Advancing Cultural Competency Toward Sexual and Gender Minorities: Innovation in Maternal and Child Health Pedagogy.

PURPOSE: The purpose of this project was to develop and disseminate an innovative teaching activity to increase cultural competency toward sexual and gender minority (SGM) populations within the maternal and child health (MCH) context. DESCRIPTION: Over 4.5% of the population (16 million people in the US) identify as SGM, and this population is an often-overlooked group within the traditional MCH context. SGM individuals have specific healthcare needs, including reproductive healthcare needs, that are currently left unaddressed. Given these gaps, the future MCH workforce should be prepared with cultural competency skills to address reproductive health inequities from many perspectives, including SGM populations. An innovative SGM activity was developed and disseminated to supplement the MCH and Reproductive Health curricula. ASSESSMENT: The objectives of this SGM Reproductive Health activity were: (1) to understand SGM populations, terminology, culture, and health inequities within an MCH context; (2) enhance cultural competency and the communication skills appropriate for this population; and (3) develop culturally competent resources for practice. The teaching activity includes a lesson plan, lecture with script, recorded lecture, assignment description, and grading rubric, designed for a U.S. based curriculum. The activity was evaluated and modified based on feedback from students, and pilot tested in practice in a graduate-level reproductive health course.
CONCLUSION: Future MCH leaders must have the skills to provide culturally competent care to the populations they serve, including SGM populations. Through teaching about SGM populations and cultural competence, educators can equip future MCH leaders with a culturally competent skillset to prepare them to work in cross-cultural situations.

Significance Statement

What is known People identifying as sexual and gender minorities are often overlooked in traditional MCH contexts. However, this population may have specific healthcare needs, including reproductive healthcare needs, that are currently left unaddressed. Future MCH leaders need the skills to provide culturally competent care to the populations they serve.

What this study adds This paper describes the development of a teaching activity on cultural competence and sexual and gender minority populations. Used by educators, this activity can equip future MCH leaders with a culturally competent skillset to prepare them to work in cross-cultural situations.

Introduction and Purpose

People who identify as sexual and gender minorities (SGM) include those who “identify as lesbian, gay, bisexual, transgender, queer, or intersex, as well as those who do not self-identify with one of these terms, but whose sexual orientation, gender identity, or reproductive development varies from traditional, societal, cultural, or physiological norms” (The National Institutes of Health, 2019). Over 4.5% of the population (16 million people in the United States) identify as SGM (The Williams Institute, 2019), and this population is an often-overlooked group within the traditional Maternal and Child Health (MCH) context. People who identify as SGM have specific healthcare needs, including reproductive healthcare needs, that are currently left unaddressed. Given these gaps, the future MCH workforce should be prepared with cultural competency skills to address reproductive health inequities from many perspectives, including SGM populations.

Within the MCH context, the reproductive health needs of people who identify as SGM and their families are changing, given the legalization of marriage equality nationwide (Family Equality Council, 2019). In the US, over 63% of SGM people are considering expanding their families and potential options for building or growing a family include the child welfare system, adoption, assisted reproductive technology, and conception from intercourse (Family Equality Council, 2019). However, numerous people who identify as SGM do not express their desire to build their families or their reproductive health concerns with their healthcare providers because of the associated stigma (Chen et al., 2018). Many of these options for family building involve interaction with MCH professionals who may not have received training regarding the unique culture and needs of SGM populations. Numerous comprehensive sources of cultural competency training related to SGM populations exist for healthcare providers (American College of Physicians, 2015; Eliason & Chinn, 2017; National LGBT Cancer Network, 2013), but far fewer target training MCH practitioners in public health practice settings who may address reproductive health concerns.

Since the U.S. Supreme Court’s 2015 ruling that the Fourteenth Amendment requires all states to grant and recognize same-sex marriages granted in other states, there has been a public acknowledgement of the need to provide equitable services and treatment for SGM populations. The changing family structures and reproductive needs of people who identify as SGM in the US have resulted in a need for cultural competency training among MCH providers and practitioners. Previous studies of the nursing curriculum have identified this gap and implemented culturally tailored, SGM-specific content (Bosse et al., 2015; Yingling et al., 2017). However, this cultural competency training has not yet been extended to address the needs of future MCH leaders. Thus, the purpose of this project was to develop and disseminate an innovative teaching activity to increase cultural competency toward SGM populations within the MCH context.

This innovative teaching activity addresses a current gap in training for MCH leaders by increasing their knowledge of SGM populations, including terminology, implicit bias, and how these social identities may influence health inequities. To meet these needs, this innovative teaching activity was designed to align with and strengthen four of the MCH Leadership Competencies: (1) cultural competency; (2) communication; (3) MCH knowledge base; and (4) critical thinking skills (Maternal and Child Health Bureau, 2018b). Additionally, the assignment included in this activity utilizes a strategy proposed by the Division of MCH Workforce Development to address diversity and health equity: develop and disseminate cultural and linguistic competence resources such as assessment tools and guides for practice (Strategy 2.2) (Maternal and Child Health Bureau, 2018a). These national priorities and MCH Leadership Competencies demonstrate that training in cultural competence focused on SGM populations is needed to prepare the future MCH workforce.

Description

Teaching Activity Overview

Given the need for cultural competency training, an innovative SGM activity was developed and disseminated to supplement the MCH and Reproductive Health curricula. The objectives of this SGM Reproductive Health activity were: (1) to understand SGM populations, terminology, culture, and health inequities within an MCH context; (2) enhance cultural competency and the communication skills appropriate for this population; and (3) develop culturally competent resources for practice. The following items were developed (Table 1): a lesson plan, which includes instructor notes; a lecture, both in narrated form and un-narrated PowerPoint with script; and an assignment, including instructions, the rubric, and sample deliverables. The lesson plan describes the purpose of the activity, the learning objectives, and the alignment with the MCH Leadership Competencies.

Table 1

Teaching activity items developed

Lesson plan and instructor notes • Introduction • Purpose and learning objectives • Alignment with MCH leadership competencies • Time requirement for instructor: one hour to review, update, and prepare prior to presenting

Narrated lecture/presentation and powerpoint slide deck with detailed script • Cultural competence - Definitions of cultural competence - MCH definitions of cultural competence - Cultural competence continuum - Elements of cultural competency - Discussion questions • Sexual and gender minorities - Definitions - The gender unicorn - Sexual orientation - Sex - Gender - Gender expression - Health disparities - Inclusive language • Integrating cultural competency - Reflection and discussion questions • References and resources • Time requirement for instructor: narrated lecture is 33 min; May take up to 45 min to present slide deck in person or live

Sexual and gender minority reproductive health assignment • Assignment description • Assignment components and requirements (four parts) • Instructor grading rubric for each component • Time requirement for instructor: Overview of assignment, 20 min; total assignment grading depends on the number of students (10 min for viewing each presentation)

Sample assignment materials • Sample assignment report submission • Sample culturally competent materials • Sample final presentation

Lecture

The lecture portion of the teaching activity focused on two components, cultural competence and SGM populations. The cultural competence portion included an overview of cultural competency, definitions used in MCH, the cultural competence continuum (Cross, 1989), elements of cultural competency, and discussion questions. The portion of the lecture focused on sexual and gender minorities includes definitions of sexual orientation, sex assigned at birth, gender, gender expression, sexual behaviors, health disparities by gender identity and sexual orientation, and use of inclusive language. As language is fluid, recommendations are given for the presenter to review and update the language prior to each presentation. Throughout this section there are graphics to delineate the differences between gender identity, gender expression, sex assigned at birth, physical attraction, and emotional attraction, based on the Gender Unicorn (Trans Student Educational Resources, 2015; See Fig. 1).

Fig. 1

The gender unicorn, image used in lecture, creative commons licensed (Trans Student Educational Resources, 2015)

To close the lecture, there is an opportunity for discussion and/or self-reflection on the importance of integrating cultural competency into reproductive care and services. Discussion questions include application of cultural competence with SGM populations. The finalized teaching activity includes a PowerPoint slide deck with a script and a narrated version of the lecture in video format.

Assignment

Students will select and describe a reproductive health topic or guideline (such as prenatal care, adolescent health, family planning) and the gaps, inequities, and needs of SGM populations. Once the topic is identified, students will determine the appropriate audience (MCH practitioners, community members, healthcare providers) to communicate about their reproductive health topic and the needs of SGM populations. To incorporate cultural competence into the chosen topic/guideline, the student will develop evidence-based materials tailored to the chosen audience; and identify best practices and specific, culturally competent actions that providers can incorporate into practice. These evidence-based deliverables will provide knowledge and skills to assist MCH professionals in addressing the healthcare needs of SGM populations regarding the specific topic or guideline the student has selected.

The assignment has four components: (1) an outline of the selected topic/guideline and audience; (2) a five-page fully referenced report on the topic and audience; (3) a three-page summary of the culturally competent adaptations recommended and draft materials; and (4) a brief presentation including an overview of the topic/guideline among SGM populations, the target audience, the aspects of cultural competency included in the materials, and the final materials (see Table 1). A grading rubric was developed for each part of the assignment to guide assessment and is included in the assignment description.

Alignment with MCH Leadership Competencies

This innovative teaching activity was aligned with the MCH Leadership Competency of cultural competency, defined as knowledge of how ability, age, class, race, sex, gender identity, and sexual orientation impact health (Maternal and Child Health Bureau, 2018b). After completing this activity, future MCH leaders will have the cultural competency skills to (1) assess, without making assumptions, the strengths and needs of individuals and communities based on sensitivity to, and respect for, their diverse backgrounds, and respond appropriately, and (2) incorporate an understanding and appreciation of differences in experiences and perspectives into professional behaviors and attitudes while maintaining an awareness of the potential for implicit bias (Maternal and Child Health Bureau, 2018b). Students will demonstrate these skills through the assignment, focusing on resource development and dissemination to MCH providers with a goal of reducing SGM health inequities. Through the activity, students will gain skills in another MCH Leadership Competency, communication (Maternal and Child Health Bureau, 2018b). Students demonstrate effective communication skills through presentation and written scholarship (Maternal and Child Health Bureau, 2018b), and apply these skills to enact change in an MCH context. This activity will prepare future MCH leaders to communicate the needs of SGM populations by designing and tailoring educational materials to meet the needs of different healthcare audiences. From this activity, students will also gain the skills to critically describe reproductive health inequities among SGM populations and develop strategies to address them. This activity also serves to strengthen the MCH Leadership Competencies of MCH knowledge base and critical thinking skills (Maternal and Child Health Bureau, 2018b).

Assessment

Face and Content Validity

Following the development of the teaching activity, the lecture with script and the assignment description and rubric were reviewed by MCH practitioners (n = 4). The practitioners were asked to provide input regarding the validity of the information provided, as well as recommendations for modifying the activity for students. Specific feedback on the lecture included modifying the content to meet the needs of the target audience, reducing the script and content per slide, and that the slides were lacking visual appeal. Feedback on the assignment included changing of language (from “reproductive health issue or recommendation” to “reproductive topic or guideline”) and including an option for the assignment as a group project. These recommendations were incorporated prior to pilot testing the lecture and assignment.

Pilot-Testing of Lecture

After the edits to the lecture, it was pilot tested in Mid-February 2020 with graduate students in the following programs: Master of Public Health, Master of Health Administration, and Master of Science in Epidemiology. Students attending the lecture were asked to complete an online pre-test survey (n = 15) and a post-test survey (n = 31) via Qualtrics to measure SGM knowledge, cultural competence, and identify areas to improve the lecture. The number of pre-tests is limited as many of the participating students attended after the lecture had begun. Additionally, we did not match pre- and post-tests and we did not obtain sociodemographic information, including SGM identity, from the students.

Students were asked to rate their knowledge of cultural competence on a scale of 1–10 (1 = “not knowledgeable at all” to 10 “extremely knowledgeable”). The mean pre-test score for knowledge about cultural competence was 7.3 (SD = 1.4), which increased to 8.1 (SD = 1.2) at post-test but was not significantly different (p = 0.386). At pre-test, 80% of students strongly agreed/agreed they were confident in their ability to provide culturally competent care/services, which increased to 94% at post-test, but this finding was not significant (p = 0.413). Similarly, just 60% strongly agreed/agreed they were confident in providing culturally competent care/services to SGM populations at pre-test, whereas 87% did so at post-test (not significant, p = 0.097). All students strongly agreed/agreed that they learned something about cultural competency and 90% strongly agreed/agreed they learned something about SGM populations, and these items were only included on the post-test.

The most commonly listed area for improvement was the need to include common language mistakes made and practical information about the language used in SGM populations (for example, the history and current standing of the word “queer”). Similarly, some students felt that the content related to risk factors was inappropriate and distracted from the focus of the presentation. Based on this feedback, the lecture was amended to include definitions of words like heteronormativity (the societal assumption that heterosexuality is the norm) and three slides on how to incorporate inclusive language into conversations and terms to avoid. Examples of terms to avoid include “transgendered” or “a transgender” and instead recommending transgender or transgender person (GLAAD and the Movement Advancement Project (MAP), 2012). Additionally, students recommended adding “pizazz” and eye-catching graphics, given that the lecture will be recorded into video form. These modifications were made in the final lecture.

Pilot Testing of Assignment

To evaluate the assignment, a cognitive focus group was conducted with 2nd year Master of Public (MPH) students in the MCH concentration (n = 7). Students reviewed the assignment during the focus group and provided feedback. Recommendations from this included: (1) changing the assignment to include “materials” rather than focusing on the development of a “tool-kit” as the materials may not be as comprehensive; (2) lengthening the page limitations on parts of the assignment; (3) adding an outline as part one to allow time to change topics if the student desires; and (4) changing the assignment to be an individual project rather than a group assignment. The assignment was amended to reflect the recommendations, and notes were made in the instructor notes that the assignment could be used as an individual project or a group project based on their discretion. The language around “tool-kit” development was changed in the assignment to be “materials”.

Evaluation in Practice

The lecture and assignment were included in a reproductive health course to evaluate their effectiveness in practice. After participating in the lecture and completing the activity, which was assigned as a pairs project, MCH MPH students (n = 6) were sent a questionnaire to assess their (1) self-efficacy for communication; (2) cultural competence; and (3) population specific knowledge. Items were based on self-efficacy scales (Axboe et al., 2016; Bandura, 2006), the objectives of the assignment, and the MCH Leadership Competencies. Overall, all students strongly agreed/agreed that their communication skills, knowledge, and critical thinking skills improved as a result of the lecture and the assignment (Table 2). Additionally, all students rated their confidence levels highly in communication about SGM populations and cultural competence upon completing the SGM assignment (Table 3). Average grades on each part of the assignment are also presented in Table 3. Given the small sample size, no statistical testing was performed.

Table 2

Evaluation in practice, assessment of communication skills, knowledge, and critical thinking skills, n = 6

	Agree	Strongly agree
As a result of the lecture on sexual and gender minorities and cultural competence…
My written communication skills improved	3 (50%)	3 (50%)
My knowledge of cultural competence increased	1 (17%)	5 (83%)
My knowledge base regarding SGM populations increased	0 (0%)	6 (100%)
My knowledge of reproductive health inequities among SGM populations increased	0 (0%)	6 (100%)
My knowledge of SGM populations, terminology and culture improved	0 (0%)	6 (100%)
My critical thinking skills related to cultural competency issues improved	1 (17%)	5 (83%)
My critical thinking skills related to health disparities among SGM populations improved	0 (0%)	6 (100%)
As a result of the sexual and gender minority cultural competence assignment…
My written communication skills improved	4 (66%)	2 (33%)
My knowledge of cultural competence increased	1 (17%)	5 (83%)
My ability to apply cultural competence to practice improved	0 (0%)	6 (100%)
My skills in translating cultural competence into practice improved	1 (17%)	5 (83%)
My knowledge of SGM populations, terminology and culture improved	0 (0%)	6 (100%)
My critical thinking skills related to cultural competency issues improved	2 (33%)	4 (66%)
My critical thinking skills related to health disparities among SGM populations improved	1 (17%)	5 (83%)

Response options were strongly agree, agree, neutral, disagree, and strongly disagree

Table 3

Evaluation in practice, confidence in communication and overall assignment grading, n = 6

	Mean (SD)
After completing the SGM assignment, how confident are you that you are able to successfully…
Communicate with healthcare providers about cultural competence	9.0 (1.0)
Communicate with healthcare providers about SGM populations	8.8 (0.9)
Communicate with healthcare providers about SGM populations and reproductive health disparities	8.8 (0.9)
Communicate with other MCH professionals about cultural competence	9.5 (0.5)
Communicate with other MCH professionals about SGM populations	9.2 (0.6)
Communicate with other MCH professionals about SGM populations and reproductive health disparities	9.2 (0.6)
Develop culturally competent materials for practice	9.2 (1.1)
Develop materials to communicate with healthcare providers	9.3 (0.9)
Identify reproductive health disparities SGM populations may experience	9.0 (1.0)
Average assignment grades
Part 1: Outline of topic and audience	4.5/5
Part 2: Overview of topic and audience	5/5
Part 3: Incorporation of cultural competence and draft materials	10/10
Part 4: Final materials and presentation	19.6/20

Response options were presented on a 1–10 scale, with 1 = “not at all confident” and 10 = “completely confident”

Conclusion

The teaching activity developed is innovative as the population of focus is often excluded from MCH and reproductive health work. The project and the associated skills can be applied to a range of MCH settings, other health topics, and across the life course. The lecture and assignment could be modified to meet the needs of many undergraduate and graduate courses, such as Introduction and Advanced MCH, Health Disparities, and Health Communication, and has been pilot-tested in a graduate-level Reproductive Health course. Additionally, this assignment is flexible and can be modified to meet the needs of asynchronous, online courses, allowing students to develop skills in communication via technology. The pilot-testing of the lecture and activity occurred in person prior to the COVID-19 pandemic, however, during pilot-testing the final student presentations were recorded and presented remotely. The full lecture, materials, and grading rubrics to evaluate the competencies are available on the Association of Teachers in Maternal and Child Health Innovative Teaching Website.

This innovative teaching project was designed to address a gap in cultural competency, specifically among SGM populations. Given the societal changes in acceptance and many SGM families choosing to expand, future MCH leaders need the skills to provide culturally competent care to the populations they serve. Through this curriculum and assignment, future MCH leaders will develop begin to develop a culturally competent skillset to prepare them to work in cross-cultural situations. If they continue to advance these skills through public health practice, they could enter the workforce prepared, interact more effectively in practice with diverse populations, and communicate with clinicians and healthcare providers to meet the needs SGM populations and others.

Given the potential barriers to incorporating cultural competency into existing education offerings, this teaching activity contributes to the integration SGM health-related content into maternal and child health curricula. The activity addresses recommendations such as education on inclusive language, avoidance of stereotypes and assumptions, and exploring the complexities of an SGM identity and how it may be related to health (Solotke et al., 2019). Additionally, this work situates both sexual orientation and gender identity within a life course approach, a developmental framework familiar to those in MCH training. While medical training and MCH training share many similarities, MCH leaders are positioned to apply this knowledge to entire communities, larger populations, and in the development of programming.

However, this activity is not without limitations. For example, a limited number of people identifying as sexual and gender minorities participated in the development of the lecture. Future work related to this topic should prioritize inclusion of voices from the SGM community. We did not collect any sociodemographic factors from students participating in the lecture, pilot-testing of assignment, or evaluation in practice, which may have influenced the findings. For example, students identifying as part of the SGM community may have had higher knowledge and comfort with the information presented than students who did not. By collecting this information in future teaching activities, we can identify provide a clearly picture of the activity’s impact. Another limitation is the lack of consideration of intersecting identities within the SGM community. To further incorporate SGM and cultural competency training across public health and MCH curricula, programs such as this should be expanded to include a consideration of complex intersectional identities whenever possible, particularly the intersection of race and SGM identity. Finally, this lecture and activity were only tested at one university with a small group of graduate-level students. This course was designed for use in U.S. based graduate-level coursework, but could be modified to meet the needs of other cultural contexts and levels.

Additionally, it is important to stress to learners that cultural competency is a process, not an endpoint. For future MCH leaders, developing and strengthening this skillset can expand the sphere of influence from self, to others, to the wider community. These skills may intersect with interdisciplinary, community-based MCH Leadership Competencies such as Working with Communities and Systems, and Policy (Maternal and Child Health Bureau, 2018b). Advancing cultural competence will be invaluable for the diverse MCH leaders of the future, with the ultimate goal of reducing health inequities in marginalized populations.