An Innovative Gamification Tool to Enhance Intercultural Competence and Self-Efficacy among Healthcare Professionals Caring for Vulnerable Migrants and Refugees

An Innovative Gamification Tool to Enhance Intercultural Competence and Self-Efficacy among Healthcare Professionals Caring for Vulnerable Migrants and Refugees | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article An Innovative Gamification Tool to Enhance Intercultural Competence and Self-Efficacy among Healthcare Professionals Caring for Vulnerable Migrants and Refugees Ruben Moreno-Comellas, Adria Murias-Closas, Stella Evangelidou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4788752/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Nov, 2024 Read the published version in International Journal for Equity in Health → Version 1 posted 8 You are reading this latest preprint version Abstract Background This article explores the burgeoning challenge of providing adequate healthcare to vulnerable migrants and refugees (VMRs) within the European Union, an issue exacerbated by the recent surge in migration and asylum applications. A critical gap identified is the lack of intercultural competence (ICC) training in healthcare education, which impedes healthcare professionals' ability to offer culturally sensitive care. The study introduces an innovative educational tool, the "Refugee Escape Room" (RER), to address this gap. Methods The RER is a novel gamification-based initiative, conceptualized to enhance ICC, self-efficacy (SE), and knowledge among healthcare students and professionals. It employs an immersive learning approach, where participants engage in a simulated migratory scenario set in a future world crisis, necessitating collaborative problem-solving and decision-making under pressure. The study uses a mixed-methods approach, including a pre-post intervention design with a newly validated questionnaire and thematic content analysis of qualitative feedback. Results Results from the 101 recruited participants indicate significant improvements in ICC (d=1.13; t=-12.64, p<0.001), SE (d=0.38; t=-3.56; p=0.001), and knowledge (d=1.19; t=-8.40; p<0.001) post-intervention. Participants reported enhanced understanding of VMRs' health challenges and increased empathy, translating their learning into improved attitudes and skills. The study also highlights the potential of educational escape rooms in engaging diverse learners and fostering experiential learning. Conclusions The RER, with its focus on VMRs and ICC training, is an innovative, acceptable and feasableeducational tool that attemps to fill a crucial gap in healthcare education. It represents a promising step towards more effective intercultural training in healthcare, thereby addressing health disparities and improving care quality for vulnerable populations. The study suggests the need for more structured research and methodological rigor to further assess the impact of novel educational tools in healthcare training. refugees cultural competence migration health refugee Figures Figure 1 BACKGROUND Since the beginning of the early 2000s, the number of migrants and mobile European Union (EU) citizens living in the EU has gone from 34 million (or 6.9% of the total EU population) in the early 2000s to over 90 million (or 10%) in recent years 1 . Asylum applications submitted in EU Member States has been following a similar upward trend, with 648,000 applications registered in 2021 and a 25.7% increase compared to 2020 2 . Worldwide, with millions of Ukrainians displaced, the total forced displacement by violence, conflict, persecution, food insecurity, and human rights violations, now exceeds 100 million people. That is, 1 out of every 78 people on earth has been forced to flee their home 3 . The growing segment of vulnerable migrants and refugees (VMRs) across Europe represents a significant challenge to the healthcare systems of receiving countries. An essential problem in facing such challenges is the scarcity of intercultural competence (ICC) training offered within healthcare education at large 4 . Consequently, healthcare professionals often lack the necessary ICC skills, that is, the capability to deliver effective, respectful, and understandable care to VMRs seeking medical attention in a manner fitting the patient’s health beliefs, practices, and language 5 , 6 . In turn, low ICC in the clinical encounter has consistently been shown to impact health service utilization and quality of care of the most vulnerable patients 7 , 8 . Despite numerous calls to action to include ICC training in public health education across the globe 9 , only a limited number of programs have truly implemented the necessary educational opportunities to meet such goals 5 , 10 . In Spain alone, very few official programs offer a focused training curriculum about the unique health realities and barriers experienced by VMR 11 , 12 . Results from several Spanish studies on the perceptions of healthcare providers caring for VMRs suggest that low levels of ICC are similarly perceived by professionals themselves as an important contributor to health-access disparities 13 – 15 . The rapid development of novel gamification-based initiatives such as educational Escape Rooms (ERs) may offer a promising solution to the ICC training gap. Educational ERs have been defined as a teaching method requiring learners to participate in collaborative “gamified” activities explicitly designed for knowledge acquisition or skill development to accomplish a specific goal (e.g. escape from a physical room) by solving time-limited puzzles related to prespecified educational goals 16 . More importantly, the data suggest that educational ESs are particularly successful at engaging participants in the learning process while providing an excellent framework for effective competency building 17 . Several examples of published educational ERs in healthcare are worth mentioning. For example, researchers developed an ER aimed at Nurse Practitioners to teach bedside nursing skills 18 . The authors argued that the ERs provided a unique opportunity to diversify learning strategies, as each puzzle required a varied set of skills to successfully solve (kinesthetic, knowledge, visual cues). Other authors created an escape-room-inspired game as part of a genetics course curriculum 19 , with the objective to consolidate course materials. Overall, designers of ER educational activities report high levels of engagement, satisfaction, and knowledge retention. Efforts are also being made to design educational ERs that tackle more complex, societally relevant topics. For instance, researchers developed an ER focusing on the topic of elder abuse 20 . The game, titled Sandra’s Keys, encouraged players to engage with the story of an imaginary older woman struggling with abuse through a series of puzzles. The goal of the ER is to bring participants into a dialogue about the different forms of elder abuse, deepening the understanding of the bystander’s role. Despite the potential of educational ER to promote competency-building, none of the educational ERs found in the literature have focused on VMRs nor targeted ICC training. Furthermore, the majority of published educational ERs have important methodological problems such as a lack of a control group; the overutilization of poorly validated instruments; small sample sizes, and, overall, a lack of methodological rigor 18 , 21 , 22 . To bridge the identified research gap, we introduce the preliminary evidence-base of a novel educational ER, titled "Refugee Escape Room" (RER). This innovative ER was conceptualized and initially developed through a collaborative effort between authors NDC and LW during an academic exchange between Spain and Canada in 2017 as part of a Master of Public Health course focusing on gamification-based teaching methodologies. The RER, initially trialed with public health and health sciences students, draws upon the authors' extensive research on the health ramifications of migration and VMR's interactions with the healthcare system. Our main objective is to showcase a novel educational ER that aims to train ICC , improve self-efficacy (SE) and increase the knowledge (Kw) of healthcare students and professionals caring for VMRs. Additionally, we aim to gain a deeper insight into the feasibility, acceptability, and the learning process of the RER experience. METHODS Study type Our study employed a mixed-method approach, utilizing a pre-post, single-group intervention design. The primary aim was to assess the feasibility, acceptability, and preliminary effectiveness of the intervention on three key outcomes: ICC, SE, and Knowledge (Kw). To evaluate these metrics, we administered a newly validated questionnaire tailored to these specific domains. The participant pool, comprising a total of 101 individuals, was selected through convenience sampling. RER Activity Description The RER consists of a three-staged, two-hour-long face-to-face activity set in a fictitious scenario of a global crisis caused by overpopulation, global warming, wars, and changes in the geographical distribution of infectious diseases in the year 2084. In this carefully crafted scenario, participants are organized into teams, each representing a family unit. To avoid reinforcing or perpetuating existing societal stereotypes, family units are deliberately composed of diverse ethnic, geographical, and socioeconomic backgrounds intentionally designed not to mimic current real-world demographics. Within this setting, teams are tasked with collaboratively solving a series of complex puzzles, while also engaging in a competitive dynamic to secure a place on an interplanetary spaceship destined for Mars - depicted as a safer haven compared to a deteriorating Earth. The initial stage of the RER establishes the theoretical framework of the migratory process in a classroom setting, with an expert discussing basic aspects of health and migration followed by a Q&A session. This section lasts 30 minutes and cues participants with the necessary knowledge to solve specific puzzles during the following RER stages. The second section introduces a simulated Border Control environment, presenting participants with a series of stringent and complex bureaucratic challenges set in four different Offices. These include passport control, where actors use a fictional "Martian" language to issue instructions, necessitating participants to solve language-based puzzles. Additionally, participants undergo evaluations of their educational background, language skills, and health status in the health and education offices. Throughout the exercise, participants often encounter unforgiving challenges, including but not limited to stringent penalties such as mandatory quarantine due to disease outbreaks or incarceration due to presumed terrorist links, both in virtue of the country of origin. Moreover, this section incorporates scenarios with fictional corrupt officials, creating improvised conflicts that often demand bribes, disproportionately affecting participants from 'poorer' family units. This immersive experience reaches its climax as participants either successfully arrive on Mars or, more commonly, confront a much harsher reality, reflecting the complex dynamics of modern-day migration. This outcome intends to mirror the complex nature of modern migration, underscoring the stark differences in experiences based on socio-economic backgrounds and amplifies the depth of experiential learning. The activity culminates in a 30-minute semi-structured debriefing session. Here, participants are invited to discuss the various challenges they encountered during the game, their emotional reactions to the activity, and the interpersonal skills and coping strategies employed to navigate adversities. They are also encouraged to reflect on significant insights gained from the experience. For a detailed summary of materials, time allocation, and human resources required to carry out the RER please refer to Table 1 , and consult Fig. 1 RER for the process flowchart and puzzle definitions. Table 1 Overview of the Refugee Escape Room Game - Objectives, Structure, and Required Materials Objectives Increase knowledge about epidemiological, chronological and health aspects in relation to people that recently arrived because of the migration crisis. To better intercultural competency and self-efficacy of healthcare professionals that work directly or indirectly with migrants recently arrived in Europe. General Aspects of the RER Age : +18 years. Number of participants : 15–40 (5 to 7 groups of 3 to 6 participants). Duration : approximately 120 minutes. Format : session in classroom. Subject area : Refugees and migration process. Keywords : refugees, cultural competence, migration, health, refugee. Overview and context Earth is dying and must migrate to Mars to survive. Participants will be divided by groups (families) and must survive multiple challenges related to the migration process. Their goal is to reach the end of the game to discover a new land of opportunities. Materials and Human Resources 1 coordinator/teacher and 4 teacher assistants. Classroom 1 : computer, screen, internet connection, audio, 4 tables, 15–40 chairs. Classroom 2 : computer, 4 tables, 12 chairs. 4 boxes with coded lock. 5–7 envelops with groups information (family profile, passport, savings, pen). Border control documents (forms, flight tickets, poster signs pointing different offices) Game structure Description Human Resource Duration Theoretical Framework Introduction of basic aspects of health and immigration (room 1) 1 coordinator/teacher 30 minutes Escape Room activity Context of the game, rules, and familiar groups (room 1) 1 coordinator/teacher 10 minutes First phase: knowledge puzzles (room 1) 2 teacher assistants 25 minutes Second phase: fictitious border (room 2) 4 teacher assistants 25 minutes Debriefing Signifying the experience: lessons learned (room 1) 1 coordinator/teacher 30 minutes Procedure Eligible participants for the RER study included health and social sciences professionals and students, all above 18 years of age, who voluntarily enrolled and provided signed consent forms. Participation in the study was free of charge and offered no financial incentives. To preserve anonymity, participants were assigned non-traceable identifiers. The recruitment strategy employed convenience sampling and successfully enlisted 26 Master of Science students (achieving a 100% participation rate) and 50 students from an international education program (IES Abroad, also with a 100% participation rate). Additionally, recruitment efforts for healthcare professionals involved sending 197 email invitations to those who had previously agreed to receive information about such activities. From these, 25 healthcare professionals consented to participate in the study. The RER intervention was piloted through 4 sessions (2 in English and 2 in Spanish) across three different institutions of the Barcelona area (Spain). At the campus for the Master of International Health of the Universitat Autònoma de Barcelona (UAB) the 17th of June 2019, at the Auditorium of the Catalan Health Institute the 18th of June 2019, and at the International Education of Students Abroad (IES Abroad) campus in Barcelona the 19th and 20th of June 2019. Each of these 4 sessions required 2:00 hours for the development of the RER ; and 30 minutes for signing the consent form and filling the pre and post-test (see questionnaire items in appendices). Prior to the beginning of each RER, pre-preparation activities were carried out, wherein assistants engaged in specific roles such (e.g. corrupt official, passport officer, educational officer, health officer, and ticket officer) received detailed instructions pertinent to their roles. Additionally, a team member was assigned the supporter role to resolve any participant queries during problem-solving. Data to monitor the performance of the RER across the four piloting sessions was collected using using PRE and POST questionnaires. The PRE questionnaire was answered before participating in the RER (pre-test) and the other at the end of the intervention (post-test). After completing the questionnaire’s, printed copies were returned and manually digitized via a newly created Google Forms. The Google Forms database was later exported to an SPSS database for data analysis. Ethics statement The study was carried out in accordance with the Harmonized Tripartite Standards for Good Clinical Practice, following current national regulations (Law 14/2007 of Biomedical Research) and the Ethical principles derived from the Declaration of Helsinki. Data confidentiality of study participants was guaranteed in compliance with the Spanish Organic Law 15/1999, of December 13, on the Protection of Personal Data. This research was evaluated and approved by the Clinical Research Ethics Committee (CEIC) of the Vall d’Hebron Hospital in Barcelona and adhered to the best clinical practices. Statistical analysis First, we conducted a descriptive analysis of our data by assessing the distribution, central tendency, and dispersion (interquartile) of our main outcomes, as well as sociodemographic data. Second, we performed hypothesis testing by comparing pre- and post-scores of all outcomes with the paired-sample t-test. We used the 'd' index to measure the effect size and magnitude of change. Finally, we conducted complementary correlation analyses between scores and subsample variables using variance and correlation analysis. While the proportion of missing values were less than 5%, we used the multiple imputation technique to deal with missing questionnaire data. The software package used for the analyses was SPSS (version 25, 'Statistical Package for the Social Sciences'). Outcomes Measurement and Survey Validation To effectively assess our study's key outcomes— ICC, SE, and Knowledge—while maintaining a contextually relevant, practical, and budget-conscious approach, we opted to adapt and validate a shortened version of an existing inventory for ICC assessment while introducing newly crafted items for SE and Knowledge (see process below). This decision was motivated by the need to obtain accurate and relevant results within the framework of our research, rather than developing a new psychometrically validated instrument for widespread application. The validation process followed a stepwise approach. The first step of our questionnaire development was carrying out a brief literature review on the most used ICC questionnaires that were: 1) published in peer-review journals; 2) aimed at healthcare professionals; 3) had easily accessible online questionnaires, and 4) matched our RER learning objectives. While we found several questionnaires that were frequently cited in the literature 23 – 25 , most focused on United States of America population composition and migratory dynamics; had a different target population (general population versus healthcare professionals); and/or took too long to administer. After careful review of each questionnaire, we opted to adapt and modify a reduced version of the Clinical Cultural Competency Questionnaire (CCCQ) 26 . The CCCQ is a psychometrically validated 23 , 25 , 27 86-item self-assessment aimed at healthcare professionals that measures four dimensions of ICC ( Knowledge, Skills, Attitudes, Awareness) consistent with established models for ICC (e.g. The Multidimensional Model of Cultural Competence 28 , Culturally Competent Model of Care 29 ). Next, for the purpose of item reduction, we established a scoring system whereby two of our researchers read and scored each item from the original CCCQ questionnaire on a scale of 1 to 10 for appropriateness and relevancy to our RER goals and target population. Inter-judge reliability was later used as a criterion for the final selection of items, narrowing down the total item size from 86 to 13. Three modified items from the Scale of Ethno-Cultural Empathy 24 were also included following a similar approach to item reduction. At the item level, modifications were made in wording to ensure focus on our target population of VMRs entering Europe. A two-way translation to Spanish was then carried out. Post-hoc, we tested the structural validity of the questionnaire by conducting an exploratory factor analysis (EFA) using Promax rotation and Kaiser criterion to determine the number of overall ICC dimensions. The preliminary results of the EFA suggested that the psychometric properties of the questionnaire are adequate. Results indicated that a reduced ICC model, consisting of 16 items and 5 dimensions, explained over 70% of the variance, with Eigenvalues greater than 1, and a screen test indicating a factor structure consistent with the original questionnaire (please refer to Supplemental Digital Appendix 2: Exploratory Factor Analysis Results with Eigenvalues and Explained Variance ). All items were scored on a 1–5 Likert scale. For SE and Knowledge, all items were newly created as no suitable validated questionnaires were identified in the literature. We evaluated participants' objective knowledge with newly created multiple-choice questions that covered various topics on VMRs covered during the activity. Finally, internal consistency was analyzed using the Cronbach's Alpha test, showing overall acceptable levels (alpha > 0.7 threshold) for all subscales with > 1 item, as well as for the overall ICC and SE scores (please refer to Supplemental Digital Appendix 3: Reliability Analysis of Outcome Indicators in Intercultural Competence, Self-efficacy, and Knowledge Scales). The pre-test questionnaire included sociodemographic items and had a total of 24 questions. The post-test questionnaire included two open-ended qualitative questions and a 10-point Likert item on activity satisfaction, totaling 27 items (please refer to Supplemental Digital Appendix 4: Pretest to assess the impact on Intercultural Competence, Self-efficacy, and Knowledge of the Refuge Escape Roomfor the questionnaires). Qualitative Analysis We asked two open-ended questions in our survey that captured several themes of the student experience. A thematic content analysis took place for the analysis of the answers to the two open questions of the questionnaire. The answers were read thoroughly, and coded segments were grouped into categories that informed the content of the generated themes. This process was carried out by two researchers for triangulation purposes. RESULTS The total sample size was 101 participants (see Table 2 Sociodemographic Characteristics of Participants), with a mean age of 25.76 years (sd 7.94). Most identified as women (76%). Approximately half of our sample were health science students (51%), followed by healthcare workers (44%) comprising 50% nurses and 50% physicians. The remaining participants were professionals from other backgrounds (5%). Participants’ primary areas of origin were Europe (46%) and USA (43%), with 91% of all Europeans hailing from Spain. Most participants had previous work experience (69%), while only a quarter reported experience working with migrants (28%). Table 2 Sociodemographic Characteristics of Participants Characteristic Value n (%) Sex Female 76 (76%) Male 23 (23%) Other 1 (1%) Age - 25.76 (sd = 7.9) Professional occupation Nurse 22 (22%) Physician 22 (22%) Student 51 (51%) Other 5 (5%) Activity Location MSc 26 (26%) ICS 24 (24%) IES 50 (50%) Worked with migrants? Yes 28 (28%) No 72 (72%) Has work experience? Yes 69 (69%) No 31 (31%) Note: he table represents a comprehensive breakdown of the sociodemographic data of participants in the study. Percentages were calculated based on the total sample size of 101 participants. The mean age is provided with the standard deviation (SD). Intercultural competence Overall, participants had a baseline ICC overall score of 10.57 (sd 1.54). Baseline scores for the different subscales were as follows: 2.02 (sd 0.67) for the knowledge on health disparities subscale; 4.61 (sd 0,85) for the attitudes towards factors contributing to health disparities subscale; 0.79 (sd 0.18) for the awareness of racial, ethnic, or cultural stereotypes subscale; 0.94 (sd 0.12) for the importance of ICC training for healthcare professionals subscale; and 2.22 (sd 0.54) for the Empathy subscale (see Table 3 Comparative Analysis of Pre and Post-Intervention Scores in Intercultural Competence, Self-efficacy, and Knowledge Related to Health Disparities and VMR). Table 3 Comparative Analysis of Pre and Post-Intervention Scores in Intercultural Competence, Self-efficacy, and Knowledge Related to Health Disparities and VMR Scale Subscale Description Mean (SD) Cohen's d Coefficient of variation (CV = SD/Mean) t Sig. (bilateral) PRE POST PRE POST Intercultural Competence Knowledge Self-reported knowledge on health disparities 2.02 (0.67) 2.94 (0.59) 1.57 0.33 0.20 -14.28 < 0.001 Attitudes Attitudes towards factors contributing to health disparities 4.61 (0.85) 4.98 (0.86) 0.43 0.18 0.17 -4.80 < 0.001 Awareness Awareness of racial, ethnic, or cultural stereotypes 0.79 (0.18) 0.82 (0.17) 0.21 0.24 0.20 -2.62 0.01 Importance Importance of cultural competency training for health professionals 0.94 (0.12) 0.97 (0.09) 0.40 0.12 0.09 -2.99 < 0.01 Empathy Empathic perspective taking & empathic awareness 2.22 (0.54) 2.52 (0.45) 0.67 0.24 0.18 -6.92 < 0.001 TOTAL 10.57 (1.54) 12.23 (1.47) 1.13 0.15 0.12 -12.64 < 0.001 Self-efficacy Awareness on the personal capacity to assess factors related VMR 3.08 (0.62) 3.29 (0.54) 0.38 0.20 0.16 -3.56 0.001 Knowledge General knowledge on VMR 3.03 (1.13) 4.08 (0.88) 1.19 0.37 0.22 -8.40 < 0.001 Note: This table displays the results of a bivariate analysis comparing pre- and post-intervention scores of the intercultural competence, self-efficacy and knowledge scales. The mean (M) and standard deviation (SD) are reported for each subscale for both the pre- and post-intervention groups. The effect size is measured using Cohen's d, and the coefficient of variation (CV) is also provided. The t-value and bilateral significance level are reported for each subscale, indicating whether there was a significant difference between pre- and post-intervention scores. Coefficient of variation (CV) was calculated using the formula: CV = SD / Mean. Significance level (Sig.) was set at p < 0.05. Baseline ICC scores did not significantly differ between genders, age and previous working experience. However, participants that had previously worked with migrants reported higher overall ICC scores (11.28 vs 10.29; p < 0.05) at baseline, with the largest difference observed in the Knowledge subscale (2.41 vs 1.86; p < 0.05) and a tendency to score higher, albeit not statistically significant, in the rest of the subscales. Lastly, healthcare professionals had higher ICC scores compared to students (11.07 vs 10.01; p < 0.05) showing higher scores for the Knowledge (2.25 vs 1.76; p < 0.05) and Empathy (2.48 vs 1.94; p < 0.05) subscales. For more, refer to Table 4 : 4 Analysis of Baseline Scores in Relation to Sociodemographic Factors. Table 4 4 Analysis of Baseline Scores in Relation to Sociodemographic Factors INTERCULTURAL COMPETENCY SELF EFFICACY KNOWLEDGE PRE-POST Differences Overall Score Subjective Knowledge Attitudes Awareness Importance Empathy - - ICC SE Kw Previous work experience? Yes 10.74a (1.49) 2.08a (0.66) 4.4a (0.85) .78a (0.17) .94a (0.11) 2.31a (0.50) 3.2a (0.63) 3.03a (1.19) 1.61 a .16 a 1.14 a No 10.17a (1.61) 1.88a (0.68) 4.55a (0.87) .81a (0.21) .93a (0.13) 2.01b (0.58) 3.00a (0.62) 3.03a (1.02) 1.79 a .31 a .84 a Worked with migrants? Yes 11.28a (1.66) 2.41a (0.66) 4.74a (0.78) .84a (0.15) .93a (0.14) 2.36a (0.60) 3.19a (0.63) 2.96a (1.00) 1.42 a .26 a 1.11 a No 10.29b (1.42) 1.86b (0.62) 4.56a (0.88) .77a (0.19) .94a (0.11) 2.16a (0.51) 3.04a (0.62) 3.06a (1.19) 1.76 a .18 a 1.03 a Professional vs Student Prof. 11.07a (1.24) 2.25a (0.49) 4.65a (0.84) .74a (0.16) .95a (0.10) 2.48a (0.33) 3.17a (0.53) 3.07a (1.19) 1.27 a .14 a 1.36 a Student 10.01b (1.60) 1.76b (0.71) 4.57a (0.89) .82a (0.20) .92a (0.13) 1.94b (0.55) 2.98a (0.70) 3.02a (1.12) 2.04 b .25 a .69 b Sex Male 10.13a (1.66) 1.89a (0.63) 4.47a (0.86) .79a (0.19) .91a (0.13) 2.07a (0.67) 2.78a (0.66) 3.17a (1.40) 1.64 a .34 a .83 a Female 10.66a (1.47) 2.04a (0,67) 4.65a (0.85) .78a (0.19) .94a (0.11) 2.25a (0.49) 3.17b (0.59) 2.99a (1.05) 1.68 a .16 a 1.11 a Regional Differences Europe 11.08a (1.23) 2.27a (0.51) 4.61a (0.82) .76a (0.17) .97a (0.08) 2.47a (0.33) 3.21a (0.55) 3.20a (1.05) 1.30 a .13 a 1.28 a North America 9.92b (1.55) 1.73b (0.73) 4.8a (0.86) .79a (0.21) .91b (0.14) 1.90b (0.55) 3.00a (0.69) 3.09a (1.11) 2.22 b .24 a .67 a Note: Values in the same row and subtable not sharing the same subscript are significantly different at p< ,05 in the two-sided test of equality for column means. Cells with no subscript are not included in the test. Tests assume equal variances.2 1. This category is not used in comparisons because the sum of case weights is less than two. 2. Tests are adjusted for all pairwise comparisons within a row of each innermost subtable using the Bonferroni correction. Self-efficacy Overall, the mean baseline SE score for participants was 3.08 (sd 0.62). While a trend of higher scores was observed for participants with previous work experience (3.12 vs 3), those having worked with migrants (3.19 vs 3.04), and healthcare professionals compared to students (3.17 vs 2.98), only gender differences in SE baseline scores were statistically significant. Females scored higher than their male counterparts, with a mean baseline score of 3.17 versus 2.78 (p < 0.05). Please refer to Tables 3 and 4 for more detailed information. Knowledge Baseline scores of the knowledge-based multiple-choice test were 3.03 (sd 1.13). No statistically significant differences were observed at baseline for any of the sociodemographic categories (please refer to Tables 3 and 4 for more). PRE-POST Analysis Pre-post analysis using paired t-tests revealed a significant increase in ICC scores compared to baseline (t=-12.64, p < 0.001), with a large observed effect size (Cohen’s d = 1.13). Similarly, all subscale scores exhibited higher averages after the RER intervention, with the largest effect size observed in the self-reported Knowledge subscale (d = 1.57, t=-14.28; p < 0.001), followed by Empathy (d = 0.67 t=-6.92; p < 0.001), Attitudes (d = 0.43, t=-4.80; p < 0.001), Importance (0.40, t=-2.99; p < 0.01) and Awareness (d = 0.21, t=-2.63; p < = 0.05) subscales. Average SE and Knowledge scores were also significantly higher at the post-intervention evaluation (t=-3.56; p = 0.001 and t=-8.40; p < 0.001, respectively), with a large effect size observed for Knowledge (d = 1.19) and a lowest for SE (d = 0.38) (Table 4 ). Pre-post average score changes were most pronounced for specific sociodemographic groups. Specifically, students demonstrated the highest reported ICC score gains (2.04 vs 1.27 for professionals; p < 0.05). Finally, participants were asked to rate their overall activity satisfaction from a 1 to 10 scale in the post-activity questionnaire. The average activity satisfaction rate was 8.29 (sd 1.64, with 10 being maximum satisfaction). Analysis revealed a significant positive correlation between achieving the objective (reaching Mars) and satisfaction levels; participants who successfully boarded the spaceship reported higher satisfaction scores (r = 0.37, p < 0.01) compared to those who remained on Earth. Qualitative results The first open question on “what did you learn new from this activity” had a 91% response rate. Twelve percent responded affirmatively to the question without specifying the area of new learning. “I was more ignorant than I thought; I was more unknowing about what I thought”. (Male, Spanish, nurse, 26 years old) Eighty-eight out of the 91 respondents commented on the question overtly. The three identified themes of learning were related to knowledge (60/91 respondents, 65.9%), attitudes (23/91, 25.3%), and skills (6/91, 6.6%). Under the theme of knowledge, two sub-themes were included concerning migrant stressors and migration demographics. Thirty-three out of the 91 respondents (36.3%) mentioned that they learned about migrant stressors, such as “everyday stressors”, “language barriers”, “injustices”, “stressors that increase inequality”, “factors relating to disparities in health”. Twenty-seven out of the 91 respondents (29.7%) commented that they learned about migration demographics, such as “statistics and facts”, “amount of migrants worldwide”, “number of countries that host refugees”, and “magnitude of migratory movements both at European level and worldwide”. Under the theme of attitudes, empathy was the concept that best described the answers of the respondents. A quarter of the respondents commented that the activity helped them understand the frustration, helplessness, and distress that migrants may feel during their migration and settlement trajectory as well as the prejudices and injustices they face along the way. “It put me in the skin of immigrants and made me feel their sensations although it's just a game”. (Female, Spanish, nurse, 28 years old) “I learned to be more empathetic towards the immigration process”. (Female, North American, undergraduate student, 21 years old) “With a simple game I felt stress, anxiety, frustration and it's interesting to be able to translate that to reality”. (Female, Spanish, nurse, 23 years old) A small percentage of respondents (6.6%) translated their acquired knowledge and attitudes into skills. They were able to adopt a shift of perspective towards a more contextualized and informed view on migration. “I learned that the immigration crisis is not specific to the US. It's easy to only think of my country and forget that this is an international crisis. It definitely changed my perspective on how hard it is to get into another country”. (Female, North American, undergraduate student, 21 years old) “Learning the process of immigration is important for working with a population with these characteristics. I learned about the suffering, pain, and stress that affect their health status (Female, Spanish, nurse, 25 years old) At the second open question on “what aspects of the activity could be improved”, there was a 58% response rate. Interestingly, 18/58 respondents (31.0%) took the time to comment very positively on the activity under this question. The areas for improvement were grouped into four themes: facilitation, content, space, and organization. In terms of facilitation, 22.4% of respondents suggested more instructions prior to the start of the game and more intensity in the facilitation, so that participants could enter more adequately into the role-playing of the migrant. Concerning the content, 22.4% mentioned that they needed a more thorough debriefing at the end of the activity and others were curious to know whether the game had been validated with migrants themselves. Some of them, 13.8%, commented that the space was quite small, but some mentioned that this may have been on purpose to simulate the stressful migration process. Lastly, 6.9% suggested improvement in the organization of the activity in terms of the small groups’ composition. DISCUSSION Efforts to design and implement educational ERs that tackle more complex, societally relevant topics are increasingly growing 20 . Adding to this trend, our study preliminary data suggests that educational ERs can also be effective tools to improve the ICC, SE, and KW of students and professionals regarding the health needs and challenges faced by VMRs. Like other studies 21 , 22 , 30 , our qualitative data also suggests that our ER’s success is partly explained by the high levels of engagement, motivation, problem-solving and teamwork experienced by participants. After completing the ER, our qualitative data suggests that most participants reported a sense of improved knowledge of VMR’s health status, stressors, and demographics; attitudinal changes through increased awareness and empathy; as well as a perspective shift toward a more contextualized and informed view on migration. While research on ICC training has traditionally focused on standalone workshops 5 , 6 , 31 – 34 , our study is, to the best of our knowledge, one of the first to utilize the principles of an educational ER to increase levels of ICC of participants, with the largest gains obtained by students whom, in turn, had the lowest baseline ICC scores. In addition, baseline ICC scores were higher for those with previous working experience, matching published data on the positive correlation between clinical exposure to diverse patient populations and higher levels of cultural awareness and sensitivity of healthcare providers 35 , 36 . Perhaps the most relevant implication of improving ICC scores derives from the evidence that a higher ICC in the clinical encounter has been shown to significantly impact health service utilization and quality of care of vulnerable patients 7 , 8 . Despite our promising results, we are aware that the concept of ICC has often suffered from a lack of conceptual clarity 35 , and subscribe to the views of other authors 37 arguing that ICC training cannot be detached from a deeper understanding of cultural complexity and the social determinants of inequality. In terms of our sample, the inclusion of older non-student participants complements previous research on the effectiveness of educational ERs which had mostly focused on higher education “gen Z” students 22 . In this regard, our results show that all age groups benefit from the ER experience in terms of improved outcomes and activity satisfaction. Research on educational ERs has shown that self-perceived knowledge retention is higher compared to traditional learning 39 , 40 . However, notwithstanding notable exceptions 38 , few studies have formally tested knowledge retention objectively. Our study consequently adds to the evidence base on the effectiveness of educational ERs for domain-specific learning, by showing significant improvement of participant’s PRE-POST knowledge scores in a multiple-choice test. While the question of long-term retention remains unanswered, reports indicate that knowledge retention may persist over time 41 . Our results further reveal that while all participants had similar objective knowledge scores at baseline, those with previous working experience considered themselves as more knowledgeable about VMRs compared to the rest of the participants -- judging by the higher scores obtained in the self-perceived Knowledge subscale of the ICC questionnaire. The observed mismatch between the two scores perhaps suggests that experienced participants tend to overestimate their true knowledge-base regarding the complex topic of VMRs and healthcare. Nevertheless, taken together, our results are congruent with the literature suggesting that experiential learning promotes information retention and knowledge gap identification 42 , leading to positive learning outcomes regardless even of an individual’s preferred learning method 43 . As noted elsewhere 33 , 44 , 45 , educational ERs may provide an experience that improves SE, that is, the extent of an individual’s belief in his or her abilities to engage in specific behaviors 46 . Our results mirror such findings, with observed increases in the SE scores of all participants regardless of sociodemographics. In other words, after completing the RER, participants reported an improved sense of being able to provide culturally sensitive care of VMRs, which is a promising result given the established literature on SE as predictive of actual behavior 46 , 47 . Lastly, we implemented a debrief after the activity with trained facilitators to ensure emotional well-being and discuss the player’s experience. This aspect has also shown to be crucial to decontextualize knowledge for use in future situations 48 . Limitations & Future Research We employed a mixed-method, pre-post design for our pilot intervention due to its resource-efficient nature and alignment with our budget limitations. While our methodology improves upon many published ER interventions 21 , 22 , 48 , we acknowledge significant limitations. First, the lack of randomization and control group introduced a higher risk of bias (e.g. measurement, confounding, and attrition biases). These factors also hinder our ability to establish a causal relationship between the intervention and its outcomes and consequently limit our ability to confidently assess other significant variables that might contribute to our results. Furthermore, the absence of long-term follow-up restricts our capacity to evaluate the persistence of knowledge retention over time, despite existing literature 41 indicating notable long-term retention. Second, the absence of a power analysis combined with the reliance on a convenience-based sampling approach, likely introduced selection bias. Specifically, our sample primarily consisted of self-selected physicians and students enrolled in a global health curriculum. This particular group might possess an inherently greater sensitivity towards issues related to migration and health, differing significantly from other more diverse populations. Third, while the psychometric properties of the adapted inventory are satisfactory, exhibiting acceptable internal validity and reliability, it lacks in several key areas of the validation process. Notably, we did not obtain normative scores from a broader, demographically representative sample. Furthermore, the structural integrity of the ICC questionnaire was not evaluated using confirmatory factor analysis on an additional sample, and other important domains of validity, such as concurrent validity, were not assessed. However, it is important to clarify that the aim of our validation process was not to develop a new inventory for widespread application, but rather to enhance the validity of our results in alignment with our objective of assessing the feasibility, acceptability, and preliminary effectiveness of our novel educational ER. Lastly, at the intervention level, identified barriers during the debriefing and qualitative analysis include excessive competition which may be threatening to some participants; the need for more detailed instructions and more intense facilitation; idiomatic barriers as evidenced in some RER sessions; and logistical barriers inherent to the activity per se (e.g., time required for planning and execution, human resources cost, materials, and so on.). Several of our detected barriers have also been reported numerous times 22 and may arguably be intrinsic to the ER format per se . Despite these limitations, we recognize the exploratory proof-of-concept nature of our pilot intervention and the need to include more robust study designs in the future. Future studies will also benefit from the inclusion of an economic analysis in its design, which will, in turn, lay the grounds for scaling up efforts. Similarly, while our study has a strong emphasis on quantitative data and its validation, the qualitative content analysis could be further developed with the addition of more comprehensive qualitative techniques (e.g., focus groups) beyond the thematic analysis of open-ended questions, highlighting an area for potential future research. CONCLUSIONS Health professionals have a professional and ethical obligation to provide adequate care for VMRs. Teaching healthcare professionals and students to be more culturally competent may help them become better healthcare providers and, in turn, tackle healthcare access and quality of care barriers affecting the most vulnerable. While in the last years there has been a notable rise in educational ERs with promising results regarding teamwork, engagement, satisfaction, and communication 30 , 48 , research on the actual educational significance is still limited. In this paper, we presented a feasible, acceptable, and innovative educational ER that effectively expands the significance and utility of ER by exploring its potential impact on the ICC, SE, and Knowledge of healthcare students and professionals that care for VMRs. There exist ample opportunities to foster synergies between global health, ICC training, and gamification initiatives within the curriculum of healthcare education 10 . Failing to meet the challenges of an increasingly diverse population through intercultural training may continue to broaden health disparities and limit access to health care resources for the most vulnerable patients. While there is a need for more structured research and superior methodological rigor, we hope that the RER intervention here presented is a small albeit important step to building the evidence base for a more effective curriculum that trains healthcare providers about the health challenges faced by asylum seekers and refugees worldwide. Declarations Ethical approval: This research was evaluated and approved by the Clinical Research Ethics Committee (CEIC) of the Vall d’Hebron Hospital in Barcelona and adhered to the best clinical practices on the 7 th of June of 2019. Consent to Participate: All participants gave their consent to participate in this study. Consent for publication : not aplicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request Competing interests: The authors declare that they have no competing interests. Funding/Support: Research reported in this publication was supported by co-funding from the Third EU Health Program (2014-2020) Project Grants (HP-PJ-2016) under Grant Agreement 738091 (MyHealth Consortium). Author contributions . NSD, LW: conception of the RER activity. NSD: RER intervention coordination. RM NSD: protocol and survey development. RM, AM: database creation, data monitoring, quantitative analysis. SE: qualitative analysis. NSD, RM, AM, SE: verified results and analytic methods. NSD: Study resources. RM, NSD, AM, SE: wrote the first draft of the manuscript. RM, NSD, SE, AM, LW: writing-review and editing. All authors contributed to the article and approved the submitted version. Acknowledgments : The authors extend sincere gratitude to all volunteer participants and actors whose invaluable contributions were crucial to the success of the Refugee Escape Room research project. Their dedication and enthusiasm significantly enhanced the project's outcomes. Footnotes : The content of this article is the sole responsibility of the authors and does not necessarily represent the views of any of the sponsoring organizations, institutes, or the European Commission. References Global Trends to 2030. The Future of Migration and Integration. Published online 2018. 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Gamification in medical education. Published online 2015. Adams V, Burger S, Crawford K, Setter R. Can you escape? Creating an escape room to facilitate active learning. J Nurses Prof Dev. 2018;34(2):E1–5. Brady SC, Andersen EC. An escape-room inspired game for genetics review. J Biol Educ Published online 2019:1–12. Lafontaine C, Sawchuk K, DeJong S. Social Justice Games: Building an Escape Room on Elder Abuse through Participatory Action Research. Comput Games J. 2020;9(2):189–205. 10.1007/s40869-020-00105-5 . Taraldsen LH, Haara FO, Lysne MS, Jensen PR, Jenssen ES. A review on use of escape rooms in education – touching the void. Educ Inq. 2022;13(2):169–84. 10.1080/20004508.2020.1860284 . Fotaris P, Mastoras T. Escape Rooms for Learning: A Systematic Review.:9. Harris-Haywood S, Goode T, Gao Y et al. Psychometric evaluation of a cultural competency assessment instrument for health professionals. 2014;52(2):e7–15. 10.1097/MLR.0b013e31824df149 Wang YW, Davidson MM, Yakushko OF, Savoy HB, Tan JA, Bleier JK. The Scale of Ethnocultural Empathy: Development, Validation, and Reliability. Published online 2003. 10.1037/0022-0167.50.2.221 Bernhard G, Knibbe RA, von Wolff A, Dingoyan D, Schulz H, Mösko M. Development and Psychometric Evaluation of an Instrument to Assess Cross-Cultural Competence of Healthcare Professionals (CCCHP). Christiansen H, ed. 2015;10(12):e0144049. 10.1371/journal.pone.0144049 Wetzel Angela P. Critical Synthesis Package: Clinical Cultural Competency Questionnaire (CCCQ). MedEdPORTAL . 9:9390. 10.15766/mep_2374-8265.9390 Apostolara P, Sourtzi P, Tsoumakas K et al. Reliability and validity of the Clinical Cultural Competency Questionnaire-Greek version (CCCQ-G). Balk Mil Med Rev. 2016;19(2). Sue DW. Multidimensional Facets of Cultural Competence. Couns Psychol. 2001;29(6):790–821. 10.1177/0011000001296002 . Campinha-Bacote J. The Process of Cultural Competence in the Delivery of Healthcare Services: a model of care. J Transcult Nurs Off J Transcult Nurs Soc . 2002;13(3):181–184; discussion 200–201. 10.1177/10459602013003003 Veldkamp A, Knippels MCPJ, van Joolingen WR. Beyond the Early Adopters: Escape Rooms in Science Education. Front Educ. 2021;6:622860. 10.3389/feduc.2021.622860 . Carter MM, Lewis EL, Sbrocco T et al. Cultural Competency Training for Third-Year Clerkship Students: Effects of an Interactive Workshop on Student Attitudes .; 2006. Aamc. Assessing Change: Evaluating Cultural Competence Education and Training Assessing Change: Evaluating Cultural Competence Education and Training Assessing Change: Evaluating Cultural Competence Education and Training .; 2015. Accessed May 13, 2019. www.aamc.org. Jin Jhyun, Cleofas JV. A proposed cultural competence training program for nurses based on their transcultural self-efficacy. Int J Adv Cult Technol. 2018;6(2):86–99. 10.17703/IJACT.2018.6.2.86 . Beach MC, Price EG, Gary TL et al. Cultural competence: a systematic review of health care provider educational interventions. 2005;43(4):356–73. Thackrah RD, Thompson SC. Refining the concept of cultural competence: building on decades of progress. Med J Aust. 2013;199(1):35–8. 10.5694/mja13.10499 . Boyer CJ, Rice MJ, Sorrell TR, Spurling AM. Advancing Racial/Ethnic and Cultural Sensitivity Among PMHNP Students Through Education, Practice, and Experience. J Am Psychiatr Nurses Assoc. 2019;25(6):487–95. 10.1177/1078390318824651 . Sakamoto I, AN ANTI-OPPRESSIVE APPROACH, TO CULTURAL COMPETENCE. Can Soc Work Rev Rev Can Serv Soc. 2007;24(1):105–14. Fusco NM, Foltz-Ramos K, Ohtake PJ. Interprofessional Escape Room Improves Knowledge and Collaboration Among Nursing, Pharmacy and Physical Therapy Students. Am J Pharm Educ Published online Dec. 2021;15:8823. 10.5688/ajpe8823 . Bartlett KA, Anderson JL. Using an Escape Room to Support the Learning of Science Content.:6. Dimova G, Videnovik M, Trajkovik V. Using Educational Escape Room to Increase Students’ Engagement in Learning Computer Science.:7. Liu C, Patel R, Ogunjinmi B, et al. Feasibility of a paediatric radiology escape room for undergraduate education. Insights Imaging. 2020;11(1):50. 10.1186/s13244-020-00856-9 . Khanna A, Ravindran A, Ewing B, et al. Escape MD: Using an Escape Room as a Gamified Educational and Skill-Building Teaching Tool for Internal Medicine Residents. Cureus. 2021;13(9). 10.7759/cureus.18314 . Kolb A, Kolb D. Learning styles and learning spaces: A review of the multidisciplinary application of experiential learning theory in higher education. Learn Styles Learn Key Meet Account Demands Educ . Published online January. 2006;1:45–91. Mathieson A, Duca E. STEM escape rooms for public engagement. Res All. 2021;5(2). 10.14324/RFA.05.2.10 . Asurakkody TA. Predictors for Transcultural Self-efficacy of Nursing Students: Application of Ecological Model. Health Sci J. Published online 2018:7. Bandura A, Adams NE. Analysis of self-efficacy theory of behavioral change. Cogn Ther Res. 1977;1(4):287–310. 10.1007/BF01663995 . Sharifirad G, Azadbakht L, Feizi A, Kargar M, Mohebi S. Review the key role of self-efficacy in diabetes care. J Educ Health Promot. 2013;2(1):36. 10.4103/2277-9531.115827 . Veldkamp A, van de Grint L, Knippels MCPJ, van Joolingen WR. Escape education: A systematic review on escape rooms in education. Educ Res Rev. 2020;31:100364. 10.1016/j.edurev.2020.100364 . Footnotes Details on the context of the game can be seen at the video which all participants see prior to starting the game: https://www.youtube.com/watch?v=GxdA87MDST4&list=UU_CU6nrajWq1lr6BnoNYw3A&index=4 ). Additional Declarations No competing interests reported. Supplementary Files SupplementalDigitalAppendix1.docx Cite Share Download PDF Status: Published Journal Publication published 11 Nov, 2024 Read the published version in International Journal for Equity in Health → Version 1 posted Editorial decision: Revision requested 17 Sep, 2024 Reviews received at journal 14 Sep, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers invited by journal 05 Aug, 2024 Editor assigned by journal 05 Aug, 2024 Submission checks completed at journal 25 Jul, 2024 First submitted to journal 23 Jul, 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. 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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-4788752","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":339224874,"identity":"45e1777d-92cd-4d6e-94d7-27f1a65927f6","order_by":0,"name":"Ruben Moreno-Comellas","email":"","orcid":"","institution":"FIDMAG Germanes Hospitalàries Research Foundation","correspondingAuthor":false,"prefix":"","firstName":"Ruben","middleName":"","lastName":"Moreno-Comellas","suffix":""},{"id":339224875,"identity":"d035dd06-cfa9-402b-aebf-56b252bf0e5f","order_by":1,"name":"Adria Murias-Closas","email":"","orcid":"","institution":"Vall d’Hebron Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Adria","middleName":"","lastName":"Murias-Closas","suffix":""},{"id":339224876,"identity":"050e9989-0e40-47a8-8b97-ab4b3726d8b3","order_by":2,"name":"Stella Evangelidou","email":"","orcid":"","institution":"Vall d’Hebron Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Stella","middleName":"","lastName":"Evangelidou","suffix":""},{"id":339224877,"identity":"1339839c-76b9-421d-a9f1-2653e722dabb","order_by":3,"name":"Lloy Wylie","email":"","orcid":"","institution":"Western University","correspondingAuthor":false,"prefix":"","firstName":"Lloy","middleName":"","lastName":"Wylie","suffix":""},{"id":339224878,"identity":"428dfbfa-7690-417f-aa74-6ba66a1c4f32","order_by":4,"name":"Nuria Serre-Delcor","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie3OMUvDQBjG8acE4vJK1xtC8hUuBNIK+TCRQlxUcBOU6JSpOl9w8DO4OV45SJfYOeKgXZw6NEvpIOJJhAom1dHh/tNx3I/nAJPpH8YlIL/OvRdg6HDQdjL8RiwOMNoQu51EcnO22d9IdTSXa6Tu4EYVZ3TOaLBzVSzre3j928tWElYHfDKGCpxZkjxRwWhvPBvleQlfFO0rYZVAEuS+IAofha0/Vh0G1m6GGB0k0GTyhvRCUH91It41eV40xOsgviaKYMWMyEadfa5QQ3gXKV+hHK58QXbA6mtNyuNRL8+Yf1fErYRPE6tenKYeI2u+jFeRy6cPSs9Fnqtk+0wDf16xLc9NJpPJ9Fsf4spYTVETWlsAAAAASUVORK5CYII=","orcid":"","institution":"International Health Unit Vall d’Hebron-Drassanes, Vall d’Hebron University Hospital, PROSICS Barcelona","correspondingAuthor":true,"prefix":"","firstName":"Nuria","middleName":"","lastName":"Serre-Delcor","suffix":""}],"badges":[],"createdAt":"2024-07-23 12:29:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4788752/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4788752/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12939-024-02304-2","type":"published","date":"2024-11-11T15:57:36+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":63374200,"identity":"3d811108-a84e-4a68-b81b-eb01b208d862","added_by":"auto","created_at":"2024-08-27 12:22:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":114567,"visible":true,"origin":"","legend":"\u003cp\u003eRER Intervention Flowchart\u003c/p\u003e\n\u003cp\u003eNote: This flowchart illustrates the progression through the escape room game, detailing each phase from the initial lecture to the final stage of reaching Mars. After the lecture participants are given instructions and form 'family units,' undergo a series of puzzles and challenges related to migration, and interact with various themed offices such as Passport, Health, Education, and Ticket offices. Description of the puzzles and offices:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1 Chronological Cards Puzzle\u003c/strong\u003e: Participants arrange migration fact cards in chronological order to obtain a code. \u003cstrong\u003e2 Migration Terminology Puzzle\u003c/strong\u003e: A crossword puzzle with migrant term definitions reveals a code. \u003cstrong\u003e3 Migratory Trends Puzzle\u003c/strong\u003e: An alphabet soup puzzle about migration trends; unused letters form a code. \u003cstrong\u003e4 Migration \u0026amp; Health Literacy Puzzle\u003c/strong\u003e: Filling gaps in a text about migration health aspects on a computer generates a code. \u003cstrong\u003e5 Passport Office:\u003c/strong\u003e Presenting a family passport with previous codes, participants fill out an application in Martian and pay for translation. Outcomes depend on origin and suspected terrorist links\u003cstrong\u003e. 6\u003c/strong\u003e \u003cstrong\u003eHealth Office:\u003c/strong\u003e Families undergo medical checks, facing potential treatment costs, quarantine, or rejection. \u003cstrong\u003e7 Education Office\u003c/strong\u003e: Validation of diplomas and demonstrating the relevance of professions for life on Mars. \u003cstrong\u003e8 Ticket Office\u003c/strong\u003e: Families must buy tickets to Mars; inability to pay means returning to their country. \u003cstrong\u003e9 Penalties \u0026amp; Random Encounters:\u003c/strong\u003e Participants face various obstacles like detention for epidemiological/geopolitical risks or corrupt officials demanding bribes. \u003cstrong\u003e10 Reaching the Rocket\u003c/strong\u003e: This immersive experience reaches its climax as participants either successfully reach the rocket to Mars or, more commonly, confront a much harsher reality. The experience concludes with a debriefing session, aimed at consolidating the key learning outcomes and the insights participants have gained throughout their journey.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4788752/v1/c5d3d35ad2ccdb63ff5cc589.png"},{"id":69275008,"identity":"e5093af2-9bf8-41d7-99f0-e6810cd247c8","added_by":"auto","created_at":"2024-11-18 16:44:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1103884,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4788752/v1/77bf2d99-c3bc-4878-b7f3-3d93352da410.pdf"},{"id":63374201,"identity":"6d199ba8-2552-49e3-981f-ece9f490b4c5","added_by":"auto","created_at":"2024-08-27 12:22:14","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":776202,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalDigitalAppendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4788752/v1/d9a16e83874d3d46e0a440ba.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"An Innovative Gamification Tool to Enhance Intercultural Competence and Self-Efficacy among Healthcare Professionals Caring for Vulnerable Migrants and Refugees","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eSince the beginning of the early 2000s, the number of migrants and mobile European Union (EU) citizens living in the EU has gone from 34\u0026nbsp;million (or 6.9% of the total EU population) in the early 2000s to over 90\u0026nbsp;million (or 10%) in recent years\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Asylum applications submitted in EU Member States has been following a similar upward trend, with 648,000 applications registered in 2021 and a 25.7% increase compared to 2020\u003csup\u003e2\u003c/sup\u003e. Worldwide, with millions of Ukrainians displaced, the total forced displacement by violence, conflict, persecution, food insecurity, and human rights violations, now exceeds 100\u0026nbsp;million people. That is, 1 out of every 78 people on earth has been forced to flee their home\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe growing segment of vulnerable migrants and refugees (VMRs) across Europe represents a significant challenge to the healthcare systems of receiving countries. An essential problem in facing such challenges is the scarcity of intercultural competence (ICC) training offered within healthcare education at large\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Consequently, healthcare professionals often lack the necessary ICC skills, that is, the capability to deliver effective, respectful, and understandable care to VMRs seeking medical attention in a manner fitting the patient\u0026rsquo;s health beliefs, practices, and language \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. In turn, low ICC in the clinical encounter has consistently been shown to impact health service utilization and quality of care of the most vulnerable patients\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eDespite numerous calls to action to include ICC training in public health education across the globe\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e, only a limited number of programs have truly implemented the necessary educational opportunities to meet such goals\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. In Spain alone, very few official programs offer a focused training curriculum about the unique health realities and barriers experienced by VMR\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. Results from several Spanish studies on the perceptions of healthcare providers caring for VMRs suggest that low levels of ICC are similarly perceived by professionals themselves as an important contributor to health-access disparities\u003csup\u003e\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe rapid development of novel gamification-based initiatives such as educational Escape Rooms (ERs) may offer a promising solution to the ICC training gap. Educational ERs have been defined as a teaching method requiring learners to participate in collaborative \u0026ldquo;gamified\u0026rdquo; activities explicitly designed for knowledge acquisition or skill development to accomplish a specific goal (e.g. escape from a physical room) by solving time-limited puzzles related to prespecified educational goals\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. More importantly, the data suggest that educational ESs are particularly successful at engaging participants in the learning process while providing an excellent framework for effective competency building\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral examples of published educational ERs in healthcare are worth mentioning. For example, researchers developed an ER aimed at Nurse Practitioners to teach bedside nursing skills\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. The authors argued that the ERs provided a unique opportunity to diversify learning strategies, as each puzzle required a varied set of skills to successfully solve (kinesthetic, knowledge, visual cues). Other authors created an escape-room-inspired game as part of a genetics course curriculum\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, with the objective to consolidate course materials. Overall, designers of ER educational activities report high levels of engagement, satisfaction, and knowledge retention.\u003c/p\u003e \u003cp\u003eEfforts are also being made to design educational ERs that tackle more complex, societally relevant topics. For instance, researchers developed an ER focusing on the topic of elder abuse\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The game, titled Sandra\u0026rsquo;s Keys, encouraged players to engage with the story of an imaginary older woman struggling with abuse through a series of puzzles. The goal of the ER is to bring participants into a dialogue about the different forms of elder abuse, deepening the understanding of the bystander\u0026rsquo;s role.\u003c/p\u003e \u003cp\u003eDespite the potential of educational ER to promote competency-building, none of the educational ERs found in the literature have focused on VMRs nor targeted ICC training. Furthermore, the majority of published educational ERs have important methodological problems such as a lack of a control group; the overutilization of poorly validated instruments; small sample sizes, and, overall, a lack of methodological rigor\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo bridge the identified research gap, we introduce the preliminary evidence-base of a novel educational ER, titled \"Refugee Escape Room\" (RER). This innovative ER was conceptualized and initially developed through a collaborative effort between authors NDC and LW during an academic exchange between Spain and Canada in 2017 as part of a Master of Public Health course focusing on gamification-based teaching methodologies. The RER, initially trialed with public health and health sciences students, draws upon the authors' extensive research on the health ramifications of migration and VMR's interactions with the healthcare system. Our main objective is to showcase a novel educational ER that aims to train \u003cem\u003eICC\u003c/em\u003e, improve self-efficacy (SE) and increase the knowledge (Kw) of healthcare students and professionals caring for VMRs. Additionally, we aim to gain a deeper insight into the feasibility, acceptability, and the learning process of the RER experience.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy type\u003c/h2\u003e \u003cp\u003eOur study employed a mixed-method approach, utilizing a pre-post, single-group intervention design. The primary aim was to assess the feasibility, acceptability, and preliminary effectiveness of the intervention on three key outcomes: ICC, SE, and Knowledge (Kw). To evaluate these metrics, we administered a newly validated questionnaire tailored to these specific domains. The participant pool, comprising a total of 101 individuals, was selected through convenience sampling.\u003c/p\u003e \u003cp\u003e \u003cb\u003eRER\u003c/b\u003e \u003cb\u003eActivity Description\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe RER\u003ca class=\"FNLink\" href=\"#Fn1\" id=\"#FNLinkFn1\"\u003e\u003c/a\u003e consists of a three-staged, two-hour-long face-to-face activity set in a fictitious scenario of a global crisis caused by overpopulation, global warming, wars, and changes in the geographical distribution of infectious diseases in the year 2084. In this carefully crafted scenario, participants are organized into teams, each representing a family unit. To avoid reinforcing or perpetuating existing societal stereotypes, family units are deliberately composed of diverse ethnic, geographical, and socioeconomic backgrounds intentionally designed not to mimic current real-world demographics. Within this setting, teams are tasked with collaboratively solving a series of complex puzzles, while also engaging in a competitive dynamic to secure a place on an interplanetary spaceship destined for Mars - depicted as a safer haven compared to a deteriorating Earth.\u003c/p\u003e \u003cp\u003eThe initial stage of the RER establishes the theoretical framework of the \u003cem\u003emigratory process\u003c/em\u003e in a classroom setting, with an expert discussing basic aspects of health and migration followed by a Q\u0026amp;A session. This section lasts 30 minutes and cues participants with the necessary knowledge to solve specific puzzles during the following RER stages.\u003c/p\u003e \u003cp\u003eThe second section introduces a simulated Border Control environment, presenting participants with a series of stringent and complex bureaucratic challenges set in four different Offices. These include passport control, where actors use a fictional \"Martian\" language to issue instructions, necessitating participants to solve language-based puzzles. Additionally, participants undergo evaluations of their educational background, language skills, and health status in the health and education offices. Throughout the exercise, participants often encounter unforgiving challenges, including but not limited to stringent penalties such as mandatory quarantine due to disease outbreaks or incarceration due to presumed terrorist links, both in virtue of the country of origin.\u003c/p\u003e \u003cp\u003eMoreover, this section incorporates scenarios with fictional corrupt officials, creating improvised conflicts that often demand bribes, disproportionately affecting participants from 'poorer' family units. This immersive experience reaches its climax as participants either successfully arrive on Mars or, more commonly, confront a much harsher reality, reflecting the complex dynamics of modern-day migration. This outcome intends to mirror the complex nature of modern migration, underscoring the stark differences in experiences based on socio-economic backgrounds and amplifies the depth of experiential learning.\u003c/p\u003e \u003cp\u003eThe activity culminates in a 30-minute semi-structured debriefing session. Here, participants are invited to discuss the various challenges they encountered during the game, their emotional reactions to the activity, and the interpersonal skills and coping strategies employed to navigate adversities. They are also encouraged to reflect on significant insights gained from the experience. For a detailed summary of materials, time allocation, and human resources required to carry out the RER please refer to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and consult Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e RER for the process flowchart and puzzle definitions.\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\u003eOverview of the Refugee Escape Room Game - Objectives, Structure, and Required Materials\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eObjectives\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eIncrease knowledge about epidemiological, chronological and health aspects in relation to people that recently arrived because of the migration crisis. To better intercultural competency and self-efficacy of healthcare professionals that work directly or indirectly with migrants recently arrived in Europe.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeneral Aspects of the RER\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: +18 years. \u003cb\u003eNumber of participants\u003c/b\u003e: 15\u0026ndash;40 (5 to 7 groups of 3 to 6 participants). \u003cb\u003eDuration\u003c/b\u003e: approximately 120 minutes. \u003cb\u003eFormat\u003c/b\u003e: session in classroom. \u003cb\u003eSubject area\u003c/b\u003e: Refugees and migration process. \u003cb\u003eKeywords\u003c/b\u003e: refugees, cultural competence, migration, health, refugee.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverview and context\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eEarth is dying and must migrate to Mars to survive. Participants will be divided by groups (families) and must survive multiple challenges related to the migration process. Their goal is to reach the end of the game to discover a new land of opportunities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMaterials and Human Resources\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e1 coordinator/teacher and 4 teacher assistants. \u003cb\u003eClassroom 1\u003c/b\u003e: computer, screen, internet connection, audio, 4 tables, 15\u0026ndash;40 chairs. \u003cb\u003eClassroom 2\u003c/b\u003e: computer, 4 tables, 12 chairs. 4 boxes with coded lock. 5\u0026ndash;7 envelops with groups information (family profile, passport, savings, pen). Border control documents (forms, flight tickets, poster signs pointing different offices)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGame structure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDescription\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eHuman Resource\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eDuration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheoretical Framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntroduction of basic aspects of health and immigration (room 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 coordinator/teacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEscape Room activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContext of the game, rules, and familiar groups (room 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 coordinator/teacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFirst phase: knowledge puzzles (room 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 teacher assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecond phase: fictitious border (room 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 teacher assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDebriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSignifying the experience: lessons learned (room 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 coordinator/teacher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30 minutes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003e Eligible participants for the RER study included health and social sciences professionals and students, all above 18 years of age, who voluntarily enrolled and provided signed consent forms. Participation in the study was free of charge and offered no financial incentives. To preserve anonymity, participants were assigned non-traceable identifiers. The recruitment strategy employed convenience sampling and successfully enlisted 26 Master of Science students (achieving a 100% participation rate) and 50 students from an international education program (IES Abroad, also with a 100% participation rate). Additionally, recruitment efforts for healthcare professionals involved sending 197 email invitations to those who had previously agreed to receive information about such activities. From these, 25 healthcare professionals consented to participate in the study.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eRER\u003c/em\u003e intervention was piloted through 4 sessions (2 in English and 2 in Spanish) across three different institutions of the Barcelona area (Spain). At the campus for the Master of International Health of the Universitat Aut\u0026ograve;noma de Barcelona (UAB) the 17th of June 2019, at the Auditorium of the Catalan Health Institute the 18th of June 2019, and at the International Education of Students Abroad (IES Abroad) campus in Barcelona the 19th and 20th of June 2019. Each of these 4 sessions required 2:00 hours for the development of the \u003cem\u003eRER\u003c/em\u003e; and 30 minutes for signing the consent form and filling the pre and post-test (see questionnaire items in appendices). Prior to the beginning of each RER, pre-preparation activities were carried out, wherein assistants engaged in specific roles such (e.g. corrupt official, passport officer, educational officer, health officer, and ticket officer) received detailed instructions pertinent to their roles. Additionally, a team member was assigned the supporter role to resolve any participant queries during problem-solving.\u003c/p\u003e \u003cp\u003eData to monitor the performance of the RER across the four piloting sessions was collected using using PRE and POST questionnaires. The PRE questionnaire was answered before participating in the RER (pre-test) and the other at the end of the intervention (post-test). After completing the questionnaire\u0026rsquo;s, printed copies were returned and manually digitized via a newly created Google Forms. The Google Forms database was later exported to an SPSS database for data analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eEthics statement\u003c/h2\u003e \u003cp\u003e The study was carried out in accordance with the Harmonized Tripartite Standards for Good Clinical Practice, following current national regulations (Law 14/2007 of Biomedical Research) and the Ethical principles derived from the Declaration of Helsinki. Data confidentiality of study participants was guaranteed in compliance with the Spanish Organic Law 15/1999, of December 13, on the Protection of Personal Data. This research was evaluated and approved by the Clinical Research Ethics Committee (CEIC) of the Vall d\u0026rsquo;Hebron Hospital in Barcelona and adhered to the best clinical practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eFirst, we conducted a descriptive analysis of our data by assessing the distribution, central tendency, and dispersion (interquartile) of our main outcomes, as well as sociodemographic data. Second, we performed hypothesis testing by comparing pre- and post-scores of all outcomes with the paired-sample t-test. We used the 'd' index to measure the effect size and magnitude of change. Finally, we conducted complementary correlation analyses between scores and subsample variables using variance and correlation analysis. While the proportion of missing values were less than 5%, we used the multiple imputation technique to deal with missing questionnaire data. The software package used for the analyses was SPSS (version 25, 'Statistical Package for the Social Sciences').\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes Measurement and Survey Validation\u003c/h2\u003e \u003cp\u003eTo effectively assess our study's key outcomes\u0026mdash; ICC, SE, and Knowledge\u0026mdash;while maintaining a contextually relevant, practical, and budget-conscious approach, we opted to adapt and validate a shortened version of an existing inventory for ICC assessment while introducing newly crafted items for SE and Knowledge (see process below). This decision was motivated by the need to obtain accurate and relevant results within the framework of our research, rather than developing a new psychometrically validated instrument for widespread application.\u003c/p\u003e \u003cp\u003eThe validation process followed a stepwise approach. The first step of our questionnaire development was carrying out a brief literature review on the most used ICC questionnaires that were: 1) published in peer-review journals; 2) aimed at healthcare professionals; 3) had easily accessible online questionnaires, and 4) matched our \u003cem\u003eRER\u003c/em\u003e learning objectives. While we found several questionnaires that were frequently cited in the literature\u003csup\u003e\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, most focused on United States of America population composition and migratory dynamics; had a different target population (general population versus healthcare professionals); and/or took too long to administer. After careful review of each questionnaire, we opted to adapt and modify a reduced version of the Clinical Cultural Competency Questionnaire (CCCQ)\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The CCCQ is a psychometrically validated\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e 86-item self-assessment aimed at healthcare professionals that measures four dimensions of ICC (\u003cem\u003eKnowledge, Skills, Attitudes, Awareness)\u003c/em\u003e consistent with established models for ICC (e.g. The Multidimensional Model of Cultural Competence\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e, Culturally Competent Model of Care\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e). Next, for the purpose of item reduction, we established a scoring system whereby two of our researchers read and scored each item from the original CCCQ questionnaire on a scale of 1 to 10 for appropriateness and relevancy to our RER goals and target population. Inter-judge reliability was later used as a criterion for the final selection of items, narrowing down the total item size from 86 to 13. Three modified items from the Scale of Ethno-Cultural Empathy\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e were also included following a similar approach to item reduction. At the item level, modifications were made in wording to ensure focus on our target population of VMRs entering Europe. A two-way translation to Spanish was then carried out. Post-hoc, we tested the structural validity of the questionnaire by conducting an exploratory factor analysis (EFA) using Promax rotation and Kaiser criterion to determine the number of overall ICC dimensions. The preliminary results of the EFA suggested that the psychometric properties of the questionnaire are adequate. Results indicated that a reduced ICC model, consisting of 16 items and 5 dimensions, explained over 70% of the variance, with Eigenvalues greater than 1, and a screen test indicating a factor structure consistent with the original questionnaire (please refer to Supplemental Digital Appendix 2: \u003cem\u003eExploratory Factor Analysis Results\u003c/em\u003e with \u003cem\u003eEigenvalues and Explained Variance\u003c/em\u003e). All items were scored on a 1\u0026ndash;5 Likert scale. For SE and Knowledge, all items were newly created as no suitable validated questionnaires were identified in the literature. We evaluated participants' objective knowledge with newly created multiple-choice questions that covered various topics on VMRs covered during the activity. Finally, internal consistency was analyzed using the Cronbach's Alpha test, showing overall acceptable levels (alpha\u0026thinsp;\u0026gt;\u0026thinsp;0.7 threshold) for all subscales with \u0026gt;\u0026thinsp;1 item, as well as for the overall ICC and SE scores (please refer to Supplemental Digital Appendix 3: Reliability Analysis of Outcome Indicators in Intercultural Competence, Self-efficacy, and Knowledge Scales). The pre-test questionnaire included sociodemographic items and had a total of 24 questions. The post-test questionnaire included two open-ended qualitative questions and a 10-point Likert item on activity satisfaction, totaling 27 items (please refer to Supplemental Digital Appendix 4: Pretest to assess the impact on Intercultural Competence, Self-efficacy, and Knowledge of the Refuge Escape Roomfor the questionnaires).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Analysis\u003c/h2\u003e \u003cp\u003eWe asked two open-ended questions in our survey that captured several themes of the student experience. A thematic content analysis took place for the analysis of the answers to the two open questions of the questionnaire. The answers were read thoroughly, and coded segments were grouped into categories that informed the content of the generated themes. This process was carried out by two researchers for triangulation purposes.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe total sample size was 101 participants (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e Sociodemographic Characteristics of Participants), with a mean age of 25.76 years (sd 7.94). Most identified as women (76%). Approximately half of our sample were health science students (51%), followed by healthcare workers (44%) comprising 50% nurses and 50% physicians. The remaining participants were professionals from other backgrounds (5%). Participants\u0026rsquo; primary areas of origin were Europe (46%) and USA (43%), with 91% of all Europeans hailing from Spain. Most participants had previous work experience (69%), while only a quarter reported experience working with migrants (28%).\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\u003eSociodemographic Characteristics of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (23%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.76 (sd\u0026thinsp;=\u0026thinsp;7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (51%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivity Location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMSc\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eICS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (24%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIES\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorked with migrants?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (28%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e72 (72%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas work experience?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (69%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (31%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: he table represents a comprehensive breakdown of the sociodemographic data of participants in the study. Percentages were calculated based on the total sample size of 101 participants. The mean age is provided with the standard deviation (SD).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eIntercultural competence\u003c/h2\u003e \u003cp\u003eOverall, participants had a baseline ICC overall score of 10.57 (sd 1.54). Baseline scores for the different subscales were as follows: 2.02 (sd 0.67) for the knowledge on health disparities subscale; 4.61 (sd 0,85) for the attitudes towards factors contributing to health disparities subscale; 0.79 (sd 0.18) for the awareness of racial, ethnic, or cultural stereotypes subscale; 0.94 (sd 0.12) for the importance of ICC training for healthcare professionals subscale; and 2.22 (sd 0.54) for the Empathy subscale (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e Comparative Analysis of Pre and Post-Intervention Scores in Intercultural Competence, Self-efficacy, and Knowledge Related to Health Disparities and VMR).\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\u003eComparative Analysis of Pre and Post-Intervention Scores in Intercultural Competence, Self-efficacy, and Knowledge Related to Health Disparities and VMR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubscale\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDescription\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCohen's d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCoefficient of variation (CV\u0026thinsp;=\u0026thinsp;SD/Mean)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSig. (bilateral)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePRE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePOST\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePRE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePOST\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eIntercultural Competence\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-reported knowledge on health disparities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.02 (0.67)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.94 (0.59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.57\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-14.28\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAttitudes towards factors contributing to health disparities\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.61 (0.85)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.98 (0.86)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-4.80\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAwareness of racial,\u0026nbsp;ethnic, or cultural stereotypes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.79 (0.18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82 (0.17)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.62\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImportance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eImportance of cultural competency training for health professionals\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94 (0.12)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97 (0.09)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.40\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.99\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEmpathic perspective taking \u0026amp; empathic awareness\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.22 (0.54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.52 (0.45)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.67\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.24\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-6.92\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTOTAL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.57 (1.54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.23 (1.47)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-12.64\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAwareness on the personal capacity to assess factors related VMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.08 (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.29 (0.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-3.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGeneral knowledge on VMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.03 (1.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.08 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-8.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003eNote: This table displays the results of a bivariate analysis comparing pre- and post-intervention scores of the intercultural competence, self-efficacy and knowledge scales. The mean (M) and standard deviation (SD) are reported for each subscale for both the pre- and post-intervention groups. The effect size is measured using Cohen's d, and the coefficient of variation (CV) is also provided. The t-value and bilateral significance level are reported for each subscale, indicating whether there was a significant difference between pre- and post-intervention scores.\u003c/p\u003e \u003cp\u003eCoefficient of variation (CV) was calculated using the formula: CV\u0026thinsp;=\u0026thinsp;SD / Mean.\u003c/p\u003e \u003cp\u003eSignificance level (Sig.) was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBaseline ICC scores did not significantly differ between genders, age and previous working experience. However, participants that had previously worked with migrants reported higher overall ICC scores (11.28 vs 10.29; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) at baseline, with the largest difference observed in the Knowledge subscale (2.41 vs 1.86; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and a tendency to score higher, albeit not statistically significant, in the rest of the subscales. Lastly, healthcare professionals had higher ICC scores compared to students (11.07 vs 10.01; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) showing higher scores for the Knowledge (2.25 vs 1.76; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and Empathy (2.48 vs 1.94; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) subscales. For more, refer to Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e: \u003cem\u003e4\u003c/em\u003e Analysis of Baseline Scores in Relation to Sociodemographic Factors.\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\u003e4 Analysis of Baseline Scores in Relation to Sociodemographic Factors\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\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 \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c8\" namest=\"c3\"\u003e \u003cp\u003eINTERCULTURAL COMPETENCY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSELF EFFICACY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eKNOWLEDGE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c13\" namest=\"c11\"\u003e \u003cp\u003ePRE-POST Differences\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 \u003cp\u003eOverall Score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubjective Knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAwareness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eImportance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eEmpathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eICC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eKw\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePrevious work experience?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.74a (1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.08a (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.4a (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.78a (0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.94a (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.31a (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.2a (0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.03a (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.61\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.16\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.14\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.17a (1.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.88a (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.55a (0.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.81a (0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.93a (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.01b (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.00a (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.03a (1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.79\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.31\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.84\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWorked with migrants?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.28a (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.41a (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.74a (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.84a (0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.93a (0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.36a (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.19a (0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.96a (1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.42\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.26\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.11\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.29b (1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.86b (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.56a (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.77a (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.94a (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.16a (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.04a (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.06a (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.76\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.18\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.03\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eProfessional vs Student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProf.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.07a (1.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.25a (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.65a (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.74a (0.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.95a (0.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.48a (0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.17a (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.07a (1.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.27\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.14\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.36\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.01b (1.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.76b (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.57a (0.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.82a (0.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.92a (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.94b (0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.98a (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.02a (1.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.04\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.25\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.69\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.13a (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.89a (0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.47a (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.79a (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.91a (0.13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.07a (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.78a (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.17a (1.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.64\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.34\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.83\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.66a (1.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.04a (0,67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.65a (0.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.78a (0.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.94a (0.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.25a (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.17b (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.99a (1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.68\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.16\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.11\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRegional Differences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEurope\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.08a (1.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.27a (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.61a (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.76a (0.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.97a (0.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.47a (0.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.21a (0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.20a (1.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e1.30\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.13\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.28\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorth America\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.92b (1.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.73b (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.8a (0.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.79a (0.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.91b (0.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.90b (0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3.00a (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.09a (1.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e2.22\u003csub\u003eb\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e.24\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e.67\u003csub\u003ea\u003c/sub\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003eNote: Values in the same row and subtable not sharing the same subscript are significantly different at p\u0026lt; ,05 in the two-sided test of equality for column means. Cells with no subscript are not included in the test. Tests assume equal variances.2\u003c/p\u003e \u003cp\u003e1. This category is not used in comparisons because the sum of case weights is less than two.\u003c/p\u003e \u003cp\u003e2. Tests are adjusted for all pairwise comparisons within a row of each innermost subtable using the Bonferroni correction.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSelf-efficacy\u003c/h2\u003e \u003cp\u003eOverall, the mean baseline SE score for participants was 3.08 (sd 0.62). While a trend of higher scores was observed for participants with previous work experience (3.12 vs 3), those having worked with migrants (3.19 vs 3.04), and healthcare professionals compared to students (3.17 vs 2.98), only gender differences in SE baseline scores were statistically significant. Females scored higher than their male counterparts, with a mean baseline score of 3.17 versus 2.78 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Please refer to Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for more detailed information.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge\u003c/h2\u003e \u003cp\u003eBaseline scores of the knowledge-based multiple-choice test were 3.03 (sd 1.13). No statistically significant differences were observed at baseline for any of the sociodemographic categories (please refer to Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for more).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePRE-POST Analysis\u003c/h2\u003e \u003cp\u003ePre-post analysis using paired t-tests revealed a significant increase in ICC scores compared to baseline (t=-12.64, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with a large observed effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.13). Similarly, all subscale scores exhibited higher averages after the RER intervention, with the largest effect size observed in the self-reported Knowledge subscale (d\u0026thinsp;=\u0026thinsp;1.57, t=-14.28; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), followed by Empathy (d\u0026thinsp;=\u0026thinsp;0.67 t=-6.92; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Attitudes (d\u0026thinsp;=\u0026thinsp;0.43, t=-4.80; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Importance (0.40, t=-2.99; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and Awareness (d\u0026thinsp;=\u0026thinsp;0.21, t=-2.63; p\u0026thinsp;\u0026lt;\u0026thinsp;=\u0026thinsp;0.05) subscales. Average SE and Knowledge scores were also significantly higher at the post-intervention evaluation (t=-3.56; p\u0026thinsp;=\u0026thinsp;0.001 and t=-8.40; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively), with a large effect size observed for Knowledge (d\u0026thinsp;=\u0026thinsp;1.19) and a lowest for SE (d\u0026thinsp;=\u0026thinsp;0.38) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePre-post average score changes were most pronounced for specific sociodemographic groups. Specifically, students demonstrated the highest reported ICC score gains (2.04 vs 1.27 for professionals; p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eFinally, participants were asked to rate their overall activity satisfaction from a 1 to 10 scale in the post-activity questionnaire. The average activity satisfaction rate was 8.29 (sd 1.64, with 10 being maximum satisfaction). Analysis revealed a significant positive correlation between achieving the objective (reaching Mars) and satisfaction levels; participants who successfully boarded the spaceship reported higher satisfaction scores (r\u0026thinsp;=\u0026thinsp;0.37, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) compared to those who remained on Earth.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQualitative results\u003c/h2\u003e \u003cp\u003eThe first open question on \u0026ldquo;what did you learn new from this activity\u0026rdquo; had a 91% response rate. Twelve percent responded affirmatively to the question without specifying the area of new learning.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I was more ignorant than I thought; I was more unknowing about what I thought\u0026rdquo;.\u003c/p\u003e \u003cp\u003e(Male, Spanish, nurse, 26 years old)\u003c/p\u003e \u003cp\u003eEighty-eight out of the 91 respondents commented on the question overtly. The three identified themes of learning were related to knowledge (60/91 respondents, 65.9%), attitudes (23/91, 25.3%), and skills (6/91, 6.6%).\u003c/p\u003e \u003cp\u003eUnder the theme of knowledge, two sub-themes were included concerning migrant stressors and migration demographics. Thirty-three out of the 91 respondents (36.3%) mentioned that they learned about migrant stressors, such as \u0026ldquo;everyday stressors\u0026rdquo;, \u0026ldquo;language barriers\u0026rdquo;, \u0026ldquo;injustices\u0026rdquo;, \u0026ldquo;stressors that increase inequality\u0026rdquo;, \u0026ldquo;factors relating to disparities in health\u0026rdquo;. Twenty-seven out of the 91 respondents (29.7%) commented that they learned about migration demographics, such as \u0026ldquo;statistics and facts\u0026rdquo;, \u0026ldquo;amount of migrants worldwide\u0026rdquo;, \u0026ldquo;number of countries that host refugees\u0026rdquo;, and \u0026ldquo;magnitude of migratory movements both at European level and worldwide\u0026rdquo;.\u003c/p\u003e \u003cp\u003eUnder the theme of attitudes, empathy was the concept that best described the answers of the respondents. A quarter of the respondents commented that the activity helped them understand the frustration, helplessness, and distress that migrants may feel during their migration and settlement trajectory as well as the prejudices and injustices they face along the way.\u003c/p\u003e \u003cp\u003e\u0026ldquo;It put me in the skin of immigrants and made me feel their sensations although it's just a game\u0026rdquo;.\u003c/p\u003e \u003cp\u003e(Female, Spanish, nurse, 28 years old)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I learned to be more empathetic towards the immigration process\u0026rdquo;.\u003c/p\u003e \u003cp\u003e(Female, North American, undergraduate student, 21 years old)\u003c/p\u003e \u003cp\u003e\u0026ldquo;With a simple game I felt stress, anxiety, frustration and it's interesting to be able to translate that to reality\u0026rdquo;.\u003c/p\u003e \u003cp\u003e(Female, Spanish, nurse, 23 years old)\u003c/p\u003e \u003cp\u003eA small percentage of respondents (6.6%) translated their acquired knowledge and attitudes into skills. They were able to adopt a shift of perspective towards a more contextualized and informed view on migration.\u003c/p\u003e \u003cp\u003e\u0026ldquo;I learned that the immigration crisis is not specific to the US. It's easy to only think of my country and forget that this is an international crisis. It definitely changed my perspective on how hard it is to get into another country\u0026rdquo;.\u003c/p\u003e \u003cp\u003e(Female, North American, undergraduate student, 21 years old)\u003c/p\u003e \u003cp\u003e\u0026ldquo;Learning the process of immigration is important for working with a population with these characteristics. I learned about the suffering, pain, and stress that affect their health status\u003c/p\u003e \u003cp\u003e(Female, Spanish, nurse, 25 years old)\u003c/p\u003e \u003cp\u003eAt the second open question on \u0026ldquo;what aspects of the activity could be improved\u0026rdquo;, there was a 58% response rate. Interestingly, 18/58 respondents (31.0%) took the time to comment very positively on the activity under this question. The areas for improvement were grouped into four themes: facilitation, content, space, and organization.\u003c/p\u003e \u003cp\u003eIn terms of facilitation, 22.4% of respondents suggested more instructions prior to the start of the game and more intensity in the facilitation, so that participants could enter more adequately into the role-playing of the migrant. Concerning the content, 22.4% mentioned that they needed a more thorough debriefing at the end of the activity and others were curious to know whether the game had been validated with migrants themselves. Some of them, 13.8%, commented that the space was quite small, but some mentioned that this may have been on purpose to simulate the stressful migration process. Lastly, 6.9% suggested improvement in the organization of the activity in terms of the small groups\u0026rsquo; composition.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEfforts to design and implement educational ERs that tackle more complex, societally relevant topics are increasingly growing\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. Adding to this trend, our study preliminary data suggests that educational ERs can also be effective tools to improve the ICC, SE, and KW of students and professionals regarding the health needs and challenges faced by VMRs. Like other studies\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e, our qualitative data also suggests that our ER\u0026rsquo;s success is partly explained by the high levels of engagement, motivation, problem-solving and teamwork experienced by participants. After completing the ER, our qualitative data suggests that most participants reported a sense of improved knowledge of VMR\u0026rsquo;s health status, stressors, and demographics; attitudinal changes through increased awareness and empathy; as well as a perspective shift toward a more contextualized and informed view on migration.\u003c/p\u003e \u003cp\u003eWhile research on ICC training has traditionally focused on standalone workshops\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, our study is, to the best of our knowledge, one of the first to utilize the principles of an educational ER to increase levels of ICC of participants, with the largest gains obtained by students whom, in turn, had the lowest baseline ICC scores. In addition, baseline ICC scores were higher for those with previous working experience, matching published data on the positive correlation between clinical exposure to diverse patient populations and higher levels of cultural awareness and sensitivity of healthcare providers\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePerhaps the most relevant implication of improving ICC scores derives from the evidence that a higher ICC in the clinical encounter has been shown to significantly impact health service utilization and quality of care of vulnerable patients\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Despite our promising results, we are aware that the concept of ICC has often suffered from a lack of conceptual clarity\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, and subscribe to the views of other authors\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e arguing that ICC training cannot be detached from a deeper understanding of cultural complexity and the social determinants of inequality.\u003c/p\u003e \u003cp\u003eIn terms of our sample, the inclusion of older non-student participants complements previous research on the effectiveness of educational ERs which had mostly focused on higher education \u0026ldquo;gen Z\u0026rdquo; students\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. In this regard, our results show that all age groups benefit from the ER experience in terms of improved outcomes and activity satisfaction.\u003c/p\u003e \u003cp\u003eResearch on educational ERs has shown that self-perceived knowledge retention is higher compared to traditional learning\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. However, notwithstanding notable exceptions\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e, few studies have formally tested knowledge retention objectively. Our study consequently adds to the evidence base on the effectiveness of educational ERs for domain-specific learning, by showing significant improvement of participant\u0026rsquo;s PRE-POST knowledge scores in a multiple-choice test. While the question of long-term retention remains unanswered, reports indicate that knowledge retention may persist over time\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur results further reveal that while all participants had similar objective knowledge scores at baseline, those with previous working experience considered themselves as more knowledgeable about VMRs compared to the rest of the participants -- judging by the higher scores obtained in the self-perceived Knowledge subscale of the ICC questionnaire. The observed mismatch between the two scores perhaps suggests that experienced participants tend to overestimate their true knowledge-base regarding the complex topic of VMRs and healthcare. Nevertheless, taken together, our results are congruent with the literature suggesting that experiential learning promotes information retention and knowledge gap identification\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e, leading to positive learning outcomes regardless even of an individual\u0026rsquo;s preferred learning method\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs noted elsewhere\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e,\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e, educational ERs may provide an experience that improves SE, that is, the extent of an individual\u0026rsquo;s belief in his or her abilities to engage in specific behaviors\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. Our results mirror such findings, with observed increases in the SE scores of all participants regardless of sociodemographics. In other words, after completing the RER, participants reported an improved sense of being able to provide culturally sensitive care of VMRs, which is a promising result given the established literature on SE as predictive of actual behavior\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e,\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLastly, we implemented a debrief after the activity with trained facilitators to ensure emotional well-being and discuss the player\u0026rsquo;s experience. This aspect has also shown to be crucial to decontextualize knowledge for use in future situations\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations \u0026amp; Future Research\u003c/h2\u003e \u003cp\u003eWe employed a mixed-method, pre-post design for our pilot intervention due to its resource-efficient nature and alignment with our budget limitations. While our methodology improves upon many published ER interventions\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e, we acknowledge significant limitations.\u003c/p\u003e \u003cp\u003eFirst, the lack of randomization and control group introduced a higher risk of bias (e.g. measurement, confounding, and attrition biases). These factors also hinder our ability to establish a causal relationship between the intervention and its outcomes and consequently limit our ability to confidently assess other significant variables that might contribute to our results. Furthermore, the absence of long-term follow-up restricts our capacity to evaluate the persistence of knowledge retention over time, despite existing literature\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e indicating notable long-term retention.\u003c/p\u003e \u003cp\u003eSecond, the absence of a power analysis combined with the reliance on a convenience-based sampling approach, likely introduced selection bias. Specifically, our sample primarily consisted of self-selected physicians and students enrolled in a global health curriculum. This particular group might possess an inherently greater sensitivity towards issues related to migration and health, differing significantly from other more diverse populations.\u003c/p\u003e \u003cp\u003eThird, while the psychometric properties of the adapted inventory are satisfactory, exhibiting acceptable internal validity and reliability, it lacks in several key areas of the validation process. Notably, we did not obtain normative scores from a broader, demographically representative sample. Furthermore, the structural integrity of the ICC questionnaire was not evaluated using confirmatory factor analysis on an additional sample, and other important domains of validity, such as concurrent validity, were not assessed. However, it is important to clarify that the aim of our validation process was not to develop a new inventory for widespread application, but rather to enhance the validity of our results in alignment with our objective of assessing the feasibility, acceptability, and preliminary effectiveness of our novel educational ER.\u003c/p\u003e \u003cp\u003eLastly, at the intervention level, identified barriers during the debriefing and qualitative analysis include excessive competition which may be threatening to some participants; the need for more detailed instructions and more intense facilitation; idiomatic barriers as evidenced in some RER sessions; and logistical barriers inherent to the activity \u003cem\u003eper se\u003c/em\u003e (e.g., time required for planning and execution, human resources cost, materials, and so on.). Several of our detected barriers have also been reported numerous times\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and may arguably be intrinsic to the ER format \u003cem\u003eper se\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eDespite these limitations, we recognize the exploratory proof-of-concept nature of our pilot intervention and the need to include more robust study designs in the future. Future studies will also benefit from the inclusion of an economic analysis in its design, which will, in turn, lay the grounds for scaling up efforts. Similarly, while our study has a strong emphasis on quantitative data and its validation, the qualitative content analysis could be further developed with the addition of more comprehensive qualitative techniques (e.g., focus groups) beyond the thematic analysis of open-ended questions, highlighting an area for potential future research.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eHealth professionals have a professional and ethical obligation to provide adequate care for VMRs. Teaching healthcare professionals and students to be more culturally competent may help them become better healthcare providers and, in turn, tackle healthcare access and quality of care barriers affecting the most vulnerable.\u003c/p\u003e \u003cp\u003eWhile in the last years there has been a notable rise in educational ERs with promising results regarding teamwork, engagement, satisfaction, and communication\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e, research on the actual educational significance is still limited. In this paper, we presented a feasible, acceptable, and innovative educational ER that effectively expands the significance and utility of ER by exploring its potential impact on the ICC, SE, and Knowledge of healthcare students and professionals that care for VMRs.\u003c/p\u003e \u003cp\u003eThere exist ample opportunities to foster synergies between global health, ICC training, and gamification initiatives within the curriculum of healthcare education\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Failing to meet the challenges of an increasingly diverse population through intercultural training may continue to broaden health disparities and limit access to health care resources for the most vulnerable patients. While there is a need for more structured research and superior methodological rigor, we hope that the RER intervention here presented is a small albeit important step to building the evidence base for a more effective curriculum that trains healthcare providers about the health challenges faced by asylum seekers and refugees worldwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval:\u003c/strong\u003e This research was evaluated and approved by the Clinical Research Ethics Committee (CEIC) of the Vall d\u0026rsquo;Hebron Hospital in Barcelona and adhered to the best clinical practices on the 7\u003csup\u003eth\u003c/sup\u003e of June of 2019.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate:\u003c/strong\u003e All participants gave their consent to participate in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: not aplicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding/Support:\u003c/strong\u003e Research reported in this publication was supported by co-funding from the Third EU Health Program (2014-2020) Project Grants (HP-PJ-2016) under Grant Agreement 738091 (MyHealth Consortium).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e. NSD, LW: conception of the \u003cem\u003eRER\u003c/em\u003e activity. NSD: \u003cem\u003eRER\u003c/em\u003e intervention coordination. RM NSD: protocol and survey development. RM, AM: database creation, data monitoring, quantitative analysis. SE: qualitative analysis. NSD, RM, AM, SE: verified results and analytic methods. NSD: Study resources. \u0026nbsp;RM, NSD, AM, SE: wrote the first draft of the manuscript. RM, NSD, SE, AM, LW: writing-review and editing. All authors contributed to the article and approved the submitted version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: The authors extend sincere gratitude to all volunteer participants and actors whose invaluable contributions were crucial to the success of the Refugee Escape Room research project. Their dedication and enthusiasm significantly enhanced the project\u0026apos;s outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFootnotes\u003c/strong\u003e: The content of this article is the sole responsibility of the authors and does not necessarily represent the views of any of the sponsoring organizations, institutes, or the European Commission. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Trends to 2030. The Future of Migration and Integration. Published online 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eMigration Outlook\u003c/em\u003e 2022 \u003cem\u003eTwelve Migration Issues to Look out for in 2022 Origins, Key Events and Priorities for Europe\u003c/em\u003e. International Centre for Migration Policy Development; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMore than 100 million now forcibly displaced. UNHCR report. 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Review the key role of self-efficacy in diabetes care. J Educ Health Promot. 2013;2(1):36. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/2277-9531.115827\u003c/span\u003e\u003cspan address=\"10.4103/2277-9531.115827\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeldkamp A, van de Grint L, Knippels MCPJ, van Joolingen WR. Escape education: A systematic review on escape rooms in education. Educ Res Rev. 2020;31:100364. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.edurev.2020.100364\u003c/span\u003e\u003cspan address=\"10.1016/j.edurev.2020.100364\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Details on the context of the game can be seen at the video which all participants see prior to starting the game: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.youtube.com/watch?v=GxdA87MDST4\u0026amp;list=UU_CU6nrajWq1lr6BnoNYw3A\u0026amp;index=4\u003c/span\u003e\u003cspan address=\"https://www.youtube.com/watch?v=GxdA87MDST4\u0026amp;list=UU_CU6nrajWq1lr6BnoNYw3A\u0026amp;index=4\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e).\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":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"refugees, cultural competence, migration, health, refugee","lastPublishedDoi":"10.21203/rs.3.rs-4788752/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4788752/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article explores the burgeoning challenge of providing adequate healthcare to vulnerable migrants and refugees (VMRs) within the European Union, an issue exacerbated by the recent surge in migration and asylum applications. A critical gap identified is the lack of intercultural competence (ICC) training in healthcare education, which impedes healthcare professionals' ability to offer culturally sensitive care. The study introduces an innovative educational tool, the \"Refugee Escape Room\" (RER), to address this gap.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe RER is a novel gamification-based initiative, conceptualized to enhance ICC, self-efficacy (SE), and knowledge among healthcare students and professionals. It employs an immersive learning approach, where participants engage in a simulated migratory scenario set in a future world crisis, necessitating collaborative problem-solving and decision-making under pressure. The study uses a mixed-methods approach, including a pre-post intervention design with a newly validated questionnaire and thematic content analysis of qualitative feedback.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults from the 101 recruited participants indicate significant improvements in ICC (d=1.13; t=-12.64, p\u0026lt;0.001), SE (d=0.38; t=-3.56; p=0.001), and knowledge (d=1.19; t=-8.40; p\u0026lt;0.001) post-intervention. Participants reported enhanced understanding of VMRs' health challenges and increased empathy, translating their learning into improved attitudes and skills. The study also highlights the potential of educational escape rooms in engaging diverse learners and fostering experiential learning.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe RER, with its focus on VMRs and ICC training, \u0026nbsp;is an innovative, acceptable and feasableeducational tool that attemps to fill a crucial gap in healthcare education. It represents a promising step towards more effective intercultural training in healthcare, thereby addressing health disparities and improving care quality for vulnerable populations. The study suggests the need for more structured research and methodological rigor to further assess the impact of novel educational tools in healthcare training.\u003c/p\u003e","manuscriptTitle":"An Innovative Gamification Tool to Enhance Intercultural Competence and Self-Efficacy among Healthcare Professionals Caring for Vulnerable Migrants and Refugees","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-27 12:22:09","doi":"10.21203/rs.3.rs-4788752/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-17T09:24:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-14T11:57:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"240822741972503532345571385123693685977","date":"2024-08-26T00:28:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"171957578902909440664331217803226265622","date":"2024-08-24T01:27:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-06T02:41:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-06T02:38:20+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-26T01:14:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal for Equity in Health","date":"2024-07-23T12:27:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-for-equity-in-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijeh","sideBox":"Learn more about [International Journal for Equity in Health](http://equityhealthj.biomedcentral.com)","snPcode":"12939","submissionUrl":"https://submission.nature.com/new-submission/12939/3","title":"International Journal for Equity in Health","twitterHandle":"@equityhealthj","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a8281513-9023-40b7-aff0-91bc6570f5e4","owner":[],"postedDate":"August 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-18T16:02:14+00:00","versionOfRecord":{"articleIdentity":"rs-4788752","link":"https://doi.org/10.1186/s12939-024-02304-2","journal":{"identity":"international-journal-for-equity-in-health","isVorOnly":false,"title":"International Journal for Equity in Health"},"publishedOn":"2024-11-11 15:57:36","publishedOnDateReadable":"November 11th, 2024"},"versionCreatedAt":"2024-08-27 12:22:09","video":"","vorDoi":"10.1186/s12939-024-02304-2","vorDoiUrl":"https://doi.org/10.1186/s12939-024-02304-2","workflowStages":[]},"version":"v1","identity":"rs-4788752","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4788752","identity":"rs-4788752","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}