Dental students need to acquire the ability to effectively interact with and provide holistic, person-centred care for patients from diverse backgrounds, and also to understand the social, structural and cultural influences on oral health behaviour that are common in a multicultural society such as Australia, They need to develop attitudes that accommodate difference as well as the ability to communicate effectively with patients across cultures. . Findings from this study suggest that dentistry and oral health students exhibited dissimilar levels of self-perceived cultural competence at different stages of their education and also within different courses. Overall results indicate that, at the end of their professional training, students’ exposure to professional education and socialization would have resulted in an overall improved score on cultural competence survey. Australian Dental Council requirements include students’ acquisition of core cultural competency skills to provide culturally safe oral health care, at the end of their professional training [13]. Of course, further assessments of students’ cultural competence needs to be conducted using multiple approaches to feel confident that learning outcomes in cultural competence (and safety) had been met.
Furthermore, multivariate results indicate that final year BOH students scored significantly higher in cultural competence, when compared to final year DDS students. These students were from two different courses, one of which is an undergraduate degree (i.e., BOH) whilst the other is a graduate degree (i.e., DDS). These courses also lead students into different dental professions with a differing scope of practice. Therefore, despite their exposure to patients being largely in the same clinics with patients drawn from the same pools, their clinical experiences between courses varied. In a review of cultural competence content in the DDS and BOH curricula, the DDS course showed less time devoted to formal teaching of this content compared to BOH courses [6,19].
It has also been identified that cultural competency skills can be developed indirectly via clinical placements and via interactive learning programs [5,21]. In addition, a detailed assessment of the extent of cultural competence education, which took into consideration all written and current documentations of the curriculum at the UoMDS, as well as the number of formal contact hours and credit points allocated [6,18], reported that the BOH course assigned fifty-four hours to the teaching of cultural competence contents throughout the first two years of the course [19]. Whereas, the DDS course allocated forty hours confined to the first year of the course [19]. However, that assessment was done just counting hours and some other contents may not be visible in the curriculum of both courses using this method.
Other reports indicated that the teaching techniques used might have been ineffective. Strauss and collaborators [18] observed that most North American dental schools favoured less effective and passive learning techniques such as lectures. This inadequacy was also reported by dental students and graduates who indicated that inclusion of cultural awareness was important in the dental curricula, but that the current curricula needed revising to develop their skills in interacting with patients [7]. In another study, Saleh and collaborators [17] found that the time assigned to complete course tasks and the lack of knowledgeable educators on the topic were major contributing factors. This is further supported by the inconsistency of the cultural competence education between dental curricula of various schools in Australia and New Zealand, thus indicating a need for a standard framework for cultural competency education [9].
Clinical placements offer important opportunities for dental students to develop cultural competence skills first-hand via demonstration of patient management by experienced dental practitioners, having direct interactions with patients and their families, as well as interaction with clinical supervisors that are observing them and are able to give them further insights [5]. The development of cultural competence relies on good role modelling and attention from supervisors to cultural competence skills development of students, reflective practice and active assessment of knowledge, attitudes and practice skills.
Continuous teaching with a gradual increase in complexity has been considered the most effective method of teaching cultural competence, thus exposure to these concepts in previous undergraduate study may also contribute to differences between the courses [24,25]. Interestingly, a study investigating social and cultural teaching of medical students concluded that the teaching made little to no difference when students began clinical rotations [26]. The medical students explained that despite an interest in the content, the goal of clinical practice was to treat everyone neutrally, as if they were cultureless [26]. Similarly, clinical supervisors at the UoMDS commented that DDS students appeared to focus on completing treatment rather than building rapport with patients [5]. It was noted that this may be a result of students being graded mostly on their technical skills, rather than their cultural or communication skills [5].
It is also important to consider, in addition to the effects of course curriculum, students’ socio-demographic, immigration and cultural backgrounds, as these factors may affect an individual’s perceived cultural competency level irrespective of their degree of clinical experience. In this regard, it is possible that socio-demographic background has a bearing on an individual’s perceived cultural competence, as these factors influence their beliefs, expectations and interpretation of their own experiences. Such factors include how the participants identified culturally and whether they were linguistically diverse. The participants’ country of birth or family history of immigration, that is, whether they were overseas born or are first, second or third generation Australian, may further influence how they interpret competence and how culturally competent they perceive themselves to be. However, despite the variation in cultural identity among respondents, a consistent pattern of responses across the scales was evident when comparing Australian and overseas born participants. This may be explained by the idea that country of birth alone may not be an accurate descriptor of cultural background, as there are many other factors such as level of acculturation, self-reported ethnicity and languages spoken, life experiences and socio-economic status that contribute to one’s culture [27-29].
The present analysis of the cultural competence scores indicated that those born overseas tended to have lower scores. Moreover, the multivariate analysis indicated that those who self-identified as “Australian”, scored higher than those who did not. These findings may reflect the culturally located nature of the survey, or the socialisation inherent in Australian dental curricula. Furthermore, overseas born students may also not recognise that their ability to traverse their own and Australian cultures represents an element of competence. This also highlights the notion that there might be a distinction between having a culturally and linguistically diverse background (CALD) and being culturally competent. It cannot be assumed that a CALD individual possesses cultural competence because of birthplace, cultural background, or the languages that he or she speaks [30], but rather that this is developed from tolerance, empathy and understanding of cross-cultural issues. This concept was also challenged by Marino and his collaborators, who found that dentistry students reported cultural values that were largely similar regardless of their backgrounds [31].
Although this study provides valuable insights into the cultural competence acquisition process among dentistry and oral health students, it is not without limitations. The most obvious limitation was the cross-sectional nature of this study, which precludes a strong conclusion about increasing cultural competence with exposure to dental professional education, or the use of year of study as a good proxy for years of exposure to professional socialization. This introduces the influence of variation between cohorts in terms of socio- demographics, personalities, experiences and other factors. As such, it may be that some significant differences have resulted from this. Additionally, the study relied on self-reported data, which may not be an accurate reflection of the relationship between self-perceived and actual culturally competent practice [7,32]. Another concern is that participants were all students at the UoMDS. As a result, conclusions drawn from this study may not be representative of the cultural competency of all Australian dental profession students, or students at dental schools elsewhere [33]. However, considering these limitations, we believe that the current approach was adequate given the exploratory nature of the study.