Limitations of Trainings in Cross-Cultural Competence - The Practitioner Perspective.

INTRODUCTION: Objective: Trainings in cross-cultural competence1 are of increasing importance for psychotherapists in order to provide adequate mental health care for patients with a migration background. Yet, little is known about practitioners´ perspectives on working with migrants. Method: Problem-centered interviews with 30 practitioners offering psychotherapy within the German mental health care system have been analyzed using Grounded Theory Methodology to get an insight into practitioners´ experiences with cross-cultural work. Results: Practitioners have to deal with strong feelings of insecurity in their cross-cultural work. Feelings of insecurity were influenced by practitioners' underlying cultural concepts, how specific they perceived the cross-cultural contact to be and how they saw themselves in their professional role as psychotherapists. Interestingly, the analysis shows that trainings in cross-cultural competence which mainly convey "culture specific" knowledge on a rather theoretical level might even increase practitioners' feelings of insecurity. Conclusions: Conventional teaching formats in cross-cultural competence might not provide psychotherapists with sufficient space to reflect on their insecurities, their "cultural concepts", and their expectations of themselves in their professional role. Therefore, other settings are required. Dealing with practitioners' perceived lack of knowledge in the context of culture could be an effective starting point to deal with cross-cultural insecurities.

Comparing ChatGPT's ability to rate the degree of stereotypes and the consistency of stereotype attribution with those of medical students in New Zealand in developing a similarity rating test: a methodological study.

Learning about one's implicit bias is crucial for improving one's cultural competency and thereby reducing health inequity. To evaluate bias among medical students following a previously developed cultural training program targeting New Zealand Maori, we developed a text-based, self-evaluation tool called the Similarity Rating Test (SRT). The development process of the SRT was resource-intensive, limiting its generalizability and applicability. Here, we explored the potential of ChatGPT, an automated chatbot, to assist in the development process of the SRT by comparing ChatGPT's and students' evaluations of the SRT. Despite results showing non-significant equivalence and difference between ChatGPT's and students' ratings, ChatGPT's ratings were more consistent than students' ratings. The consistency rate was higher for non-stereotypical than for stereotypical statements, regardless of rater type. Further studies are warranted to validate ChatGPT's potential for assisting in SRT development for implementation in medical education and evaluation of ethnic stereotypes and related topics.

Study Preregistration: Does State-level Structural Racism Impact Risk for Suicidal Thoughts and Behaviors Among US Adolescents Across Race and Ethnicity?

In the United States, suicide deaths have disproportionately increased among Black and Hispanic youth over the past 2 decades.1 Despite the critical need for more culturally responsive suicide prevention strategies, there has been only sparse research into unique risk factors commonly experienced among ethnoracially minoritized youth, such as racism-related experiences. Experiences of racial and ethnic discrimination (ie, a behavioral manifestation of racism via unfair treatment predicated on an individual's racial and/or ethnic group affiliation) have been associated with higher rates of suicidal thoughts and behaviors (STBs) in Black and Hispanic adolescents.2,3 This research has largely focused on individual-level racism (ie, interpersonal exchanges) assessed via subjective self-report surveys. Thus, less is known about the impact of structural racism, which is enacted at the system level.

Understanding the resilience of children living on an American Indian reservation: A mixed methods participatory study.

AIM: To explore the resilience of children, six to thirteen years old, living on a Northern Plains American Indian Reservation using a situation specific nursing theory. BACKGROUND: American Indian and Alaska Native children experience mental health inequities compared to their white peers, including substance use, suicide, depression, and anxiety. Resilience is a strength of children that can be leveraged to improve their mental health. DESIGN: A parallel convergent mixed methods design. METHODS: A community advisory board culturally adapted resilience instruments. During two weeks in summer 2022, forty-seven children/caregiver dyads completed surveys about the child's resilience. Descriptive statistics gave the scores of each child's personal, relational, and total resilience. A subset of 20 children participated in a semi-structured interview. RESULTS: Children scored high on overall resilience, and higher on the relational subscale than the personal subscale. Caregiver survey scores were not significantly correlated with their child's scores and were higher than the children's scores. Qualitative coding revealed six themes of resilience. Integration of data showed a concordance and expansion of the quantitative data across themes. CONCLUSION: The children reported high resilience supported by a strong ecosystem of relationships. Resilience, as explained through children's voices, corroborated with findings from the surveys. IMPLICATIONS FOR NURSING: Findings will help nurses across sectors of primary, secondary, and tertiary care create resilience-enhancing interventions and prevent mental health crises in this community. IMPACT STATEMENT: This findings from this study will inform local mental health interventions on the Reservation. The study provides a reproducible design to adapt to other Indigenous communities. PUBLIC CONTRIBUTION: A community advisory board was a partner in every stage of the study. Children and caregivers participated in data collection. CONTRIBUTION TO THE WIDER CLINICAL COMMUNITY: This research provides knowledge that will further social justice efforts within nursing to promote health equity across diverse populations.

Interprofessional Simulation as an Educational Tool to Assess Cultural Competence Among Health Professions Students.

BACKGROUND: The concept of collaborative practice within health professions is viewed as "best practice." Poor collaboration can adversely affect patient safety. Interprofessional (IP) teamwork skills can be developed and nurtured through the health professionals' education; however, many barriers exist, which deter this from occurring. A lack of cultural diversity exposure within the healthcare setting can result in treatment disparities and place the patient at risk. One healthcare area that has gained considerable interest is the practitioners' understanding of multiculturalism and how cultural competence subsequently influences health disparities. OBJECTIVES: This study examined the application of culturally complex clinical simulation scenarios that intentionally integrated IP teamwork and hypothesized that participants' understanding of cultural competence would improve. METHODS: Participants were junior-level nursing, bachelor-level social work, graduate-level occupational therapy, and PharmD students (N = 180) who participated in an IP simulation exercise composed of culturally complex clinical scenarios performed by trained standardized patients designed to demonstrate underrepresented populations with diverse religious/spiritual, sexual orientation, racial/ethnic, socioeconomic, psychosocial, and geographic characteristics. Survey tools included an adapted Multicultural Awareness, Knowledge, and Skills Survey (MAKSS) and the Cultural Awareness Assessment Tool (CAAT). Descriptive statistical analyses were conducted to describe the sample population with the use of inferential statistics to analyze the MAKSS and CAAT scores using a statistical significance level of 0.05. Data were analyzed using SPSS v25 using paired t tests to compare pretest-posttest results. RESULTS: Results showed that there was a statistically significant increase in MAKSS and CAAT scores from presimulation to postsimulation. The findings also suggest that participation in this type of exercise may have increased self-assessment of cultural awareness and multicultural awareness, knowledge, and skills among health professions students. CONCLUSIONS: This study described the planning and execution of a large multiple scenario simulation event that involved 180 students spanning 5 healthcare disciplines. Findings demonstrated that the IP simulation event improved the students' self-assessment of multicultural awareness, knowledge, and skills as well as their own cultural awareness. The exploration of cultural competence and humility should be a priority for simulation-based learning.

The impact of historical loss on Native American college students' mental health: The protective role of ethnic identity.

Culturally relevant stressors and protective factors are vital to understanding and effectively supporting Native American/Alaska Native (NA/AN) college students' mental health and well-being. This study examined the theorized pathways among historical loss, well-being, psychological distress, and the proposed cultural buffer of ethnic identity in the indigenist stress-coping model (ISCM). Cross-sectional data were collected via online survey and analyzed using structural equation modeling. Participants were a national sample of 242 NA/AN college students. Participants were predominantly women (n = 185; 76%) and median age was 21 years. Partial support was found for the ISCM. Participants reported frequent thoughts of historical loss, which were associated with lower well-being and higher levels of psychological distress. Ethnic identity moderated the relationship between historical loss and well-being such that those with stronger ethnic identities reported a weaker relationship between historical loss and lower well-being. Results underscore the importance of culturally specific risk and protective factors in NA/AN college students' resiliency and inform needed interventions and systemic change in higher education. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

From Deficit to Strength-Based Aboriginal Health Research-Moving toward Flourishing.

Aboriginal Australians have a fundamental human right to opportunities that lead to healthy and flourishing lives. While the impact of trauma on Aboriginal Australians is well-documented, a pervasive deficit narrative that focuses on problems and pathology persists in research and policy discourse. This narrative risks further exacerbating Aboriginal disadvantage through a focus on 'fixing what is wrong' with Aboriginal Australians and the internalising of these narratives by Aboriginal Australians. While a growing body of research adopts strength-based models, limited research has sought to explore Aboriginal flourishing. This conceptual paper seeks to contribute to a burgeoning paradigm shift in Aboriginal research, seeking to understand what can be learned from Aboriginal people who flourish, how we best determine this, and in what contexts this can be impactful. Within, we argue the case for a new approach to exploring Aboriginal wellbeing that integrates salutogenic, positive psychology concepts with complex systems theory to understand and promote Aboriginal wellbeing and flourishing. While deeper work may be required to establish the parameters of a strength-based, culturally aligned Aboriginal conceptualisation of positive psychology, we suggest the integration of Aboriginal and Western methodologies offers a unique and potent means of shifting the dial on seemingly intractable problems.

Improving cultural competence of healthcare workers in First Nations communities: a narrative review of implemented educational interventions in 2015-20.

BACKGROUND: Cultural competency is often promoted as a strategy to address health inequities; however, there is little evidence linking cultural competency with improved patient outcomes. This article describes the characteristics of recent educational interventions designed to improve cultural competency in healthcare workers for First Nations peoples of Australia, New Zealand, Canada and the USA. METHODS: In total, 13 electronic databases and 14 websites for the period from January 2015 to May 2021 were searched. Information on the characteristics and methodological quality of included studies was extracted using standardised assessment tools. RESULTS: Thirteen published evaluations were identified; 10 for Australian Aboriginal and Torres Strait Islander peoples. The main positive outcomes reported were improvements in health professionals' attitudes and knowledge, and improved confidence in working with First Nations patients. The methodological quality of evaluations and the reporting of methodological criteria were moderate. CONCLUSIONS: Cultural competency education programs can improve knowledge, attitudes and confidence of healthcare workers to improve the health of First Nations peoples. Providing culturally safe health care should be routine practice, particularly in places where there are concentrations of First Nations peoples, yet there is relatively little research in this area. There remains limited evidence of the effectiveness of cultural education programs alone on community or patient outcomes.

A national survey of Swiss paediatric oncology care providers' cross-cultural competences.

BACKGROUND AND PURPOSE: Culturally diverse countries such as Switzerland face the challenge of providing cross-cultural competent care. Cross-cultural competent care needs an understanding of a patient's cultural context in order to provide safe and effective care. Therefore, we sought to examine cross-cultural competence of Swiss paediatric oncology care providers, and to explore their perceptions of barriers to and facilitators of cross-culturally competent care. DESIGN AND SAMPLE: We conducted a cross-sectional study. The data collection period was three weeks. Providers were recruited through collaborators at the participating paediatric oncology centres. All occupational groups who are in direct contact with patients and involved in their care were eligible (e.g., physicians, nurses, social workers, occupational therapists and physiotherapists). Surveying providers online, we captured five subscales of their cross-cultural competence and their perceptions as to how to facilitate cross-culturally competent paediatric oncology care. We employed the Cross-Cultural Competence of Healthcare Professionals (CCCHP) questionnaire. Besides descriptive and inferential statistics, we performed content analysis. FINDINGS: The response rate was 73.2% (n = 183/250). Analyses revealed differences in cross-cultural competence between occupational groups of paediatric oncology providers. Overall, social workers' cross-cultural competence was higher than nurses' or occupational therapists' and physiotherapists' cross-cultural competence. Physicians' cross-cultural competence was higher than nurses (with no statistically significant difference identified between physicians, occupational therapists and physiotherapists). Furthermore, our results suggest noteworthy differences among the four main occupational groups on the five CCCHP subscales. Physicians and social workers declared more positive attitudes than nurses; occupational therapists and physiotherapists reported lower skills than the other three groups; social workers scored higher on the emotions and empathy subscale than the other three groups; physicians were more knowledgeable and aware than nurses. Most frequently mentioned barriers were: language barriers (68.5%), different culture and values (19.2%), different illness understanding (9.2%). Most frequently mentioned facilitators were: professional translators (47.2%), continuous training (20.8%), professional cultural mediators (8.8%). CONCLUSIONS/IMPLICATIONS: Trainings and interventions are widely considered a principal strategy to advance providers' cross-cultural competence. Our findings of differences in cross-cultural competence among occupational groups further underpin the need to adapt training programmes and interventions to the respective occupational group and the respective dimension(s) of cross-cultural competence. In addition, professional translators and cultural mediators should be used. Lastly, reciprocal supervision and the promotion of multidisciplinary teams is crucial to enable oncology care providers to learn from each other and this exchange could also help to reduce some of the differences between the various occupational groups.

White and non-White Australian mental health care practitioners' desirable responding, cultural competence, and racial/ethnic attitudes.

BACKGROUND: Racial, ethnic, religious, and cultural diversity in Australia is rapidly increasing. Although Indigenous Australians account for only approximately 3.5% of the country's population, over 50% of Australians were born overseas or have at least one migrant parent. Migration accounts for over 60% of Australia's population growth, with migration from Asia, Sub-Saharan African and the Americas increasing by 500% in the last decade. Little is known about Australian mental health care practitioners' attitudes toward this diversity and their level of cultural competence. AIM: Given the relationship between practitioner cultural competence and the mental health outcomes of non-White clients, this study aimed to identify factors that influence non-White and White practitioners' cultural competence. METHODS: An online questionnaire was completed by 139 Australian mental health practitioners. The measures included: the Balanced Inventory of Desirable Responding (BIDR); the Multicultural Counselling Inventory (MCI); and the Color-blind Racial Attitudes Scale (CoBRAS). Descriptive statistics were used to summarise participants' demographic characteristics. One-way ANOVA and Kruskal-Wallis tests were conducted to identify between-group differences (non-White compared to White practitioners) in cultural competence and racial and ethnic blindness. Correlation analyses were conducted to determine the association between participants' gender or age and cultural competence. Hierarchical multiple regression analysis was conducted to predict cultural competence. RESULTS: The study demonstrates that non-White mental health practitioners are more culturally aware and have better multicultural counselling relationships with non-White people than their White counterparts. Higher MCI total scores (measuring cultural competence) were associated with older age, greater attendance of cultural competence-related trainings and increased awareness of general and pervasive racial and/or ethnic discrimination. Practitioners with higher MCI total scores were also likely to think more highly of themselves (e.g., have higher self-deceptive positive enhancement scores on the BIDR) than those with lower MCI total scores. CONCLUSION: The findings highlight that the current one-size-fits-all and skills-development approach to cultural competence training ignores the significant role that practitioner diversity and differences play. The recommendations from this study can inform clinical educators and supervisors about the importance of continuing professional development relevant to practitioners' age, racial/ethnic background and practitioner engagement with prior cultural competence training.

Culturally Sensitive Interventions in Pediatric Primary Care Settings: A Systematic Review.

CONTEXT: Culturally sensitive interventions in the pediatric primary care setting may help reduce health disparities. Less is known on the development of these interventions, their target groups, and their feasibility, acceptability, and impact on health outcomes. OBJECTIVE: We conducted a systematic review to describe culturally sensitive interventions developed for the pediatric primary care setting. DATA SOURCES: PubMed, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo (January 2000 to July 2020). STUDY SELECTION: Studies were eligible for inclusion if they were (1) original research on an intervention with an evaluation, (2) within a pediatric primary care setting, (3) not limited to education for providers, (4) not limited to interpreter use, and (5) based in the United States. DATA EXTRACTION: The following were extracted: study topic, study design, intervention, cultural sensitivity strategies and terminology, setting, target group, sample size, feasibility, acceptability, and health outcomes. RESULTS: Twenty-five studies described 23 interventions targeting a variety of health topics. Multiple cultural sensitivity strategies were used, most commonly sociocultural (83%). Most interventions (57%) were focused on Hispanic/Latino families. Interventions were generally reported as being feasible and acceptable; some also changed health outcomes. LIMITATIONS: Small samples and heterogenous methods subject to bias were used. Relevant articles may have been missed because of the variety of terms used to describe cultural sensitivity. CONCLUSIONS: The included articles provide preliminary evidence that culturally sensitive interventions can be feasible and effective and may help eliminate disparities for patients from communities with barriers to equitable care.

Factors Influencing Transcultural Self-Efficacy Among Nurses With Foreign Patient Care Experience.

INTRODUCTION: As the cultural diversity among patients increases, it becomes important for nurses to be prepared and efficient in providing culturally congruent care. The purpose of this study is to examine the factors influencing transcultural self-efficacy (TSE) among Korean nurses. METHODOLOGY: A descriptive cross-sectional survey was used, and 131 nurses with foreign patient-care experience were recruited from a university tertiary hospital. RESULTS: The mean TSE score of participants was 5.27 out of 10 (SD = 1.50). The practical subscale of TSE was the lowest, while the affective subscale was the highest. A regression analysis revealed that education level, cultural competence, and intergroup anxiety are predictors explaining 58.8% of its variance (F = 27.5, p < .001). DISCUSSION: A low level of TSE causes avoidant behavior and ineffective communication in foreign patient care, resulting in unsatisfactory clinical performance. Effective education programs and administration guidelines may be critical for nurses to improve their TSE.

Nursing students' experience of learning cultural competence.

INTRODUCTION: European societies are rapidly becoming multicultural. Cultural diversity presents new challenges and opportunities to communities that receive immigrants and migrants, and highlights the need for culturally safe healthcare. Universities share a responsibility to build a fair and equitable society by integrating cultural content in the nursing curricula. This paper aims to analyze European student nurses´ experience of learning cultural competence and of working with patients from diverse cultural backgrounds. MATERIALS AND METHODS: A phenomenological approach was selected through a qualitative research method. 7 semi-structured focus groups with 5-7 students took place at the participants' respective universities in Spain, Belgium, Turkey and Portugal. RESULTS: 5 themes and 16 subthemes emerged from thematic analysis. Theme 1, concept of culture/cultural diversity, describes the participants' concept of culture; ethnocentricity emerged as a frequent element in the students' discourse. Theme 2, personal awareness, integrates the students' self-perception of cultural competence and their learning needs. Theme 3, impact of culture, delves on the participants' perceived impact of cultural on both nursing care and patient outcomes. Theme 4, learning cultural competence, integrates the participants' learning experiences as part of their nursing curricula, as part of other academic learning opportunities and as part of extra-academic activities. Theme 5, learning cultural competence during practice placements, addresses some important issues including witnessing unequal care, racism, prejudice and conflict, communication and language barriers, tools and resources and positive attitudes and behaviors witnesses or displayed during clinical practice. CONCLUSION: The participants' perceived level of cultural competence was variable. All the participants agreed that transcultural nursing content should be integrated in the nursing curricula, and suggested different strategies to improve their knowledge, skills and attitudes. It is important to listen to the students and take their opinion into account when designing cultural teaching and learning activities.

A 4-Part Strategy to Engage Frontline Nurses in Cultural Humility.

Although many clinical leaders use the cultural competency model to help clinicians deliver equitable care, evidence on the model's effectiveness is mixed. In this article, the authors propose that nursing leaders adopt cultural humility as a framework that better positions nurses to build trust, engage patients in their care, and improve health outcomes. This article outlines 4 strategies that leaders can use to actively engage staff in cultural humility and support the cultural transformation required to mitigate the impact of clinician bias in care delivery.

Racial and ethnic differences in perception of provider cultural competence among patients with depression and anxiety symptoms: a retrospective, population-based, cross-sectional analysis.

BACKGROUND: Racial and ethnic minorities face disparities in access to health care. Culturally competent care might lessen these disparities. Few studies have studied the patients' view of providers' cultural competence, especially in psychiatric care. We aimed to examine the associations of race, ethnicity, and mental health status with patient-reported importance of provider cultural competence. METHODS: Our retrospective, population-based, cross-sectional study used data extracted from self-reported questionnaires of adults aged at least 18 years who participated in the US National Health Interview Survey (NHIS; 2017 cycle). We included data on all respondents who answered supplementary cultural competence questions and the Adult Functioning and Disability survey within the NHIS. We classified participants as having anxiety or depression if they reported symptoms at least once a week or more often, and responded that the last time they had symptoms the intensity was "somewhere between a little and a lot" or "a lot." Participant answers to cultural competency survey questions (participant desire for providers to understand or share their culture, and frequency of access to providers who share their culture) were the outcome variables. Multivariable ordinal logistic regressions were used to estimate adjusted odds ratios (aORs) for the outcome variables in relation to sociodemographic characteristics (including race and ethnicity), self-reported health status, and presence of symptoms of depression, anxiety, or both. FINDINGS: 3910 people had available data for analysis. Mean age was 52 years (IQR 36-64). 1422 (39·2%, sample weight adjusted) of the participants were men and 2488 (60·9%) were women. 3290 (82·7%) were White, 346 (9·1%) were Black or African American, 31 (0·8%) were American Indian or Alaskan Native, 144 (4·8%) were Asian American, and 99 (2·6%) were Mixed Race. 380 (12·5%) identified as Hispanic ethnicity and 3530 (87·5%) as non-Hispanic. Groups who were more likely to express a desire for their providers to share or understand their culture included participants who had depression symptoms (vs those without depression or anxiety symptoms, aOR 1·57 [95% CI 1·13-2·19], p=0·008) and participants who were of a racial minority group (Black vs White, aOR 2·54 [1·86-3·48], p=0·008; Asian American vs White, aOR 2·57 [1·66-3·99], p<0·001; and Mixed Race vs White, aOR 1·69 [1·01-2·82], p=0·045) or ethnic minority group (Hispanic vs non-Hispanic, aOR 2·69 [2·02-3·60], p<0·001); these groups were less likely to report frequently being able to see providers who shared their culture (patients with depression symptoms vs those without depression or anxiety symptoms, aOR 0·63 (0·41-0·96); p=0·030; Black vs White, aOR 0·56 [0·38-0·84], p=0·005; Asian American vs White, aOR 0·38 [0·20-0·72], p=0·003; Mixed Race vs White, aOR 0·35 [0·19-0·64], p=0·001; Hispanic vs non-Hispanic, aOR 0·61 [0·42-0·89], p=0·010). On subgroup analysis of participants reporting depression symptoms, patients who identified their race as Black or African American, or American Indian or Alaskan Native, and those who identified as Hispanic ethnicity, were more likely to report a desire for provider cultural competence. INTERPRETATION: Racial and ethnic disparities exist in how patients perceive their providers' cultural competence, and disparities are pronounced in patients with depression. Developing a culturally competent and humble approach to care is crucial for mental health providers. FUNDING: None.

Gestational diabetes mellitus: a qualitative study of lived experiences of South Asian immigrant women and perspectives of their health care providers in Melbourne, Australia.

BACKGROUND: South Asian women are at a high risk of developing gestational diabetes mellitus than other women in Australia. Gestational diabetes affects up to 14-19% of all pregnancies among South Asian, South East Asian, and Arabic populations placing women at risk of adverse pregnancy outcomes. Although, gestational diabetes resolves after childbirth, women with gestational diabetes are up to seven times more likely to develop type 2 diabetes within five to ten years of the index pregnancy. Increasingly, South Asian women are being diagnosed with gestational diabetes in Australia. Therefore, we aimed to gain a better understanding of the lived experiences of South Asian women and their experiences of self-management and their health care providers' perspectives of treatment strategies. METHODS: Using an ethnographic qualitative research methodology, semi-structured one-on-one, face-to-face interviews were conducted with 21 health care providers involved in gestational diabetes management and treatment from the three largest tertiary level maternity hospitals in Melbourne, Victoria, Australia. In-depth interviews were conducted with 23 South Asian women post diagnosis between 24-28 weeks gestation in pregnancy. RESULTS: Health care providers had challenges in providing care to South Asian women. The main challenge was to get women to self-manage their blood glucose levels with lifestyle modification. Whilst, women felt self-management information provided were inadequate and inappropriate to their needs. Women felt 'losing control over their pregnancy', because of being preoccupied with diet and exercise to control their blood glucose level. CONCLUSIONS: The gestational diabetes clinical practice at the study hospitals were unable to meet consumer expectations. Health care providers need to be familiar of diverse patient cultures, rather than applying the current 'one size fits all' approach that failed to engage and meet the needs of immigrant and ethnic women. Future enabling strategies should aim to co-design and develop low Glycaemic Index diet plans of staple South Asian foods and lifestyle modification messages.

Why don't illiterate women in rural, Northern Tanzania, access maternal healthcare?

BACKGROUND: In 2017, roughly 540 women in Sub-Saharan Africa died every day from preventable causes related to pregnancy and childbirth. To stem this public-health crisis, the WHO recommends a standard continuity of maternal healthcare, yet most women do not receive this care. Surveys suggest that illiteracy limits the uptake of the recommended care, yet little is understood about why this is so. This gap in understanding why healthcare is not sought by illiterate women compromises the ability of public health experts and healthcare providers to provide culturally relevant policy and practice. This study consequently explores the lived experiences related to care-seeking by illiterate women of reproductive age in rural Tanzania to determine why they may not access maternal healthcare services. METHODS: An exploratory, qualitative study was conducted in four communities encompassing eight focus group discussions with 81 illiterate women, 13 in-depth interviews with illiterate women and seven key-informant interviews with members of these communities who have first-hand experience with the decisions made by women concerning maternal care. Interviews were conducted in the informant's native language. The interviews were coded, then triangulated. RESULTS: Two themes emerged from the analysis: 1) a communication gap arising from a) the women's inability to read public-health documents provided by health facilities, and b) healthcare providers speaking a language, Swahili, that these women do not understand, and 2) a dependency by these women on family and neighbors to negotiate these barriers. Notably, these women understood of the potential benefits of maternal healthcare. CONCLUSIONS: These women knew they should receive maternal healthcare but could neither read the public-health messaging provided by the clinics nor understand the language of the healthcare providers. More health needs of this group could be met by developing a protocol for healthcare providers to determine who is illiterate, providing translation services for those unable to speak Swahili, and graphic public health messaging that does not require literacy. A failure to address the needs of this at-risk group will likely mean that they will continue to experience barriers to obtaining maternal care with detrimental health outcomes for both mothers and newborns.

Using social network tools to facilitate cultural adjustment of self-initiated Malaysian female expatriate nurses in Saudi Arabia.

BACKGROUND: This research study aims to:(1) identify and explore the social network communication tools used to facilitate the adjustment process of Malaysian female expatriate nurses working in the Kingdom of Saudi Arabia (hereafter "the Kingdom" or "SA") who are accompanied by neither their spouses nor families and (2) determine how these tools facilitate their adjustment to their new environment. Emphasis is placed on this particular group of respondents primarily due to the dearth of research conducted on female expatriate nurses. METHOD: We conducted a preliminary study using semi-structured interviews with sixteen (16) Malaysian female expatriate nurses working in SA to obtain a broader understanding of their experiences with cross-cultural adaptation and their use of social media tools to connect with their families and friends in their home country. RESULTS: This study uncovers numerous social media communication tools being used by female expatriate nurses to help curb their loneliness and lessen the culture shock of living and working in a foreign country. Continuous engagement with these tools helps Malaysian female expatriate nurses maintain their emotional stability, thereby enabling them to remain mentally strong and ultimately prolonging their stay in SA. CONCLUSIONS: This study's outcomes contribute significantly to the knowledge of the government, various organizations, and aspiring female expatriate nurses in the healthcare industry because the results can assist female expatriate nurses during the adjustment period, enabling them to work efficiently and successfully in the host country.

Improving Healthcare Access by Teaching Intercultural Communication.

Nonnative English speakers may hesitate or avoid accessing healthcare in the United States due to cultural and communication barriers. Role-play is effective as a method of reducing healthcare access due to inadequate communication skills. A role-play activity used with female Muslim immigrants to the United States enabled participants to develop communication skills and gain confidence for future interactions with a healthcare provider.