Observational Study of the Effect of ESFT Approach on Cross-Culture Competency Teaching for Young PGY Physicians

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This study aims to investigate the impact of a cross-cultural competence course, based on the ESFT (Explanation, Social and Environmental Factors, Fears and Concerns, Therapeutic Contracting) model, on young physicians' cultural sensitivity and related competencies within Taiwan’s healthcare system. Methods Forty young PGY physicians enrolled in this study and ESFT teaching model was implemented. By using a mixed-methods approach, which combines both quantitative and qualitative surveys allows for a comprehensive evaluation of the course's effectiveness. Results It showed that significant improvements in cultural sensitivity, multicultural perceptions, multicultural competencies, and cultural care competence, particularly among male physicians and those with over two years of clinical experience. However, female participants and those with less clinical experience did not demonstrate significant improvement. The study identifies regional cultural diversity as a potential factor contributing to the observed differences in competence development. Furthermore, qualitative feedback emphasized the importance of real-life clinical scenarios in enhancing learning outcomes. Conclusion The study's findings underscore the need for targeted, adaptable cross-cultural education programs that account for gender and clinical experience differences. Future research should focus on long-term effects and diversified teaching strategies to optimize cross-cultural competence training in medical education. This approach could improve physician-patient communication and healthcare quality in increasingly multicultural societies. Cross-Culture Competency ESFT PGY Background With the rapid development of globalization, international mobility has become increasingly frequent, leading to more intensive cross-cultural contact and exchange. As an essential region under the influence of globalization, Taiwan has seen a continuous rise in the number of new immigrants, individuals who have recently moved to Taiwan from other countries, gradually becoming the second-largest ethnic group in Taiwanese society. According to the National Immigration Agency of the Ministry of the Interior, from 1987 to 2021, the number of new immigrants in Taiwan exceeded 560,000, mainly from China, Vietnam, Indonesia, and other countries [ 1 ]. These immigrants from different cultural backgrounds have further contributed to Taiwan’s societal diversity, particularly within the healthcare system, where the needs of patients from diverse cultural backgrounds are significantly different. Healthcare providers are increasingly facing cross-cultural challenges, especially in patient care, doctor-patient communication, and treatment outcomes. According to Betancourt's research, cross-cultural competency can be enhanced through organizational, structural, and clinical interventions to improve the quality of care in the context of cultural differences [ 2 , 3 ]. Therefore, cultivating the cultural competence of healthcare professionals has become essential to better meet the needs of cross-cultural care and has gradually become one of the core issues in medical education. Although the importance of cross-cultural competency has been widely recognized in academia and medical practice, there are still several gaps in current research and practice. Firstly, past medical education has predominantly focused on overcoming language barriers, primarily emphasizing establishing diagnoses and treatment [ 4 ]. This treatment-centered model often overlooks the more profound influence of cultural factors in doctor-patient communication, leading to superficial approaches to cross-cultural care in practice. Secondly, although international assessment tools for cultural competency, such as Campinha-Bacote’s IAPCC scale [ 5 ], exist, most of these tools are based on Western cultural contexts. They may need to reflect the cultural differences within Taiwan's healthcare environment fully. Furthermore, Taiwanese medical students' understanding of the health disparities and care needs of patients from different cultural backgrounds still needs to be improved. According to preliminary studies, while young physicians perform well in cultural sensitivity, they demonstrate relatively weaker performance in cultural care competence and self-assessment skills, reflecting significant room for improvement in Taiwan's medical education regarding enhancing cross-cultural competency. Current cross-cultural curricula are primarily one-directional lectures, lacking experiential learning mechanisms such as situational simulations. These are crucial for developing medical students’ abilities to respond to cross-cultural challenges in real-life contexts. Given the current situation, while the course content can benefit cross-cultural competency learning, the "banking education method" commonly reduces learners' acceptance, resulting in lower learning effectiveness in cross-cultural competence. According to Freire's critique, banking education places students in a passive role, where knowledge is transmitted rather than internalized, limiting students' critical thinking and problem-solving abilities, especially when developing cross-cultural competency [ 6 ]. This educational model often fails to promote students' interaction and understanding of different cultures effectively, thus affecting their cross-cultural learning outcomes [ 6 ]. Therefore, this study utilizes an innovative teaching model—the ESFT (Explanation, Social and Environmental Factors, Fears and Concerns, Therapeutic Contracting) model—to explore the relationship between the ESFT model and teaching cultural competency to young physicians. It examines the effectiveness of the ESFT model in enhancing young physicians' communication and care abilities in cross-cultural contexts. The ESFT model has traditionally been used for educational communication between physicians and patients, with the advantages of being structured and personalized. This model emphasizes understanding the patient's cultural background, social and environmental factors, fears and concerns, and establishing a therapeutic contract. This approach enhances communication efficiency between doctors and patients, promoting trust and cooperation in the doctor-patient relationship [ 7 – 9 ]. By systematically addressing patient needs, this model ensures that medical plans align more with patients' cultural and personal circumstances, which helps improve treatment adherence and overall outcomes. From the adult education perspective, this study assumes that the relationship between the physician and the patient is similar to that between the educator and the learner in medical knowledge. Therefore, applying the ESFT model to cultural competency teaching is expected to promote the relationship between the educator and the learner. This study adopts this teaching model in cultural competency teaching to help physicians better understand their patients' cultural backgrounds and needs. The ESFT model emphasizes four core dimensions: Explanation, which focuses on understanding the patient's or learner’s beliefs and understanding of the disease or problem; Social and Environmental Factors, which consider the impact of the patient’s or learner's social background and living environment on their health and learning; Fears and Concerns, which identify the anxieties and worries in cross-cultural interactions; and Therapeutic Contracting, where feasible treatment or learning plans are jointly discussed and negotiated [ 10 ]. The results of this study provide educators with an innovative teaching method to help young physicians understand the needs of patients from different cultural backgrounds, enhancing their cross-cultural competency and offering empirical support for cultivating cross-cultural competency in medical education. Methods This study adopts a mixed methods design to evaluate the effectiveness of a cross-cultural competence course, based on the ESFT model, in enhancing the multicultural competence of young physicians. The research methodology comprises two main components: quantitative assessment and qualitative analysis. The quantitative part measures changes in the young physicians' multicultural competence using related scales. In contrast, the qualitative part explores the participants' learning experiences and the effectiveness of the course design through focus group discussions. Clinical trial number: Not applicable. Participants This study's participants were medical interns and young PGY (Postgraduate Year) physicians with at least one year of clinical experience at a medical center. Participants were collected using convenient sampling and snowball sampling methods. All participants fully understand the contents of the Consent to Participate declaration document, including information about the ethical guidelines followed, the voluntary nature of participation, and how participant data will be used in the manuscript. Course Design Before starting the cross-cultural competency course, pre-course meetings were held with experts and instructors on cross-cultural topics to reach a consensus. The course used visual aids and reflective videos as guiding tools, with scenario simulations to enhance cross-cultural communication skills. The content was designed around the four core dimensions of the ESFT model: Explanation, Social and Environmental Factors, Fears and Concerns, and Therapeutic Contracting. These four dimensions covered the following areas: Explanation, Social and Environmental Factors, Fears and Concerns, and Therapeutic Contracting. The course utilized experiential learning, reflective learning, and focus group interviews as teaching methods, emphasizing participatory learning and experiential reflection. Post-course assessments incorporated cross-cultural issues into the OSCE simulation exams to evaluate the course’s effectiveness. Quantitative Data Collection The evaluation of cross-cultural competence teaching was divided into four areas: cultural sensitivity, cultural care competence, multicultural perceptions, and multicultural competence. Cultural sensitivity was assessed using a translated and modified Intercultural Sensitivity Scale. Cultural care competence was measured using a cultural care competence scale. Multicultural perceptions were adapted from the Multicultural Perceptions Scale (MCP) [ 11 ], and multicultural competence was assessed using the Multicultural Competences Scale (MCC) [ 12 ]. Qualitative Data Collection Qualitative data were collected through focus group discussions to gain in-depth insights into the participants' learning experiences and perceptions of the application of the ESFT model. Trained interviewers led the research team's talks. Discussion topics centered on the participants' views regarding the course content, teaching methods, and perceived changes in cultural competence. The entire discussion was audio-recorded, transcribed verbatim, and later analyzed using thematic analysis. Results Demographic Information of Participants Among the participants in this study, 60% were male (24 participants), and 40% were female (16 participants), with an average age of 26.4 years (SD = 2.4). Most (60%, 24 participants) lived in southern Taiwan before university, followed by central Taiwan. In terms of religion, Taoism and no religion/others were the most common, accounting for 47.5% (19 participants) and 37.5% (15 participants), respectively. The majority ethnic group was Hokkien, representing 70% (28 participants). Performance in Cross-Cultural Competence The participants’ cross-cultural competence was assessed using a combination of the cultural care competence scale, the multicultural perceptions scale (MCP), and the multicultural competence scale (MCC). Pre- and post-test results showed significant differences. The overall post-test mean score on the cultural care competence (M = 38.4, SD = 4.6) was higher than the pre-test mean score (M = 36.6, SD = 4.2) (t = 3, p < .01). Similarly, the overall post-test mean score on the multicultural perceptions (M = 68.9, SD = 7.9) was higher than the pre-test mean score (M = 66.1, SD = 8.4) (t = 3.63, p < .01). The overall post-test mean score on the multicultural competences (M = 60.4, SD = 7.9) was higher than the pre-test mean score (M = 57.6, SD = 8.5) (t = 3.02, p < .01), indicating a significant improvement in cross-cultural competence following the course. Table 1 T-test of cross-culture competency ( N = 30) Pre-test Mean SD Post-test Mean SD t-test Cultural Sensitivity 52.3 6.8 54.0 6.2 1.96 Cultural Care Competence 36.6 4.2 38.4 4.6 3.0** Multicultural Perceptions 66.1 8.4 68.9 7.9 3.63** Multicultural Competences 57.6 8.5 60.4 7.9 3.02** * p < .05 **p < .01 The Impact of Pre-University Residence on Cultural Care Competence According to the results of non-parametric statistical analysis, participants who resided in southern and central Taiwan before university exhibited significantly higher cultural care competence than those from northern Taiwan (Table 2 ). This result suggests that the change in cultural care competence after attending the cross-cultural competence course is influenced by the participants' pre-university residence. Table 2 Kruskal-Wallis Test Analysis on Cultural Competence Assessment Scales by Pre-University Residence ( N = 40) Pre-University Residence N Difference between pre and post-test Mean SD Cultural Sensitivity North 6 -0.67 1.51 Middle 9 4.67 6.26 South 24 1.25 6.04 East 1 3.00 Cultural Care Competence* North 6 -0.67 1.03 Middle 9 2.22 2.59 South 24 2.38 4.42 East 1 -1.00 Multicultural Perceptions North 6 -0.17 2.86 Middle 9 4.78 3.56 South 24 2.38 5.07 East 1 10.00 Multicultural Competences North 6 1.83 2.48 Middle 9 4.44 5.13 South 24 2.83 6.66 East 1 -6.00 The Impact of Clinical Exposure Time on Cultural Care Competency Non-parametric statistical analysis revealed significant differences in the change in cultural care competency based on participants' clinical exposure time. Participants with more than two years of clinical experience had significantly higher post-test scores in cultural care competence compared to those with less than two years of experience. It indicates that those with more significant clinical experience showed more noticeable improvements in cross-cultural competency after the course (Table 3 ). Table 3 Kruskal-Wallis Test on cross-cultural competency by Clinical Exposure Time (N = 40) Clinical Exposure N Difference between pre and post-test Mean SD Culture Sensitivity Under one year 5 -3.20 7.92 1–2 years 16 1.31 4.70 2–3 years 14 4.14 5.48 Above three years 5 1.60 5.13 Cultural Care Competence Under one year 5 0.00 6.75 1–2 years 16 0.94 2.86 2–3 years 14 3.14 3.88 Above three years 5 2.60 1.14 Multicultural Perceptions Under one year 5 1.80 8.01 1–2 years 16 2.00 3.60 2–3 years 14 4.50 4.96 Above three years 5 1.00 3.00 Multicultural Competences Under one year 5 -2.20 4.02 1–2 years 16 1.88 4.40 2–3 years 14 6.00 7.22 Above three years 5 2.00 3.54 Differences in cross-culture competency Gender The analysis of gender differences revealed no significant differences between pre-and post-test scores in cultural sensitivity, cultural care competence, multicultural perceptions, or multicultural competence among female participants. Specifically, no statistical significance was found in cultural sensitivity (t = 0.52, p > 0.05), cultural care competence (t = 1.72, p > 0.05), multicultural perceptions (t = 1.95, p > 0.05), or multicultural competence (t = 1.28, p > 0.05). However, male participants showed significant improvements in cultural sensitivity (t = 2.77, p < 0.05), cultural care competence (t = 2.61, p < 0.05), multicultural perceptions (t = 3.28, p < 0.01), and multicultural competence (t = 3.04, p < 0.01), indicating that the course had a significant impact on male participants' multicultural competence (Table 4 ). Table 4 Paired Sample t-Test for Multicultural Competences Among Male (N = 24) Pre-test Post test t-test M SD M SD Culture Sensitivity 51.08 5.62 53.38 6.23 2.77* Cultural Care Competence 36 4.19 37.63 4.67 2.61* Multicultural Perceptions 64.21 8.05 66.83 7.88 3.28** Multicultural Competences 56.25 7.53 59.46 8.34 3.04** * p < .05 ** p 0.05), cultural care competence (t = 0.83, p > 0.05), multicultural perceptions (t = 1.88, p > 0.05), or multicultural competences (t = 0.91, p > 0.05). In contrast, participants with more than two years of clinical exposure demonstrated significant differences across all indicators: cultural sensitivity (t = 2.82, p < 0.05), cultural care competence (t = 3.9, p < 0.01), multicultural perceptions (t = 3.31, p < 0.01), and multicultural competences (t = 3.26, p < 0.01). It shows that the course had a more pronounced effect on enhancing multicultural competence among participants with more clinical experience. Qualitative Results Analysis key themes Real-World Case Scenarios Enhance Understanding Participants noted that using real-world cases relevant to the Taiwanese context was crucial for understanding cross-cultural scenarios. For example, one participant mentioned a case involving the impact of pigskin capsules on Muslim patients, which provided more practical value than theoretical discussions (B2, Male, 27 years old). Effective Use of Resources to Overcome Professional Barriers Many participants highlighted that the course taught them how to utilize cross-cultural resources provided by hospitals, which helped them navigate specific clinical situations. For instance, one participant mentioned that educational brochures were effective in assisting foreign patients to understand treatment plans (A2, Male, 27 years old). Hands-On Practice and Role-Playing Enhance Learning Most participants believed that hands-on practice in the classroom was more effective than theoretical explanations in helping them understand the application of cultural sensitivity. One participant emphasized that practicing communication with the instructor was an essential learning experience, especially when applying these skills in real-life scenarios (B4, Female, 26 years old). Discussion This study explored the growing cross-cultural challenges within Taiwan's healthcare system and their impact on medical education. As globalization accelerates, Taiwan's population of new immigrants has significantly increased, making it the second-largest social group and introducing diverse cultural demands into healthcare services. Although the importance of cross-cultural competence is widely recognized, current medical education in Taiwan still faces shortcomings, such as an overemphasis on language barriers, the lack of assessment tools suited to Taiwan’s environment, and medical students' insufficient awareness of cultural differences. This study introduced an innovative cross-cultural competency course based on the ESFT model, aiming to enhance the cross-cultural capabilities of young physicians. The ESFT model has been successfully applied in nursing to improve cultural competence, providing healthcare professionals with a systematic framework for addressing the needs of patients from different cultural backgrounds [ 10 ]. This research employed a mixed-methods approach, combining quantitative scale measurements with qualitative focus group interviews to comprehensively assess the course's effectiveness. The study fills a gap in Taiwan's medical education regarding cross-cultural competence training. It offers empirical evidence for future curriculum development and implementation, with the expectation of improving the overall quality of healthcare, particularly in cross-cultural care. The study’s results show that although the young physicians who participated in the course served in the same region, there were no significant differences in cultural sensitivity, multicultural perceptions, and multicultural competence based on their pre-university residential areas. However, in terms of cultural care competence, physicians from middle and southern Taiwan showed significant improvements after completing the cross-cultural competence course, in contrast to those from northern Taiwan. This finding may be related to the cultural diversity in their early life environments. Studies have suggested that culturally diverse regional environments contribute to developing cross-cultural competence [ 7 , 13 ]. Middle and southern Taiwan are relatively more varied, and physicians from these regions may have encountered more diverse cultural groups in their early lives, allowing them to internalize and apply what they learned in the course more effectively in cultural care competence practices [ 7 , 14 ]. In comparison, despite receiving the same training, physicians from northern Taiwan experienced a more homogeneous cultural environment during their upbringing, resulting in more minor improvements in cultural care competence. Aligning with the broader understanding of cultural diversity, educators can foster personal innovation and the development of cross-cultural competencies [ 13 ]. Additionally, exploring the role of "difference" in cultural contact emphasizes the need for more profound multicultural education and critical awareness in developing cultural competence [ 15 ]. The intervention of the cross-cultural course significantly enhanced young physicians' cross-cultural competence, particularly in male participants and those with more clinical experience, where cultural care competence showed more pronounced improvements. These results are consistent with previous findings, indicating that clinical experience is crucial in developing cultural care competence [ 2 ]. The study utilized the ESFT model in designing the innovative cross-cultural competence course, focusing on enhancing cultural sensitivity and effectively improving participants' multicultural competence. Traditional cross-cultural teaching methods have primarily relied on lectures, with students generally reporting low interest and engagement, leading to poor learning outcomes. Therefore, this course integrated the ESFT model and clinical scenario simulations, shifting from passive listening to experiential learning. In addition, it also increased the course's feasibility and student engagement, making the learning experience more interactive and meaningful. By structuring the course around the ESFT model, the interactions between physicians and patients were transformed into valuable teaching resources, simulating real clinical situations that helped participants master deeper levels of cross-cultural competence. The results demonstrate that applying the model has notable benefits for promoting cross-cultural learning, especially in enhancing participants' subjective cultural perceptions, showcasing the ESFT model's potential for innovation in medical education. Furthermore, qualitative findings revealed that participants generally believed that real-world case-sharing and clinical examples were crucial to their learning outcomes. These findings suggest that providing case studies and resources closely aligned with real clinical situations is essential in enhancing learners' cultural sensitivity in cross-cultural education. These findings support existing research on the value of experiential learning and case-based teaching, indicating that simulated practice and real-world case examples can better help learners apply what they have learned in actual clinical settings [ 16 ]. However, female participants did not show significant differences in cultural sensitivity or subjective cultural scales after the course. It may be related to insufficient gender adaptability in the course design or teaching methods and requires further exploration in future research. Additionally, the study found that participants with less clinical experience did not show significant improvements in cultural sensitivity, possibly reflecting their lack of sufficient cross-cultural interaction experience in clinical settings, which affected the development of their cross-cultural competence. This result suggests that the richness of clinical experience may be an essential factor influencing course effectiveness. For such participants, while the course content is educationally meaningful, the lack of practical application opportunities may limit the development of cross-cultural competence. Therefore, introducing this type of cross-cultural competence training earlier, such as during physicians' early career stages or even in the early phases of medical education, may help physicians develop sufficient cross-cultural understanding and coping abilities when they face clinical practice, reducing initial challenges and difficulties in cross-cultural situations. Such preemptive training can help physicians adapt more quickly to the multicultural challenges of clinical practice, enhancing their cultural sensitivity and care abilities compared to those who have not received the training. This study shows that cross-cultural courses significantly enhance the cultural sensitivity of young physicians, particularly among male participants and those with extensive clinical experience. Therefore, medical education institutions can integrate such cross-cultural courses into young physicians' training programs for patients from diverse cultural backgrounds to promote communication and understanding between physicians and patients more effectively. Case-based teaching methods that simulate real clinical situations have also proven effective. Hospitals can utilize this method to improve young physicians' cross-cultural communication skills, further enhancing their ability to provide culturally competent care and ultimately improving the quality of healthcare services and patient outcomes. From an economic perspective, cross-cultural education can effectively reduce medical errors, misdiagnoses, and patient dissatisfaction caused by cultural differences, thus lowering the likelihood of medical lawsuits and related costs. As globalization and cross-border migration increase, hospitals that incorporate cross-cultural courses into young physicians' training programs can improve the long-term efficiency of healthcare resource utilization, enhance patient satisfaction, and reduce unnecessary waste of medical resources. At the same time, such courses can help medical institutions more effectively utilize existing resources, reduce workforce and training costs, and, by improving cross-cultural communication skills, indirectly boost their competitiveness and economic benefits in a multicultural society. In the future, there is an expectation to design a highly personalized, flexible, and adaptable cross-cultural education course tailored to the participants' different genders, cultural backgrounds, and clinical experiences. The course would use the ESFT model framework to promote cross-cultural competence and incorporate innovative technology to adjust the content in real-time based on participants’ learning responses and needs, ensuring that every young physician makes the most progress in a teaching style best suited for them. For female participants and physicians with less clinical experience, this could provide more practical simulation exercises and interactive experiences, paired with real-time feedback mechanisms, allowing physicians to confidently apply their newly acquired cross-cultural competence in clinical settings immediately after completing the course. Such a course would significantly enhance each physician’s cultural sensitivity and multicultural care abilities, promoting more effective and comprehensive cross-cultural learning outcomes. Although this study demonstrated that cross-cultural courses significantly enhance young physicians' cultural sensitivity, several limitations remain. First, the study sample was drawn from a single hospital, with participants' backgrounds being relatively homogeneous, which may limit the generalizability of the results to young physicians from different regions or cultural backgrounds. Second, the study primarily relied on quantitative questionnaires for assessment, limiting a deeper understanding of the participants' cross-cultural competence in actual clinical situations. The lack of qualitative data restricts the comprehension of the participants' accurate perceptions and behavioral changes. Furthermore, the long-term effects of the cross-cultural course have yet to be evaluated, and future follow-up studies are needed to examine the course's lasting impact on physicians' cross-cultural competence. Lastly, while the study found better outcomes among male physicians, the reasons behind the gender differences were not explored. Future studies could further investigate the relationship between gender and cross-cultural learning. Conclusion This study explored the application of the ESFT model in designing educational courses for young physicians and its impact on their cross-cultural competence. The results indicated significant improvements in cultural sensitivity, multicultural perceptions, multicultural competence, and cultural care competence among physicians who participated in the cross-cultural course, with the most notable effects observed in participants with more than two years of clinical experience and male physicians. However, improvements among female participants and those with less clinical experience were not significant, suggesting that the course's effectiveness may be influenced by gender and clinical experience. This study confirms the importance of cross-cultural courses in enhancing physicians' cross-cultural competence and highlights the need for designing more targeted teaching content for learners from diverse backgrounds. Future research can further explore diversified teaching strategies to maximize the effectiveness of cross-cultural education and promote the broader application and popularization of such courses in medical practice. Declarations Ethical Considerations Our study was approved by the hospital’s ethics review in accordance with the Declaration of Helsinki (approval no. 202102345B0C501). Conflict of Interest There is no conflict of interest in this study. Funding Ministry of Science and Technology program (No. 110-2511-H037-004). Author Contribution Chih-Hung Chen, Te-Chuan Chen, Chi-Wei Lin, Yu Chih Lin, and Wei-Chuan Chen wrote the main manuscript text, and Ya-Hui Cheng and Han Pi-Chi prepared tables 1-4. All authors reviewed the manuscript. Acknowledgement The authors thank the PGY doctors who participated in the study, which was supported by the NSTC grant (NSTC 111-2410-H-182-035). Availability of data and materials Data used to support the findings of this study are available from the corresponding author upon request. References 內政部移民署. 外籍配偶人數與大陸(含港澳)配偶人數統計表. In.; 2021. Betancourt JR, Green AR, Carrillo JE, Park ER. 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Technol Soc. 2022;69:101939. Lu P-Y, Tsai J-C, Green A, Hsu AS. Assessing Asian medical students’ readiness for diversity: localizing measures of cross-cultural care competence. Teach Learn Med. 2021;33(3):220–34. Wear D, Kumagai AK, Varley J, Zarconi J. Cultural competency 2.0: Exploring the concept of difference in engagement with the other. Acad Med. 2012;87(6):752–8. Kolb D. Learning styles and disciplinary differences. The modern American college. Ed. by AW Chickering & associates. In.: San Francisco, Jossey-Bass Publ; 1981. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 22 Mar, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 24 Oct, 2024 Editor assigned by journal 18 Oct, 2024 Submission checks completed at journal 18 Oct, 2024 First submitted to journal 14 Oct, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5264786","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":370094820,"identity":"f2e78faf-e2e6-41a2-9376-faae77bbf8f3","order_by":0,"name":"Chih-Hung Chen","email":"","orcid":"","institution":"Chang Gung University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Chih-Hung","middleName":"","lastName":"Chen","suffix":""},{"id":370094823,"identity":"8c7f1d8f-55ff-4532-8d8f-fe6ab9adebc0","order_by":1,"name":"Te-Chuan Chen","email":"","orcid":"","institution":"National Sun Yat-sen University","correspondingAuthor":false,"prefix":"","firstName":"Te-Chuan","middleName":"","lastName":"Chen","suffix":""},{"id":370094826,"identity":"7a2e23d2-bb70-413e-91a7-cd85db0e6094","order_by":2,"name":"Chi-Wei Lin","email":"","orcid":"","institution":"E-Da Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chi-Wei","middleName":"","lastName":"Lin","suffix":""},{"id":370094828,"identity":"e3bc4456-8bd1-4069-a020-0765f5f3b345","order_by":3,"name":"Yu-Chih Lin","email":"","orcid":"","institution":"Kaohsiung Medical University Chung-Ho Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yu-Chih","middleName":"","lastName":"Lin","suffix":""},{"id":370094829,"identity":"15b8f201-7b82-42f9-8691-da8c071db98c","order_by":4,"name":"Ya-Hui Cheng","email":"","orcid":"","institution":"Kaohsiung Chang Gung Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ya-Hui","middleName":"","lastName":"Cheng","suffix":""},{"id":370094830,"identity":"d479459e-e206-4dbb-bd37-9300d829bb78","order_by":5,"name":"Han Pi-Chi","email":"","orcid":"","institution":"National Normal Kaohsiung University","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"","lastName":"Pi-Chi","suffix":""},{"id":370094831,"identity":"a606ace7-3bd1-408e-99d0-66b403e35f9e","order_by":6,"name":"Wei-Chuan Chen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCElEQVRIiWNgGAWjYNACg3/1/AwMjA8+MBzgIVJLxYEEyQYGZsMZYC3MYFMIaDlzIMHgAAObNA/DAQaCWvjbe8wefGy7k2d87fgDyRkMd2TM2fsPMBdU/MGpReLMGXPDmW3Pis1u5xgYfGB4xmPZc5iBecYZ3LYYSOSYSfO2MTNuu53DkDiD4TCPwY1kBmbeNgJa/gK1bJ6d/uAwD0jL/cdALf8IaGE4czhxg3SCYTNYyw1moJYG3FokzhwrN+ypSDOWuJ1jzDjDAKjlTDKQPGaMUwt/e/O2Bz8MbOT4Z6c///Gh4rC9wfGDDx/z1Mjh1AIEbMjuhFAH8KlH0zIKRsEoGAWjAAsAAJU4VprPETZpAAAAAElFTkSuQmCC","orcid":"","institution":"Kaohsiung Veterans General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Wei-Chuan","middleName":"","lastName":"Chen","suffix":""}],"badges":[],"createdAt":"2024-10-15 03:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5264786/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5264786/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07007-y","type":"published","date":"2025-03-22T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79120444,"identity":"5619f6c6-16cd-4d4b-bdd0-c46d110a0024","added_by":"auto","created_at":"2025-03-24 16:08:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":682662,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5264786/v1/7501a883-4335-4d46-85f0-a312e075b078.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Observational Study of the Effect of ESFT Approach on Cross-Culture Competency Teaching for Young PGY Physicians","fulltext":[{"header":"Background","content":"\u003cp\u003eWith the rapid development of globalization, international mobility has become increasingly frequent, leading to more intensive cross-cultural contact and exchange. As an essential region under the influence of globalization, Taiwan has seen a continuous rise in the number of new immigrants, individuals who have recently moved to Taiwan from other countries, gradually becoming the second-largest ethnic group in Taiwanese society. According to the National Immigration Agency of the Ministry of the Interior, from 1987 to 2021, the number of new immigrants in Taiwan exceeded 560,000, mainly from China, Vietnam, Indonesia, and other countries [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These immigrants from different cultural backgrounds have further contributed to Taiwan\u0026rsquo;s societal diversity, particularly within the healthcare system, where the needs of patients from diverse cultural backgrounds are significantly different. Healthcare providers are increasingly facing cross-cultural challenges, especially in patient care, doctor-patient communication, and treatment outcomes. According to Betancourt's research, cross-cultural competency can be enhanced through organizational, structural, and clinical interventions to improve the quality of care in the context of cultural differences [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Therefore, cultivating the cultural competence of healthcare professionals has become essential to better meet the needs of cross-cultural care and has gradually become one of the core issues in medical education.\u003c/p\u003e \u003cp\u003eAlthough the importance of cross-cultural competency has been widely recognized in academia and medical practice, there are still several gaps in current research and practice. Firstly, past medical education has predominantly focused on overcoming language barriers, primarily emphasizing establishing diagnoses and treatment [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This treatment-centered model often overlooks the more profound influence of cultural factors in doctor-patient communication, leading to superficial approaches to cross-cultural care in practice. Secondly, although international assessment tools for cultural competency, such as Campinha-Bacote\u0026rsquo;s IAPCC scale [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], exist, most of these tools are based on Western cultural contexts. They may need to reflect the cultural differences within Taiwan's healthcare environment fully.\u003c/p\u003e \u003cp\u003eFurthermore, Taiwanese medical students' understanding of the health disparities and care needs of patients from different cultural backgrounds still needs to be improved. According to preliminary studies, while young physicians perform well in cultural sensitivity, they demonstrate relatively weaker performance in cultural care competence and self-assessment skills, reflecting significant room for improvement in Taiwan's medical education regarding enhancing cross-cultural competency. Current cross-cultural curricula are primarily one-directional lectures, lacking experiential learning mechanisms such as situational simulations. These are crucial for developing medical students\u0026rsquo; abilities to respond to cross-cultural challenges in real-life contexts.\u003c/p\u003e \u003cp\u003eGiven the current situation, while the course content can benefit cross-cultural competency learning, the \"banking education method\" commonly reduces learners' acceptance, resulting in lower learning effectiveness in cross-cultural competence. According to Freire's critique, banking education places students in a passive role, where knowledge is transmitted rather than internalized, limiting students' critical thinking and problem-solving abilities, especially when developing cross-cultural competency [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This educational model often fails to promote students' interaction and understanding of different cultures effectively, thus affecting their cross-cultural learning outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, this study utilizes an innovative teaching model\u0026mdash;the ESFT (Explanation, Social and Environmental Factors, Fears and Concerns, Therapeutic Contracting) model\u0026mdash;to explore the relationship between the ESFT model and teaching cultural competency to young physicians. It examines the effectiveness of the ESFT model in enhancing young physicians' communication and care abilities in cross-cultural contexts.\u003c/p\u003e \u003cp\u003eThe ESFT model has traditionally been used for educational communication between physicians and patients, with the advantages of being structured and personalized. This model emphasizes understanding the patient's cultural background, social and environmental factors, fears and concerns, and establishing a therapeutic contract. This approach enhances communication efficiency between doctors and patients, promoting trust and cooperation in the doctor-patient relationship [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. By systematically addressing patient needs, this model ensures that medical plans align more with patients' cultural and personal circumstances, which helps improve treatment adherence and overall outcomes. From the adult education perspective, this study assumes that the relationship between the physician and the patient is similar to that between the educator and the learner in medical knowledge. Therefore, applying the ESFT model to cultural competency teaching is expected to promote the relationship between the educator and the learner. This study adopts this teaching model in cultural competency teaching to help physicians better understand their patients' cultural backgrounds and needs.\u003c/p\u003e \u003cp\u003eThe ESFT model emphasizes four core dimensions: Explanation, which focuses on understanding the patient's or learner\u0026rsquo;s beliefs and understanding of the disease or problem; Social and Environmental Factors, which consider the impact of the patient\u0026rsquo;s or learner's social background and living environment on their health and learning; Fears and Concerns, which identify the anxieties and worries in cross-cultural interactions; and Therapeutic Contracting, where feasible treatment or learning plans are jointly discussed and negotiated [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The results of this study provide educators with an innovative teaching method to help young physicians understand the needs of patients from different cultural backgrounds, enhancing their cross-cultural competency and offering empirical support for cultivating cross-cultural competency in medical education.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study adopts a mixed methods design to evaluate the effectiveness of a cross-cultural competence course, based on the ESFT model, in enhancing the multicultural competence of young physicians. The research methodology comprises two main components: quantitative assessment and qualitative analysis. The quantitative part measures changes in the young physicians' multicultural competence using related scales. In contrast, the qualitative part explores the participants' learning experiences and the effectiveness of the course design through focus group discussions. Clinical trial number: Not applicable.\u003c/p\u003e \u003cp\u003eParticipants\u003c/p\u003e \u003cp\u003eThis study's participants were medical interns and young PGY (Postgraduate Year) physicians with at least one year of clinical experience at a medical center. Participants were collected using convenient sampling and snowball sampling methods. All participants fully understand the contents of the Consent to Participate declaration document, including information about the ethical guidelines followed, the voluntary nature of participation, and how participant data will be used in the manuscript.\u003c/p\u003e \u003cp\u003eCourse Design\u003c/p\u003e \u003cp\u003eBefore starting the cross-cultural competency course, pre-course meetings were held with experts and instructors on cross-cultural topics to reach a consensus. The course used visual aids and reflective videos as guiding tools, with scenario simulations to enhance cross-cultural communication skills. The content was designed around the four core dimensions of the ESFT model: Explanation, Social and Environmental Factors, Fears and Concerns, and Therapeutic Contracting. These four dimensions covered the following areas: Explanation, Social and Environmental Factors, Fears and Concerns, and Therapeutic Contracting. The course utilized experiential learning, reflective learning, and focus group interviews as teaching methods, emphasizing participatory learning and experiential reflection. Post-course assessments incorporated cross-cultural issues into the OSCE simulation exams to evaluate the course\u0026rsquo;s effectiveness.\u003c/p\u003e \u003cp\u003eQuantitative Data Collection\u003c/p\u003e \u003cp\u003eThe evaluation of cross-cultural competence teaching was divided into four areas: cultural sensitivity, cultural care competence, multicultural perceptions, and multicultural competence. Cultural sensitivity was assessed using a translated and modified Intercultural Sensitivity Scale. Cultural care competence was measured using a cultural care competence scale. Multicultural perceptions were adapted from the Multicultural Perceptions Scale (MCP) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and multicultural competence was assessed using the Multicultural Competences Scale (MCC) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eQualitative Data Collection\u003c/p\u003e \u003cp\u003eQualitative data were collected through focus group discussions to gain in-depth insights into the participants' learning experiences and perceptions of the application of the ESFT model. Trained interviewers led the research team's talks. Discussion topics centered on the participants' views regarding the course content, teaching methods, and perceived changes in cultural competence. The entire discussion was audio-recorded, transcribed verbatim, and later analyzed using thematic analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDemographic Information of Participants\u003c/p\u003e \u003cp\u003eAmong the participants in this study, 60% were male (24 participants), and 40% were female (16 participants), with an average age of 26.4 years (SD\u0026thinsp;=\u0026thinsp;2.4). Most (60%, 24 participants) lived in southern Taiwan before university, followed by central Taiwan. In terms of religion, Taoism and no religion/others were the most common, accounting for 47.5% (19 participants) and 37.5% (15 participants), respectively. The majority ethnic group was Hokkien, representing 70% (28 participants).\u003c/p\u003e \u003cp\u003ePerformance in Cross-Cultural Competence\u003c/p\u003e \u003cp\u003eThe participants\u0026rsquo; cross-cultural competence was assessed using a combination of the cultural care competence scale, the multicultural perceptions scale (MCP), and the multicultural competence scale (MCC). Pre- and post-test results showed significant differences. The overall post-test mean score on the cultural care competence (M\u0026thinsp;=\u0026thinsp;38.4, SD\u0026thinsp;=\u0026thinsp;4.6) was higher than the pre-test mean score (M\u0026thinsp;=\u0026thinsp;36.6, SD\u0026thinsp;=\u0026thinsp;4.2) (t\u0026thinsp;=\u0026thinsp;3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). Similarly, the overall post-test mean score on the multicultural perceptions (M\u0026thinsp;=\u0026thinsp;68.9, SD\u0026thinsp;=\u0026thinsp;7.9) was higher than the pre-test mean score (M\u0026thinsp;=\u0026thinsp;66.1, SD\u0026thinsp;=\u0026thinsp;8.4) (t\u0026thinsp;=\u0026thinsp;3.63, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01). The overall post-test mean score on the multicultural competences (M\u0026thinsp;=\u0026thinsp;60.4, SD\u0026thinsp;=\u0026thinsp;7.9) was higher than the pre-test mean score (M\u0026thinsp;=\u0026thinsp;57.6, SD\u0026thinsp;=\u0026thinsp;8.5) (t\u0026thinsp;=\u0026thinsp;3.02, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01), indicating a significant improvement in cross-cultural competence following the course.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eT-test of cross-culture competency ( N\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003et-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural Sensitivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e54.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural Care Competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.0**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticultural Perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e66.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e68.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.63**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticultural Competences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e57.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3.02**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 **p\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Impact of Pre-University Residence on Cultural Care Competence\u003c/p\u003e \u003cp\u003eAccording to the results of non-parametric statistical analysis, participants who resided in southern and central Taiwan before university exhibited significantly higher cultural care competence than those from northern Taiwan (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This result suggests that the change in cultural care competence after attending the cross-cultural competence course is influenced by the participants' pre-university residence.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKruskal-Wallis Test Analysis on Cultural Competence Assessment Scales by Pre-University Residence ( N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-University Residence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eDifference between pre and post-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCultural Sensitivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCultural Care Competence*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMulticultural Perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.56\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMulticultural Competences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMiddle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.66\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe Impact of Clinical Exposure Time on Cultural Care Competency\u003c/p\u003e \u003cp\u003eNon-parametric statistical analysis revealed significant differences in the change in cultural care competency based on participants' clinical exposure time. Participants with more than two years of clinical experience had significantly higher post-test scores in cultural care competence compared to those with less than two years of experience. It indicates that those with more significant clinical experience showed more noticeable improvements in cross-cultural competency after the course (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKruskal-Wallis Test on cross-cultural competency by Clinical Exposure Time (N\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinical Exposure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eDifference between pre and post-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCulture Sensitivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove three years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCultural Care Competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove three years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMulticultural Perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove three years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eMulticultural Competences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnder one year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;3 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove three years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDifferences in cross-culture competency\u003c/p\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eThe analysis of gender differences revealed no significant differences between pre-and post-test scores in cultural sensitivity, cultural care competence, multicultural perceptions, or multicultural competence among female participants. Specifically, no statistical significance was found in cultural sensitivity (t\u0026thinsp;=\u0026thinsp;0.52, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), cultural care competence (t\u0026thinsp;=\u0026thinsp;1.72, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), multicultural perceptions (t\u0026thinsp;=\u0026thinsp;1.95, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), or multicultural competence (t\u0026thinsp;=\u0026thinsp;1.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eHowever, male participants showed significant improvements in cultural sensitivity (t\u0026thinsp;=\u0026thinsp;2.77, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), cultural care competence (t\u0026thinsp;=\u0026thinsp;2.61, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), multicultural perceptions (t\u0026thinsp;=\u0026thinsp;3.28, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and multicultural competence (t\u0026thinsp;=\u0026thinsp;3.04, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), indicating that the course had a significant impact on male participants' multicultural competence (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePaired Sample t-Test for Multicultural Competences Among Male (N\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePost test\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003et-test\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCulture Sensitivity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e51.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.77*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural Care Competence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.61*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticultural Perceptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e64.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e66.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.28**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMulticultural Competences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e56.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.04**\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05 **\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.01\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eClinical Exposure Time\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eParticipants with less than two years of clinical exposure showed no statistically significant improvements in cultural sensitivity (t\u0026thinsp;=\u0026thinsp;0.19, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), cultural care competence (t\u0026thinsp;=\u0026thinsp;0.83, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), multicultural perceptions (t\u0026thinsp;=\u0026thinsp;1.88, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), or multicultural competences (t\u0026thinsp;=\u0026thinsp;0.91, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eIn contrast, participants with more than two years of clinical exposure demonstrated significant differences across all indicators: cultural sensitivity (t\u0026thinsp;=\u0026thinsp;2.82, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), cultural care competence (t\u0026thinsp;=\u0026thinsp;3.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), multicultural perceptions (t\u0026thinsp;=\u0026thinsp;3.31, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and multicultural competences (t\u0026thinsp;=\u0026thinsp;3.26, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). It shows that the course had a more pronounced effect on enhancing multicultural competence among participants with more clinical experience.\u003c/p\u003e \u003cp\u003eQualitative Results Analysis\u003c/p\u003e \u003cp\u003ekey themes\u003c/p\u003e\n\u003ch3\u003eReal-World Case Scenarios Enhance Understanding\u003c/h3\u003e\n\u003cp\u003eParticipants noted that using real-world cases relevant to the Taiwanese context was crucial for understanding cross-cultural scenarios. For example, one participant mentioned a case involving the impact of pigskin capsules on Muslim patients, which provided more practical value than theoretical discussions (B2, Male, 27 years old).\u003c/p\u003e\n\u003ch3\u003eEffective Use of Resources to Overcome Professional Barriers\u003c/h3\u003e\n\u003cp\u003eMany participants highlighted that the course taught them how to utilize cross-cultural resources provided by hospitals, which helped them navigate specific clinical situations. For instance, one participant mentioned that educational brochures were effective in assisting foreign patients to understand treatment plans (A2, Male, 27 years old).\u003c/p\u003e\n\u003ch3\u003eHands-On Practice and Role-Playing Enhance Learning\u003c/h3\u003e\n\u003cp\u003eMost participants believed that hands-on practice in the classroom was more effective than theoretical explanations in helping them understand the application of cultural sensitivity. One participant emphasized that practicing communication with the instructor was an essential learning experience, especially when applying these skills in real-life scenarios (B4, Female, 26 years old).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the growing cross-cultural challenges within Taiwan's healthcare system and their impact on medical education. As globalization accelerates, Taiwan's population of new immigrants has significantly increased, making it the second-largest social group and introducing diverse cultural demands into healthcare services. Although the importance of cross-cultural competence is widely recognized, current medical education in Taiwan still faces shortcomings, such as an overemphasis on language barriers, the lack of assessment tools suited to Taiwan\u0026rsquo;s environment, and medical students' insufficient awareness of cultural differences.\u003c/p\u003e \u003cp\u003eThis study introduced an innovative cross-cultural competency course based on the ESFT model, aiming to enhance the cross-cultural capabilities of young physicians. The ESFT model has been successfully applied in nursing to improve cultural competence, providing healthcare professionals with a systematic framework for addressing the needs of patients from different cultural backgrounds [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This research employed a mixed-methods approach, combining quantitative scale measurements with qualitative focus group interviews to comprehensively assess the course's effectiveness. The study fills a gap in Taiwan's medical education regarding cross-cultural competence training. It offers empirical evidence for future curriculum development and implementation, with the expectation of improving the overall quality of healthcare, particularly in cross-cultural care.\u003c/p\u003e \u003cp\u003eThe study\u0026rsquo;s results show that although the young physicians who participated in the course served in the same region, there were no significant differences in cultural sensitivity, multicultural perceptions, and multicultural competence based on their pre-university residential areas. However, in terms of cultural care competence, physicians from middle and southern Taiwan showed significant improvements after completing the cross-cultural competence course, in contrast to those from northern Taiwan. This finding may be related to the cultural diversity in their early life environments. Studies have suggested that culturally diverse regional environments contribute to developing cross-cultural competence [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Middle and southern Taiwan are relatively more varied, and physicians from these regions may have encountered more diverse cultural groups in their early lives, allowing them to internalize and apply what they learned in the course more effectively in cultural care competence practices [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn comparison, despite receiving the same training, physicians from northern Taiwan experienced a more homogeneous cultural environment during their upbringing, resulting in more minor improvements in cultural care competence. Aligning with the broader understanding of cultural diversity, educators can foster personal innovation and the development of cross-cultural competencies [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, exploring the role of \"difference\" in cultural contact emphasizes the need for more profound multicultural education and critical awareness in developing cultural competence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe intervention of the cross-cultural course significantly enhanced young physicians' cross-cultural competence, particularly in male participants and those with more clinical experience, where cultural care competence showed more pronounced improvements. These results are consistent with previous findings, indicating that clinical experience is crucial in developing cultural care competence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study utilized the ESFT model in designing the innovative cross-cultural competence course, focusing on enhancing cultural sensitivity and effectively improving participants' multicultural competence. Traditional cross-cultural teaching methods have primarily relied on lectures, with students generally reporting low interest and engagement, leading to poor learning outcomes. Therefore, this course integrated the ESFT model and clinical scenario simulations, shifting from passive listening to experiential learning. In addition, it also increased the course's feasibility and student engagement, making the learning experience more interactive and meaningful. By structuring the course around the ESFT model, the interactions between physicians and patients were transformed into valuable teaching resources, simulating real clinical situations that helped participants master deeper levels of cross-cultural competence. The results demonstrate that applying the model has notable benefits for promoting cross-cultural learning, especially in enhancing participants' subjective cultural perceptions, showcasing the ESFT model's potential for innovation in medical education.\u003c/p\u003e \u003cp\u003eFurthermore, qualitative findings revealed that participants generally believed that real-world case-sharing and clinical examples were crucial to their learning outcomes. These findings suggest that providing case studies and resources closely aligned with real clinical situations is essential in enhancing learners' cultural sensitivity in cross-cultural education. These findings support existing research on the value of experiential learning and case-based teaching, indicating that simulated practice and real-world case examples can better help learners apply what they have learned in actual clinical settings [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, female participants did not show significant differences in cultural sensitivity or subjective cultural scales after the course. It may be related to insufficient gender adaptability in the course design or teaching methods and requires further exploration in future research. Additionally, the study found that participants with less clinical experience did not show significant improvements in cultural sensitivity, possibly reflecting their lack of sufficient cross-cultural interaction experience in clinical settings, which affected the development of their cross-cultural competence. This result suggests that the richness of clinical experience may be an essential factor influencing course effectiveness. For such participants, while the course content is educationally meaningful, the lack of practical application opportunities may limit the development of cross-cultural competence. Therefore, introducing this type of cross-cultural competence training earlier, such as during physicians' early career stages or even in the early phases of medical education, may help physicians develop sufficient cross-cultural understanding and coping abilities when they face clinical practice, reducing initial challenges and difficulties in cross-cultural situations. Such preemptive training can help physicians adapt more quickly to the multicultural challenges of clinical practice, enhancing their cultural sensitivity and care abilities compared to those who have not received the training.\u003c/p\u003e \u003cp\u003eThis study shows that cross-cultural courses significantly enhance the cultural sensitivity of young physicians, particularly among male participants and those with extensive clinical experience. Therefore, medical education institutions can integrate such cross-cultural courses into young physicians' training programs for patients from diverse cultural backgrounds to promote communication and understanding between physicians and patients more effectively. Case-based teaching methods that simulate real clinical situations have also proven effective. Hospitals can utilize this method to improve young physicians' cross-cultural communication skills, further enhancing their ability to provide culturally competent care and ultimately improving the quality of healthcare services and patient outcomes.\u003c/p\u003e \u003cp\u003eFrom an economic perspective, cross-cultural education can effectively reduce medical errors, misdiagnoses, and patient dissatisfaction caused by cultural differences, thus lowering the likelihood of medical lawsuits and related costs. As globalization and cross-border migration increase, hospitals that incorporate cross-cultural courses into young physicians' training programs can improve the long-term efficiency of healthcare resource utilization, enhance patient satisfaction, and reduce unnecessary waste of medical resources. At the same time, such courses can help medical institutions more effectively utilize existing resources, reduce workforce and training costs, and, by improving cross-cultural communication skills, indirectly boost their competitiveness and economic benefits in a multicultural society.\u003c/p\u003e \u003cp\u003eIn the future, there is an expectation to design a highly personalized, flexible, and adaptable cross-cultural education course tailored to the participants' different genders, cultural backgrounds, and clinical experiences. The course would use the ESFT model framework to promote cross-cultural competence and incorporate innovative technology to adjust the content in real-time based on participants\u0026rsquo; learning responses and needs, ensuring that every young physician makes the most progress in a teaching style best suited for them. For female participants and physicians with less clinical experience, this could provide more practical simulation exercises and interactive experiences, paired with real-time feedback mechanisms, allowing physicians to confidently apply their newly acquired cross-cultural competence in clinical settings immediately after completing the course. Such a course would significantly enhance each physician\u0026rsquo;s cultural sensitivity and multicultural care abilities, promoting more effective and comprehensive cross-cultural learning outcomes.\u003c/p\u003e \u003cp\u003eAlthough this study demonstrated that cross-cultural courses significantly enhance young physicians' cultural sensitivity, several limitations remain. First, the study sample was drawn from a single hospital, with participants' backgrounds being relatively homogeneous, which may limit the generalizability of the results to young physicians from different regions or cultural backgrounds. Second, the study primarily relied on quantitative questionnaires for assessment, limiting a deeper understanding of the participants' cross-cultural competence in actual clinical situations. The lack of qualitative data restricts the comprehension of the participants' accurate perceptions and behavioral changes. Furthermore, the long-term effects of the cross-cultural course have yet to be evaluated, and future follow-up studies are needed to examine the course's lasting impact on physicians' cross-cultural competence. Lastly, while the study found better outcomes among male physicians, the reasons behind the gender differences were not explored. Future studies could further investigate the relationship between gender and cross-cultural learning.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study explored the application of the ESFT model in designing educational courses for young physicians and its impact on their cross-cultural competence. The results indicated significant improvements in cultural sensitivity, multicultural perceptions, multicultural competence, and cultural care competence among physicians who participated in the cross-cultural course, with the most notable effects observed in participants with more than two years of clinical experience and male physicians. However, improvements among female participants and those with less clinical experience were not significant, suggesting that the course's effectiveness may be influenced by gender and clinical experience. This study confirms the importance of cross-cultural courses in enhancing physicians' cross-cultural competence and highlights the need for designing more targeted teaching content for learners from diverse backgrounds. Future research can further explore diversified teaching strategies to maximize the effectiveness of cross-cultural education and promote the broader application and popularization of such courses in medical practice.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e Our study was approved by the hospital\u0026rsquo;s ethics review in accordance with the Declaration of Helsinki (approval no. 202102345B0C501).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThere is no conflict of interest in this study.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eMinistry of Science and Technology program (No. 110-2511-H037-004).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eChih-Hung Chen, Te-Chuan Chen, Chi-Wei Lin, Yu Chih Lin, and Wei-Chuan Chen wrote the main manuscript text, and Ya-Hui Cheng and Han Pi-Chi prepared tables 1-4. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors thank the PGY doctors who participated in the study, which was supported by the NSTC grant (NSTC 111-2410-H-182-035).\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eData used to support the findings of this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e內政部移民署. 外籍配偶人數與大陸(含港澳)配偶人數統計表. In.; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBetancourt JR, Green AR, Carrillo JE, Park ER. Cultural competence and health care disparities: critical perspectives and trends. Health Aff. 2005;24(2):499\u0026ndash;505.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBetancourt JR, Green AR, Carrillo JE, Owusu Ananeh-Firempong I. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 2003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampinha-Bacote J. The process of cultural competence in the delivery of healthcare services: A model of care. J Transcult Nurs. 2002;13(3):181\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampinha-Bacote J. Inventory for assessing the process of cultural competence (IAPCC) among health care professionals. \u003cem\u003eCincinnati, OH: TransCultural Healthcare Associates\u003c/em\u003e 1997.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFreire P. Pedagogy of the oppressed (revised). New York: Continuum. 1996;356:357\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichter NF, Schlaegel C, Taras V, Alon I, Bird A. Reviewing half a century of measuring cross-cultural competence: Aligning theoretical constructs and empirical measures. Int Bus Rev. 2023;32(4):102122.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKulińska J, Rypicz Ł, Zatońska K. The Impact of Effective Communication on Perceptions of Patient Safety\u0026mdash;A Prospective Study in Selected Polish Hospitals. Int J Environ Res Public Health. 2022;19(15):9174.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHa JF. Doctor-Patient Communication: A Review. Ochsner J 2010. 2010;Spring:10(11):38\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeard KV, Gwanmesia E, Miranda-Diaz G. Culturally competent care: Using the ESFT model in nursing. AJN Am J Nurs. 2015;115(6):58\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Y-C, Ho W-Y, Chen W-C. Critical Thinking Integrating to Medical Humanity: Development and Validation of a Multicultural Perception Scale of PhysicianPatient Relationship in Medical Professionalism for Medical Students in Taiwan. Chin J Sci Educ. 2022;30(S):425\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen W-C, Lin C-W, Chou T-Y, Chen C-H. Pioneering of Multicultural Medical Education in Medical Humanity: Development and Validation of Taiwan Medical Cultural Competence Scale. J Med Educ. 2023;27(4):232\u0026ndash;45.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHu H, Yu G, Xiong X, Guo L, Huang J. Cultural diversity and innovation: an empirical study from dialect. Technol Soc. 2022;69:101939.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu P-Y, Tsai J-C, Green A, Hsu AS. Assessing Asian medical students\u0026rsquo; readiness for diversity: localizing measures of cross-cultural care competence. Teach Learn Med. 2021;33(3):220\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWear D, Kumagai AK, Varley J, Zarconi J. Cultural competency 2.0: Exploring the concept of difference in engagement with the other. Acad Med. 2012;87(6):752\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolb D. Learning styles and disciplinary differences. The modern American college. Ed. by AW Chickering \u0026amp; associates. In.: San Francisco, Jossey-Bass Publ; 1981.\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":"Cross-Culture, Competency, ESFT, PGY","lastPublishedDoi":"10.21203/rs.3.rs-5264786/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5264786/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe increasing multicultural demands in healthcare, driven by globalization and the growing population of new immigrants, have highlighted the need for improved cross-cultural competence among medical professionals. This study aims to investigate the impact of a cross-cultural competence course, based on the ESFT (Explanation, Social and Environmental Factors, Fears and Concerns, Therapeutic Contracting) model, on young physicians' cultural sensitivity and related competencies within Taiwan\u0026rsquo;s healthcare system.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eForty young PGY physicians enrolled in this study and ESFT teaching model was implemented. By using a mixed-methods approach, which combines both quantitative and qualitative surveys allows for a comprehensive evaluation of the course's effectiveness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIt showed that significant improvements in cultural sensitivity, multicultural perceptions, multicultural competencies, and cultural care competence, particularly among male physicians and those with over two years of clinical experience. However, female participants and those with less clinical experience did not demonstrate significant improvement. The study identifies regional cultural diversity as a potential factor contributing to the observed differences in competence development. Furthermore, qualitative feedback emphasized the importance of real-life clinical scenarios in enhancing learning outcomes.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study's findings underscore the need for targeted, adaptable cross-cultural education programs that account for gender and clinical experience differences. Future research should focus on long-term effects and diversified teaching strategies to optimize cross-cultural competence training in medical education. This approach could improve physician-patient communication and healthcare quality in increasingly multicultural societies.\u003c/p\u003e","manuscriptTitle":"Observational Study of the Effect of ESFT Approach on Cross-Culture Competency Teaching for Young PGY Physicians","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-31 07:20:26","doi":"10.21203/rs.3.rs-5264786/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-24T17:25:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-18T04:20:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-18T04:18:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2024-10-15T03:41:41+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":"889d52cc-b6a8-4c93-bca1-63c4934e148d","owner":[],"postedDate":"October 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-24T16:01:03+00:00","versionOfRecord":{"articleIdentity":"rs-5264786","link":"https://doi.org/10.1186/s12909-025-07007-y","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-03-22 15:57:29","publishedOnDateReadable":"March 22nd, 2025"},"versionCreatedAt":"2024-10-31 07:20:26","video":"","vorDoi":"10.1186/s12909-025-07007-y","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07007-y","workflowStages":[]},"version":"v1","identity":"rs-5264786","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5264786","identity":"rs-5264786","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}