understanding of culture based on socio- and cultural
courses dealing with
anthropology, which views culture as a collection of ways of thinking
cultural competence,
and acting acquired in a lifetime and acknowledges cultural identity
though they are
depends on context [21].
definitely desirable.
• A nuanced and self-critical reflection of the physician’s own
2. Embedding topics of
socialization, individual culture and stereotypes.
cultural competence
• Awareness of patients as individuals, and reflection on both the
and global health in the
aspects perceived to be culturally different and shared
curricula: Due to their
commonalities.
relevance to the routine
• The ability to assess the linguistic proficiency of individual patients
of medical care, cultural
along with knowing the advantages and disadvantages of using
competence and global
professional or non-professional interpreters to communicate with
health should be
patients.
integrated into the
• Attentiveness to the patients’ prior experiences regarding
standard curricula and
healthcare in their country of origin and abroad, to possible
required from all
migration backgrounds and experiences therein, as well as to
medical students.
individual concepts regarding health, disease and therapy.
Longitudinal embedding
• Critical reflection on beliefs, patterns of thought and action, as well
in the curriculum with
as the hierarchies of values held by the medical personnel in
consideration of
medical schools, hospitals and medical practices [3], [64].
university-specific pre-
• Systematic consideration of the social, economic, political and
requisites and
structural factors influencing medical care, in particular as regards
structures should be
alleged “cultural” challenges [23], [28].
aimed for. Sufficient
These central aspects contradict the frequently expressed desire for staffing and funding is
simple checklists and rules of conduct for certain cultures and medical to be ensured. In-depth
situations. Culturally competent care for patients can only be ensured courses for particularly
through constant communication and comprehension of the priorities motivated students are
and needs of those involved. recommended.
3. Faculty qualification
and teaching
5. Recommendations methodology: In
addition to the above
The following recommendations are made based on the above definitions and core
definitions and theoretical considerations, the teaching experience of content, individual
the experts involved in reaching the consensus-building process, and commitment to the
relevant international publications. objectives, content and
1. Utilization of synergies by linking cultural competence with global theoretical background
health in medical education: The advantages of linking these two of these concepts is an
areas, though they are often considered and taught separately, important pre-requisite
arise from the important overlap of topics and ideas. Topics for teaching cultural
relevant to both include migration, diversity or the necessity of a competence and global
broadly conceived interdisciplinary perspective. In addition, health. The ability to
students’ international experiences connected to a global health adequately analyze the
perspective (e.g. specialized studies abroad) offer a wide variety of root causes and

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 Mews et al.: Cultural Competence and Global Health: Perspectives ...

consequences of diversity is essential, as is systematic reflection The references have been

on one’s own attitude and actions. Professionalization of faculty compiled by the committee
and the development of criteria for quality assurance are also as a list of publications
required. In terms of didactics, conventional approaches should be relevant to this position
complemented by methods involving the students’ individual paper. This selection
experiences and backgrounds, e.g. intercultural experiences in intends by no means to be
their personal lives, daily clinical practice, or participation in an exhaustive one. The
international student exchange projects. position paper was
4. Interdisciplinary approach: Cultural competence and global health accepted by the GMA
embody a broad interdisciplinarity that combines the study of executive board on June
culture, society, law, politics, religion, economics, medical ethics 11, 2018.
and other disciplines. Justice will need to be done to this cross-
disciplinary aspect when designing a curriculum, since the
inclusion of the social, economic, political and cultural Competing
determinants in global healthcare is a major goal of teaching
cultural competence and global health. Cultural competence and interests
global health thus combine to form a subject area that reflects in a The authors declare that
very special manner the overall mandate of higher education to they have no competing
foster comprehensive academic learning. interests.
5. Research in education: Concurrent research in education and
evaluationare a necessary accompaniment to the continued
development and optimization of this interdisciplinary topic Attachments
currently undergoing development and taking form in a plethora of
different courses and teaching approaches. Available from
http://www.egms.de/en/jo
urnals/zma/2018-
35/zma001174.shtml
6. Outlook 1. Attachment_1.pdf (94
High-quality healthcare as a goal calls for the systematic KB)
internationalization of undergraduate medical education. In addition Questions for
to offering specific courses on cultural competence and global health, (decentralized)
synergies would be created through the integration of cultural preparation of the
competence and global health content into the curricula of already Retreat (virtual
existing subject areas. platform, March
The NKLM [http://www.nklm.de] adopted in 2015 represents an 2014)
important basis for integrating cultural competence and global health
into existing curricula. As this is accomplished, it will be important to
consider universityspecific structures and individual national
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