Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study.

Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study. Jerry Draper-Rodi, Hilary Abbey, John Hammond, Oliver Thomson, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3921151/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Apr, 2024 Read the published version in BMC Medical Education → Version 1 posted 9 You are reading this latest preprint version Abstract Background Individuals from minority groups have historically faced social injustices. Those from underrepresented groups have been less likely to access both healthcare services and higher education. Little is known about the experiences of underrepresented students during their undergraduate studies in osteopathy in the UK. The aim of this project was to evaluate osteopathic students' awareness of cultural diversity and their beliefs about patients from underrepresented backgrounds, as well as their preparedness to manage them. The project also aimed to investigate the educational experiences of students from underrepresented backgrounds during their training and their opinions on changes that could support better levels of recruitment and achievement. The findings were disseminated to stakeholders through interactive workshops with the aim to develop recommendations for action and change. Methods A transformative action research paradigm informed this mixed methods project. It included: 1/ a survey of students from all seven osteopathic educational providers in the UK using the Multidimensional Cultural Humility Scale (MCHS); 2/ a series of focus groups with students from underrepresented groups (women, students with disabilities, students from minority ethnic backgrounds, and students identifying as LGBTQIA+); and 3/ a workshop forum to discuss findings. Results A total of 202 participants completed the MCHS and demographic questionnaire and seven focus groups were conducted. A model was developed to describe participants' training experiences comprising two main themes: institutional contextual obstacles (with four sub-themes) and underrepresented students' conceptual understanding of Equity, Diversity and Inclusion (EDI). Recommendations for change identified in the workshops were based on three topics: institutions, staff, and students. Conclusion Our findings suggest that staff education is urgently needed to create and maintain equitable, inclusive environments in osteopathic educational institutions in the UK to support all students, particularly those from underrepresented groups. Institutional EDI processes and policies also need to be clarified or modified to ensure their usefulness, accessibility, and implementation. Underrepresented Oppressed Social justice Equity diversity and inclusion Transformative action research Osteopathic undergraduate education Women Disability LGBTQIA+ Ethnic minorities Figures Figure 1 Figure 2 Figure 3 BACKGROUND Social injustices affecting people from minority groups have been highlighted in recent worldwide initiatives such as the ‘Black Lives Matter’ ( 1 ) and ‘Me Too’ ( 2 ) movements and investigations have identified institutional racism, sexism and homophobia in the police, other public services, and business organisations ( 3 – 6 ). Limited demographic diversity and evidence of discrimination against minority groups have been reported in higher education in the United Kingdom (UK) ( 7 ) and in healthcare services including medicine, psychiatry, and physiotherapy ( 8 – 10 ). Data from higher education institutions suggest there is an urgent need to improve recruitment, educational experiences, and attainment for students from minority groups ( 11 – 13 ). The terms ‘minority’ or ‘under-represented’ are often used interchangeably to describe groups of people identified by specific demographic or cultural characteristics. In this paper, the term ‘under-represented’ is used to emphasise that experiences of inequity are typically created and maintained by social constructs such as ‘othering’: the process of identifying people as different from oneself or the mainstream culture, often associated with negative beliefs and expectations ( 14 ). Characteristics used to identify others can include skin colour, ethnicity, religion, gender identity, sexual identity, ability, size, socioeconomic status, history of trauma, addiction, and family environment ( 15 ). This study focused on characteristics, and their intersectionality, associated with inequality in many areas of higher education - ethnicity; gender identity and sexual orientation (LGBTQIA+); and disabilities. People from under-represented groups (UrGs) have historically been less likely to access higher education ( 16 ), although the number of BAME, LGBTQIA + and disabled students is gradually increasing in England ( 17 , 18 ). Enrolled students from these groups are reported to experience more negative experiences during training and more limited later career opportunities afterwards ( 19 , 20 ). The General Medical Council (GMC) recently set new targets to improve access and outcomes for students from UrGs ( 21 ) as lack of diversity and limited cultural awareness among practitioners from different healthcare professions also impacts the quality and outcomes of healthcare for patients from UrGs ( 12 , 22 , 23 ). The Council of Deans recently published a report on how to build an inclusive environment which highlights issues that affect students from minority ethnic groups in Allied Health Professions ( 24 ). Patients from UrG experience substantial health disparities in the UK and across the globe due to structural and interpersonal discrimination ( 25 , 26 ). Developing cultural humility in clinicians is seen as key to bridging the gap of interpersonal discrimination. Cultural competence was once considered as an adequate way to provide an inclusive environment. It is defined as “a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or professions to work effectively in cross-cultural situations” (27 p. iv). The concept shifted to cultural humility, defined as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client” (28 p. 354). Osteopathy is a form of manual therapy which is now recognised as one of 14 Allied Healthcare Professions in England ( 29 ). In the UK, there are currently seven osteopathic education providers (OEPs) and approximately 5,300 qualified osteopaths. Training is typically over four or five years in the form of Bachelor’s or Integrated Masters awards and practitioners then register with the statutory regulator, the General Osteopathic Council (GOsC), and are required to comply with professional standards of practice ( 30 ). There is little known about discrimination, bullying and harassment in osteopathy education as highlighted in a recent systematic review ( 31 ). Therefore, the current research project aimed to assess osteopathic students’ awareness of cultural diversity and beliefs about patients from UrGs and their preparedness in managing them; to explore the educational experiences of students with UrG backgrounds during training and their opinions on changes to support better levels of recruitment and achievement. Finally, the research was disseminated to stakeholders in workshops with the overall aim of developing recommendations for action and creating change. METHODS Design To meet the multiple project aims, a mixed methods approach was implemented and included the following stages; a survey of students attending all seven OEPs in the UK; focus groups with UrG students; and a workshop forum to explore the findings with diverse stakeholders. This design was based on a transformative action research paradigm with students participating as collaborators (Mertens 2007; 2010), informed by previous research into EDI, cultural competence and cultural humility in healthcare education, outlined below. The research complies with the Good Reporting of A Mixed Methods Study (GRAMMS) guidance ( 32 ) (see supplementary material 1 – GRAMMS reporting). Figure 1 below details the mixed method stages with the quantitative data collection (top half of figure), qualitative data collection (bottom half), and mixed methods stages (middle). The stages are represented chronologically, starting on the left. ***insert Fig. 1 - study design around here*** Methodology This research project sits within a transformative paradigm that places central importance on studying the lives and experiences of marginalised groups and is appropriate for addressing inequality and injustice in society ( 33 ). An explanatory sequential mixed methods design (survey followed by focus groups) was implemented to gain insight ( 34 ) and community members were involved in initial discussions about operationalising the research focus. Transformative research has power issues and inequalities at its core and a political agenda that aims to change the experiences of the participants and institutions involved ( 35 ). The study was approved by the University College of Osteopathy Research Ethics Committee. Community engagement Two community engagement meetings with students from underrepresented groups were established prior to the project to ensure it was designed ‘with’ students rather than ‘to’, ‘about’ or ‘for’ them. Based on principles by ( 36 ), these community engagement meetings co-created the study design, modified the research questionnaire and recruitment approaches. Quantitative stage A survey of all students currently enrolled on an osteopathic course in the UK was chosen to explore the research objectives. All students enrolled at the eight OEPs in the UK (excluding postgraduate and CPD courses) were eligible to take part in the anonymous online survey on Qualtrics©. Invitations, study information and accessible links were disseminated via OEP contacts who sent it to their student body between 7th and 31st March 2022. Two reminders were sent. Survey instrument The Multidimensional Cultural Humility Scale (MCHS) was selected for this project as there is good evidence of convergent and discriminant validity and internal reliability ( 37 ). The MCHS has five dimensions, contains 15 items with a 6-point Likert scale from ‘strongly disagree’ to ‘strongly agree’ where higher scores represent greater levels of cultural humility. Modifications to the MCHS were necessary to contextualise it for osteopathy students, so a factor analysis was conducted to assess the validity of the adapted version. Following the community engagement meetings, a 7th category was added: ‘This has never crossed my mind’ to assess whether students were comfortable, confident or aware of particular issues (see supplementary material 2 for the adapted versions used in this study). Questions related to demographics and personal characteristics (clinical or pre-clinical student, age, birth sex, gender, ethnicity, health and disability status, sexual orientation, and religion), and to their experience of education were included at the end of the MCHS and were analysed separately to the MCHS questionnaire. Qualitative stage : Focus groups were selected for this phase and represented four UrG: ethnic minority, disability, LGBTQIA + or women. Whilst women are not numerically under-represented in UK osteopathic undergraduate training, socially they are more oppressed than men, including in manual therapy training ( 31 ). The choice of these four groups was discussed and validated during the community engagement meetings. For sensitive topics, homogeneous groups foster a sense of belonging and facilitate disclosure ( 38 ). The usual number of groups is around 4 but depends on the complexity of the topic and heterogeneity of the samples ( 39 ). Students from any UK OEP who identified as belonging to at least one UrG (ethnic minority, disability, LGBTQIA + or women) were eligible to participate with students from the same and/or other OEPs. Each OEP was responsible for forwarding invitations to participate to their students. For convenience, focus groups were conducted online as students from different OEPs were geographically dispersed ( 40 ). The research team members acting as focus group facilitators identified with one or more minority groups, representing diversity and were therefore part of the data, as is good practice in transformative paradigmatic research ( 41 ). All facilitators had previously used focus group methods, participated in training, or were used to managing student group discussions. Teams© created automatic initial draft transcriptions to aid later transcription if participants talked simultaneously ( 39 ). Final transcripts only included pseudonyms, as is common in qualitative research ( 42 ). Focus groups usually comprise 6 to 8 people who meet once for approximately 90–120 minutes. Focus groups sessions ran for approximately 90 minutes. Students who had participated in one of the four initial groups were invited to join one final mixed group to discuss the previous findings, and students who participated in at least one group were invited to take part in the workshop forum. Dissemination forum and workshops An interactive face-to-face workshop-based forum was held on 06/04/2023 to disseminate the survey and focus group results, explore their implications, and develop recommendations for action. Key stakeholders invited to attend free of charge included UK OEPs, the General Osteopathic Council, the Institute of Osteopathy, the Osteopathic Foundation, and other healthcare profession organisations, NHS representatives, and Health Education England. Approximately 70 people attended the event. Three interactive workshops explored responses to the study results, personal experiences, and opinions about ways to develop a more supportive educational environment and inclusive curriculum. Mixed methods analysis Quantitative stage To assess whether the 5-factor model of the MCHS remained valid following changes made to the scale, a confirmatory factor analysis was carried out using using R (version 4.3.2) ( 43 )and the R lavaan package (version 0.6–16)( 44 ). Missing MCHS data was imputed using multivariate imputation by chained equations (45). MCHS data was checked for normality using QQ plots and the Henze-Zirkler test. A sum of all MCHS items (reverse coded as appropriate) was calculated as an overall measure of cultural humility. Linear regression was carried out to determine which demographic factors influenced this total score. Additionally, a Welch Two Sample t-test ( 46 ) was carried out to determine if MCHS total score differed between clinical and pre-clinical students. Chi-squared tests, with p-values estimated by Monte-Carlo simulation, were used to test for associations between students’ report of having been treated differently one the one hand, and demographic factors on the other. Descriptive statistics were used to report survey results. Qualitative stage Focus group data analysis was conducted within a reflexive thematic analysis framework ( 47 ), which aligns with a transformative paradigm (Creswell 2014). Data was co-created by participants and facilitators, and themes were co-created with analysts through their thoughtful engagement with the data ( 47 ). After conducting one focus group with each UrG (n = 4), early analysis was conducted. Another 4 focus groups with different students were conducted to analyse how these participants’ experiences resonated with the initial findings. The last focus groups ran with students from mixed UrGs to discuss the findings, conduct a meta-synthesis, and prioritise what actions students thought OEPs should prioritise. During the three interactive forum workshops, participants’ verbatim comments were collected on post-it notes and activity outcomes were recorded on flipcharts. Data was then categorised by the facilitators using frequency analysis to identify long and short-term priorities for OEPs. The data from the quantitative and qualitative phases were analysed separately, but then were considered together both in the dissemination forum workshops and within the research team. When considering the quantitative and qualitative datasets together, the research team operated within the methodological spirit of pragmatism, whereby both data sets were integrated in such a way that a useful insight to the research provide useful insights to participants’ experiences and generate knowledge with social utility ( 48 ). In practice, this meant that the survey results were presented to the focus group participants to stimulate reflection and discussion in order to explore how the results compared with their personal experiences. Finally, the workshops provided an additional method to explore, situate and integrate the synthesised qualitative and quantitative data sets to support development of the final thematic model. RESULTS 1. Quantitative results Two hundred and two participants filled in the survey, of which 117 (58%) were complete. The response rate was 20% (Table 1). Responses per OEP ranged between 6 to 68 (Table 2 – OEP Responses). ***insert table 1 – response and completion rate*** Table 1 - response and completion rates COMPLETION FREQUENCY PERCENTAGE INCOMPLETE 85 42% COMPLETE 117 58% TOTAL 202 100% Total population Ca 1000 20% response rate Table 2 – Response by Osteopathic Education Provider Number of responses per OEP (n=202) A 10 (5%) B 25 (12%) C 25 (12%) D 39 (19%) E 6 (3%) F 8 (4%) G 21 (10%) H 68 (34%) Seventy percent of the respondents provided demographic information (n=142). Participants were mostly white (n=95), female (n=74), without a disability (n=106), heterosexual (n=89), and identifying with no religion (n=69) (see table 3 – respondent demographics). Table 3 – respondent demographics Category n= (total 142) % Sex at birth Female 77 54.2 Male 40 28.2 Intersex 0 0 Prefer not to say 2 1.4 Not answered 23 16.2 Gender Woman 74 52.1 Man 41 28.9 Non-binary / Gender-variant / Non-conforming 1 0.7 Transgender man 0 0 Transgender woman 0 0 Not listed 1 0.7 Prefer not to say 2 1.4 Not answered 23 16.2 Ethnicity White 95 66.9 Mixed or Multiple ethnic groups 7 4.9 Asian or Asian British 6 4.3 Black, African, Caribbean or Black British 5 3.5 Other ethnic groups 1 0.7 Prefer not to say 5 3.5 No response 23 16.2 Disability No 106 74.7 Yes (details below, several answers possible per participant) 11 7.7 Mental health conditions and illnesses 5 3.5 Developmental impairment, such as autistic spectrum disorders (ASD), dyslexia and dyspraxia 4 2.8 Impairments with fluctuating or recurring effects (such as rheumatoid arthritis, myalgic encephalitis (ME), chronic fatigue syndrome (CFS), fibromyalgia, depression and epilepsy) 2 1.4 Sensory impairments (such as those affecting sight or hearing) 1 0.7 Progressive impairment (such as motor neurone disease, muscular dystrophy, and forms of dementia) 1 0.7 Auto-immune conditions (such as systemic lupus erythematosis) 1 0.7 Learning disabilities 1 0.7 Impairment produced by injury to the body, including to the brain 1 0.7 Prefer not to say 2 1.4 No response 23 16.2 Sexual orientation Heterosexual 89 62.7 Bisexual / Pansexual 11 7.7 Gay / Lesbian 10 7.0 Other 1 0.7 Prefer not to say 7 5 No response 24 16.9 Religion No religion 69 48.6 Christian 23 16.2 Spiritual 13 9.2 Other religions 3 2.1 Buddhist 2 1.4 Muslim 2 1.4 Jewish 1 0.7 Sikh 1 0.7 Hindu 0 0 No response 28 19.7 Most of the participants identified to some extent with an UrG (n=62, 53%). Of all the students who responded (53% self-identifying as UrG to some extent, and 47% who did not identify as UrG), 67.8% (n=80) reported that they had not been treated differently because of their cultural background/identity. Those who had been treated differently (n=19; 16%) stated that it happened at least a few times per year (n=15, 79%) (supplementary material 3, table a – underrepresented groups treatment). Associations between demographic characteristics and UrG self-identification found that ethnicity (merging all categories excluding White), Disability and Sexual Orientation (merging all categories excluding heterosexual) were significantly associated with identifying as belonging to an UrG group (Supplementary material 3, Table b - UrG identification vs demographic group). No significant associations were found between demographic characteristics and reports of being treated differently (Supplementary material 3, table c - treated differently vs demographic group) Of the 19 participants who reported having been treated differently because of their culture or identity, 79% (n=15) did not report it to their OEP, 15.8% (n=3) did, and 5.2% (n=1) did not answer. It was not possible to confirm or deny the adequacy of the 5-factor model proposed by Gonzales et al. (37) (Supplementary material 4), so our analysis was based on their 5-factor model (see table 4 – MCHS results). Regarding the MCHS total score, no differences were found between clinical and preclinical students (Welch's t = -0.194, df = 79.3, p = 0.847). A weak correlation between MCHS total score and importance to individual was found (Spearman’s rho(114)=0.27, p =0.003), and a weak relationship between self-rating of skills and MCHS total score (rho(114)=0.26, p=0.005). There was no apparent relationship between MCHS total score and participants’ perception of support in the clinical environment for exploring patients’ backgrounds and experiences (rho(106)=0.097, p= 0.3). No scores on these three questions differed significantly between clinical and preclinical students. Table 4 – MCHS results MCHS dimension Mean SD Median IQR Openness 14.967 2.289 15 2.00 Self-awareness 14.128 3.15 15 3.75 Person-centred 11.364 3.49 12 5.00 Therapeutic interactions 10.861 2.75 11 4.00 Reflective practice 16.233 1.606 17 2.25 Qualitative results Seven groups were conducted, each were facilitated by two members of the research team (from AMM, HA, JDR, SV, YF). Data from the first 6 focus groups were organised into two themes which provide descriptive insights of participants’ reflections on the quantitative findings and how the results related and resonated with their own experiences. The two primary themes were named institutional contextual obstacles (with 4 sub-themes) and UrG students’ conceptual understanding of EDI (with 3 sub-themes). The themes and sub-themes were modelled and presented to the final focus group to facilitate reflective discussions, see figure 2. ***insert figure 2 - model based on focus groups’ themes and sub-themes *** Theme 1: Institutional contextual obstacles The first sub-theme, Faculty’s lack of awareness & knowledge, was a commonly reported barrier. “ I think there’s a lot of talk of self-reflection, at least at the OEP, and it doesn’t to me feel like all of our teachers practise that.” “I’ve had more problems with staff understanding than student understanding”. (Talking about their disability) “There was no awareness, you know, of that within the class or from the tutors, in those circumstances (managing an LGBTQ+ patient), what do we do, what language do we use, (…) when it was raised the tutor was sort of like, actually, I don’t have an answer, I’m not sure.” Racist, sexist and ableist comments made by staff negatively affected the way students interacted with patients in the OEPs clinics, and with other students, particularly in practical classes. “I was doing a neck and then teacher wants me to talk when I’m doing it and I say, because / when I’m doing it, I can’t talk and he made a comment, as a woman, you should talk and you should do it, you should multi-task and at that time I couldn’t say anything because I [was] already panicking and I’m doing this thing. I couldn’t say anything.” “[A male tutor] put [a female tutor acting as a model] side-lying and [he] was going to crack her back but then when he pulled her shirt up her scrubs pants were like mid-way / quite / kind of showing her underwear (…) When we told him that he should pull her scrubs up, he made the thing super uncomfortable.” “When they make an attack, as a joke, and people laugh, that’s positive behaviour, they’re going to make the joke again because it’s funny, so I don’t know if they can understand that it’s actually a knife that you’re throwing at someone and not just a joke.” The second sub-theme related to a lack of support from institutions for students from UrG, and a lack of clarity of processes available to them to complain about discriminatory behaviours against them. “When I was sort of going through the process of applying for the disabled students’ allowance, which I didn’t even know that I was / its existence to be honest, (…) I had to get the OEP to fill out a form and rubber stamp it and it seemed to get lost in this abyss of I don’t know where it went. (…) but there was a lot of chasing up to do [laughs] and even getting the form signed again, because I have to reapply every year, was a bit of a faff.” Participants who reported discrimination, were lacking certainty that reported these instances would lead to change. “Particularly when it’s a comment like that that’s made and it almost leaves you like gobsmacked and you’re like well what do I say to that, how do I go about telling someone about that?” The third sub-theme was Student attitudes e.g., peers making sexist comments and using negative language about UrGs. “People have said things, especially kind of bisexual tropes and things like that about you know being greedy and I know it’s / (…) people think oh that’s funny (…) it just makes you feel like you are going inward kind of thing.” “I don’t have that much of an understanding of the difference that ethnicity has on sort of different diseases and different morphologies and things like that, so it’s something (…) I’d love to learn more about.” “I was practicing thoracic HVT with (…) some first years [students] and I started doing thoracic HVT and one of the first years asked me to do it on him, so I was like, okay, umm, I explained to him you know everything, asked for his consent and stuff, but because he was like a funny guy, he was talking all the time, I was like, okay, can you just sit down for me to do the technique and I told him my nationality before that and then he goes like oh that’s how I know you are Brazilian, your attitude, you probably go on top. I’m just like what? You know / yes, I didn’t even know what to say at this time, because I was just / I just told him, look, I’m not doing the technique, I thought, goodbye.” Participants reported instances where students from privileged backgrounds remained silent when facing discriminatory comments from educational faculty; a factor that perpetuated a non-inclusive culture, as people who used discriminatory or ‘othering’ language were not challenged to reflect on their attitudes and behaviour. In contrast, participants from UrGs felt a sense of duty to raise concerns: “I don’t create problems and stuff, but if there is something if I see it not going right, I like to raise my voice as much as I can and I try to make changes.” The fourth sub-theme was Lack of representation in the student body, patient population and the curriculum. “Everything that we get taught is 99% on like a male sex anatomy. Like I remember when I was learning how to do all the like umm cardiac testing and respiratory we were taught by a male teacher on a male body and then when it came to like a female and like you have boobs and they’re like, oh, you can’t do this bit at the front, or you have to be more careful, but then there was no example of how” ““I think I felt surprised when coming into the / into osteopathy how less diverse (in student demographics?) it is than my previous position.” “I feel quite diverse but people that we see in clinic are mainly Caucasian, so I also think there’s something about the outreach of osteopathy into different cultural communities, for example, most of my family, though we’ve all been brought up here, nobody would use an osteopath (…)” “When we learn about physiology and pathologies, I feel like there’s now a real effort to talk about say like black people, which is fantastic, but then you know what about Asian (…)” Theme 2: Underrepresented students’ understanding of EDI The first sub-theme related to the definition of discrimination and echoed findings from community engagement discussions. Students distinguished between 'othering' and 'intent'. Participants perceived discrimination only when actions had an intent to discriminate against individuals or communities, rather than actions that led to people or groups being treated differently regardless of intent. During the focus groups, participants reported equal treatment, but data analysis suggests instances of discrimination. “No, only in so much as, you know, the reasonable adjustments aspect, but then I’ll ask for that, but besides that, I haven’t / I haven’t had any different treatment.” “I’ve definitely been treated differently as a woman and / but I’ve witnessed the / in my class Asian women being treated differently, but the Asian men not so much so.” The second sub-theme related to the advocacy of UrG students as role models for their peers. Students used their own experience of belonging to an UrG as personal knowledge to help inform their peers about what it is like to be a person from wider UrG communities. This helped to fill gaps in the EDI training or make up for a lack of training received by educators. UrG students acted as advocates to prevent wrong messages, jokes being shared, e.g., “I think it’s / not just from my disability, but yes, from / for all other students I think when they / things come up, sometimes quite surprising things actually, it’s usually / yes, pretty interesting and helpful for all of us.” “We use it [disability] sometimes in class as part of like chronic pain, as part of that kind of presentation and things like that because I have an understanding of it, whereas instead of just pulling stories out of thin air.” The third related sub-theme was that students from UrGs appeared to have a better understanding of EDI than their peers and faculty members. Students’ advocacy role included training and supporting their peers in how they should manage situations when facing patients with specific conditions, e.g. type 1 diabetes, and offered a useful insight which would be valued by patient. “I mean do they have to? Should they? I think you know, like I’ve said, the only reason I do [disclose] it is because you know I wouldn’t want to put anybody else in a tricky position if I was to, you know, have like a hypo in class or anything like that, which you know, I may do one day.” This created an environment where students from UrGs not only had to teach other students and faculty, but also had to learn on their own, as they were not able to gain knowledge from staff on topics related to UrG, and then had to teach what they learned to their peers and faculty members. “But we don’t get taught about how to deal with somebody that’s transgender or anything like that. It’s like well you’ll have to you know just find out about that yourself.” “I don’t have that much of an understanding of the difference that ethnicity has on sort of different diseases and different morphologies and things like that, so it’s something (…) I’d love to learn more about.” The final mixed focus group was used to explore whether the above findings represented the experiences of these participants, and to generate suggestions for OEP action to become more inclusive. Goals thought to be quickly achievable and likely to lead to sustained change was providing urgent training for staff, and then students, to improve awareness and knowledge, and to break the issue of the cycle of unaware students becoming unaware teachers. “ L ack of diversity ‘breeds’ a lack of diversity” ” “A lot of the main institutional barriers is the university’s lack of knowledge and the best way to deal with that is directly linked to how the under-represented students can like just you know break this barrier by teaching others and also by getting contact with the university” Active bystander training was recommended to promote collective responsibility in challenging bias and negative views. Other suggestions included providing support for students from UrGs, countering negative views amongst peers and faculty, employing active strategies to promote patient diversity, being more equitable in services offered, and ensuring training was implemented. The final recommendation was to increase representativeness in the curriculum, as a way of training staff and students through regular exposure to up-to-date information regarding UrGs. “if the institutions were to be more aware [of EDI] and have [EDI training] ...., I don’t know what training’s mandatory training’s given, but it would seem like potentially a lot of it [othering] could potentially be stopped. It just seems because you’ve got the lack of representation to faculty, race in faculty, they all sort of interlink with the other parts.” Participants felt that more and better training was needed for staff on EDI issues; a potential barrier to implementation was time, but short courses were expected to be effective. “ every job I’ve ever done, either private sector, public sector, there is mandatory training and EDI’s, (…) human trafficking, (…) blackmail. (…) But I think we’re only talking like a half an hour” Workshop results Quantitative and qualitative data were considered together in the forum workshops by presenting of the survey results and focus group data prior to the workshops. The themes identified during the series of workshops using frequency analysis of post-it notes and recurring comments across the three workshops were organised in Fig 3 in relation to the groups involved in the recommended actions. Supplementary material 5 provides further details on the recommended actions. DISCUSSION The aims of this innovative mixed methods study were to survey student osteopaths’ levels of cultural humility as a proxy for preparedness to work with patients from underrepresented groups (UrGs) and to explore the educational experiences of UrG students, to support recruitment and achievement. Results were disseminated in an interactive forum with a variety of stakeholders using workshops to develop recommendations for action. The main obstacles to enhancing EDI in OEPs were lack of clarity and awareness about EDI; lack of representation and inclusivity in the curriculum; and lack of student support and action to address discrimination. Suggestions for action, validated by the final focus groups and workshops, focused on educating staff, supporting students, and clarifying or changing processes and policies in osteopathic educational institutions. Implications of the findings are discussed below in the context of research, wider EDI issues, and osteopathic education. Educating staff This study focused on assessing levels of cultural humility in student osteopaths, but findings indicated that experiences of discrimination were often associated with lack of awareness or negative attitudes among staff, suggesting that staff training is urgently required. Similar findings were found in Bakaa et al. ( 49 ) who surveyed cultural competence in a sample of 3,000 chiropractors and suggested that gaps between knowledge and self-reported behaviour required further research to clarify barriers and guide future training. Cultural humility is a lifelong commitment to developing awareness to disparities experienced by people from diverse cultural groups, reflecting and being open to learning ( 50 – 53 ). This model encourages practitioners to collaborate with patients, and educators to collaborate with students, to find solutions to discrimination and inequality based on their lived experiences and priorities ( 54 ) and could be a basis for osteopathic educator training and practice. There is limited evidence exploring the impact of cultural humility training with healthcare professional educators. There is mixed evidence about whether cultural competence training improves patient outcomes or reduces health disparities in healthcare professionals ( 55 ). A focus group study by Shapiro et al. ( 56 ) suggests training increased awareness among third year medical students (first year of clinical training) but was less helpful in developing specific management skills or for balancing group-based knowledge and individual patient needs. In another study, medical students have been found to minimise the importance of self-awareness or the need to reflect on, and confront, personal biases ( 50 ). Despite these challenges of impact of training, there is consensus that the absence of training is also problematic. Whether based on concepts of cultural awareness, competence and humility ( 52 ) it is important that the sceptical perception that training is trying to be ‘politically correct’ is transformed into a way of rehumanising healthcare education ( 56 ). Flateland et al. ( 57 ) concluded that inclusivity could be increased through mandatory diversity training which emphasised individual learning needs for students from all backgrounds and was supported by mentoring from personal academic tutors and a buddy system for students from under-represented groups. Therefore, osteopathic education staff education is warranted and requires further investigation to identify the impact of this on students and on patients. Supporting students Inequalities in healthcare education are well documented ( 11 , 12 , 16 , 18 ). Physiotherapy students from black, Asian and minority ethnic (BAME) backgrounds received lower marks in observed assessments compared to white students, with gaps in attainment also recorded for people with disabilities and students with non-traditional entry routes ( 10 ). Studies suggest that explanatory factors include limited disclosure of difficulties, especially for ‘invisible’ disabilities ( 18 ), the complex challenges faced by students with intersectional backgrounds ( 58 , 59 ), and lack of awareness among staff ( 20 , 60 ). Inconsistent institutional support practices also reinforce students’ disabled status and limit participation, rather than optimising their abilities and resilience ( 60 ). Overseas students, especially those who do not speak English as a first language, report isolation, loneliness, and lack of support, which is increased by intersectionality including race and gender ( 9 , 57 ). There is a need to develop clear and robust systems to support students from UrG in higher educational institutions and to assess how these could be further improved. Clarifying or changing processes and policies in osteopathic educational institutions All educational institutions have a responsibility to overcome the challenges of inaction in the face of discrimination. Training inequalities are known to be a concern in medical and allied health professions. The General Medical Council has recently set new targets to eradicate disadvantage and discrimination in medical education and training ( 21 ). There is an urgent need for the osteopathic profession to conduct similar work. In recent decades, access and participation from minority groups to higher education in the UK has been a core focus and entry rates for non-white students have increased: in 2019 they were higher for all ethnic groups compared with rates in 2006 and the entry rates increased in 2019 compared with 2018 ( 61 ). There is limited information about experiences of inequalities reported by UrG students in osteopathic education or discrepancies in levels of attainment. A systematic review by MacMillan et al. ( 31 ) analysed discrimination, bullying and harassment in manual therapy education. They reported that there was evidence of widespread discrimination, harassment and bullying within manual therapy education; and there was a clear need for further research to focus upon the intersection of the characteristics identified as being linked to these experiences. Unfortunately, no osteopathic studies were found, although findings from physiotherapy and chiropractic education are likely to be transferable. Practising osteopaths from UrGs are also reported to be dissatisfied with lack of diversity within the profession and concerns have been raised about a lack of cultural competence training in OEPs. Norris et al. ( 60 ) recommended that healthcare education institutions need to provide consistent and accessible information to help students find appropriate support and education to increase staff awareness about how individual experiences of disability affect learning. Further research is needed to identify actions which would enhance educational experiences and outcomes for student osteopaths from UrGs. New data would also provide insights into the extent that osteopathic education prepares students to work with patients from UrGs and support long-term plans to enhance access and quality of care and attract more students from these UrG to enhance the profession and represent more inclusively the communities they serve ( 62 ). Limitations of the study It is difficult to collect data from people who feel marginalised or vulnerable to discrimination, as demonstrated by low survey response rates with participants who typically have strong positive or negative views but few from the ‘silent majority’ (Shapiro et al 2016). The MCHS is a new instrument which was adapted to osteopathy students, and due to the small sample size, it was not possible to get useful results with the confirmatory factor analysis. More research is also needed with this instrument to establish meaningful scores for dimensions of questionnaire. The response rate to this survey was low at 20% and there were fewer than 8 participants in all the focus groups, nevertheless it is representative of all osteopathic courses in UK and the mixed methods help to confirm the findings. The impact of facilitators as ‘insiders’ on data collection was not assessed and it was challenging to synthesise and weight results from the three stages. CONCLUSIONS The aims of this mixed methods study were to assess the level of cultural humility of osteopathic students and to explore the educational experiences of UrG students. Recommendations for urgent action included staff training, student support, and clarifying or changing processes and policies in osteopathic educational institutions. Declarations Ethics approval and consent to participate: The study was approved by the University College of Osteopathy Research Ethics Committee. For the survey, consent was assumed by return of the completed questionnaire (this was explained in the participant information sheet), and for the focus groups, informed consent was obtained from all participants. Consent for publication: not applicable Availability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to the sensitivity of data collected and risk of identification of participants but are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: This project received funding from four organisations: The Osteopathic Foundation provided £20,000, the General Osteopathic Council provided £7,500, the University College of Osteopathy provided £7,500, and the Institute of Osteopathy provided £3,000. The authors, including the Principal Investigator, are employed by the University College of Osteopathy. However, the University College of Osteopathy and other funders did not have any specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript. Authors' contributions: JDR, HA and SV designed the study and applied for ethical approval. AMM, HA, JDR, SV, YF facilitated the focus groups. KB collected and analysed the quantitative data; OT analysed and interpreted the qualitative data. HA, JDR, SV, YF facilitated the workshops. HA and JDR analysed the workshop data. All authors contributed, read and approved the final manuscript. Acknowledgements: Our thanks to Dr Phil Bright and Mr Dévan Rajendran for their support with the project, including the community engagement meetings. Authors' information: as described in the manuscript, the research team members acting as focus group and workshop facilitators identified with one or more minority groups. References Szetela A. Black Lives Matter at five: limits and possibilities. Ethn Racial Stud. 2020;43(8):1358–83. Regulska J. The #MeToo movement as a global learning moment. Int High Educ. 2018;94:5–6. Dodd V. Met police found to be institutionally racist, misogynistic and homophobic. 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Supplementary Files Supplmaterial1GRAMMSreporting.docx Supplmaterial2AdaptedversionofMCHS.docx Supplmaterial3tables.docx Supplmaterial4factoranalysis.docx Supplmaterial5workshopsthemes.xlsx Cite Share Download PDF Status: Published Journal Publication published 26 Apr, 2024 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 19 Mar, 2024 Reviews received at journal 08 Mar, 2024 Reviewers agreed at journal 27 Feb, 2024 Reviewers agreed at journal 27 Feb, 2024 Reviewers invited by journal 27 Feb, 2024 Editor assigned by journal 27 Feb, 2024 Editor invited by journal 05 Feb, 2024 Submission checks completed at journal 05 Feb, 2024 First submitted to journal 02 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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19:41:13","extension":"xlsx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14170,"visible":true,"origin":"","legend":"","description":"","filename":"Supplmaterial5workshopsthemes.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-3921151/v1/411c3207a580895e30dcfdc3.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study.","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSocial injustices affecting people from minority groups have been highlighted in recent worldwide initiatives such as the \u0026lsquo;Black Lives Matter\u0026rsquo; (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) and \u0026lsquo;Me Too\u0026rsquo; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) movements and investigations have identified institutional racism, sexism and homophobia in the police, other public services, and business organisations (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Limited demographic diversity and evidence of discrimination against minority groups have been reported in higher education in the United Kingdom (UK) (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and in healthcare services including medicine, psychiatry, and physiotherapy (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Data from higher education institutions suggest there is an urgent need to improve recruitment, educational experiences, and attainment for students from minority groups (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe terms \u0026lsquo;minority\u0026rsquo; or \u0026lsquo;under-represented\u0026rsquo; are often used interchangeably to describe groups of people identified by specific demographic or cultural characteristics. In this paper, the term \u0026lsquo;under-represented\u0026rsquo; is used to emphasise that experiences of inequity are typically created and maintained by social constructs such as \u0026lsquo;othering\u0026rsquo;: the process of identifying people as different from oneself or the mainstream culture, often associated with negative beliefs and expectations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Characteristics used to identify others can include skin colour, ethnicity, religion, gender identity, sexual identity, ability, size, socioeconomic status, history of trauma, addiction, and family environment (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This study focused on characteristics, and their intersectionality, associated with inequality in many areas of higher education - ethnicity; gender identity and sexual orientation (LGBTQIA+); and disabilities.\u003c/p\u003e \u003cp\u003ePeople from under-represented groups (UrGs) have historically been less likely to access higher education (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), although the number of BAME, LGBTQIA\u0026thinsp;+\u0026thinsp;and disabled students is gradually increasing in England (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Enrolled students from these groups are reported to experience more negative experiences during training and more limited later career opportunities afterwards (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The General Medical Council (GMC) recently set new targets to improve access and outcomes for students from UrGs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) as lack of diversity and limited cultural awareness among practitioners from different healthcare professions also impacts the quality and outcomes of healthcare for patients from UrGs (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The Council of Deans recently published a report on how to build an inclusive environment which highlights issues that affect students from minority ethnic groups in Allied Health Professions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients from UrG experience substantial health disparities in the UK and across the globe due to structural and interpersonal discrimination (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Developing cultural humility in clinicians is seen as key to bridging the gap of interpersonal discrimination. Cultural competence was once considered as an adequate way to provide an inclusive environment. It is defined as \u0026ldquo;a set of congruent behaviours, attitudes and policies that come together in a system, agency or among professionals that enable that system, agency or professions to work effectively in cross-cultural situations\u0026rdquo; (27 p. iv). The concept shifted to cultural humility, defined as \u0026ldquo;the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the client\u0026rdquo; (28 p. 354).\u003c/p\u003e \u003cp\u003eOsteopathy is a form of manual therapy which is now recognised as one of 14 Allied Healthcare Professions in England (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the UK, there are currently seven osteopathic education providers (OEPs) and approximately 5,300 qualified osteopaths. Training is typically over four or five years in the form of Bachelor\u0026rsquo;s or Integrated Masters awards and practitioners then register with the statutory regulator, the General Osteopathic Council (GOsC), and are required to comply with professional standards of practice (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is little known about discrimination, bullying and harassment in osteopathy education as highlighted in a recent systematic review (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Therefore, the current research project aimed to assess osteopathic students\u0026rsquo; awareness of cultural diversity and beliefs about patients from UrGs and their preparedness in managing them; to explore the educational experiences of students with UrG backgrounds during training and their opinions on changes to support better levels of recruitment and achievement. Finally, the research was disseminated to stakeholders in workshops with the overall aim of developing recommendations for action and creating change.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e \u003cstrong\u003eDesign\u003c/strong\u003e \u003cp\u003eTo meet the multiple project aims, a mixed methods approach was implemented and included the following stages; a survey of students attending all seven OEPs in the UK; focus groups with UrG students; and a workshop forum to explore the findings with diverse stakeholders. This design was based on a transformative action research paradigm with students participating as collaborators (Mertens 2007; 2010), informed by previous research into EDI, cultural competence and cultural humility in healthcare education, outlined below. The research complies with the Good Reporting of A Mixed Methods Study (GRAMMS) guidance (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) (see supplementary material 1 \u0026ndash; GRAMMS reporting).\u003c/p\u003e \u003c/p\u003e \u003cp\u003eFigure 1 below details the mixed method stages with the quantitative data collection (top half of figure), qualitative data collection (bottom half), and mixed methods stages (middle). The stages are represented chronologically, starting on the left.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e***insert Fig.\u0026nbsp;1 - study design around here***\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eMethodology\u003c/strong\u003e \u003cp\u003eThis research project sits within a transformative paradigm that places central importance on studying the lives and experiences of marginalised groups and is appropriate for addressing inequality and injustice in society (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). An explanatory sequential mixed methods design (survey followed by focus groups) was implemented to gain insight (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and community members were involved in initial discussions about operationalising the research focus. Transformative research has power issues and inequalities at its core and a political agenda that aims to change the experiences of the participants and institutions involved (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). The study was approved by the University College of Osteopathy Research Ethics Committee.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCommunity engagement\u003c/strong\u003e \u003cp\u003eTwo community engagement meetings with students from underrepresented groups were established prior to the project to ensure it was designed \u0026lsquo;with\u0026rsquo; students rather than \u0026lsquo;to\u0026rsquo;, \u0026lsquo;about\u0026rsquo; or \u0026lsquo;for\u0026rsquo; them. Based on principles by (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), these community engagement meetings co-created the study design, modified the research questionnaire and recruitment approaches.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eQuantitative stage\u003c/strong\u003e \u003cp\u003eA survey of all students currently enrolled on an osteopathic course in the UK was chosen to explore the research objectives. All students enrolled at the eight OEPs in the UK (excluding postgraduate and CPD courses) were eligible to take part in the anonymous online survey on Qualtrics\u0026copy;. Invitations, study information and accessible links were disseminated via OEP contacts who sent it to their student body between 7th and 31st March 2022. Two reminders were sent.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSurvey instrument\u003c/strong\u003e \u003cp\u003eThe Multidimensional Cultural Humility Scale (MCHS) was selected for this project as there is good evidence of convergent and discriminant validity and internal reliability (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). The MCHS has five dimensions, contains 15 items with a 6-point Likert scale from \u0026lsquo;strongly disagree\u0026rsquo; to \u0026lsquo;strongly agree\u0026rsquo; where higher scores represent greater levels of cultural humility.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eModifications to the MCHS were necessary to contextualise it for osteopathy students, so a factor analysis was conducted to assess the validity of the adapted version. Following the community engagement meetings, a 7th category was added: \u0026lsquo;This has never crossed my mind\u0026rsquo; to assess whether students were comfortable, confident or aware of particular issues (see supplementary material 2 for the adapted versions used in this study).\u003c/p\u003e \u003cp\u003eQuestions related to demographics and personal characteristics (clinical or pre-clinical student, age, birth sex, gender, ethnicity, health and disability status, sexual orientation, and religion), and to their experience of education were included at the end of the MCHS and were analysed separately to the MCHS questionnaire.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQualitative stage\u003c/b\u003e: Focus groups were selected for this phase and represented four UrG: ethnic minority, disability, LGBTQIA\u0026thinsp;+\u0026thinsp;or women. Whilst women are not numerically under-represented in UK osteopathic undergraduate training, socially they are more oppressed than men, including in manual therapy training (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The choice of these four groups was discussed and validated during the community engagement meetings. For sensitive topics, homogeneous groups foster a sense of belonging and facilitate disclosure (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The usual number of groups is around 4 but depends on the complexity of the topic and heterogeneity of the samples (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudents from any UK OEP who identified as belonging to at least one UrG (ethnic minority, disability, LGBTQIA\u0026thinsp;+\u0026thinsp;or women) were eligible to participate with students from the same and/or other OEPs. Each OEP was responsible for forwarding invitations to participate to their students. For convenience, focus groups were conducted online as students from different OEPs were geographically dispersed (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). The research team members acting as focus group facilitators identified with one or more minority groups, representing diversity and were therefore part of the data, as is good practice in transformative paradigmatic research (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). All facilitators had previously used focus group methods, participated in training, or were used to managing student group discussions. Teams\u0026copy; created automatic initial draft transcriptions to aid later transcription if participants talked simultaneously (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Final transcripts only included pseudonyms, as is common in qualitative research (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Focus groups usually comprise 6 to 8 people who meet once for approximately 90\u0026ndash;120 minutes. Focus groups sessions ran for approximately 90 minutes. Students who had participated in one of the four initial groups were invited to join one final mixed group to discuss the previous findings, and students who participated in at least one group were invited to take part in the workshop forum.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDissemination forum and workshops\u003c/strong\u003e \u003cp\u003eAn interactive face-to-face workshop-based forum was held on 06/04/2023 to disseminate the survey and focus group results, explore their implications, and develop recommendations for action. Key stakeholders invited to attend free of charge included UK OEPs, the General Osteopathic Council, the Institute of Osteopathy, the Osteopathic Foundation, and other healthcare profession organisations, NHS representatives, and Health Education England. Approximately 70 people attended the event. Three interactive workshops explored responses to the study results, personal experiences, and opinions about ways to develop a more supportive educational environment and inclusive curriculum.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMixed methods analysis\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative stage\u003c/h2\u003e \u003cp\u003eTo assess whether the 5-factor model of the MCHS remained valid following changes made to the scale, a confirmatory factor analysis was carried out using using R (version 4.3.2) (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e)and the R lavaan package (version 0.6\u0026ndash;16)(\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Missing MCHS data was imputed using multivariate imputation by chained equations (45). MCHS data was checked for normality using QQ plots and the Henze-Zirkler test.\u003c/p\u003e \u003cp\u003eA sum of all MCHS items (reverse coded as appropriate) was calculated as an overall measure of cultural humility. Linear regression was carried out to determine which demographic factors influenced this total score. Additionally, a Welch Two Sample t-test (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) was carried out to determine if MCHS total score differed between clinical and pre-clinical students. Chi-squared tests, with p-values estimated by Monte-Carlo simulation, were used to test for associations between students\u0026rsquo; report of having been treated differently one the one hand, and demographic factors on the other. Descriptive statistics were used to report survey results.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eQualitative stage\u003c/h2\u003e \u003cp\u003eFocus group data analysis was conducted within a reflexive thematic analysis framework (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), which aligns with a transformative paradigm (Creswell 2014). Data was co-created by participants and facilitators, and themes were co-created with analysts through their thoughtful engagement with the data (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). After conducting one focus group with each UrG (n\u0026thinsp;=\u0026thinsp;4), early analysis was conducted. Another 4 focus groups with different students were conducted to analyse how these participants\u0026rsquo; experiences resonated with the initial findings. The last focus groups ran with students from mixed UrGs to discuss the findings, conduct a meta-synthesis, and prioritise what actions students thought OEPs should prioritise.\u003c/p\u003e \u003cp\u003eDuring the three interactive forum workshops, participants\u0026rsquo; verbatim comments were collected on post-it notes and activity outcomes were recorded on flipcharts. Data was then categorised by the facilitators using frequency analysis to identify long and short-term priorities for OEPs.\u003c/p\u003e \u003cp\u003eThe data from the quantitative and qualitative phases were analysed separately, but then were considered together both in the dissemination forum workshops and within the research team. When considering the quantitative and qualitative datasets together, the research team operated within the methodological spirit of pragmatism, whereby both data sets were integrated in such a way that a useful insight to the research provide useful insights to participants\u0026rsquo; experiences and generate knowledge with social utility (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). In practice, this meant that the survey results were presented to the focus group participants to stimulate reflection and discussion in order to explore how the results compared with their personal experiences. Finally, the workshops provided an additional method to explore, situate and integrate the synthesised qualitative and quantitative data sets to support development of the final thematic model.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003e1. Quantitative results\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwo hundred and two participants filled in the survey, of which 117 (58%) were complete. The response rate was 20% (Table 1). Responses per OEP ranged between 6 to 68 (Table 2 \u0026ndash; OEP Responses).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e***insert table 1 \u0026ndash; response and completion rate***\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1 - response and completion rates\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"407\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.94103194103194%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOMPLETION\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.95823095823096%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFREQUENCY\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.1007371007371%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePERCENTAGE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.94103194103194%\" valign=\"top\"\u003e\n \u003cp\u003eINCOMPLETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.95823095823096%\" valign=\"top\"\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.1007371007371%\" valign=\"top\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.94103194103194%\" valign=\"top\"\u003e\n \u003cp\u003eCOMPLETE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.95823095823096%\" valign=\"top\"\u003e\n \u003cp\u003e117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.1007371007371%\" valign=\"top\"\u003e\n \u003cp\u003e58%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.94103194103194%\" valign=\"top\"\u003e\n \u003cp\u003eTOTAL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.95823095823096%\" valign=\"top\"\u003e\n \u003cp\u003e202\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.1007371007371%\" valign=\"top\"\u003e\n \u003cp\u003e100%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.94103194103194%\" valign=\"top\"\u003e\n \u003cp\u003eTotal population\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.95823095823096%\" valign=\"top\"\u003e\n \u003cp\u003eCa 1000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"37.1007371007371%\" valign=\"top\"\u003e\n \u003cp\u003e20% response rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2 \u0026ndash; Response by Osteopathic Education Provider\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003eNumber of responses per OEP (n=202)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e10 (5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e25 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e25 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e39 (19%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e6 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e8 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e21 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"25.806451612903224%\" valign=\"top\"\u003e\n \u003cp\u003eH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"74.19354838709677%\" valign=\"top\"\u003e\n \u003cp\u003e68 (34%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSeventy percent of the respondents provided demographic information (n=142). Participants were mostly white (n=95), female (n=74), without a disability (n=106), heterosexual (n=89), and identifying with no religion (n=69) (see table 3 \u0026ndash; respondent demographics).\u003c/p\u003e\n\u003cp\u003eTable 3 \u0026ndash; respondent demographics\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"600\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003en= (total 142)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex at birth\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e54.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e28.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eIntersex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNot answered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eWoman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e52.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eMan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e28.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNon-binary / Gender-variant / Non-conforming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eTransgender man\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eTransgender woman\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNot listed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNot answered\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e66.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eMixed or Multiple ethnic groups\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eAsian or Asian British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eBlack, African, Caribbean or Black British\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eOther ethnic groups\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDisability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e74.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eYes (details below, several answers possible per participant)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eMental health conditions and illnesses\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e3.5\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eDevelopmental impairment, such as autistic spectrum disorders (ASD), dyslexia and dyspraxia\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2.8\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eImpairments with fluctuating or recurring effects (such as rheumatoid arthritis, myalgic encephalitis (ME), chronic fatigue syndrome (CFS), fibromyalgia, depression and epilepsy)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1.4\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eSensory impairments (such as those affecting sight or hearing)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eProgressive impairment (such as motor neurone disease, muscular dystrophy, and forms of dementia)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eAuto-immune conditions (such as systemic lupus erythematosis)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eLearning disabilities\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eImpairment produced by injury to the body, including to the brain\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e0.7\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSexual orientation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eHeterosexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e62.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eBisexual / Pansexual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eGay / Lesbian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e7.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eOther\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003ePrefer not to say\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e48.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eChristian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSpiritual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eOther religions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eBuddhist\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eMuslim\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eJewish\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eSikh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eHindu\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"64.16666666666667%\" valign=\"top\"\u003e\n \u003cp\u003eNo response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"17.5%\" valign=\"top\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.333333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e19.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMost of the participants identified to some extent with an UrG (n=62, 53%). Of all the students who responded (53% self-identifying as UrG to some extent, and 47% who did not identify as UrG), 67.8% (n=80) reported that they had not been treated differently because of their cultural background/identity. Those who had been treated differently (n=19; 16%) stated that it happened at least a few times per year (n=15, 79%) (supplementary material 3, table a \u0026ndash; underrepresented groups treatment).\u003c/p\u003e\n\u003cp\u003eAssociations between demographic characteristics and UrG self-identification found that ethnicity (merging all categories excluding White), Disability and Sexual Orientation (merging all categories excluding heterosexual) were significantly associated with identifying as belonging to an UrG group (Supplementary material 3, Table b - UrG identification vs demographic group).\u003c/p\u003e\n\u003cp\u003eNo significant associations were found between demographic characteristics and reports of being treated differently (Supplementary material 3, table c - treated differently vs demographic group)\u003c/p\u003e\n\u003cp\u003eOf the 19 participants who reported having been treated differently because of their culture or identity, 79% (n=15) did not report it to their OEP, 15.8% (n=3) did, and 5.2% (n=1) did not answer.\u003c/p\u003e\n\u003cp\u003eIt was not possible to confirm or deny the adequacy of the 5-factor model proposed by Gonzales et al.\u0026nbsp;(37)\u0026nbsp;(Supplementary material 4), so our analysis was based on their 5-factor model (see table 4 \u0026ndash; MCHS results). Regarding the MCHS total score, no differences were found between clinical and preclinical students (Welch\u0026apos;s t = -0.194, df = 79.3, p = 0.847). A weak correlation between MCHS total score and importance to individual was found (Spearman\u0026rsquo;s rho(114)=0.27, p =0.003), and a weak relationship between self-rating of skills and MCHS total score (rho(114)=0.26, p=0.005). There was no apparent relationship between MCHS total score and participants\u0026rsquo; perception of support in the clinical environment for exploring patients\u0026rsquo; backgrounds and experiences (rho(106)=0.097, p= 0.3). No scores on these three questions differed significantly between clinical and preclinical students.\u003c/p\u003e\n\u003cp\u003eTable 4 \u0026ndash; MCHS results\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMCHS dimension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\"\u003e\n \u003cp\u003eOpenness\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e14.967\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e2.289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e2.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\"\u003e\n \u003cp\u003eSelf-awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e14.128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e3.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e3.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\"\u003e\n \u003cp\u003ePerson-centred\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e11.364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e3.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e5.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\"\u003e\n \u003cp\u003eTherapeutic interactions\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e10.861\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e4.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33%\"\u003e\n \u003cp\u003eReflective practice\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.5%\"\u003e\n \u003cp\u003e16.233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.833333333333332%\"\u003e\n \u003cp\u003e1.606\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.666666666666666%\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12%\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"2\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eQualitative results\u003c/strong\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eSeven groups were conducted, each were facilitated by two members of the research team (from AMM, HA, JDR, SV, YF). Data from the first 6 focus groups were organised into two themes which provide descriptive insights of participants\u0026rsquo; reflections on the quantitative findings and how the results related and resonated with their own experiences. The two primary themes were named institutional contextual obstacles (with 4 sub-themes) and UrG students\u0026rsquo; conceptual understanding of EDI (with 3 sub-themes). The themes and sub-themes were modelled and presented to the final focus group to facilitate reflective discussions, see figure 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e***insert figure 2 -\u0026nbsp;\u003c/em\u003emodel based on focus groups\u0026rsquo; themes and sub-themes\u003cem\u003e\u0026nbsp;***\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 1: Institutional contextual obstacles\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first sub-theme,\u003cem\u003e\u0026nbsp;Faculty\u0026rsquo;s lack of awareness \u0026amp; knowledge,\u003c/em\u003e was a commonly reported barrier.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI think there\u0026rsquo;s a lot of talk of self-reflection, at least at the OEP, and it doesn\u0026rsquo;t to me feel like all of our teachers practise that.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve had more problems with staff understanding than student understanding\u0026rdquo;. (Talking about their disability)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;There was no awareness, you know, of that within the class or from the tutors, in those circumstances (managing an LGBTQ+ patient), what do we do, what language do we use, (\u0026hellip;) when it was raised the tutor was sort of like, actually, I don\u0026rsquo;t have an answer, I\u0026rsquo;m not sure.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRacist, sexist and ableist comments made by staff negatively affected the way students interacted with patients in the OEPs clinics, and with other students, particularly in practical classes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was doing a neck and then teacher wants me to talk when I\u0026rsquo;m doing it and I say, because / when I\u0026rsquo;m doing it, I can\u0026rsquo;t talk and he made a comment, as a woman, you should talk and you should do it, you should multi-task and at that time I couldn\u0026rsquo;t say anything because I [was] already panicking and I\u0026rsquo;m doing this thing. I couldn\u0026rsquo;t say anything.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;[A male tutor] put [a female tutor acting as a model] side-lying and [he] was going to crack her back but then when he pulled her shirt up her scrubs pants were like mid-way / quite / kind of showing her underwear (\u0026hellip;) When we told him that he should pull her scrubs up, he made the thing super uncomfortable.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When they make an attack, as a joke, and people laugh, that\u0026rsquo;s positive behaviour, they\u0026rsquo;re going to make the joke again because it\u0026rsquo;s funny, so I don\u0026rsquo;t know if they can understand that it\u0026rsquo;s actually a knife that you\u0026rsquo;re throwing at someone and not just a joke.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe second sub-theme related to a lack of support from institutions for students from UrG, and a lack of clarity of processes available to them to complain about discriminatory behaviours against them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When I was sort of going through the process of applying for the disabled students\u0026rsquo; allowance, which I didn\u0026rsquo;t even know that I was / its existence to be honest, (\u0026hellip;) I had to get the OEP to fill out a form and rubber stamp it and it seemed to get lost in this abyss of I don\u0026rsquo;t know where it went. (\u0026hellip;) but there was a lot of chasing up to do [laughs] and even getting the form signed again, because I have to reapply every year, was a bit of a faff.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants who reported discrimination, were lacking certainty that reported these instances would lead to change.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Particularly when it\u0026rsquo;s a comment like that that\u0026rsquo;s made and it almost leaves you like gobsmacked and you\u0026rsquo;re like well what do I say to that, how do I go about telling someone about that?\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe third sub-theme was \u003cem\u003eStudent attitudes\u003c/em\u003e e.g., peers\u003cem\u003e\u0026nbsp;\u003c/em\u003emaking sexist comments and using negative language about UrGs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;People have said things, especially kind of bisexual tropes and things like that about you know being greedy and I know it\u0026rsquo;s / (\u0026hellip;) people think oh that\u0026rsquo;s funny (\u0026hellip;) it just makes you feel like you are going inward kind of thing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have that much of an understanding of the difference that ethnicity has on sort of different diseases and different morphologies and things like that, so it\u0026rsquo;s something (\u0026hellip;) I\u0026rsquo;d love to learn more about.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I was practicing thoracic HVT with (\u0026hellip;) some first years [students] and I started doing thoracic HVT and one of the first years asked me to do it on him, so I was like, okay, umm, I explained to him you know everything, asked for his consent and stuff, but because he was like a funny guy, he was talking all the time, I was like, okay, can you just sit down for me to do the technique and I told him my nationality before that and then he goes like oh that\u0026rsquo;s how I know you are Brazilian, your attitude, you probably go on top. I\u0026rsquo;m just like what? \u0026nbsp;You know / yes, I didn\u0026rsquo;t even know what to say at this time, because I was just / I just told him, look, I\u0026rsquo;m not doing the technique, I thought, goodbye.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants reported instances where students from privileged backgrounds remained silent when facing discriminatory comments from educational faculty; a factor that perpetuated a non-inclusive culture, as people who used discriminatory or \u0026lsquo;othering\u0026rsquo; language were not challenged to reflect on their attitudes and behaviour. In contrast, participants from UrGs felt a sense of duty to raise concerns:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t create problems and stuff, but if there is something if I see it not going right, I like to raise my voice as much as I can and I try to make changes.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe fourth sub-theme was \u003cem\u003eLack of representation\u003c/em\u003e in the student body, patient population and the curriculum.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Everything that we get taught is 99% on like a male sex anatomy. Like I remember when I was learning how to do all the like umm cardiac testing and respiratory we were taught by a male teacher on a male body and then when it came to like a female and like you have boobs and they\u0026rsquo;re like, oh, you can\u0026rsquo;t do this bit at the front, or you have to be more careful, but then there was no example of how\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026ldquo;I think I felt surprised when coming into the / into osteopathy how less diverse (in student demographics?) it is than my previous position.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I feel quite diverse but people that we see in clinic are mainly Caucasian, so I also think there\u0026rsquo;s something about the outreach of osteopathy into different cultural communities, for example, most of my family, though we\u0026rsquo;ve all been brought up here, nobody would use an osteopath (\u0026hellip;)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;When we learn about physiology and pathologies, I feel like there\u0026rsquo;s now a real effort to talk about say like black people, which is fantastic, but then you know what about Asian (\u0026hellip;)\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTheme 2: Underrepresented students\u0026rsquo; understanding of EDI\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe first sub-theme related to the \u003cem\u003edefinition of discrimination\u003c/em\u003e and echoed findings from community engagement discussions. Students distinguished between \u0026apos;othering\u0026apos; and \u0026apos;intent\u0026apos;. Participants perceived discrimination only when actions had an intent to discriminate against individuals or communities, rather than actions that led to people or groups being treated differently regardless of intent. During the focus groups, participants reported equal treatment, but data analysis suggests instances of discrimination.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;No, only in so much as, you know, the reasonable adjustments aspect, but then I\u0026rsquo;ll ask for that, but besides that, I haven\u0026rsquo;t / I haven\u0026rsquo;t had any different treatment.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026rsquo;ve definitely been treated differently as a woman and / but I\u0026rsquo;ve witnessed the / in my class Asian women being treated differently, but the Asian men not so much so.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe second sub-theme related to the advocacy of UrG students as role models for their peers. Students used their own experience of belonging to an UrG as personal knowledge to help inform their peers about what it is like to \u003cem\u003ebe\u003c/em\u003e a person from wider UrG communities. This helped to fill gaps in the EDI training or make up for a lack of training received by educators. UrG students acted as advocates to prevent wrong messages, jokes being shared, e.g.,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I think it\u0026rsquo;s / not just from my disability, but yes, from / for all other students I think when they / things come up, sometimes quite surprising things actually, it\u0026rsquo;s usually / yes, pretty interesting and helpful for all of us.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We use it [disability] sometimes in class as part of like chronic pain, as part of that kind of presentation and things like that because I have an understanding of it, whereas instead of just pulling stories out of thin air.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe third related sub-theme was that students from UrGs appeared to have a better understanding of EDI than their peers and faculty members. Students\u0026rsquo; advocacy role included training and supporting their peers in how they should manage situations when facing patients with specific conditions, e.g. type 1 diabetes, and offered a useful insight which would be valued by patient.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I mean do they have to? Should they? I think you know, like I\u0026rsquo;ve said, the only reason I do [disclose] it is because you know I wouldn\u0026rsquo;t want to put anybody else in a tricky position if I was to, you know, have like a hypo in class or anything like that, which you know, I may do one day.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis created an environment where students from UrGs not only had to teach other students and faculty, but also had to learn on their own, as they were not able to gain knowledge from staff on topics related to UrG, and then had to teach what they learned to their peers and faculty members.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;But we don\u0026rsquo;t get taught about how to deal with somebody that\u0026rsquo;s transgender or anything like that. It\u0026rsquo;s like well you\u0026rsquo;ll have to you know just find out about that yourself.\u0026rdquo;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have that much of an understanding of the difference that ethnicity has on sort of different diseases and different morphologies and things like that, so it\u0026rsquo;s something (\u0026hellip;) I\u0026rsquo;d love to learn more about.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe final mixed focus group was used to explore whether the above findings represented the experiences of these participants, and to generate suggestions for OEP action to become more inclusive.\u0026nbsp;Goals thought to be quickly achievable and likely to lead to sustained change was providing urgent training for staff, and then students, to improve awareness and knowledge, and to break the issue of the cycle of unaware students becoming unaware teachers.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eL\u003c/em\u003e\u003cem\u003eack of diversity \u0026lsquo;breeds\u0026rsquo; a lack of diversity\u0026rdquo;\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;A lot of the main institutional barriers is the university\u0026rsquo;s lack of knowledge and the best way to deal with that is directly linked to how the under-represented students can like just you know break this barrier by teaching others and also by getting contact with the university\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eActive bystander training was recommended to promote collective responsibility in challenging bias and negative views. Other suggestions included providing support for students from UrGs, countering negative views amongst peers and faculty, employing active strategies to promote patient diversity, being more equitable in services offered, and ensuring training was implemented. The final recommendation was to increase representativeness in the curriculum, as a way of training staff and students through regular exposure to up-to-date information regarding UrGs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;if the institutions were to be more aware\u0026nbsp;\u003c/em\u003e[of EDI] \u003cem\u003eand have\u0026nbsp;\u003c/em\u003e[EDI training]\u003cem\u003e\u0026nbsp;...., \u0026nbsp;I don\u0026rsquo;t know what training\u0026rsquo;s mandatory training\u0026rsquo;s given, but it would seem like potentially a lot of it\u0026nbsp;\u003c/em\u003e[othering] \u003cem\u003ecould potentially be stopped. It just seems because you\u0026rsquo;ve got the lack of representation to faculty, race in faculty, they all sort of interlink with the other parts.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants felt that more and better training was needed for staff on EDI issues; a potential barrier to implementation was time, but short courses were expected to be effective.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003e\u003c/strong\u003e\u003cem\u003eevery job I\u0026rsquo;ve ever done, either private sector, public sector, there is mandatory training and EDI\u0026rsquo;s, (\u0026hellip;) human trafficking, (\u0026hellip;) blackmail. (\u0026hellip;) But I think we\u0026rsquo;re only talking like a half an hour\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n\u003col start=\"3\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eWorkshop results\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eQuantitative and qualitative data were considered together in the forum workshops by presenting of the survey results and focus group data prior to the workshops. The themes identified during the series of workshops using frequency analysis of post-it notes and recurring comments across the three workshops were organised in Fig 3 in relation to the groups involved in the recommended actions. Supplementary material 5 provides further details on the recommended actions.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe aims of this innovative mixed methods study were to survey student osteopaths\u0026rsquo; levels of cultural humility as a proxy for preparedness to work with patients from underrepresented groups (UrGs) and to explore the educational experiences of UrG students, to support recruitment and achievement. Results were disseminated in an interactive forum with a variety of stakeholders using workshops to develop recommendations for action. The main obstacles to enhancing EDI in OEPs were lack of clarity and awareness about EDI; lack of representation and inclusivity in the curriculum; and lack of student support and action to address discrimination. Suggestions for action, validated by the final focus groups and workshops, focused on \u003cb\u003eeducating staff, supporting students, and clarifying or changing processes and policies in osteopathic educational institutions.\u003c/b\u003e Implications of the findings are discussed below in the context of research, wider EDI issues, and osteopathic education.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEducating staff\u003c/h2\u003e \u003cp\u003eThis study focused on assessing levels of cultural humility in student osteopaths, but findings indicated that experiences of discrimination were often associated with lack of awareness or negative attitudes among staff, suggesting that staff training is urgently required. Similar findings were found in Bakaa et al. (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) who surveyed cultural competence in a sample of 3,000 chiropractors and suggested that gaps between knowledge and self-reported behaviour required further research to clarify barriers and guide future training.\u003c/p\u003e \u003cp\u003eCultural humility is a lifelong commitment to developing awareness to disparities experienced by people from diverse cultural groups, reflecting and being open to learning (\u003cspan additionalcitationids=\"CR51 CR52\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). This model encourages practitioners to collaborate with patients, and educators to collaborate with students, to find solutions to discrimination and inequality based on their lived experiences and priorities (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) and could be a basis for osteopathic educator training and practice. There is limited evidence exploring the impact of cultural humility training with healthcare professional educators. There is mixed evidence about whether cultural competence training improves patient outcomes or reduces health disparities in healthcare professionals (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). A focus group study by Shapiro et al. (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) suggests training increased awareness among third year medical students (first year of clinical training) but was less helpful in developing specific management skills or for balancing group-based knowledge and individual patient needs. In another study, medical students have been found to minimise the importance of self-awareness or the need to reflect on, and confront, personal biases (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Despite these challenges of impact of training, there is consensus that the absence of training is also problematic. Whether based on concepts of cultural awareness, competence and humility (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e) it is important that the sceptical perception that training is trying to be \u0026lsquo;politically correct\u0026rsquo; is transformed into a way of rehumanising healthcare education (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Flateland et al. (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e) concluded that inclusivity could be increased through mandatory diversity training which emphasised individual learning needs for students from all backgrounds and was supported by mentoring from personal academic tutors and a buddy system for students from under-represented groups. Therefore, osteopathic education staff education is warranted and requires further investigation to identify the impact of this on students and on patients.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSupporting students\u003c/h2\u003e \u003cp\u003eInequalities in healthcare education are well documented (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Physiotherapy students from black, Asian and minority ethnic (BAME) backgrounds received lower marks in observed assessments compared to white students, with gaps in attainment also recorded for people with disabilities and students with non-traditional entry routes (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Studies suggest that explanatory factors include limited disclosure of difficulties, especially for \u0026lsquo;invisible\u0026rsquo; disabilities (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), the complex challenges faced by students with intersectional backgrounds (\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e), and lack of awareness among staff (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Inconsistent institutional support practices also reinforce students\u0026rsquo; disabled status and limit participation, rather than optimising their abilities and resilience (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Overseas students, especially those who do not speak English as a first language, report isolation, loneliness, and lack of support, which is increased by intersectionality including race and gender (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). There is a need to develop clear and robust systems to support students from UrG in higher educational institutions and to assess how these could be further improved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eClarifying or changing processes and policies in osteopathic educational institutions\u003c/h2\u003e \u003cp\u003eAll educational institutions have a responsibility to overcome the challenges of inaction in the face of discrimination. Training inequalities are known to be a concern in medical and allied health professions. The General Medical Council has recently set new targets to eradicate disadvantage and discrimination in medical education and training (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). There is an urgent need for the osteopathic profession to conduct similar work. In recent decades, access and participation from minority groups to higher education in the UK has been a core focus and entry rates for non-white students have increased: in 2019 they were higher for all ethnic groups compared with rates in 2006 and the entry rates increased in 2019 compared with 2018 (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). There is limited information about experiences of inequalities reported by UrG students in osteopathic education or discrepancies in levels of attainment. A systematic review by MacMillan et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e) analysed discrimination, bullying and harassment in manual therapy education. They reported that there was evidence of widespread discrimination, harassment and bullying within manual therapy education; and there was a clear need for further research to focus upon the intersection of the characteristics identified as being linked to these experiences. Unfortunately, no osteopathic studies were found, although findings from physiotherapy and chiropractic education are likely to be transferable. Practising osteopaths from UrGs are also reported to be dissatisfied with lack of diversity within the profession and concerns have been raised about a lack of cultural competence training in OEPs.\u003c/p\u003e \u003cp\u003eNorris et al. (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) recommended that healthcare education institutions need to provide consistent and accessible information to help students find appropriate support and education to increase staff awareness about how individual experiences of disability affect learning.\u003c/p\u003e \u003cp\u003eFurther research is needed to identify actions which would enhance educational experiences and outcomes for student osteopaths from UrGs. New data would also provide insights into the extent that osteopathic education prepares students to work with patients from UrGs and support long-term plans to enhance access and quality of care and attract more students from these UrG to enhance the profession and represent more inclusively the communities they serve (\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of the study\u003c/h2\u003e \u003cp\u003eIt is difficult to collect data from people who feel marginalised or vulnerable to discrimination, as demonstrated by low survey response rates with participants who typically have strong positive or negative views but few from the \u0026lsquo;silent majority\u0026rsquo; (Shapiro et al 2016). The MCHS is a new instrument which was adapted to osteopathy students, and due to the small sample size, it was not possible to get useful results with the confirmatory factor analysis. More research is also needed with this instrument to establish meaningful scores for dimensions of questionnaire. The response rate to this survey was low at 20% and there were fewer than 8 participants in all the focus groups, nevertheless it is representative of all osteopathic courses in UK and the mixed methods help to confirm the findings. The impact of facilitators as \u0026lsquo;insiders\u0026rsquo; on data collection was not assessed and it was challenging to synthesise and weight results from the three stages.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe aims of this mixed methods study were to assess the level of cultural humility of osteopathic students and to explore the educational experiences of UrG students. Recommendations for urgent action included staff training, student support, and clarifying or changing processes and policies in osteopathic educational institutions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eEthics approval and consent to participate: The study was approved by the University College of Osteopathy Research Ethics Committee. For the survey, consent was assumed by return of the completed questionnaire (this was explained in the participant information sheet), and for the focus groups, informed consent was obtained from all participants.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsent for publication: not applicable\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvailability of data and materials: The datasets generated and/or analysed during the current study are not publicly available due to the sensitivity of data collected and risk of identification of participants but are available from the corresponding author on reasonable request.\u003c/li\u003e\n \u003cli\u003eCompeting interests: The authors declare that they have no competing interests\u003c/li\u003e\n \u003cli\u003eFunding: This project received funding from four organisations: The Osteopathic Foundation provided \u0026pound;20,000, the General Osteopathic Council provided \u0026pound;7,500, the University College of Osteopathy provided \u0026pound;7,500, and the Institute of Osteopathy provided \u0026pound;3,000. The authors, including the Principal Investigator, are employed by the University College of Osteopathy. However, the University College of Osteopathy and other funders did not have any specific role in the conceptualization, design, data collection, analysis, decision to publish, or preparation of the manuscript.\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; contributions: JDR, HA and SV designed the study and applied for ethical approval. AMM, HA, JDR, SV, YF facilitated the focus groups. KB collected and analysed the quantitative data; OT analysed and interpreted the qualitative data. HA, JDR, SV, YF facilitated the workshops. HA and JDR analysed the workshop data. All authors contributed, read and approved the final manuscript.\u003c/li\u003e\n \u003cli\u003eAcknowledgements: Our thanks to Dr Phil Bright and Mr D\u0026eacute;van Rajendran for their support with the project, including the community engagement meetings.\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; information: as described in the manuscript, the research team members acting as focus group and workshop facilitators identified with one or more minority groups.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSzetela A. Black Lives Matter at five: limits and possibilities. Ethn Racial Stud. 2020;43(8):1358\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegulska J. The #MeToo movement as a global learning moment. Int High Educ. 2018;94:5\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDodd V. 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Int J Osteopath Med. 2021;40:38\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Underrepresented ,Oppressed ,Social justice ,Equity diversity and inclusion ,Transformative action research ,Osteopathic undergraduate education ,Women ,Disability ,LGBTQIA+ ,Ethnic minorities","lastPublishedDoi":"10.21203/rs.3.rs-3921151/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3921151/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eIndividuals from minority groups have historically faced social injustices. Those from underrepresented groups have been less likely to access both healthcare services and higher education. Little is known about the experiences of underrepresented students during their undergraduate studies in osteopathy in the UK. The aim of this project was to evaluate osteopathic students' awareness of cultural diversity and their beliefs about patients from underrepresented backgrounds, as well as their preparedness to manage them. The project also aimed to investigate the educational experiences of students from underrepresented backgrounds during their training and their opinions on changes that could support better levels of recruitment and achievement. The findings were disseminated to stakeholders through interactive workshops with the aim to develop recommendations for action and change.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA transformative action research paradigm informed this mixed methods project. It included: 1/ a survey of students from all seven osteopathic educational providers in the UK using the Multidimensional Cultural Humility Scale (MCHS); 2/ a series of focus groups with students from underrepresented groups (women, students with disabilities, students from minority ethnic backgrounds, and students identifying as LGBTQIA+); and 3/ a workshop forum to discuss findings.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 202 participants completed the MCHS and demographic questionnaire and seven focus groups were conducted. A model was developed to describe participants' training experiences comprising two main themes: institutional contextual obstacles (with four sub-themes) and underrepresented students' conceptual understanding of Equity, Diversity and Inclusion (EDI). Recommendations for change identified in the workshops were based on three topics: institutions, staff, and students.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur findings suggest that staff education is urgently needed to create and maintain equitable, inclusive environments in osteopathic educational institutions in the UK to support all students, particularly those from underrepresented groups. Institutional EDI processes and policies also need to be clarified or modified to ensure their usefulness, accessibility, and implementation.\u003c/p\u003e","manuscriptTitle":"Overcoming barriers to equality, diversity, inclusivity, and sense of belonging in healthcare education: the Underrepresented Groups’ Experiences in Osteopathic Training (UrGEnT) mixed methods study.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-07 19:41:07","doi":"10.21203/rs.3.rs-3921151/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-19T04:10:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-08T23:54:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"dec8d3f4-0ce4-484d-9bc8-e11fc078e502","date":"2024-02-28T02:22:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6af98f3f-269f-409a-8bad-17b453f1ad11","date":"2024-02-27T21:49:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-27T19:08:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-27T19:02:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-05T10:39:06+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-05T10:37:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-02-02T14:09:47+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e3391b7a-33ed-4afd-9d52-d745df4d0240","owner":[],"postedDate":"February 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-05-01T22:42:01+00:00","versionOfRecord":{"articleIdentity":"rs-3921151","link":"https://doi.org/10.1186/s12909-024-05404-3","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2024-04-26 22:42:01","publishedOnDateReadable":"April 26th, 2024"},"versionCreatedAt":"2024-02-07 19:41:07","video":"","vorDoi":"10.1186/s12909-024-05404-3","vorDoiUrl":"https://doi.org/10.1186/s12909-024-05404-3","workflowStages":[]},"version":"v1","identity":"rs-3921151","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3921151","identity":"rs-3921151","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}