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Teaching intercultural awarenessto first‐year medical students viaexperiential exercisesKeith R. Aronson , Rhonda Venable , Nicholas Sieveking & BonnieMillera The Pennsylvania State University, USAPublished online: 07 Oct 2010.

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Intercultural Education,Vol. 16, No. 1, March 2005, pp. 15–24

ISSN 1467-5986 (print)/ISSN 1469-8439 (online)/05/010015–10© 2005 Taylor & Francis Group LtdDOI: 10.1080/14636310500061649

Teaching intercultural awareness to first-year medical students via experiential exercises

Keith R. Aronson*, Rhonda Venable, Nicholas Sieveking and Bonnie MillerThe Pennsylvania State University, USATaylor and Francis LtdCEJI106147.sgm10.1080/14636310500061649Intercultural Education1467-5986 (print)/1469-8439 (online)Original Article2005Taylor & Francis Ltd161000000March 2005Ph.D KeithAronsonkra105@psu.edu

This study assessed the extent to which a one-time experiential intervention improved interculturalawareness and sensitivity among first-year medical students. The students participated in groupactivities in which they shared personal experiences, solved a hypothetical problem, and engaged inteam building exercises. Post-intervention, students reported less intercultural awareness, but agreater commitment to improving the intercultural climate of the medical school and an increasedwillingness to work in diverse groups during their medical training. The results of the study suggestthat experiential interventions may provide an important complement to didactics around issues ofintercultural awareness and sensitivity with medical students. Importantly, experiential interven-tions must provide students with sufficient time to reflect upon and discuss feelings, thoughts andattitudes that emerge during this kind of intercultural awareness training.

Introduction

Two relatively new trends have emerged, one in education and one in medicine, whichcould have an important impact on the extent to which, and the manner in which,student attitudes and skills related to intercultural sensitivity are developed. Institutesof higher education are increasingly committed to using innovative pedagogicalapproaches to improve student civility, increase student participation in their commu-nities (broadly defined), and increase student appreciation and respect for diversity(Novek, 2000; Ramaley, 2000; Flanagan & Faison, 2001; Flanagan et al., in press).The field of medicine has become increasingly aware of the importance of interculturalfactors in health, health behavior and healthcare. For example, the American Medical

*Corresponding author. Social Sciences Research Institute, The Pennsylvania State University,105 Health and Human Development East Building, University Park, PA 16801, USA. Email:kra105@psu.edu

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16 K. R. Aronson et al.

Association (AMA) has recently passed a number of resolutions and policies callingfor increased intercultural awareness, sensitivity and tolerance among physicians(AMA, 1998). The AMA has strongly recommended that medical schools offereducational programs promoting knowledge and tolerance of cultural diversity in anattempt to serve patients from various cultural backgrounds better.

A review of the existing literature suggests that few medical schools are providingintercultural education opportunities for their students. The few medical schoolsaddressing intercultural awareness training are typically providing only didacticswithin the classroom (Kai et al., 1999). There are few, if any, medical schools thatreport using experiential training outside the classroom to promote interculturalawareness. This is a problematic state of affairs, because there is substantive litera-ture to suggest that learning is an active process, best done when students are givenopportunities for involvement, reflection, and in vivo experience (Boyer, 1990a, b;Eyler & Giles, 1999; Giddings, 2003). In this paper, we report on an experientialintervention using in vivo, active, involved and reflective components designed topromote intercultural awareness among first-year medical students.

What is intercultural awareness and why teach it?

Intercultural awareness (also called intercultural competence) has been defined as anintegration of knowledge, attitudes and skills that enhances cross-cultural communi-cation and appropriate and effective interactions with others (Smith, 1998). Intercul-tural awareness includes: (1) knowledge of the effects of culture on the beliefs andbehaviors of others; (2) awareness of one’s own cultural attributes and biases and theirimpact on others; and (3) understanding the impact of sociopolitical, environmentaland economic context of others. In a medical setting, intercultural awareness requiresthe knowledge and interpersonal skills that allow health care providers to understand,appreciate and work with individuals from cultures other than their own. Interculturalawareness involves an awareness and acceptance of cultural differences, a degree ofself-awareness, knowledge of the patient’s culture and the adaptation of skills.

There are a number of cogent reasons for teaching intercultural awareness to medi-cal students (see Bussey-Jones et al., 2003, for a recent review). The minoritypopulation of the US is growing at a rapid rate, with the greatest growth occurring inthe Hispanic and Asian populations (Brewer & Suchan, 2001). A number of culture-specific health beliefs and behaviors have been identified, and these must be under-stood if treatment of culturally diverse populations is to be effective (Harwood, 1981).Compared with the majority population of European-Americans, ethnic, racial, andcultural minority individuals experience higher rates of morbidity and mortality(Gabel & Weddington, 1993; Bahl, 1996; Feldman & Fullwood, 1999; Williams,1999) and poorer access to health care resources (Jarosik et al., 2003). Furthermore,culture influences the manner in which individuals experience and report somatic andpsychological symptoms (Kirmayer et al., 1995; Kirmayer & Young, 1998; Kirmayer& Minas, 2000). Ethnic minority patients also report higher levels of distrust inphysicians from cultures different from their own, and these feelings of distrust may

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Teaching intercultural awareness 17

be reduced if physicians were sensitive to intercultural differences (Baker & Daigle,2000). Not surprisingly, increased awareness of culture results in more effective andappropriate patient–physician contacts (Lieberman et al., 1997; Misra-Hebert, 2003).

It is clear that healthcare personnel must take into account issues related to diversity,marginalization and vulnerability due to culture, race, gender, age and sexual orien-tation if healthcare outcomes are to be maximized (AMA, 1998; Zweifer & Gonzalez,1998; Cooper-Patrick et al., 1999; Schneider & Levin, 1999). Therefore, it is incum-bent upon medical schools to teach intercultural awareness to physicians in training.

How to teach intercultural awareness?

While there is convergence of opinion as to the need to teach intercultural awareness,there is no such agreement about the means to teach it. Because the AMA’s initia-tives on teaching cultural competence are so recent, it remains unclear as to the bestmanner in which to teach cultural awareness to medical students. It is clear,however, from educational and cognitive psychology (as well as other related fields)that individuals learn most effectively when taught concepts through multiplemodalities and channels of learning (e.g. reading, visualizing, discussing, simulating)(Tonra, 1974; Kobus et al., 1994; Sternberg et al., 1998; Jewitt et al., 2000; 2001;Gellevij et al., 2002). For example, effective structured approaches to changing prej-udicial attitudes have used multi-modal interventions with some success (Brislin,1978). Giving students time to reflect on what they are learning, exposure to ‘reallife’ learning, and providing them with engaging learning situations also appears tocontribute to students ‘getting it’ (Billig, 2000), and this may be particularly impor-tant when dealing with sensitive topics such as intercultural awareness and sensitiv-ity (Paige, 1986; Tatum, 1994; Brown et al., 1996; Richard, 1996).

We undertook an experiential intervention with first-year medical students,designed as an introduction to cultural awareness. We took students out of the class-room and spent one day engaging them in several small group activities in whichthey shared personal experiences, worked together to solve a hypothetical problem,and participated in team building exercises that were physical in nature. Wepredicted that students would: (1) demonstrate improved intercultural awarenesspost-intervention, (2) be more willing to act as cultural change agents to improve thediversity climate at the medical school, and (3) become more willing to work insmall groups with diverse members.

Methods

Participants

Participants were first-year medical students (N=85) at an urban medical schoollocated in the southern part of the US. Nearly half the sample was male (48%), 28%were female, and 14% did not respond to this demographic question. The studentsranged in age from 21 to 34 years, with an average age of 23.5 years. The sample was

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18 K. R. Aronson et al.

46% European-American, 22% Asian, 4% Hispanic, 2% African-American, and26% of the respondents did not answer this demographic question. Sixty per cent ofthe sample were born in the US, 17% outside the US, and 23% did not respond tothis demographic question. This study was conducted in accordance with the ethicalstandards of the responsible committee on human experimentation at VanderbiltUniversity.

Procedures

Participants were required to attend a day-long retreat on health and wellness inmedical school within one month of the students’ first semester. This is important tonote, because we were not able to assess the impact of the retreat on any academicoutcomes. This study reports on attitudinal outcomes only. The retreat was held at ascenic park approximately one hour from the medical school. The day began withregistration, where each participant was given his or her small group team assign-ment and an individual schedule for the day. Participants then ate breakfast,completed pre-intervention measures, and were given an overview of how the retreatwould proceed for the rest of the day. The participants then engaged in severaldiverse activities (described below). The activities were interspersed with lunch andsnacks. After the last activity, the students were re-assembled for a brief wrap-up.Participants completed post-intervention questionnaires, a program evaluation formincluding both quantitative and qualitative information, and were then dismissed.

Measures

Multicultural counseling inventoryThe MCI (Sodowsky et al., 1994) was originally designed to measure how culturallycompetent counselors (e.g. psychologists, social workers) work with diverse clients.We re-worded and shortened the MCI to make it relevant to medical students. Ourrevised version of the MCI demonstrated adequate internal consistency (α=0.63pre-intervention, α=0.72 post-intervention). A factor analysis of our version of theMCI revealed eight factors related to multicultural awareness (i.e. cultural knowl-edge, self–other understanding, social comfort/discomfort, communication skills,recognizing differences, freedom from bias, intercultural understanding and culturaldefensiveness).

Cultural change agent questionnaireThe Cultural Change Agent Questionnaire (Berry & Aronson, 2001) asks respon-dents to indicate how willing they are to engage in various behaviors that reducecultural bias and improve multicultural sensitivity. The measure was internallyconsistent (α=0.75 pre-intervention, α=0.86 post-intervention). Factor analysisrevealed seven factors (i.e. willingness to learn about other cultures, refusal to usehostile language, taking social and political action, interpersonal sharing, challengingcultural insensitivity, cultural sensitivity and recognition of personal biases).

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Teaching intercultural awareness 19

Working in small groupsWe asked participants to rate the extent to which they agreed or disagreed withseveral statements about working in small groups (i.e. comfort level in working insmall groups, efficacy of their involvement in small groups, degree to which smallgroups work well).

Experiential exercisesOur first experiential exercise was considered an ‘icebreaker’. We asked people towrite on a piece of paper something about themselves that no one would guess aboutthem. We have used this exercise extensively in many cultural competence outreachprograms. The exercise allows students to see, in an entertaining and safe way, thattheir conceptions of people, often based on first impressions, can be quite wrong.

Our second experiential exercise asked students to talk with their small groupabout a time (usually the first time) when they felt different from other people. Thishas been a powerful exercise in previous cultural competence training sessions wehave used with students, administrators and police departments. The purpose of theexercise is to remind participants how it feels to be different. The exercise is useful inframing discussions about people in society who always feel different because of theirrace, ethnicity, language, disability, sexual orientation, etc. By reminding medicalstudents how it feels to be different, we predicted that this would increase theirempathy and patience with those who are culturally different.

Students also worked together in small groups to solve a hypothetical problemthat required them to make decisions about who will and will not survive on a life-boat lost at sea. Each student was assigned a role as a person on the lifeboat. Eachrole reflected a different cultural background. After the role play concluded, weallowed the group to reflect upon the experience in terms of how the group madedecisions, how the cultural characteristics of the people who survived and diedaffected the group decision-making process, and how power was distributed in thegroup. In the past, this exercise has allowed students to examine how cultural differ-ences influence group processes and decision making, often without consciousawareness. The purpose of this exercise was to make the influence of multiculturalfactors more conscious so that they can be dealt with rather than ignored.

The students also participated in team building exercises (i.e. low ropes course).Culturally diverse students worked together on challenging physical tasks thatrequired a significant amount of teamwork.

Results

Multicultural awareness

To examine the extent to which the interventions impacted multicultural awareness,we examined pre- and post-change scores on the revised Multicultural CounselingInventory using Multivariate Analysis of Variance (MANOVA). As demonstrated inTable 1, and contrary to our predictions, scores on the majority of awareness indicesdeclined (i.e. became less tolerant). There were a few exceptions. There was a small

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increase in recognition of differences and freedom from bias. There was a trend foran increase in cultural knowledge.

Willingness to engage as a cultural change agent

As shown in Table 2, post-intervention scores for all the dimensions of willingness toengage as a change agent for multicultural awareness and sensitivity changed in theexpected direction, although the magnitude of these changes was small.

Working in diverse small groups

In general, the participants were willing to work in diverse small groups prior to theintervention. However, there was a trend from pre- (M=9.92) to post-intervention(M=10.19) for participants to increase their willingness to work in diverse groups.

Discussion

This day-long intervention to increase the multicultural sensitivity and awareness ofmedical students produced mixed results. Multicultural awareness actually declined

Table 1. Pre- and post-intervention scores on dimensions of cultural awareness

MCI factor Pre-score Post-score p value

Cultural knowledge 11.02 11.44 0.10, trendSelf/other understanding 12.13 12.06 0.75Social comfort 9.92 6.98 0.001Communication 8.69 6.75 0.001Recognizing differences 7.50 7.98 0.04Freedom from bias 5.71 6.10 0.03Cultural understanding 11.52 10.10 0.001Cultural difference 6.42 4.90 0.001

Table 2. Pre- and post-scores on multicultural change agent questionnaire

Change agent factor Pre-score Post-score p value

Willingness to learn 11.86 12.68 0.001Refuse hostile language 13.79 14.98 0.001Social political action 6.49 7.17 0.01Interpersonal sharing 5.06 5.67 0.001Challenge insensitivity 4.22 4.73 0.01Cultural sensitivity 5.67 6.06 0.01Recognizing bias 5.41 6.02 0.01

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Teaching intercultural awareness 21

pre- to post-intervention. The most parsimonious explanation for this finding comesfrom the feedback received from the students themselves. Specifically, manystudents felt that there was not sufficient time to process important interculturalissues that arose during different experiential exercises. In essence, many studentsfelt that questions were raised in their minds about the cultural experiences ofothers, but they did not have time to get answers to those questions. The decline incultural awareness during the course of the day could also reflect participantscoming to realize that their intercultural awareness is more limited than they thoughtprior to the intervention. Participation in the retreat, however, did appear to increasethe medical students’ willingness to become more active in changing their behaviorto improve the cultural climate within the medical school. However, these changeswere small.

It is not easy to change cultural attitudes (Brislin, 1978), especially in a sustain-able way (Hill & Augoustinos, 2001). Our intervention was a simplistic, one-timeintervention aimed at shifting the cultural attitudes of first-year medical students.While the results of the intervention were mixed, we think they suggest that experi-ential exercises with medical students may prove fruitful as part of a cultural compe-tence curriculum within medical schools. Our experience with this intervention leadsus to conclude that more time needs to be provided for in vivo training. Studentsindicated that they often felt rushed during discussions and processing. More timeboth on the day(s) of an intervention as well as periodic ‘refresher’ sessions wouldseem appropriate given the sensitive nature of the subject matter.

Future studies should use sound theoretical models of ethnic/cultural identitydevelopment and attitude change to construct the most effective cultural awarenessinterventions with medical students. Care must be taken to give participants in theseinterventions sufficient time to reflect upon the experience and process their reactionswith each other and well-trained facilitators. Multiple experiential interventions maybe needed for students to sufficiently integrate the experience, feelings and thoughtsthat arise during these highly interpersonal interactions. Future studies should alsouse appropriate control groups to evaluate interventions (i.e. randomly assignstudents to intervention vs control conditions). Ethnographic studies with medicalstudents and patients should also be undertaken to obtain a more comprehensiveunderstanding of cultural awareness in this population and how best to teach it.

Keith R. Aronson is the Assistant Director of the Social Sciences Research Insti-tute at Penn State. Dr Aronson is a clinical psychologist with a specialization inhealth psychology. He conducts research related to medical student training,intercultural sensitivity training at predominantly white institutions of highereducation, job satisfaction of mental health workers, and the influence ofpersonality on health outcomes.

Rhonda Venable is the Assistant Director of the Vanderbilt University Psychologi-cal and Counseling Center. Dr Venable has been creating and delivering inter-cultural sensitivity and awareness programs for more than 20 years. She has beena paid diversity consultant for a number of public and private sector entities.

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Nicholas Sieveking is the Director of the Vanderbilt University Psychological andCounseling Center. He is also a principle in Bellet, Sieveking, and Associates aninternational consulting firm specializing in evaluating and preparing corporateemployees for cross-cultural work assignments. He has published a number ofstudies examining cross-cultural adjustment.

Bonnie Miller is the Associate Dean for Medical Students and Associate Professorof Surgery at Vanderbilt University.

*Address for correspondence: Children, Youth & Families Consortium, The Pennsylva-nia State University, 105 Health and Human Development Building East, Univer-sity Park, PA 16801, USA. Email: keith.r.aronson@psu.edu

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