Context

Athletic trainers provide care to diverse patients, many of whom exist in a culture different from that of the athletic trainer. As health care providers it is imperative to provide patient-centered care while practicing the empathy needed to perform services best for the patient.

Objective

To provide a brief historical view of the need for health care provider to demonstrate cultural competence and ethnocultural empathy when caring for patients.

Background

Cultural competence—understanding other's beliefs, values, and differences—is one piece to quality health care. Ethnocultural empathy is the ability to not only understand but also to relate to others in these areas. Both must be practiced for complete patient-centered care.

Data Synthesis

By teaching ethnocultural empathy, students will demonstrate an empathetic response to diverse clients, deepening their quality of relationship.

Results

There is limited description of ethnocultural empathy in the athletic training literature, but for many clinicians, it is an innate characteristic that can be improved.

Recommendation(s)

Athletic training educators should consider ways to incorporate ethnocultural empathy into how cultural competency is being addressed to produce more culturally aware and enriched students.

Conclusion(s)

Integrating ethnocultural empathy into an athletic training curriculum provides deeper levels of cultural competence by moving beyond understanding and toward actionable improvement of patient relationships.

  • The progressive change within the United States to a more cultural and diverse population requires health care providers to adjust to the future of their patients.

  • Health disparities need to be addressed. One of the core factors associated with these disparities is race and ethnicity. By having a more robust curriculum focused on diversity, athletic training students will be able to better treat their patients.

  • Ethnocultural empathy can be cultivated, as it can be a learned ability.

  • Educators need to consider cultural competence beyond understanding; teaching to relate to and understand other's values will result in improved patient care.

The athletic training profession provides care to diverse patient populations, which means that providers often care for those from a culture that differs from their own. The need for provides to understand diversity has been a necessity in the profession since its beginning, but today it is imperative that athletic trainers understand there is more than reaching the elusive goal of cultural competency. Rather, athletic trainers should look within themselves to work toward ethnocultural empathy for more robust patient-centered care.

The demographics of the United States is progressively changing to reflect a more diverse population. According to the 2020 Census Bureau, 2030 brings a turning point in the United States as all baby boomers will be older than 65 years old.1  As a result of the expansion of the older population, 1 in 5 Americans will be of retirement age. The projection is that by 2034, older adults will outnumber children for the first time in US history. Population growth will move slowly as baby boomers move into older adulthood and deaths outnumber births. The expectation is by 2035, the number of people 85 years and older will nearly double. Because of this aging population, there may be a shift in health care as more older adults seek out medical care compared with younger generations.1 

It is also projected that the United States will become more racially and ethnically diverse.1  As the population ages, international migration expects to overtake natural increase. One in 3 Americans will be of a race other than White by 2060, with those who are 2 or more races serving as the fastest-growing racial or ethnic group in the United States. The only group projected to shrink is the non-Hispanic White population. Between 2016 and 2060, the non-Hispanic White population can expect to decrease from 198 million to 179 million people; thus, this group will no longer comprise the majority of the US population. As the ethnic population changes and the United States becomes more racially diverse, those in health care will need to change and become more culturally competent to provide proper health care to those whose race might be different than their own.

Negative attitudes and discrimination exist within the dominant US culture, as well as in health care systems, contributing to health care disparities.2  Given changing US demographic trends, achieving greater diversity in the health care workforce will likely yield the practical benefit of producing a culturally competent workforce.3  This in turn may improve access to high-quality care for the medically underserved, increase the breadth and depth of the US health research agenda, and expand the pool of medically trained executives and policymakers ready to take up leadership positions in the health care system in the future.3 

More than 30 years of caregiving literature on diverse populations reveals that limited attention has been paid to multicultural issues, including (1) the experience of caregiving; (2) social support, access to, and use of caregiving resources; (3) predictors and outcomes of caregiving; and (4) interventions.4  Additionally, research has demonstrated some underlying causes for racial and ethnic disparities in health care, including provider/patient communication, clinical decision-making, and mistrust.5  Health care organizations suffer from a disparate distribution of racial or ethnic minority employees in professional positions,6  creating disparities in decision-making at all levels.

One of the most relevant factors related to health disparities is race and ethnicity.7  Behaviors of health care providers can contribute to health disparities in the US population.8  Poor communication between patient and provider when racial or ethnic backgrounds differ is a relevant factor in suboptimal health care services to ethnic minorities.7  Patients within ethnic minorities report less involvement in medical decision-making, less partnership with physicians, and lower levels of satisfaction with the care received.7  Change is required in the way health care providers address illness and wellness issues among those from different cultures.9  As a result of demographic shifts and subpar care provided to ethnically diverse groups by health professionals, it is important to increase the number of minority physicians and the diversity of the health care workforce to help close the current health disparity gap, thereby responding to the needs of all Americans.3,10,11  Providing better cultural competency education for current and emerging health care professionals in order to provide improved quality health care to all minority groups should be a priority; it has been demonstrated3,6,12,13  that a more culturally sensitive workforce is more likely to reduce minority health disparities.

Culture and language are critical to the delivery of health care services, defining the limits and effectiveness of the working relationship between the health care provider and patient receiving care. Health care programs wanting to produce more providers who choose to work with underserved populations need to prepare students to be sensitive to the needs and preferences of culturally diverse patients.14  Although racial diversity in the medical profession was once on the rise, research found that affirmative action bans have led to an approximately 17% decline (from 18.5% to 15.3%) in the first-time matriculation of medical school students who are underrepresented students of color.12  Little progress has been made relative to underrepresented minority academicians in the public health workforce.12  This research is yet to be explored in athletic training.

The American Society of Health-System Pharmacists' Statement on Racial and Ethnic Disparities in Health Care15  describes general principles to guide the actions of health care pharmacists in an effort to eliminate racial and ethnic disparities in health, including the following:

  • All patients have the right to high-quality care;

  • Medication-use practices should reflect knowledge of, sensitivity to, and respect for the race and/or culture of the patient; and

  • Health-system pharmacists have a vital role to play in eliminating racial and ethnic disparities in health care.

The statement describes the belief that “all patients, regardless of race, ethnicity, sex, age, sexual orientation, religion, physical or mental disability (or impairment), education, socioeconomic status, diagnosis, or limitations in access, have the right to high-quality health care that reflects knowledge of, sensitivity to, and respect for their differences.” Setting the standard for other professions, pharmacists have demonstrated that all health care workers need to interact and work with diverse patient populations to increase their empathy and become culturally competent.8 

Another important concept to understand is that of health literacy, defined by the American Medical Association (2006) and the US Department of Health and Human Services (2000) as the degree to which individuals can obtain, process, and understand the basic health information needed to make appropriate health decisions.16  Often, even patients who speak the same language as the provider have a hard time understanding the health information given to them. In the United States, average adults read at an 8th-grade level, whereas most written health information is drafted at a 12th-grade level.17  This can affect the patient's ability to read and understand instructions related to prescriptions, appointment information, health insurance, and other health care information. Insufficient communication leads to poor health, decreased adherence to medical instructions, an increase in hospitalizations, and increased health care costs.17  These problems increase when there are language barriers and lack of cultural competence.

There is no one definition of cultural competency. In athletic training research, “cultural competence” has been defined as understanding and integrating differences and incorporating them into daily care and working effectively in cross-cultural situations, which is also known as “transcultural health.”18  Other authors17  state that cultural competency influences effective communication between provider and patient with diverse values, beliefs, and behaviors. In health care, cultural competence encompasses understanding social and cultural influences on patients' health beliefs and behaviors. Having an appropriate level of cultural competence enables the health care provider to consider the background of the patient, which assists in implementing quality care and results in less misunderstanding between provider and patient.19,20  Providers who have a knowledge of patients' beliefs, values, and preferences are able to understand how cultural differences affect their health care decision-making processes, resulting in more patient-centered care, assisting the provider in knowing how to best care for their patients from diverse backgrounds.17  Improved patient-centered care can also lead to higher cultural humility, requiring a life-long commitment to self-evaluation and self-critique, to redress the power imbalances in the patient-provider dynamic and to develop mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations.21 

When linked, race, gender, and/or cultures are often lumped into prescriptive approaches to health care for diverse groups, contributing to the increase in disparity in care and medical errors. Programs that establish accountability for understanding cultural and behavioral facets of working in health care, as well as those that construct tools for more effective communication, will benefit both colleagues and the patients in our care.22  Having a high level of cultural competence enables the health care provider to be considerate of the background of the patient, which assists in implementing quality care and results in less misunderstanding between provider and patient.20 

Researchers and program developers in medical education have faced the challenge of implementing and evaluating curricula that teach medical students and house staff effective and respectful delivery of health care relative to the increasingly diverse populations of the United States.21  This health care delivery challenge occurs in the athletic training profession. In assessing certified athletic trainers, self-reported scores were higher than the same students' Cultural Competence Assessment scores.18  Assessment of a Doctor of Pharmacy curriculum found that integrating health literacy and cultural competency content throughout the curriculum resulted in improvement in students' scores in these areas from the first to the fourth professional year. When there were no integrated activities, scores dropped.23  Using the Yo Veo Salud (I See Health) as an intervention, the intervention group showed greater ethnocultural empathy, health care empathy, and patient-centeredness compared to the comparison group in medical trainees.2  We would be remiss to ignore the culture suppositions, including the notion that culture is learned, localized, patterned, evaluative, and continuous with change,19  because culturally competent care is an ongoing process requiring critical components of culturally appropriate care, including social justice, beliefs and actions, ethnocultural empathy, and cultural humility.24 

Measurement of Ethnocultural Empathy

Measurement of cultural competence is only one piece of the puzzle of quality health care. Although a health care provider may understand others' beliefs, values, and cultural differences, empathy toward the individuals who are different from the provider may be the missing aspect. Empathy itself is a trait or an ability to know another person's inner experience or to feel or perceive the feelings and emotions of others. Further, ethnocultural empathy is the ability to understand and relate to others from ethnic and racial cultural groups different from one's own.7  A tool to measure ethnocultural empathy was developed to help better understand how a person exhibits this trait.25  It consists of 4 factors, each interrelated by aspects of each factor standing alone. “Empathetic Perspective Taking” includes questions regarding an individual's effort to understand the experiences and emotions of people from different racial and ethnic backgrounds to better understand their view of the world. “Empathetic Feeling and Expressions” inquires about a clinician's communication regarding thoughts, feelings, words, and/or actions that directly relate to discriminatory experiences. “Empathetic Awareness” highlights a clinician's awareness of knowledge that patients of a different racial or ethnic background may have experiences different from their own. “Acceptance of Cultural Differences” includes questions regarding the clinician's accepting and valuing customs and cultural differences of the patients from different racial and ethnic groups.25  Communication empathy combines both intellectual and empathic empathy and is the expression of ethnocultural empathic thoughts (intellectual empathy) and feelings (empathic emotions) toward members of racial and ethnic groups different from one's own.25 

The validity and reliability of the Scale of Ethnocultural Empathy (SEE) via 3 studies by Wang et al25  demonstrated that ethnocultural empathy, as a learned ability and personal trait, can be determined. The first study demonstrated the expectation that ethnocultural empathy would be multidimensional, consisting of empathic emotion, intellectual empathy, and communicative empathy and the correlation among them. The second study focused on supportive factor analysis and validity estimates, and the third examined test-retest reliability of the SEE over a 2-week period. There was a correlation between demographics and levels of ethnocultural empathy. For example, women are more ethnoculturally empathic, and non-White individuals have higher levels of ethnocultural empathy than do their White equivalents.

The SEE is a valuable instrument for measuring how individuals relate to people with different ethnocultural backgrounds as well for capturing gender characteristics in empathic responsiveness. By understanding where student knowledge is lacking, measuring cultural competence and ethnocultural empathy can be a valuable tool to aid efforts in establishing an effective curriculum that addresses these issues. As the country's demographics change, and as the need for production of culturally competent health care providers increases, the need for ethnocultural empathy training will become imperative. These future health professionals need to provide care to ethnically diverse populations by being culturally sensitive; encouraging open, safe communication; and showing empathy to those who are different from themselves.7 

Cultivating the development of ethnocultural empathy in future health care providers may help develop the relative skills needed to provide exemplary care regardless of whether or not the provider's own race is in alignment with the patient's.7  In order to provide effective health care, providers must build relationships with their patients that encourage communication, trust, and understanding. Showing a high level of empathy is another way to build those relationships. Since cultural empathy is a learned ability, health professional programs, including athletic training, should be implementing ethnocultural empathy into their curriculum. The curriculum should include how to provide quality care, how to effectively communicate with patients regardless of cultural background, and how to not only exhibit cultural competence but also how to show empathy toward ethnically diverse patients.9,24,25 

Diversity education is necessary for all health care education programs. It has proven to be positive in those who are of a different background or have a stronger ethnic identity.26,27  There does not seem to be research supporting White health care providers and ethnocultural training, although students in psychology and social work have been shown to distinguish themselves in terms of ethnocultural empathy.28  Research has revealed that ethnocultural empathy is not acquired through multicultural readings or discussions,29  nor is it based on study abroad programs.30 

Awareness and ethnocultural-focused education must provide didactic and clinical experiences to enhance the students' understanding of the importance of ethnocultural empathy. A mentor's cultural identity and empathy may link to mentees' willingness to explore their own ethnic identities.27  Additionally, having a preceptor or mentor who identifies with the similar cultural distinctiveness and who is a role model for ethnocultural empathy may lead to stronger relationships in the athletic training profession.

Some research has examined ethnocultural empathy in various groups. Females and students who volunteer 10 hours or more in any capacity have higher empathy scores.31,32  In health care students during a targeted intervention workshop, increases were found from baseline to postintervention on the SEE, and gains were maintained at 1-month follow-up.9  There is evidence24  that it is feasible to teach and improve Indigenous-specific health knowledge of medical students using a brief intervention of lectures.

A study of first-year physician assistant students over 3 cohorts noted that they had high levels of ethnocultural empathy. Non-White students and females had higher scores than did White students or males.14  Though not specifically ethnocultural empathy, a systematic review33  of the effectiveness of empathy education for undergraduate nursing students found that 9 of 23 empathy education studies demonstrated practical improvements in empathy, and the most effective were immersive and experiential simulations focusing on vulnerable patient groups and provided guided reflection.

First-year nursing and dental medicine students participated in a workshop, “Appreciating Diversity,” which promoted appreciation for individual differences and the value of diversity to improve communication and empathy for other cultures.7  It also addressed misconceptions and prejudices that many health care providers have about their patients who come from different race, ethnicity, and cultural backgrounds and how this affects patient-provider communication. The delivery of the SEE pre- and postsemester of participation in the workshop demonstrated an increase in ethnocultural empathy after the workshop. Interestingly, results also suggested that students entering a profession that solely helps other individuals might not inherently possess high levels of ethnocultural empathy. It was due to specific instruction that many students were able to appreciate individual differences and were encouraged to have better communication and understanding between patients from backgrounds different from their own. The induction of empathy into health professional programs is an effective way to change individuals' attitudes toward stigmatized groups. Inclusive of ethnocultural empathy research, several truths have been uncovered across the research, as follows:

  1. Individuals who express more empathy toward individuals from diverse backgrounds are likely to have positive perceptions of women in authority or leadership positions.34 

  2. Females are more likely than males to report higher levels of ethnic or cultural empathy.34 

  3. Individuals with high levels of ethnocultural empathy are less likely to stereotype toward athletes; female athletes were also less likely to do so compared with male athletes.35 

  4. Women and those higher in ethnic/cultural empathy reported greater behavioral intentions to attend as well as more positive perceptions of diversity programs.36 

  5. Racial minority women tended to report significantly higher initial levels of ethnocultural empathy than did racial minority men and White students.37 

There is a positive relationship between multicultural awareness and empathetic response to diverse clients.38  In response to the changing demographics of the United States, athletic training programs should incorporate diversity training for students, including, but not limited to, diverse clinical opportunities, work with diversity programs at their institutions, provision of hands-on volunteer work with local free clinics or migrant health facilities, or simply through having the hard discussions within didactic courses. Athletic trainers may be the first line of care for many who are culturally diverse, and expressing ethnocultural empathy toward their patients can create a trust that is sorely lacking. Health disparities continue at all levels of health care. Cultural competency is only part of caring for patients; ethnocultural empathy demonstrates patient-centered care at a level to which all athletic trainers should aspire.

1. 
Vespa
J,
Armstrong
DM,
Medina
L.
Demographic turning points for the United States: population projections for 2020 to 2060. Accessed October 15, 2022.
2. 
Chapman
MV,
Hall
WJ,
Lee
K,
et al
Making a difference in medical trainees' attitudes toward Latino patients: a pilot study of an intervention to modify implicit and explicit attitudes
.
Soc Sci Med
.
2018
;
199
:
202
208
.
3. 
Cohen
JJ,
Gabriel
BA,
Terrell
C.
The case for diversity in the health care workforce
.
Health Affairs
.
2002
;
21
(5)
:
90
102
.
4. 
Apesoa-Varano
EC,
Tang-Feldman
Y,
Reinhard
SC,
Choula
R,
Young
HM.
Multi-cultural caregiving and caregiver interventions: a look back and a call for future action
.
Generations
.
2015
;
10
:
39
48
.
5. 
Betancourt
JR,
Beiter
S,
Landry
A.
Improving quality, achieving equity, and increasing diversity in healthcare: the future is now
.
J Best Pract Health Prof Divers
.
2013
;
6
(1)
:
903
917
.
6. 
Flores
K,
Combs
G.
Minority representation in healthcare: increasing the number of professionals through focused recruitment
.
Hosp Topics
.
2013
;
91
(2)
:
25
36
.
https//doi.org/10.1080/00185868.2013.793556
7. 
Fleming
BD,
Thomas
SE,
Burnham
WS,
Charles
LT,
Shaw
D.
Improving ethnocultural empathy in healthcare students through a targeted intervention
.
J Cult Divers
.
2015
;
22
(2)
:
59
63
.
8. 
Abrishami
D.
The need for cultural competency in health care
.
Radiol Tech
.
2018
;
89
(5)
:
441
448
.
9. 
Fitzgerald
EM,
Cronin
SN,
Campinha-Bacote
J.
Psychometric testing of the inventory for assessing the process of cultural competence among healthcare professionals—student version (IAPCC-SV)
.
J Theory Construct Test
.
2009
;
13
(2)
:
64
68
.
10. 
Larrieux
SL,
Izzicupo
A,
Kapadi
X,
Latorre
J.
Northeastern University
and
Edward
M.
Kennedy School's “Shadow Day” program: impact on minority students in healthcare careers
.
J Best Pract Health Prof Divers Educ Res Policy
.
2012
;
5
(2)
:
799
809
.
11. 
Mittman
IS,
Sullivan
LW.
Forming state collaborations to diversity the nation's health workforce: the experience of the Sullivan Alliance to Transform the Health Professions
.
J Genet Counsel
.
2011
;
20
:
547
555
.
12. 
Annang
L,
Richter
DL,
Fletcher
FE,
Weis
MA,
Fernandes
PR,
Clary
LA.
Diversifying the academic public health workforce: strategies to extend the discourse about limited racial and ethnic diversity in the public health academy
.
ABNF J
.
2010
;
21
(2)
:
39
43
.
13. 
McGee
V,
Fraher
E.
The diversity of North Carolina's health care workforce
.
J Best Pract Health Prof Divers Educ Res Policy
.
2012
;
5
(2)
:
790
798
.
14. 
Rodriguez
MMD,
Phelps
PB,
Tarp
HC.
Baseline cultural competence in physician assistant students
.
PLoS ONE
.
2019
;
14
(4)
:
15. 
American Society of Health-System Pharmacists.
ASHP statement on racial and ethnic disparities in health care
.
Am J Health-Syst Pharm
.
2008
;
65
:
378
382
.
16. 
Ingram
RR.
Using Campinha-Bacote's process of cultural competence model to examine the relationship between health literacy and cultural competence
.
J Adv Nurs
.
2012
;
68
(3)
:
695
704
.
17. 
Cailor
SM,
Chen
AMH.
Immediate and longitudinal effects of incorporating health literacy and cultural competency into a yearlong pharmacy curriculum
.
Curr Pharm Teach Learn
.
2015
;
7
(3)
:
292
301
.
18. 
Marra
J,
Covassin
T,
Shingles
RR,
Canady
RB,
Mackowiak
T.
Assessment of certified athletic trainer's levels of cultural competence in the delivery of health care
.
J Athl Train
.
2010
;
45
(4)
:
380
385
.
19. 
Bonder
B,
Martin
L,
Miracle
A.
Achieving cultural competence: the challenge for clients and healthcare workers in a multicultural society
.
Workforce Issues Changing Soc
.
2001
;
(Spring)
:
35
42
.
20. 
Momeni
P,
Jirwe
M,
Emami
A.
Enabling nursing students to become culturally competent—a documentary analysis of curricula in all Swedish nursing programs
.
Scand J Caring Sci
.
2008
;
22
:
499
506
.
21. 
Tervalon
M,
Murray-Garcia
J.
Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education
.
J Health Care Poor Underserved
.
1998
;
9
(2)
:
1998
.
22. 
Musolino
GM,
Burkhalter
ST,
Crookston
B,
et al
Understanding and eliminating disparities in health care: development and assessment of cultural competence for interdisciplinary health professionals at the University of Utah—a 3-year investigation
.
J Phys Ther Educ
.
2010
;
24
(1)
:
25
36
.
23. 
Chen
AMH,
Cailor
SM,
Wicker
E,
Harper
NG,
Franz
TT,
Pahl
B.
Integrating health literacy and cultural competency concepts across the doctor of pharmacy curriculum
.
Am J Pharm Educ
.
2020
;
84
(10)
:
1352
1362
.
24. 
Lewis
ME.
The effects of an Indigenous health curriculum for medical students
.
Med Sci Educ
.
2020
;
30
:
891
903
.
25. 
Wang
YW,
Davidson
MM,
Yakushko
OF,
Savoy
HB,
Tan
JA,
Bleier
JK.
The scale of ethnocultural empathy: development, validation, and reliability
.
J Consult Psych I
.
2003
;
50
(2)
:
221
234
.
26. 
Monroe
AD.
The Effects of College Diversity Education on Ethnocultural Empathy. Eastern Kentucky University;
2018
.
27. 
Nguyen
P.
Social Context, Ethnic Identity, and Ethnocultural Empathy. master's thesis. University of California, Davis;
2003
.
28. 
Rasoal
C.
Ethnocultural Empathy: Measurement, Psychometric Properties, and Differences Between Students in Health Care Education Programmes. Thesis. Linköping University;
2009
.
29. 
Bhaskar
T.
Assessing Effectiveness of Multicultural Readings in Increasing Empathy for Undergraduate Students. Dissertation. University of Tennessee–Knoxville;
2011
.
30. 
Hansen
RA.
Impact of Study Abroad on Ethnocultural Empathy and Global-Mindedness. Dissertation. Ball State University;
2010
.
31. 
Peifer
JS,
Lawrence
EC,
Williams,
JL,
Leyton-Armakan
J.
The culture of mentoring: ethnocultural empathy and ethnic identity in mentoring for minority girls
.
Cult Divers Ethnic Minorities
2016
;
22
(3)
:
440
446
.
32. 
Pieters
AJ.
Service Learning and Ethnocultural Empathy: Developing Cultural Empathy Through Experience. Master's thesis. North Dakota State University;
2015
.
33. 
Levett-Jones
T,
Cant
R,
Lapkin
S.
A systematic review of the effectiveness of empathy education for undergraduate nursing students
.
Faculty Sci Med Health Papers Part B
.
2019
.
34. 
Cundiff
NL,
Komarraju
M.
Gender differences in ethnocultural empathy and attitudes toward men and women in authority
.
J Leadership Org Stud
.
2008
;
15
(1)
:
5
15
.
35. 
Karafantis
DM.
The effects of ethnocultural empathy on level of stereotyping toward college athletes
.
J Evidence-Based Soc Work
.
2011
;
8
:
426
444
.
36. 
Cudiff
NL,
Nadler
JT,
Swan
A.
The influence of cultural empathy and gender on perceptions of diversity programs
.
J Leadership Org Stud
.
2009
;
16
(1)
:
97
110
.
37. 
Lu
Y,
Hill
CE,
Hancock
GR,
Keum
BT.
The effectiveness of helping skills training for undergraduate students: changes in ethnocultural empathy
.
J Couns Psych
.
2019
.
38. 
Reese
M.
Multicultural Competence and Ethnocultural Empathy. Dissertation. Carlow University;
2007
.