A3-Attitudes beliefs and behavior cultural competence
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RESEARCH ARTICLEAttitudes, beliefs and behaviors of religiosity,spirituality, and cultural competence in themedical profession: A cross-sectional surveystudyVictoria DillardID1*, Julia Moss2, Natalie Padgett1, Xiyan TanID3, Ann Blair KennedyID1*1University of South Carolina School of Medicine Greenville, Greenville, South Carolina, United States ofAmerica,2Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah,United States of America,3Clemson University School of Mathematical and Statistical Sciences, Clemson,South Carolina, United States of America*vdillard@email.sc.edu(VD);kenneda5@greenvillemed.sc.edu(ABK)AbstractIntroductionReligion and spirituality play important roles in the lives of many, including healthcare provid-ers and their patients. The purpose of this study was to examine the relationships betweenreligion, spirituality, and cultural competence of healthcare providers.MethodsPhysicians, residents, and medical students were recruited through social platforms to com-plete an electronically delivered survey, gathering data regarding demographics, culturalcompetency, religiosity, and spirituality. Four composite variables were created to catego-rize cultural competency: Patient Care Knowledge, Patient Care Skills/Abilities, ProfessionalInteractions, and Systems Level Interactions. Study participants (n = 144) were grouped asChristian (n = 95)/non-Christian (n = 49) and highly religious (n = 62)/not highly religious (n =82); each group received a score in the four categories. Wilcoxon rank sum and Chi-squaretests were used for analysis of continuous and discrete variables.ResultsA total of 144 individuals completed the survey with the majority having completed medicalschool (n = 87), identifying as women (n = 108), white (n = 85), Christian (n = 95), and nothighly religious (n = 82). There were no significant differences amongst Christian versusnon-Christian groups or highly religious versus not highly religious groups when comparingtheir patient care knowledge (p = .563, p = .457), skills/abilities (p = .423, p = .51), profes-sional interactions (p = .191, p = .439), or systems level interaction scores (p = .809, p =.078). Nevertheless, participants reported decreased knowledge of different healing tradi-tions (90%) and decreased skills inquiring about religious/spiritual and cultural beliefs thatmay affect patient care (91% and 88%). Providers also reported rarely referring patients toreligious services (86%).PLOS ONEPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20211 / 18a1111111111a1111111111a1111111111a1111111111a1111111111OPEN ACCESSCitation:Dillard V, Moss J, Padgett N, Tan X,Kennedy AB (2021) Attitudes, beliefs and behaviorsof religiosity, spirituality, and cultural competencein the medical profession: A cross-sectional surveystudy. PLoS ONE 16(6): e0252750.https://doi.org/10.1371/journal.pone.0252750Editor:Rosemary Frey, University of Auckland,NEW ZEALANDReceived:July 30, 2020Accepted:May 23, 2021Published:June 15, 2021Peer Review History:PLOS recognizes thebenefits of transparency in the peer reviewprocess; therefore, we enable the publication ofall of the content of peer review and authorresponses alongside final, published articles. Theeditorial history of this article is available here:https://doi.org/10.1371/journal.pone.0252750Copyright:©2021 Dillard et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, whichpermits unrestricted use, distribution, andreproduction in any medium, provided the originalauthor and source are credited.Data Availability Statement:The data has beenuploaded to the Figshare repository (DOI:10.6084/m9.figshare.14442560).
ConclusionsAlthough this study demonstrated no significant impact of healthcare providers’ religious/spiritual beliefs on the ability to deliver culturally competent care, it did reveal gaps aroundhow religion and spirituality interact with health and healthcare. This suggests a need forimproved cultural competence education.IntroductionAccording to the 2014 Religious Landscape Study by the Pew Research Center, 77% of alladults in the United States identify with a religious faith [1]. Various studies have found a linkbetween religious involvement and decreased mortality [2–4], leading many to further exam-ine the role religion and spirituality should play in healthcare delivery.According to a 2001 article written by the American Psychological Society, religiondescribes specific behavior patterns and practices that align with a traditional system of faithand worship, where spirituality involves the pursuit of an ultimate truth and reality that issacred to an individual [5]. It is important to note the differences between these two concepts—as spirituality should not be confined to religion, but appreciated within a broader definitionthat encompasses meaning, purpose, and relationships [6].In 2015, the U.S. experienced a drop in traditional religious beliefs and practices and a risein what is considered the religious “nones”: a group of Americans who are not religiously affili-ated, but retain their belief in God [1]. This shift in the religious landscape has further widenedthe generational gap and challenged traditional methods of religious observance. Nevertheless,77% of all adults continue to identify with a religious faith, and 41% of these persons say theirreligious beliefs lay the foundation for their moral sense and ethical motives [1]. As religionand spirituality remain a complex and multidimensional phenomena, they continue to add tothe depth of diversity in healthcare organizations.Cultural competence is defined as “a set of congruent behaviors, attitudes, and policies thatcome together in a system, agency, or among professionals and enable that system, agency, orthose professionals to work effectively in cross-cultural situations” [7]. Some of the barriersthat affect the ability of patients to access care can be minimized through cultural competencetechniques, including communication with patients in their preferred language, leadershipand workforce diversity, cross-cultural training of providers, identification of structural barri-ers, and the provision of culturally appropriate health education materials [8,9]. Individualproviders’ attributes, behaviors, and attitudes impact interactions with patients as well as theenvironment of their workplace and is therefore important to understand as a contributor tothe cultural competence of the health system as a whole [9].When we consider the intersection of religion, spirituality, and culturally competent health-care, one study found that among a group of neonatologists, there were no differences amongstreligious and non-religious providers in the decision to withhold or withdraw life-saving treat-ment to neonates in the intensive care unit [10]. Nevertheless, 7% of the study participantsreported no obligation to refer patients to an alternate provider for options that they wouldobject [10]. This is further highlighted in a study done by Curlin et al., which demonstratedthat 18% of U.S. physicians reported no moral obligation to refer a patient to an alternativeprovider willing to perform a procedure or offer a treatment that they feel is morally wrong[11]. This challenges one to consider how personal religious and spiritual beliefs may play arole in interactions with patients in the healthcare setting. As globalization continues and thePLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20212 / 18Funding:The author(s) received no specificfunding for this work.Competing interests:The authors have declaredthat no competing interests exist.
population of the United States becomes increasingly diverse, the ability to care for diversepeople is becoming ever more important for healthcare providers. Furthermore, the ability todo this despite one’s own personal religious and spiritual belief systems reinforces an impor-tant angle of social and behavioral research.Although robust literature exists that explores provider religiosity and spirituality and theimpact this may have on different aspects of culturally competent healthcare (specifically, spiri-tual care in clinical settings), to our knowledge, there have been no studies that have specifi-cally assessed how providers’ religious and spiritual identities impact the domains of cross-cultural knowledge, culturally aware patient care skills and abilities, cross-cultural professionalinteractions, and healthcare systems-level interactions.This study examined attitudes, behaviors and beliefs associated with religious and spiritualvariables of cultural competence among attending physicians, fellows, resident physicians, andmedical students in the United States. The results of this study will be used to guide futureresearch and inform cultural competence training efforts in healthcare and medical educationsettings.MethodsStudy design and inclusion criteriaA cross-sectional survey design was used to gather data regarding participant demographics(race/ethnicity, age, and gender identity), cultural sensitivity, religiosity, and spirituality frommedical students in the clinical years, residents, fellows, and attending physicians (either MDor DO) (MsRP) practicing in the United States at the time of the survey. To be included in thesurvey, participants were required to meet the following qualities: 1) reside, work, and/orattend school in the United States, 2) be a medical student (MD or DO) in the clinical years, aresident, fellow, or a practicing physician (MD or DO), and 3) agree to participate in the sur-vey. An online survey was selected to allow for a broader distribution of the instrument acrossgeographic areas and levels of training. Participants were recruited through social media (Face-book, Twitter) and local and national (i.e. Student National Medical Association) email list-servs. Participation in the study was voluntary and uncompensated. All participants wereadults. Written consent to participate in the study was obtained from all participants.Survey instrumentInstrument resources.The survey instrument (S1 Appendix)was developed based on theadoption of three primary resources: Clinical Cultural Competency Questionnaire (CCCQ,Post-Training Version), Promoting Cultural and Linguistic Competency Self-AssessmentChecklist for Personnel Providing Primary Healthcare Services, and Cultural CompetenceSelf-Assessment Questionnaire (CCSAQ).The following represent the survey domains of the present study:demographics;patientpopulationrace/ethnicity;patientpopulationreligion;participantreligiosityandspirituality;theinteractionofreligion,spirituality,andpatientcare;knowledge;skills;comfort;communication;diversityofinteractions;socioculturalidentities;andtrainingandeducation. The questions thatwere included in each of these domains were selected by expert faculty in the field of culturalcompetency and health disparities.Demographics & patient population.The first part of the survey collecteddemographicdata, which included MsRP level of training, state and type of practice/medical school, spe-cialty (intended or actual), race/ethnicity, gender identity, age, and religious identity. Respon-dents were then asked to provide their best estimates of the demographics of their patientpopulation in the section,patientpopulationbyethnicity,race,andreligion. Respondents werePLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20213 / 18
required to estimate, and they were offered nine percentage ranges to choose from as well asan option for “do not know.” This metric was inspired by the Cultural Competence Self-Assessment Questionnaire (CCSAQ), a tool developed by the Portland Research and TrainingCenter that is now applied in a variety of settings: from child and family service agencies tocurriculum planning (the alpha coefficient for all but one subscale in the questionnaire was0.8) [12].Personal values.Participants were asked about their personal values and beliefs towardreligiosity and spirituality (participantreligiosityandspiritualitydomain). Definitions used forreligion and spirituality are included in the survey instrument inS1 Appendix. This sectionfocused on assessing the providers’ engagement with religious and spiritual practices, and theywere evaluated with 4, 5, and 6-point Likert scales. MsRP were asked the frequency in whichthey attend religious services, which was graded on a 4-point Likert scale (“at least once aweek,” “1–2 times a month,” “1–2 times a year,” or “never”). Frequency of prayer and practiceof mindfulness and/or meditation with or without movement (yoga, Thai Chai, etc.) wasgraded on a 6-point Likert scale (“multiple times a day,” “daily,” “weekly,” “monthly,” or“rarely”). The importance of religion and spirituality to personal life was assessed with a5-point Likert (“very important,” “somewhat important,” “I don’t know,” “not too important,”and “not at all important”). These questions were based on the Pew Research Center’s Religios-ity Landscape Study [1].Intersections with patient care.Theintersectionofreligion,spirituality,andpatientcaredomain asked respondents how often they ask patients about religious, spiritual, or culturalbeliefs and practices as well as how often they refer their patients to a chaplain or other servicesto meet their religious needs (Likert 5-point: “never,” “rarely,” “sometimes,” “frequently,” or“always”). These questions were influenced by the Pew Research Center’s study on Religiosityin the United States [1].Knowledge, skills, & comfort.Theknowledge,skills, andcomfortdomains were influencedby the Clinical Cultural Competency Questionnaire (CCCQ, Post-Training Version) with per-mission from the survey author, Robert Like, at the Robert Wood Johnson Medical School [13].The CCCQ is a 63-item measure originally developed by the Rutgers Robert Wood JohnsonMedical School to assess physicians’ competency in providing high quality care to diversepatient populations. The questionnaire assesses knowledge of health disparities, skills in deliver-ing culturally competent healthcare and dealing with sociocultural issues, comfortability withfacing cross-cultural situations, self-awareness of biases and prejudices, and the importance ofcultural competency training [13]. The questionnaire has been translated into at least six differ-ent languages and used to develop cultural competence educational programs in healthcare.Research has shown the questionnaire to be quite reliable, with an alpha coefficient greater than0.8 for all subscales; the alpha coefficient was>0.9 for theknowledgesection,>0.87 for theskillssection, and>0.8 for thecomfortsection [14]. Each question was answered using a Likert5-point scale: “never,” “rarely,” “sometimes,” “frequently,” “always”, or “I don’t know.”Some questions were modified to better accommodate the target population (MsRP). In theknowledgedomain, respondents were asked about health disparities and socioeconomic andsociocultural factors that affect populations in their community. Theskillssection askedrespondents to reflect on their ability to deliver culturally competent care; for example, per-forming and delivering culturally sensitive exams and education. In thecomfortdomain, par-ticipants were asked about how comfortable they feel in certain cross-cultural interactions likecaring for patients of a different sexual and/or gender identity than themselves or workingwith healthcare professionals from culturally diverse backgrounds.Communication and diversity of interactions.Thecommunicationanddiversityofinter-actionsdomains were adopted and modified from the Promoting Cultural and LinguisticPLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20214 / 18
Competency Self-Assessment Checklist for Personnel Providing Primary Healthcare Servicestool, which was developed by Georgetown University’s National Center for Cultural Compe-tence (NCCC), and it is a widely used self-assessment tool [15]. It is a publicly available toolthat assesses physical environment, materials and resources, communication styles, and valuesand attitudes toward cultural and linguistic competence in health and human service settingsat the physician and organizational level. It provides specific examples on the values and prac-tices that help to foster and promote cultural and linguistic competence [15]. As reliability andvalidity statistics are not available for this tool, we performed a principal components analysisto determine the Cronback’s alpha score of the survey and its components (Table 1) [16]. Thequestionnaire had a high level of internal consistency, as determined by Cronbach’s alphaof .878.Questions in thecommunicationsection focused on proper communication with patientsin their language of preference as well as the display of multimedia (artwork, printed materials,pictures, etc.) to reflect the diverse cultural and ethnic backgrounds they serve. In thediversityofinteractionssection, respondents were asked about their advocacy for policies and proce-dures that are culturally and linguistically inclusive, their ability to intervene when observingculturally insensitive behaviors, and their participation in professional development trainingto enhance knowledge and skills in cultural competence. Each question was answered using aLikert 5-point scale: “never,” “rarely,” “sometimes,” “frequently,” “always”, or “I don’t know.”Table 1. Items for composite variables with Cronbach’s alpha score.Composite variableItems within variablePatient Care Knowledge (23 dichotomized items;Cronbach’s Alpha = .889)Describe the percentage of your population by ethnicity and race• Native American/American Indian or Alaska Native• Asian• Black or African American• Hispanic or Latino/a/x• Native Hawaiian or Pacific Islander• WhiteDescribe the percentage of your population by religion• Agnostic• Atheist• Baha’i• Buddhism• Catholic• Hindu• Jewish• Mormon• Muslim• Protestant• SikhismHow knowledgeable are you about• Demographics of diverse racial, and ethnic groups in my community• Health disparities affecting the populations in my community• Socioeconomic factors that impact health• Socioeconomic factors affecting the populations in my community• Different healing traditions (e.g. Ayurvedic Medicine, Traditional Chinese Medicine)• Historical and contemporary impact of racism, bias, prejudice and discrimination in healthcareexperienced by various populations(Continued)PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20215 / 18
Sociocultural identities.In thesocioculturalidentitiessection, adapted from the CCCQ,MsRP were asked about how important they believe sociocultural identities are in workplaceinteractions with patients, staff, and colleagues in addition to their awareness of their ownbiases and prejudices toward certain races, ethnicities, and cultures. Each question wasanswered using a Likert 4-point scale: “not at all important,” “not too important,” “somewhatimportant,” or “very important.”Training and education.Lastly, thetrainingandeducationportion of this survey inquiredabout hours of cultural competence training at different levels of medical practice.Survey validation.The survey instrument was previewed by six experienced physiciansand two medical students to provide stakeholders’ feedback on the question stems, responses,design, and flow of the questionnaire.Table 1.(Continued)Composite variableItems within variablePatient Care Skills and Abilities (15 dichotomizeditems; Cronbach’s Alpha = 0.791)How religion and spirituality interact with patient care• How often do you ask your patients about their religious or spiritual beliefs?• How often do you ask your patients about their cultural beliefs and practices?• How often do you refer patients to a chaplain or other service to meet their religious needs?How skilled are you in• Eliciting the patient’s perspective about health and illness? (e.g. its etiology, name, treatment, course,prognosis)• Performing a culturally sensitive physical examination?• Providing culturally sensitive patient education, counseling, and treatment plans?• Apologizing for cross-cultural misunderstandings or errors?• Treating a patient who makes derogatory comments about your racial or ethnic background?• Caring for a patient who uses folk healers or alternative therapiesHow comfortable do you feel about the cross-cultural interactions• Caring for patients from culturally diverse backgrounds• Caring for patients with limited English proficiency• Caring for patients of a different sexual orientation than you• Caring for patients of a different gender identity than you• Interpreting different cultural expressions of pain, distress, and suffering• Advising a patient to change behaviors or practices related to cultural beliefs that impair one’s healthProfessional Interactions (4 dichotomized items;Cronbach’s Alpha = 0.497)How comfortable do you feel about the cross-cultural interactions• Working with a colleague who makes derogatory remarks about patients from a particular ethnic group?• Working with health care professionals from culturally diverse backgroundsHow often are the following true for you in your medical practice?• I intervene when I observe other students, staff, or clients within my program or agency engaging inbehaviors that show cultural insensitivity, racial biases, and prejudice.• I have participated in professional development and training to enhance my knowledge and skills in theprovision of services to culturally, and linguistically diverse groups.Systems Level Interactions (4 dichotomized items;Cronbach’s Alpha = 0.662)How often are the following true for you in your medical practice?• Artwork, printed materials, pictures, videos, and health education materials that I use and/or display inmy work environment reflect the different cultures and ethnic backgrounds of the clients I serve.• I ensure that my patients have access to healthcare services in the language they prefer.• I ensure that all notices and communications to individuals and families are written in their language oforigin and take into account the average literacy levels of those that I serve.• I advocate for the review of my program’s or agency’s mission statement, goals, policies, and proceduresto ensure that they incorporate principles and practices that promote cultural and linguistic competence.Cronbach’s Alpha on combined composite variables (46 items) = 0.878.https://doi.org/10.1371/journal.pone.0252750.t001PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20216 / 18
Procedures and statistical analysisThe survey was distributed electronically to participants via email and social media from Mayto August 2019. Demographic data were compiled both for the entire sample and for four sep-arate groups, Christian versus Non-Christian and highly religious (HR) versus not highly reli-gious (NHR), for further analysis. It is important to note that the structure of this analysis wasbased on the representation of Christianity as the largest religious group worldwide.Participants that identified as “Christian” were placed in one group. All other religiousidentities were placed in the “Non-Christian” group. Furthermore, Highly Religious (HR) andNot Highly Religious (NHR) groups were created based on responses to frequency in attend-ing religious services, frequency with praying, and importance of religion. Respondents wereplaced in the HR group if they 1) attend religious services “at least once a week” or “1–2 timesa month,” 2) pray “multiple times a day” or “daily,” and 3) chose “very important” or “some-what important” to the importance of religion to personal life question. Respondents wereplaced in the NHR group if they 1) attend religious services “1–2 times a year” or “never,” 2)pray “weekly,” “monthly,” “rarely,” or “never,” and 3) chose “not too important,” “not at allimportant,” or “I don’t know" to the importance of religion to personal life question. As thisstudy was seen as a preliminary exploration of differences between groups, sample size calcula-tions were not performed prior to analysis; however, post-hoc power analyses were conductedfor any non-significant findings.Composite variables.In an effort to demonstrate levels of cultural competency, the questionitems were grouped into four composite variables:PatientCareKnowledge,PatientCareSkillsandAbilities,ProfessionalInteractions, andSystemsLevelInteractions. All questions were dichoto-mized. For the Likert response questions, the top two responses (e.g. “extremely” and “quite abit”) received a “1” and the three other responses (e.g. “not at all,” “a little,” or “somewhat”)received a “0.” For the questions regarding the percentage of their patient population by race/eth-nicity and religion, respondents were scored a “1” for choosing any percentage range for race/eth-nicity and religious population makeup, and those that chose “do not know” were scored a “0.”S2Appendixillustrates the procedure flowchart.Table 1provides the items used to construct thefour composite variables along with the Cronbach’s alpha score for each composite variable.Statistical analysis.Quantitative data were analyzed using R statistical software (R Foun-dation for Statistical Computing, version 3.6.1) with alpha set at 0.05. Continuous variables arereported as mean±standard deviation. Discrete variables are reported as N (%). Continuousvariables were analyzed using Wilcoxon rank-sum test or two independent samples t-testwhich is two-tailed, while discrete variables were analyzed using Chi-square. Post-hoc poweranalyses were conducted using G�Power 3.1 software for any non-significant results.Ethical approval.The University of South Carolina Institutional Review Board approvedthis project (Pro00087751). Participants were given a description of the survey and asked to“opt in” if they were willing to participate.ResultsParticipants214 participants began the survey. 72 participants had incomplete responses, leaving 156 com-pleted responses. 12 of the 156 had to be removed due to not fitting the inclusion criteria ques-tions, leading to a total of 144 participants. The majority completed medical school (n = 87)and self-identified as female (n = 108), white (n = 85), Christian (n = 95), and not highly reli-gious (n = 82). Characteristics of the 144 participants who completed the survey are shown inTable 2andS3 Appendix.PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20217 / 18
Composite variablesPatient care knowledge.ThePatientCareKnowledgevariable assessed participants’knowledge of their patient population’s race/ethnicity and religious affiliations (Fig 1). Fur-thermore, it measured their awareness of health disparities, biases and prejudices, as well associoeconomic and sociocultural factors that may affect populations in their community. Witha potential maximum score of 23, the median score for Christians was 13 compared to 15 fornon-Christian groups (there was no statistical difference between these two groups, p = 0.563).Moreover, the median score for the HR group was 13.5 and 15 for the NHR group (there wasno statistical difference between these groups, p = 0.457).Patient care skills and abilities.ThePatientCareSkillsandAbilitiesvariable focused onhow providers incorporate religious, spiritual, and cultural beliefs and practices into clinicalTable 2. Participant information.N144Age, Mean±SD34.4±10.5Median (IQR)31 (26, 40.2)Position, N(%)Medical Student57 (39.58)Resident23 (15.97)Fellow5 (3.47)Attending Physician59 (40.97)Location of Practice, N(%)aUrban85 (59.02)Suburban55 (38.19)Rural14 (9.72)Tribal0 (0)Race/Ethnicity, N(%)bAmerican Indian or Alaska Native3 (2.08)Asian7 (4.86)Black or African American43 (29.86)Hispanic or Latino6 (4.17)Native Hawaiian or Pacific Islander0 (0)White85 (59.03)Other3 (2.08)Decline to Answer3 (2.08)Gender Identity, N(%)Woman108 (75)Man34 (23.61)Genderqueer0 (0)Decline to Answer2 (1.39)Religious Identity, N(%)Christian95 (65.97)Non-Christian49 (34.03)Level of Religiosity, N (%)Highly Religious62 (43.06)Not Highly Religious82 (56.94)aParticipants were allowed to select more than one practice setting.bParticipants were allowed to select more than one race/ethnic identity.https://doi.org/10.1371/journal.pone.0252750.t002PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20218 / 18
experiences (Fig 2). With a potential maximum score of 15, the median score for each of thegroups (Christian, non-Christian, HR, NHR) was 7 (Christian versus non-Christian, p = 0.423;HR vs NHR, p = 0.51).Professional interactions.TheProfessionalInteractionsvariable asked participants torespond to situational questions that centered on intervening when observing cultural insensi-tivity, racial bias, and prejudice (Fig 3). Furthermore, it inquired about provider comfortabilitywith working with healthcare professionals of diverse cultural backgrounds as well as any pre-vious professional development training that has helped to enhance cultural competence skills.With a potential maximum score of four, the median score for each of the groups (Christian,non-Christian, HR, NHR) was two (Christian versus non-Christian, p = 0.191; HR vs NHR,p = 0.439).Fig 1. Patient care knowledge results.1“1” = Identified some percentage of patient population by demographic factor“0” = Indicated “Do not know” for percentage of population for demographic factor.2“1” = {Quite a bit, Extremely};and “0” = {Not at all, A little, Somewhat}.https://doi.org/10.1371/journal.pone.0252750.g001Fig 2. Patient care skills and abilities results.1“1” = {Frequently, Always}, “0” = {Never, Rarely, Sometimes}.2“1” ={Quite a bit, Extremely}, “0” = {Not at all, A little, Somewhat}.3“1” = {Quite a bit, Extremely}, “0” = {Not at all, A little,Somewhat, don’t know}.https://doi.org/10.1371/journal.pone.0252750.g002PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 20219 / 18
Systems level interactions.TheSystemsLevelInteractionsvariable focused on culturallysensitive communications within the workplace as well as advocacy at the level of the institu-tional mission, policies, and procedures that promote cultural and linguistic competence (Fig4). With a potential maximum score of four, the median score for each of the groups (Chris-tian, non-Christian, HR, NHR) was two (Christian vs. non-Christian, p = 0.809; HR vs. NHR,p = 0.078).Score comparison.There were no significant differences between groups when compar-ing their scores for each of the composite variables (Table 3). Additionally, each group had apotential maximum composite score of 46 with the combination of all variables. Christianshad an overall median score of 25, while non-Christians had an overall score of 26 (there wasno statistical difference between the groups, p = 0.72). Both HR and NHR groups had a medianFig 3. Professional interactions results.1“1” = {Frequently, Always}, “0” = {Never, Rarely, Sometimes}.2“1” = {Quitea bit, Extremely}, “0” = {Not at all, A little, Somewhat}.https://doi.org/10.1371/journal.pone.0252750.g003Fig 4. Systems level interactions results.1“1” = {Frequently, Always}, “0” = {Never, Rarely, Sometimes}.https://doi.org/10.1371/journal.pone.0252750.g004PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202110 / 18
overall score of 25 (there was no statistical difference between the groups, p = 0.551). The nullresults in the comparison between groups led us to conduct a post hoc power analysis to deter-mine if our study was adequately powered. The priori analysis indicated that a power (1 -β)set at 0.80 andα= .05, two-tailed, sample sizes are suggested to include 67 participants in eachgroup to detect medium effects (d = .5); large effects (d = .8) could be detected with only 27participants in each group. However, the post hoc analysis to determine achieved power basedupon means and standard deviations for each group yielded an effect size d = 0.117 withPower = 0.099.Table 3. Demographic data and total score comparisons for each of the groups: Christian versus non-christian and HR versus NHR.ChristianHigh ReligiousChristianNot Christp-valueHigh ReligiousNot Highlyp-valueN95496282Age, Mean±SD33.3±10.136.5±11.333.7±10.935±10.3Median (IQR)30 (26, 39)36 (27, 43)30 (25.2, 40)32 (26, 41.8)Position, N(%)Medical Student37 (38.95)20 (40.82)24 (38.71)33 (40.24)Resident18 (18.95)5 (10.20)13 (20.97)10 (12.20)Fellow4 (4.21)1 (2.04)3 (4.84)2 (2.44)Attending Physician36 (37.89)23 (46.94)22 (35.48)37 (45.12)Location of Practice, N(%)Urban58 (61.05)27 (55.10)38 (61.29)47 (57.32)Suburban31 (32.63)24 (48.98)18 (29.03)37 (45.12)Rural11 (11.58)3 (6.12)10 (16.13)4 (4.88)Tribal0 (0)0 (0)0 (0)0 (0)Race/Ethnicity, N(%)American Indian or Alaska Native3 (3.15)0 (0)3 (4.84)0 (0)Asian4 (4.21)3 (6.12)3 (4.84)4 (4.88)Black or African American30 (31.58)13 (26.53)22 (35.48)21 (25.61)Hispanic or Latino4 (4.21)2 (4.08)2 (3.23)4 (4.88)Native Hawaiian or Pacific Islander0 (0)0 (0)0 (0)0 (0)White57 (60)28 (57.14)34 (54.84)51 (62.20)Other1 (1.05)2 (4.08)0 (0)3 (3.66)Decline to Answer0 (0)3 (6.12)0 (0)3 (3.66)Gender Identity, N(%)Woman72 (75.79)36 (73.47)43 (69.35)65 (79.27)Man23 (24.21)11 (22.45)19 (30.65)15 (18.29)PC Knowledge Score, Mean±SD (total: 23)13.9±5.6514.6±5.213.7±5.7114.4±5.34Median (IQR)13 (9.5)15 (10)0.56313.5 (10)15 (9.75)0.457PC Skills/Abilities Score, Mean±SD (total: 15)6.92±3.387.37±3.096.87±3.257.22±3.31Median (IQR)7 (5.5)7 (5)0.4237 (4)7 (5)0.51Professional Interactions Score, Mean±SD (total: 4)2.27±1.132.06±1.032.27±1.132.14±1.08Median (IQR)2 (2)2 (2)0.1912 (1)2 (2)0.439Systems Level Interactions Score, Mean±SD (total: 4)1.83±1.231.8±1.431.6±1.271.99±1.30Median (IQR)2 (2)2 (2)0.8092 (2.5)2 (2)0.078Overall Score, Mean±SD (total: 46)24.90±8.4725.80±6.820.5224.45±8.0225.77±7.870.326Median (IQR)25 (10)26 (8)0.7225 (10)25 (9.75)0.551P-values of continuous variables are from Wilcox.test; for categorical variables, P-values are from Chi square test.https://doi.org/10.1371/journal.pone.0252750.t003PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202111 / 18
DiscussionThis cross-sectional survey study was conducted to better understand how health care provid-ers’ attitudes, behaviors, and beliefs toward religion and spirituality impact the delivery of cul-turally competent care. While our study found no significant differences between Christianversus Non-Christians and Highly Religious versus Not Highly Religious groups when analyz-ing their knowledge of patient populations, culturally competent skills and abilities, profes-sionalism, and health care systems level engagement, specific sample-wide deficiencies werediscovered. An examination of the individual composite variables used to conduct this analysisrevealed deficiencies in incorporating patient religious/spiritual beliefs into clinical practice, indealing with derogatory remarks toward patients or colleagues of diverse backgrounds in theclinical setting, and in promoting systems level changes to reflect the diverse workforce andpatient populations served. These findings are further discussed below.Patient care knowledgeRespondents reported their patient population by ethnicity, race, and religion as well as rankedtheir level of knowledge on various sociocultural and socioeconomic factors (health disparities,different healing traditions, bias, prejudice, and historical impacts of racism). Respondentswere not asked to describe their patient population by sexual orientation or gender identity.Although there was no statistical difference between Christian versus Non-Christian groups orHR versus NHR groups on theirPatientCareKnowledgescores, closer inspection of the indi-vidual components that comprise this composite variable demonstrate disparities across allrespondents in regards to knowledge of their patient populations.More than 80% of the participants indicated they had a substantial amount of knowledgeabout how socioeconomic factors impact health, and 70% indicated they understand howthose socioeconomic factors impact their specific populations. Yet, only 9% of the respondentsindicated that they were knowledgeable about different healing traditions. This suggests a needfor more rigorous education on non-Western medicine and complementary and alternativemethods of healing, and it challenges providers to broaden their perspectives on medicine andhealing to be more inclusive of non-traditional modalities [17]. Understanding these variousmethods of healing is important to better serve diverse racial, ethnic, cultural, and religiouspopulations in our communities.Less than half of the participants indicated they were knowledgeable about the racial andethnic groups in their communities. When analyzing healthcare providers’ abilities to describetheir patient populations by ethnicity and race, they perceived “White,” “Black or AfricanAmerican,” and “Hispanic or Latino” to make up the majority of their respective patient popu-lations. Nevertheless, over 25% of respondents were unable to estimate the number of NativeAmericans, Native Hawaiians, or Pacific Islanders in their communities as evidenced by theirselection of “do not know” for those racial and ethnic categories. This may be indicative of lowrepresentation of these groups in healthcare providers’ respective communities, but it may alsosuggest a need for more training on how to respectfully inquire about a patient’s racial/ethnicand cultural background. Though these groups represent a relatively small percentage of theU.S. population, it is important to recognize and honor these differences between patients asthey may help to more effectively deliver care to these diverse populations.In regards to describing patient population by religion, participants perceived their patientpopulations to be primarily Protestant (69%), Catholic (67%), and Muslim (62%). The threereligions with the lowest response rate (respondents who were unable to answer) were Bud-dhism, Baha’i, and Sikhism. This, interestingly, correlates to the religious identity of the surveyparticipants in that zero participants identified with Buddhism, Baha’i, or Sikhism, whereasPLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202112 / 18
the majority of participants identified as Protestant (52%) or Catholic (14%). This suggests aneed for more awareness on how one’s personal religious beliefs may be different than that ofthe patient and how this may impact their health and healthcare. Although the majority reli-gion in America comprises Christian faiths, more education on other religions may expandknowledge and enhance the doctor-patient relationship. One study found that 80% of patientsreported physicians never or rarely offer opportunities to discuss religious and spiritual issues[18]. This aligns with our findings when we consider how respondents were largely unable toestimate the minority religious makeup of their patient populations. This suggests a need formore support and training for these types of discussions in the healthcare setting.Patient care skills & abilitiesThe ability to deliver a level of care that addresses the unique needs of patients from diversecultural and religious backgrounds is a key skill set needed to ensure equitable healthcare forall. Though this particular section demonstrated no significant differences between the skillsand abilities of Christian versus non-Christian faiths and HR versus NHR groups, an examina-tion of the individual components that comprise this composite variable reveals gaps across allrespondents in how religion and spirituality interact with patient care.The data suggests that holistically, our respondents are not inquiring about religious andcultural practices and beliefs that may affect patient care. Over 90% of respondents indicatedthat they “never,” “rarely,” or “sometimes” ask patients about their religious or spiritual beliefs.Simultaneously, over 80% of respondents indicated that they “never,” “rarely,” or “sometimes”ask patients about their cultural beliefs and practices. Our findings are in alignment with a sys-tematic review of religion and spirituality discussions with patients, finding that these factorsare infrequently addressed but increase with terminal illness and high provider religiosity andspirituality [19]. Possible barriers to discussing spirituality include insufficient time and train-ing, confusion over differences between religion and spirituality, lack of vocabulary, invasionof privacy, and lack of clarity around the physician role in these discussions [19]. Nevertheless,religious, spiritual, and cultural beliefs and practices are often interwoven, thus, cultural com-petency requires a thorough understanding of the patient’s religion and spirituality.Furthermore, there appears to be decreased ability to care for patients who use folk healersand alternative therapies with greater than 70% of respondents indicating that they are “not atall,” “a little,” or “somewhat” skilled in this area. These results align with a 2005 study on resi-dent preparedness, which found that residents reported a lack of preparedness to treat patientswith the following: religious beliefs or practices that don’t align with traditional Western medi-cine, religious beliefs that affect treatment, and alternative/complementary medicine prefer-ences [20]. This lack of improvement in these skill sets calls for a review of cultural andreligious competence curriculum and training in both undergraduate and graduate medicaleducation. In a 2001 article on spirituality and medical practice, The American Academy ofFamily Physicians encouraged the use of the HOPE Questionnaire, a tool to help integrate aspiritual assessment into the medical interview [21]. The adoption of a resource like this wouldsupport students, residents, and attending physicians in having these important but often over-looked conversations. Furthermore, the tool may help to foster a stronger spiritual self-under-standing for providers themselves, yielding a more unbiased, patient-focused, and non-judgmental spiritual assessment of patients.In contrast to the above findings, 87% of our study participants reported high levels of com-fortability with caring for patients from culturally diverse backgrounds. This gap in comfortversus skill suggests a need for more granular solutions like the HOPE Questionnaire dis-cussed previously. Further, increasing knowledge and awareness around the process ofPLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202113 / 18
referring patients to chaplains and locations of worship centers and meditation spaces is essen-tial. Although literature suggests doctors prefer chaplains to facilitate these discussions, thereappear to be gaps in rates of physicians recommending chaplain referral and actually makingthe referral. Our study revealed that 86% of study participants reported not referring theirpatients to a chaplain or other service, which calls to attention the importance of expandingthe concepts of medical management and intervention in the healthcare setting to encompassreligious and spiritual needs.This variable also explores respondents’ ability to provide care to patients who make derog-atory remarks about their racial and ethnic backgrounds. Over 69% of respondents noted theirability to treat patients was diminished when facing these overt biases. In a 2019 study onPhy-sicianandTraineeExperienceswithPatientBias, researchers found that these types of patientbehaviors lead to anger, emotional pain, confusion, and fear, which can be distracting for theprovider [22]. Lack of skills, support, and guidance from attendings and institutions as well asfear of fracturing the therapeutic alliance were noted as the primary barriers to responding insuch situations [22]. In accordance with the present study, this further underscores the needfor more training on how to appropriately navigate situations with biased patients and high-lights the need for clear institutional policies and medical curricula that support and respectthe increasingly diverse medical workforce.Over half of the participants reported low skill levels in performing culturally sensitivephysical exams, providing culturally sensitive patient education and treatment plans, interpret-ing different cultural expressions of pain, and advising patients to change cultural behaviors orpractices that impair one’s health. These vast sets of skills are imperative to ensuring positivepatient outcomes, compliance, and trust of the healthcare system. Further development of cul-tural sensitivity programs should hone in on these important competencies which were foundto be lacking in the majority of this study’s current MsRP.Our results in this particular section appear to align with several international studies onspirituality and spiritual care in the clinical setting. Specifically, in Taiwan, Australia, and NewZealand, there is a call for spiritual care education amongst both physicians and nurses inorder to meet the growing needs of patients [19,23,24]. Although our study took a broaderapproach to analyzing cultural competence, this alignment suggests a global need for enhancedcultural competency curriculum across multiple disciplines.Professional interactionsEmployee conduct and behavior is a reflection of an institution’s culture and its ability to pro-mote professionalism across the organization. Our study included four questions on profes-sional interactions in the workplace to assess its overlap with concepts of culture andinclusivity.Over 74% of our respondents reported discomfort when working with colleagues that makederogatory remarks about patients. We see a similar response in our skills and abilities subsec-tion, where providers indicated discomfort with patients who make derogatory remarks aboutproviders. Nevertheless, just over half (53%) of our study participants reported interveningwhen they see culturally insensitive acts, racial biases, and prejudice, suggesting that althoughproviders do not feel comfortable, many do feel a moral pull to advocate in situations that theydeem unjust. For the half of our respondents that indicated they do not intervene in these situ-ations, this raises the question on how institutions are equipping learners and attendings onhow to handle difficult patient-doctor and/or doctor-doctor interactions.Nearly 40% of respondents were medical students, for whom there may be even more hesi-tation in speaking out against unfair situations, especially in settings where they are beingPLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202114 / 18
evaluated. Nevertheless, there is power in training students on how to approach advocacy, asthese efforts would positively impact patient care and empower future generations ofproviders.This section also reveals that only half of our participants indicated they “frequently” or“always” participate in cultural competency training. Our respondents noted that medicalschool was the primary setting in which they received this training (66%) with engagement inresidency and Continuing Medical Education (CME) dropping off significantly (28% resi-dency, 21% CME). According to a 2013 study on cultural competence training in GraduateMedical Education (GME), there appears to be varying requirements across specialties andfragmented implementation of cultural sensitivity education, which may help to explain thefindings in our study [25]. Further, another study, which focused on cultural competencetraining in U.S. medical schools, found that of the 18 medical programs reviewed, 67% man-dated this type of education [26]. With such contrast between different levels of medical train-ing, further study on how to standardize best practices across medical schools and residencyprograms may help with continued engagement throughout undergraduate and graduatemedical education.Systems level interactionsHealth care systems play a broader role in caring for patients. Messaging and other actionstaken at this level can affect many people–both the patient population as well as healthcare pro-viders and other staff. Scores for this category were between 1.6 and 1.99 out of 4, indicatingthat less than half of the respondents were taking action to improve cultural sensitivity at thesystems level. However, there was significant variation among the four questions in thissection.Interestingly, the item in this category with the least respondents reporting it was “always”or “frequently” true for their practice was regarding whether artwork or health educationmaterials reflected the diverse populations they serve (27%). Relatively few respondents (29%)reported advocating for review of their institution’s mission statement, policies, procedures, orgoals to ensure they are culturally competent. Just over half of respondents reported that theyensure materials for patients are written in their preferred language and at an appropriate liter-acy level. 75% of respondents report they ensure their patients have access to care in their pre-ferred language; this item achieved the highest score in this category and represents an actionthat can be completed at an individual versus systems level, which may explain the greaterengagement. This higher level of engagement may also be due to system-level policies dictatingthe use of interpreters for patients whose primary language is not English (i.e. the AffordableCare Act of 2010), suggesting that the creation of policies regarding cultural and linguisticcompetence can improve provider engagement with system level efforts.The sample population may be one factor influencing the responses for this category. Sys-tems-level change is often left to those at the highest level of power within an institution.Those still in training formed 60% of the sample. Some of the questions in this category lendthemselves more to attendings, as they require the ability to make changes in the workplace.Further study of the ability to make systems-level changes from various levels of trainingwould be beneficial.LimitationsIdentifying the limitations of this study provides proper context on which it should be inter-preted. Although 214 participants attempted the survey, only 144 completed the entire instru-ment and met our inclusion criteria. Only completed surveys were analyzed which limited thePLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202115 / 18
power of the study. Further, the majority of the participants identified as white, female, Chris-tian, and not highly religious. Although effort was made to recruit a diverse group of partici-pants, the aforementioned demographics were the overwhelming majority. Additionally, therecruitment platforms present their own limitations (Facebook, Twitter, and email listservs).The lack of diversity in the respondents may be a reflection of the social networks throughwhich the survey was disseminated and regional bias. Different results may emerge with amore diverse sample. Moreover, while a sample size of 54 total individuals would be requiredto see large effect sizes, the post hoc analysis yielded a power of ~0.1. Thus, we cannot rule outthat there may be a difference between groups if sample sizes were larger.Questions on religiosity and spirituality in particular were based on frequency of prayerand attending religious services. We recognize that there are various modes of religious practice,and these more structured analyses may not reflect this diversity. Our study is further limited bythe absence of a validated tool like the DUREL (The Duke University Religious Index) to mea-sure religious involvement [27]. Additionally, the survey may have created a self-reporting biasof participants. There was no instrument to validate responses to each question. Lastly, the sur-vey was one-sided–failing to ask patient/client health outcomes and perspectives could poten-tially bias the data set. In order to improve client/patient health outcomes through increasedcultural competence, measures of both provider and patient outcomes must be considered [28].Future implicationsFuture studies should focus on how specialty practice, level of training, gender, and race/eth-nicity intersect with religion and cultural competency. Interventions to improve the incorpo-ration of religious and cultural values in the clinical encounter and care plan are also needed,and an analysis on how this impacts patient satisfaction and outcomes would help to fill gapsin the cultural competency literature.ConclusionAnalyzing healthcare providers’ attributes, behaviors, and attitudes toward culture, religion,and spirituality is important because these factors impact interactions with patients as well asthe environment of the workplace. Although this study revealed no differences in the ability todeliver culturally competent care between religious or non-religious healthcare providers, itunveiled lower levels of knowledge and skill (across all groups) in incorporating diverse reli-gious and cultural beliefs into clinical practice, in dealing with derogatory remarks towardpatients or colleagues of diverse backgrounds in the clinical setting, and in promoting sys-tems-level changes to reflect the diverse workforce and patient populations served. Theseresults demonstrate the need for improved and sustained cultural competency educationacross all levels of medical training.Supporting informationS1 Appendix. Survey instrument.(PDF)S2 Appendix. Procedure flowchart.(TIF)S3 Appendix. Number of survey participants by state.Survey disseminated May-August2019. Darker colors indicate greater numbers of survey participants.(TIF)PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202116 / 18
AcknowledgmentsWe would like to thank the UofSC School of Medicine for their support in executing thisproject.Author ContributionsConceptualization:Julia Moss, Natalie Padgett, Ann Blair Kennedy.Data curation:Xiyan Tan.Formal analysis:Xiyan Tan, Ann Blair Kennedy.Investigation:Victoria Dillard, Julia Moss, Natalie Padgett, Ann Blair Kennedy.Methodology:Victoria Dillard, Julia Moss, Natalie Padgett, Ann Blair Kennedy.Project administration:Victoria Dillard, Julia Moss, Ann Blair Kennedy.Resources:Xiyan Tan.Supervision:Ann Blair Kennedy.Validation:Ann Blair Kennedy.Visualization:Victoria Dillard, Natalie Padgett, Ann Blair Kennedy.Writing – original draft:Victoria Dillard, Julia Moss, Natalie Padgett, Ann Blair Kennedy.Writing – review & editing:Victoria Dillard, Julia Moss, Natalie Padgett, Ann Blair Kennedy.References1.U.S. Public Becoming Less Religious [Internet]. Pew Research Center’s Religion & Public Life Project.2015 [cited 2019Apr2]. Available from:https://www.pewforum.org/2015/11/03/u-s-public-becoming-less-religious2.Mccullough ME, Hoyt WT, Larson DB, Koenig HG, Thoresen C. Religious involvement and mortality: Ameta-analytic review. Health Psychology. 2000; 19(3):211–22.https://doi.org/10.1037//0278-6133.19.3.211PMID:108687653.Li S, Stampfer MJ, Williams DR, Vanderweele TJ. Association of Religious Service Attendance WithMortality Among Women. JAMA Internal Medicine. 2016; 176(6):777.https://doi.org/10.1001/jamainternmed.2016.1615PMID:271831754.Vanderweele TJ, Li S, Tsai AC, Kawachi I. Association Between Religious Service Attendance andLower Suicide Rates Among US Women. JAMA Psychiatry. 2016; 73(8):845.https://doi.org/10.1001/jamapsychiatry.2016.1243PMID:273679275.Seybold KS, Hill PC. The Role of Religion and Spirituality in Mental and Physical Health. Current Direc-tions in Psychological Science. 2001 Feb; 10(1):21–4.6.Austin P, Macleod R, Siddall P, McSherry W, Egan R. Spiritual care training is needed for clinical andnon-clinical staff to manage patients’ spiritual needs. Journal for the Study of Spirituality. 2017; 7(1):0–63.7.Cross TLAO. Towards a Culturally Competent System of Care: A Monograph on Effective Services forMinority Children Who Are Severely Emotionally Disturbed. [Internet]. ERIC. CASSP Technical Assis-tance Center, Georgetown University Child Development Center, 3800 Reservoir Rd., N.W., Washing-ton, DC 20007 ($8.50).; 1989 [cited 2020Jul25]. Available from:https://eric.ed.gov/?id=ED3301718.Betancourt JR, Green AR, Carrillo J, Ananeh-Firempong O. Defining cultural competence: a practicalframework for addressing racial/ethnic disparities in health and health care. Public Health Reports.2003; 118(4):293–302.https://doi.org/10.1093/phr/118.4.293PMID:128150769.Dell’Aversana G, Bruno A. Different and Similar at the Same Time. Cultural Competence through theLeans of Healthcare Providers. Frontiers in Psychology. 2017;8.https://doi.org/10.3389/fpsyg.2017.00008PMID:2819411810.Donohue PK, Boss RD, Aucott SW, Keene EA, Teague P. The impact of neonatologists’ religiosity andspirituality on health care delivery for high-risk neonates. Journal of palliative medicine. 2010; 13(10):1219–1224.https://doi.org/10.1089/jpm.2010.0049PMID:20831436PLOS ONEReligiosity in the medical professionPLOS ONE |https://doi.org/10.1371/journal.pone.0252750June 15, 202117 / 18
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