Using clinical vignettes to assess doctors’ and medical students’ ability to identify sociocultural factors affecting health and health care

Figures & data

Table

Practice points

Methods commonly used for assessing clinical cultural competence have been associated with a number of problems. Our results indicate that brief clinical vignettes are a relevant and feasible alternative method for exploring physicians’ knowledge of social and cultural factors affecting health and health care. Additional methods may be needed to assess other aspects of cultural competence.

Box 1. Vignettes

“The objective of the following vignettes is to explore your perceptions of social and cultural factors that can influence clinical communication and health-related behavior. For each vignette, please give as many answers as you can think of.”

• The doctor sees a patient from North Africa who complains of a cough, weight loss, and fatigue for the last 3 months. After conducting a medical history and physical exam, the doctor explains that he needs to do a chest x-ray to exclude possible TB. He organizes the x-ray, and asks the patient to return for a follow-up appointment once the X-ray has been taken. However, the patient misses his next appointment. What might explain why the patient missed his appointment?

• A young, South Asian Muslim patient is briefly hospitalized for newly diagnosed severe hypertension. The day before the patient is to leave the hospital, the ward doctor organizes an interview with the patient to explain his treatment. He begins by exploring the patient's illness perspectives. What particular issues should the doctor explore with the patient?

• An East European man presents to the emergency room with acute back pain. He speaks little French, but mentions that he works in construction. The doctor prescribes anti-inflammatory medicines, physiotherapy, and 10-day sick leave from work. He explains to the patient the importance of following his treatment recommendations to insure a speedy recovery. What factors might prevent the patient from following the doctor's advice?

• The doctor receives a female diabetic patient from the Balkans. He explains in detail the diet plan the patient should follow and provides her with a brochure on diabetes and its treatment, especially dietary aspects. A month later, the doctor sees the patient again, and asks her if she has followed the diet plan they discussed. The patient, visibly uncomfortable, says no. What factors may have prevented this patient from following the doctor's dietary plan?

Box 2. Categorization of responses to vignettes (codes)

Code	Examples of open-ended responses
1. Patient did not understand	Didn’t understand doctor's explanations
2. Illness-related beliefs	What are patient's beliefs about hypertension?
	Believes TB is caused by witchcraft
3. Money and income	No money to buy medicines
	Can’t afford to take time off from work
4. Work/employment	Works illegally; no right to sick leave
5. Dietary habits	Diet plan not adapted to patient's cultural habits
6. Language	Language barrier; patient doesn’t understand French
7. Illness-related fears	Disease-related stigma
8. Treatment expectations	Patient's ideas about hypertension treatment
	Doesn’t believe in physiotherapy
	Thinks diabetes should be treated with medicine
9. Family or social network	Pressure from family to cook traditional food
	Must send money to family back home
10. Living conditions	What are patient's living conditions?
	Patient's living conditions
11. Work/residence permit	No residence permit; undocumented worker
12. Knowledge of health system	Doesn’t know where to go for X-ray
13. Health insurance status	Has no insurance
14. Education or literacy level	Can’t read the brochure; is illiterate
15. Poor explanations from doctor	Doctor doesn’t explain well
16. Religion	How to take medicines during Ramadan
17. Gender relations	Wife has to cook what husband wants
18. Lack of trust	Doesn’t trust doctor
	Is afraid of being reported to police
19. Non-conventional treatments	Prefers alternative remedies
	Does patient use traditional medicine?
20. Psychological state	Is depressed or worried about other things
21. Housing conditions	Lives in group housing, shared kitchen
99. No response provided	[left empty]

Table 1.  Code-specific kappa statistics for each vignette, in descending order (N = 40)

	Kappa
TB vignette codes
Money and income	1.00
Illness-related fears	1.00
Gender relations	0.93
Lack of trust	0.93
Patient did not understand	0.85
Illness-related beliefs	0.82
Work/residence permit	0.80
Treatment expectations	0.64
Poor explanations from doctor	0.55
Hypertension vignette codes
Money and income	0.91
Illness-related beliefs	0.89
Treatment expectations	0.76
Family or social network	0.28
Back pain vignette codes
Money and income	1
Language	1
Patient did not understand	0.95
Health insurance status	0.93
Work/employment	0.82
Treatment expectations	0.76
Work/residence permits	0.66
Illness-related beliefs	0.61
Diabetes vignette codes
Education or literacy level	1
Religion	1
Language	0.95
Money and income	0.94
Dietary habits	0.88
Patient did not understand	0.85
Role of patient's family and/or social network	0.71
Illness-related beliefs	0.54

Table 2.  Sample characteristics (first column) and mean number of relevant answers to vignettes across subgroups, unadjusted and in multivariate model

		Univariate comparisons		Mean adjusted for all variables in model
	Frequencies (%)	Mean (SD)	P-value	Mean
Status			<0.001		0.002
Doctors in private practice	156 (26.5)	7.4 (3.2)		7.5
Hospital doctors	299 (50.8)	8.7 (3.6)		8.6
Medical students	134 (22.8)	9.1 (3.3)		8.9
Sex			0.002		0.022
Women	275 (46.5)	9.0 (3.4)		8.7
Men	317 (53.5)	8.0 (3.5)		8.0
Age group			<0.001		NS
≤24 years	57 (9.8)	9.2 (3.1)	(linear trend)
25–44 years	347 (59.9)	8.8 (3.4)
45–64 years	162 (28.9)	7.8 (3.6)
≥65 years	13 (2.2)	5.7 (3.2)
Interest in caring for migrant patients			<0.001		0.013
Absent or weak	64 (11.2)	7.0 (2.8)	(linear trend)	7.4	(linear trend)
Moderate	219 (38.9)	8.1 (3.5)		8.3
High	223 (39.6)	9.0 (3.6)		9.0
Very high	58 (10.3)	8.8 (3.4)		8.7
Training in cultural competence			0.004		0.008
Yes	177 (30.2)	9.1 (3.7)		8.8
No	409 (69.8)	8.2 (3.4)		7.9

Table 3.  Frequencies (N) of categories of explanations given by 592 respondents

	All four vignettes	Tuberculosis	Hypertension	Back pain	Diabetes
1. Patient did not understand	660	303	2	157	198
2. Illness-related beliefs	478	143	218	41	76
3. Money and income	468	108	61	153	146
4. Work/employment	409	15	4	389	1
5. Dietary habits	394	0	35	0	359
6. Language	363	30	8	117	208
7. Illness-related fears	301	282	5	12	2
8. Treatment expectations	193	53	69	55	16
9. Family or social network	182	49	34	11	88
10. Living conditions	163	29	75	31	28
11. Work/residence permit	152	65	11	74	2
12. Knowledge of health system	138	12	94	31	1
13. Health insurance status	138	14	18	105	1
14. Education or literacy level	136	12	5	4	115
15. Poor explanations from doctor	125	79	0	19	27
16. Religion	107	11	58	2	36
17. Gender relations	91	83	1	0	7
18. Lack of trust	89	71	0	14	4
19. Non-conventional treatments	33	19	9	3	2
20. Psychological status	31	10	1	14	6
21. Housing conditions	12	0	3	2	7
Total appropriate responses	5406	1398	713	1238	1340
No response	204	20	156	19	9

Table 4.  Construct validity tests of the number of relevant answers to vignettes: means across responses to validation items

Validation items		Importance ratings
In your opinion, how important for a doctor are the following elements in providing good quality care to an immigrant patient?	Expected direction of association	Not at all important (1) or (2)	(3)	(4)	Extremely important (5)	P-value (test for linear trend)
Prior clinical experience with the patient's health problem	None or negative	9.6	8.4	8.7	7.6	0.003
Availability of an effective treatment for the patient's health problem	None or negative	9.5	8.9	8.3	7.8	<0.001
Knowledge of the patient's beliefs about his/her disease	Positive	7.1	7.1	8.2	9.2	<0.001
Knowledge of the patient's social and economic context	Positive	7.4	6.9	8.2	9.0	<0.001
		Self-assessed competence ratings
How competent do you believe you are at the following tasks?		Not at all competent (1) or (2)	(3)	(4)	Perfectly competent (5)
Obtain a medical history that is relevant to the patient's complaint	None or negative	8.0	7.9	8.6	8.6	0.17
Announce bad news (e.g., an unfavorable prognosis)	None or negative	9.0	8.3	8.4	8.6	0.68
Obtain a psychosocial history from the patient	Positive	7.1	7.8	9.0	9.1	<0.001
Explore the migratory trajectory and possible traumatic experiences of an asylum seeker	Positive	7.9	8.5	8.9	9.6	0.001