Assessing Cultural Competency and Core Goal 4.2 in an Interdisciplinary Course on Culture and Health—Kathryn Rhine (2019)

Medical anthropologists seek to understand the social and cultural practices that contribute to health and disease: How are universal human phenomena such as sleep, diet, families, and physical appearance experienced differently in diverse contexts? How do we assess what is normal? Abnormal? Dangerous? Deadly? What values do we draw upon to learn the causes of disorders and determine strategies for coping? Who are the authorities we consult, and why do we grant them this power? How are these systems of beliefs reproduced? In what ways do gender, race, and class influence experiences of health? In ANTH 201/GIST 210 and ANTH 202/GIST 211 , we identify similarities across seemingly different cultural systems, while at the same time considering how health-related practices are socially embedded and culturally specific.

This course offers students a holistic, interdisciplinary approach to understandings of health, well-being, and disease within and across cultures. It introduces students to dominant paradigms for interrogating the social meanings and relations of power that shape illness experiences among patients, as well as their clinicians and caregivers, families, and communities. Further, it provides students a framework for investigating how and why the global distribution and burden of disease disproportionally falls upon poor countries and populations. The course shows how structural forces exacerbate poverty, inequality, and environmental degradation, among others, creating the conditions that expose people to illness in the first place. Throughout the course, the central theme is repeatedly illustrated: Experiences with illness are shaped by an interplay among biological, socioeconomic, historical, and cultural factors.

Course participants

The course attracts primarily first- and second-year undergraduate students with pre-health profession concentrations. Although a majority of students have yet to be admitted into their major or program of choice, the most common majors and programs are biology, biochemistry, chemistry, behavioral neuroscience, nursing, pharmacy, community health/sports science, occupational therapy/physical therapy, and psychology. Most students indicate that they enrolled in the course because it fulfills Core Goal 4.2. Most also indicate that it is a topic that interests them.

My aims for students in this course are to:

1. Analyze contemporary global and local issues with medical anthropology’s principles, theories, and methods
2. Acquire a deeper knowledge of the social organization of healthcare in contexts outside the United States, and discuss, debate, and assess these structures in relation to students’ own knowledge of the American healthcare system
3. Evaluate diverse beliefs and practices and how these understandings may address problems in healthcare settings
4. Conduct an exercise of ethnographic inquiry involving fieldwork, interpretation of qualitative data, and presentations
5. Appreciate how ethnography serves as a catalyst for transformations of unequal power structures that shape illness predispositions, prognoses, and experiences

Operationalizing Core Goal 4.2

After completing the course, students should be able to demonstrate their knowledge of the social organization of healthcare in contexts outside of the United States, as well as discuss, debate, and assess these structures in relation to students’ own knowledge of the American healthcare system. They should also be able to explain why an understanding of these diverse beliefs and practices is important to address contemporary problems in global healthcare settings. To do so, students require a solid command of medical anthropology’s principles and theories as they are applied to contemporary global and local issues. They demonstrate this knowledge through exams (multiple choice and short answer questions) and participation in discussion sections.

This class, however, goes further by requiring students to conduct a series of ethnographic exercises over the semester (writing a personal illness narrative, conducting an interview in which they collect someone else’s illness narrative, and carrying out participant observation in an alternative healing setting). Students are asked to write two essays over the semester, one at the midterm and one at the conclusion of the class. In these essays, students select an argument and key terms discussed in the lectures and readings and apply them to the data they have collected. We use a graded rubric in which we assess students’ understandings of these concepts and writing skills, and a non-graded rubric to assess cultural self-awareness and transfer. By cultural self-awareness, I mean the degree to which students can articulate insights into their own cultural rules and biases (e.g., students are aware of how their experiences have shaped these cultural rules, resulting in a shift in self‐description). By transfer, I mean the degree to which students can adapt and apply skills, abilities, theories, or methodologies gained in one situation to new situations to solve difficult problems or explore complex issues in original ways.

Students begin by learning about how anthropologists define culture, as well as how scholars critique different uses of the concept of culture. Specifically, they study how culture frequently obscures important social variations and inequities (the conflation of cultural difference and social inequality). They come to see culture as a process of making meanings, making social relations, and making the world we inhabit. While they consider the ways people actively construct culture, they also explore the relation between structure and human agency; that is, how historical, political, and economic processes may circumscribe the choices, values, beliefs, and actions of individuals.

Next, students learn how to account for worldviews that are different from their own, including how knowledge is socially constructed, negotiated, disseminated, and contested, as well as how global flows of ideas, people, capital, and goods (globalization) influence people’s understandings of the world, their bodies, their relationships, and the practice of medicine. Students also study how societies reproduce different configurations of power, as well as how power relations are inflected through culturally constructed categories of kinship, gender, generation, ethnicity, race, class, and other axes of diversity. Students explore applications of these understandings: how cultural competency is defined in and taught in the field of medical anthropology and medicine, including through the use of explanatory models and models of mediation and their critical importance in the field of medicine. Students study a series of cases that demonstrate why it is important to interrogate taken-for-granted and presumed universal disease categories. Finally, throughout the first half of the semester, students turn their lens back onto American society, questioning our own tacit understandings of the body, illness, and healing.

After this, students interrogate the culture of biomedicine; that is, the idea that biomedicine itself possesses and is embedded within a culture. This could be understood as the institutions’ orientations and values, beliefs and practices, key actors and behaviors, located within specific historical, political-economic, and social contexts. Students study how medicine, as a field, developed and the ways it is currently learned and taught. In the two texts assigned at the end of the semester, students explore a range of concepts within anthropology through nuanced cultural dynamics, including globalization, bioethics, habitus, communication, gender ideologies and inequalities, and social determinants of health and social change.

Foundational course principles

Medical anthropology is grounded in the basic tools of listening to what matters in the world and to whom. I believe that effective teaching intertwines medical anthropology and the basics of ethnographic research. In Culture and Health, my aims center on introducing students to the complexity of cultures around the world, but also requiring students to critically listen to and engage in conversations around them to better understand these complex social worlds and problems. Across my courses, a primary goal in teaching is to imbue students with an appreciation of voice; that is, what animates anything from rumors and gossip to doctor-patient dialogues, illness narratives, political speeches, and classroom debates. To reinforce this appreciation of voice among Culture and Health students, I orient my teaching philosophy and practices around the following points:

1. Students have their own voices that reflect particular cultural locations. The assignments and assessments used in this class aim to develop students’ ability to think critically about their own social positions and express themselves in diverse modes, such as personal illness narratives and debates within their discussion sections. For the midterm and final essays, I require students to connect these subjective observations and experiences to core arguments (theory) from the course texts and lectures. In evaluating students’ essays, I use a rubric with both graded and ungraded components. The ungraded components encourage students to take analytical risks in their reflections, where they can grapple with exposing and questioning the cultural rules and biases that structure their personal experiences without fear of it affecting their grade. While some students exhibit an impressive ability to identify and discuss their cultures’ tacit assumptions and practices from the moment they enter the class, other students have never been asked to question these forces and meanings in their personal lives within the context of a college course. Students may exhibit some initial reservations or even overt resistance to these exercises but develop a much more articulate voice over the course of the semester.
2. Students must be able to listen to, understand, and critically evaluate the voices of others. I aim to facilitate this through dynamic course texts, discussions, ethnographic exercises, and exams. In the second ethnographic exercise, students conduct an interview in which they obtain a person’s illness narrative. This activity allows students to gain an appreciation for the different explanatory models that humans express in their understandings of ill health. They then contrast this narrative with the personal illness narrative they constructed in class discussions. In my honors seminar, I ask students to rewrite their personal illness narrative, changing perspectives or emphasizing different features; for example, writing their narrative with a different pronoun (shifting from a first person voice to a second- or third-person voice), emphasizing the gendered or the affective experience of their condition, or writing it in the voice of an American clinician. These exercises transcend dichotomies and promote empathetic communication. Additionally, midterm and final exams require students to critically read and apply course themes to both global and local contexts. They are asked to adapt this knowledge to new situations in order to explore complex issues in essays. As the assessment results demonstrate, students improve considerably in this skill over the course of the semester.>
3. Because some individuals’ voices are louder than others, students must also be able to examine the power relations that shape whose voices are heard and whose are silent. In designing course content, I instill this principle through reading selections that examine both the voices of the powerful and of the poor. I further challenge students to identify how these power relationships play out in a third ethnographic assignment, which requires them to make an appointment or attend a class with a “healer” (broadly defined) outside of a biomedical tradition. In these settings, students conduct participant observation. In class lectures and discussions, they learn how to challenge the hegemony of biomedicine in North America, as well as the role of globalization in shaping these practices, while drawing on their own observations. I weave anthropological theory addressing inequality and everyday violence into lectures and discussions. I then require students to engage with these questions of power in their readings and assess their understandings in midterm and final exams. This assessment revealed that students possessed a significant understanding of the connections between health, culture, and inequality at the end of the course.

As the classroom itself is a setting in which these power dynamics play out, I am also guided by my concern to cater to diverse learning styles. In lectures I use both visual and auditory aids, such as handouts, slides, films, and carefully crafted syllabi. I aim to maximize student potential through encouraging collaboration, group discussions, and opportunities for extracurricular enrichment.

Assessment in Culture & Health

Students’ final grades in the course are based on the factors below:

• Attendance/participation: Class participation is an essential part of this course and consists of attendance, active listening and participation in discussion sections, and in-class assignments and presentations.
• Quizzes: In-class quizzes are given for each of the assigned texts. There is also a syllabus quiz.
• Ethnographic assignments: Over the course of the semester, there are three ethnographic exercises that require students to write reflexively, complete an interview, and conduct participant observation, as well as write up their findings. These activities include a personal illness narrative, an interview in which they collect someone else’s illness narrative, and participation in an alternative healing practice.
• Exams: There is one in-class midterm exam and one final exam, composed of multiple choice and short answer questions.
• Essays: The midterm and final writing assignments require students to identify anthropological arguments that apply to findings from these ethnographic exercises and analyze how the concepts connect to their data. Graduate teaching assistants use a detailed rubric to grade the essays and then a non-graded rubric to assess cultural self-awareness and transfer.

Assessment of Core Goal 4.2

The two core targets for assessing cultural competencies in Culture and Health are:

1. A sample of multiple choice questions from the midterm and final exams.
2. The midterm essay and final essay in which students analyze the data they collected through three ethnographic assignments, which are assessed via a non-graded rubric that measures the degree to which a student can articulate insights into their own cultural rules and biases, as well as the degree to which a student can adapt and apply skills, abilities, theories, or methodologies gained in one situation to new situations to solve difficult problems or explore complex issues in original ways. This rubric is applied in the midterm essay and in the final essay.

Both metrics showed marked improvement over the course of the class, in both ANTH 201 and ANTH 202. This conclusion is supported first by item analyses of the multiple-choice questions that required students to articulate their understanding of the concepts above. Performance across the midterm and final exams indicated that students possess a significant understanding of the importance of different worldviews and the connections among health, culture, and inequality.

• Of the five categories of questions analyzed in the above sample (culture concept, different worldviews, cross-cultural methods and models, application of cultural frames, and cultural self-awareness), students performed strongest in their understanding of the significance of different worldviews (86.5%). Specifically, through an example from the text The Spirit Catches You and You Fall Down by Anne Fadiman, students were able to articulate why the question of who is conducting translations between Hmong patients and their American doctors is so important. The text demonstrated that, by failing to work within Hmong power hierarchies, American clinicians were not directing crucial questions toward those who possess decision-making power, leading to confusion and shame. From the same text, students were also able to draw an analogy between a Hmong way of understanding meaning in the world and an American parallel: “The world is full of things that may not seem to be connected but actually are; no event occurs in isolation.”

• Students also did an outstanding job of identifying cultural explanations for why different populations make sense of trauma in different ways and the significance of a culturally specific model of treating schizophrenia and other psychiatric conditions (average 86.0%). For the former, 87% of students correctly indicated that “All populations may experience trauma when they face wars and natural disasters, but they understand and manage trauma in historically and culturally specific terms.” For the latter, 85% of students correctly indicated that a Japanese model of psychiatric treatment that is rooted in communal living, collective work, and a meaningful engagement with “voices” is significant because it demonstrates how providers are “redefining a mental illness as a condition of being human rather than one defined through biomedical lenses.”

• Of the five categories of questions, students were least successful in answering questions about the McGill Illness Narrative Interview and Arthur Kleinman argument that biomedicine needs to shift from a model of coercion to a model of mediation (average 66.5%). The former is a useful tool in cross-cultural medicine because it sets clinicians’ expert knowledge alongside (not over and above) the patient's own explanation and viewpoint. An example of the latter might be when a doctor works to accommodate the patient’s wants and needs regarding illness even if it interferes with the prescribed treatment.

• Of the questions analyzed in the above sample on the final exam, students were most successful at identifying a public health intervention that best addressed a structural determinant of poor health, such as a nonprofit organization leading an initiative to clean up water supplies, renovate schools, and feed thousands of residents with locally produced food in Haiti (91%). Ninety-one percent of students were also able to identify why women are disproportionately at risk of HIV (because women face pervasive social, legal, and economic disadvantages). Additionally, most students were able to correctly identify how a local gender ideology in northern Nigeria shapes an HIV-positive woman’s behavior (by assuming the responsibility for her husband's secret, rather than confronting him, she proves herself to be a virtuous, respectable woman and she expects him to support her).

• Students struggled on the midterm and the final exams with a question about the impact of globalization on the commodification of human bodies. Only 39% of students were able to correctly identify that globalization expands and accelerates the exchange of ideas, people, professionals, and commodities over vast distances.

Ethnographic essays

The non-graded rubric used to assess students’ essays examined two facets of Core Goal 4.2: cultural self-awareness and transfer. Cultural self-awareness indicates the degree to which students can articulate insights into their own cultural rules and biases, while transfer means the degree to which students can adapt and applies skills, abilities, theories, or methodologies gained in one situation to new situations to solve difficult problems or explore complex issues in original ways.

ANTH 201 students’ demonstration of cultural self-awareness improved significantly in their final essays (mean= 3.13) over their midterm essays (mean= 2.47), t (168) = 9.335, p < . 001 . Likewise, ANTH 201 students’ demonstration of their ability to transfer knowledge also improved significantly in the final essays (mean= 2.89) from the midterm essays (mean= 2.26), t (168) = 9.445, p < .001.

ANTH 201 students’ cultural self-awareness and transfer abilities are highly correlated with each other. Thus, if a student performed well on cultural self-awareness (in either the midterm or final), this student was highly likely to perform well on transfer (in either the midterm or final).

Unlike students’ performance in ANTH 201, students’ performance on transfer improved significantly in their final essays (mean= 3.32) over the midterm essays (mean= 2.84), t (18) = 2.28, p < .05. There is no correlation among these four variables.

The results of this review suggest that a majority of the class is meeting or exceeding the expectations for Core Goal 4.2. The next step is to continue to assess how students do on these same assignments in subsequent semesters. Some minor modifications will be needed for exam questions for which wrong answers may be misleading. Additional attention should also be paid to cultural competency approaches in lectures (e.g., explanatory models).

More broadly, this portfolio demonstrates how an assessment of core goals can be conducted with large lecture-based courses (with 100+ students). At a minimum, large courses can use the item analysis of multiple-choice questions to determine what percentage of students understand concepts relevant to Core Goal 4.2. Research-based assignments that require students to conduct interviews or fieldwork provide students first-hand observations to connect to themes in lectures, but they are difficult to grade. By requiring students to use their individual findings as examples to analyze course themes in essays, I was able to assess their understanding of these themes and writing skills through graded rubric questions. By adding two non-graded elements to the rubric (addressing cultural awareness and transfer), I was able to analyze the extent to which students are also meeting Core Goal 4.2 without punishing those who take longer to identify or articulate their own cultural rules and biases. By requiring students to write two essays over the course of the semester and using the same rubric for both assignments, I was able to analyze student improvement on both graded and non-graded elements. Rubrics are particularly important if teaching assistants are grading the assignments in order to ensure a standard measure is being used.