In an increasingly diverse world diversity education in health has gradually gained importance, principally because ethnic minority patients continue to face disparities in health care access and treatment [1–7]. The European Union is increasingly characterized by superdiversity or “diversity within diversity” [8]. As a prime example, Belgium already has a long history of migration that is mainly characterised by migrant workers from Italy, Poland, Turkey, and Morocco [9]. However, due to several international events including the refugee crisis in 2015, Belgium received an additional large influx of refugees from across the world. The Commissioner General for Refugees and Stateless Persons reported that in 2020, 27,742 persons applied for international protection in 2019, which is an increase of 18% compared to 2018, and an increase of 41% compared to 2017 [10]. In order to effectively meet the needs of superdiverse societies, scholarship calls for more research on evidence-based practices regarding diversity education in health care [11,12].
The present study explores psychosocial mechanisms of diversity sensitive health care within a Belgian health care student population. Although psychosocial mechanisms such as the relationship between attitudes and behavioural intentions is widely acknowledged [13,14], distinctions in relationships between ethnocentric attitudes, intercultural capabilities, and diversity sensitive task perceptions and behavioural intentions has been less explored, and particularly, within the health care context. More precisely, this paper focusses on two aspects of diversity sensitive care: diversity sensitive task perception, and diversity sensitive behavioural intentions; and explores which psychosocial mechanisms (i.e. ethnocentric attitudes, intercultural capabilities) influence these aspects of diversity sensitive care.
Diversity sensitivity in health care
Diversity sensitivity is an adjusted and high-quality manner of providing care that is responsive to the needs, competencies, and expectations of individuals with ethnic diverse backgrounds [16,17]. Two often used operationalisations of diversity sensitive decision-making are task perception and behavioural intentions [18,19].
Diversity sensitive task perception
Physicians who take up a diversity sensitive task perception follow a socially just and diversity responsive approach within their medical profession [16,20]. According to Paasch-Orlow [21] taking up a diversity sensitive task perception means that providing care should reach beyond a narrow biomedical perspective. Such task perception includes; (a) considering a patient’s personal preferences when making medical decisions; (b) taking up a pluralistic viewpoint that is tolerant towards a range of different views and refrain from assuming that their patients share their own perspectives; (c) being conscious about disparities in health outcomes and feeling responsible to take actions to overcome health differences due to cultural differences. Studies have highlighted that although the International Code of Ethics promotes equal care to all patients [22], when push comes to shove many physicians seem to prioritise medical principles over diversity sensitive care and principles [21,23,24].
Diversity sensitive behavioural intentions
Diversity sensitive behavioural intentions are tendencies in which respondents are more or less likely to act in diversity responsive ways during various healthcare-related situations [25]. Diversity sensitive behavioural intentions of physicians directly relate to responsive medical decision-making and interpersonal communication in the consultation room [25]. Studies indicate that behavioural intentions are strong predictors of human behaviour [13,14,18,19].
Psychosocial mechanisms
This study explores which psychosocial mechanisms (i.e. ethnocentric attitudes, intercultural capabilities) influence which aspects of diversity sensitivity (i.e. task perception, behavioural intentions).
(Ethnocentric) attitudes
Attitudes are the most common indicators of someone’s judgments and intentions [18,19]. Sarto et al. [26] and van Ryn [27] pioneered the relationship between health care professional’s attitudes towards EM-patients, their behavioural intentions, and their consultation behaviours. More precisely, both authors argue that health providers’ attitudes and beliefs about EM-patients influence their medical decision-making (e.g., diagnosis, treatment, referral, case disposition) and interpersonal communication (e.g., participatory communication style, warmth, information-giving, question-asking). These findings are substantiated by other studies. For instance, it has been shown that Caucasian physicians reported greater clinical uncertainty in diagnosing depression amongst Afro-American compared with Caucasian patients [28]. Other studies have identified the negative effect of physicians’ attitudes towards EM on patient-centred communication; they are more likely to dominate the conversation in intercultural consultations, and reported difficulties with interpreting emotional cues of EM-patients [16,29–31]. While research has already shown these behavioural differences, it is now important to open up the black box as to why physicians act this way. Only when we are aware of the underlying mechanisms, can we find ways to combat these ethnic differences in communication and treatment. van Ryn and Fu [23] claim that physicians’ attitudes towards EM-patients influence whether they are more or less likely to take up a diversity sensitive task perception, which results in flawed medical decision-making. Nevertheless, there is a lack of empirical evidence that identifies this judgemental process of taking up a diversity sensitive task perception as a mediator between attitudes and medical decision-making. Hence, it is of great importance to further elaborate on the effect of negative attitudes towards EM-patients on diversity sensitive task perception and behavioural intentions. A particular operationalization of negative attitudes towards EM is ethnocentrism [32]. Ethnocentrism can be described as a worldview in which an individual has a strong belief in the inherent superiority of one’s own ethnic group or culture [32,33]. Ethnocentrism relates to social categorisation, which contributes to the formation of prejudices, in- and-outgroup thinking and diminished levels of general trust in society [32,34,35]. While ethnocentrism is an important concept for understanding the effect of negative attitudes towards EM on diversity sensitivity, it has never been explored in a health care (student) population.
Intercultural capabilities
Understanding the effect of attitudes on diversity sensitivity insufficient to explain all variances in diversity sensitive behaviours [14,36–38]. According to Dovidio and colleagues [36], automatically activated attitudes and biases result in discriminatory actions when persons lack the motivation or cognitive resources to monitor and control their actions. Such motivational and cognitive processes have also been defined as Intercultural Capabilities (IC), which is a person’s perception of his/her capability to function effectively, especially in situations where sensitivity to diversity is important [38–41]. IC are often operationalized as intercultural intelligence [38,39]. IC comprise four dimensions to function effectively in intercultural settings: cognition, metacognition, motivation, and behaviour, which will be discussed in more detail below [38–41].
Cognitive intercultural capabilities. The cognitive dimension refers to the knowledge persons have about diversity, cultural institutions (e.g., norms, practices and conventions) and inequalities [38,40]. Such knowledge and understanding is essential for making valid judgments in culturally diverse settings [38]. The literature review found theoretical and empirical underpinnings for this relationship between intercultural knowledge and diversity sensitivity in the health care context [25,42,43]. However, certain studies indicate that cognition not necessarily has a significant effect on intercultural efficacy because there is a gap between knowledge generation and the practical implementation [44,45]. Hence, further studies are required.
Metacognitive intercultural capabilities. The metacognitive dimension considers to which extent people are conscious of their intercultural experiences, and can critically reflect upon the processes they use to acquire and understand intercultural knowledge [38,40]. Individuals with high metacognitive capabilities are more aware of the impact of their own cultural beliefs and behaviours and are more critical about their interpretation of intercultural situations [38,46]. This provides theoretical evidence for assuming that medical professionals who are more critically conscious are also more likely to take up a diversity sensitive task perception because they feel morally responsible to adjust their behaviour in a diversity sensitive way [15]. However, we found no empirical evidence on this relationship within a health care context.
Motivational intercultural capabilities. The motivational dimension refers to people’s interest and confidence to interact in intercultural environments [38,40]. To take up diversity sensitive task perceptions and behavioural intentions, a person should feel motivated and agentic, which means that he/she has a sense of control that might facilitate goal achievement (Van Dyne et al., 2012: 303)[38]. Interestingly, Fazio [47] has identified motivation as an important mediator between attitudes and behaviours. He also found that when persons are motivated, they are more likely to start a deliberative process before acting. This deliberative process involves contemplating about one’s personal attitudes, prejudices, and frame of reference. When motivation is lacking, behaviours are more likely to stem directly from automatic evaluations which can be flawed by ethnic biases [47]. Hence, motivation seems an important aspect for diversity sensitivity, also with regard to physician-patient communication an medical decision-making. A few studies have related self-efficacy or the confidence in acting in intercultural situations to concepts of diversity sensitivity in the health care context [42,48,49]. However, the relationship between motivation and diversity sensitivity in the health care context, remains understudied.
Behavioural intercultural capabilities. The behavioural dimension consists of a person’s perceived behavioural ability to verbally and non-verbally adjust to intercultural situations [38,40]. This behavioural ability draws on a flexible repertory of internalised behavioural responses suited to a variety of situations, as well as the ability to modify one’s behaviour according to the characteristics of a specific interaction or a particular context [39,40]. Van Dyne et al. [38] claim that individuals with high behavioural IC have a high sense of commitment to adjust their communication and behavioural manners to intercultural situations. This study investigates what weight a person’s repertory of internalised behavioural responses has on diversity sensitivity in the health care context. To date, training programmes in diversity sensitivity in health care have been focussing on behavioural outcomes (skills) [45,50]. The mediation-effect of cognitive behavioural intercultural capabilities on diversity sensitivity in the health care context remains understudied. Insights in this mechanism may contribute to a deeper understanding of (un)succesfull intercultural skills-development [38].
Hypotheses
Based on our literature findings we suggest that ethnocentric attitudes are negatively associated with health care students’ diversity sensitive task perceptions and behavioural intentions. We also suggest that intercultural capabilities are positively associated with health care students’ diversity sensitive task perceptions and behavioural intentions. Lastly, we suggest that diversity sensitive task perception and behavioural intentions are interrelated, because they are both operationalizations of diversity sensitive decision-making [18,19]. These hypotheses are shown in figure 1.