Linking Immigrants with Nutrition Knowledge (Project LINK): An Innovative Approach to Improve Cultural Competence in Dietetic Education

This study presents an innovative programme, Linking Immigrants with Nutrition Knowledge (Project LINK), a service-learning cultural competence training programme with the goal of developing and measuring the development of cultural competence in dietetic students. This paper reports the mixed methods evaluation of the association between participation in Project LINK and improvement in cultural competence.

Second-year nutrition and dietetic students enrolled in the University of Saskatchewan’s (USASK) nutrition and dietetic programme participated in Project LINK in 2011, 2012, 2013, and 2014. Project LINK was a required component of the course NUTR 310.3: “Food, Culture and Human Nutrition.” Although all students participated in all course requirements, they were not required to participate in the research study. All students were invited to participate in the study; however, only those who provided informed consent and agreed to complete the pre- and post-programme assessments were included.

Immigrant and refugee families were recruited in July and August each year. Recruitment of these families was co-ordinated with the assistance of Saskatoon Open Door Society and the Saskatchewan Intercultural Association (settlement agencies) in Saskatoon, Saskatchewan. Families selected were recent immigrants or refugees to Canada (< 5 years), had sufficient English proficiency, contained a range of ages (including children), and represented a variety of cultures. Over the 4 years of the programme, 14 immigrant/refugee families were recruited and consented to participate.

Ethical approval for this evaluation was obtained from the University of Saskatchewan Research Ethics Board before implementation (USask REB BIO-09-197). Additionally, students were required to undergo a criminal record check to work with vulnerable populations.

Project LINK was implemented in the fall semester of each of the 4 years. Enrolled students were briefed on the purpose and components of Project LINK.

Students participated in lessons on cultural competency and intercultural communication as well as a workshop, hosted by the project team, where dietetic students interacted with international graduate students in a role-playing scenario to implement their learnings in a semi-hypothetical situation before beginning any components of Project LINK and entering into ‘real-life’ scenarios. In groups of two, students were partnered with an immigrant/refugee family. The project was designed to ensure students and families could meet frequently during the semester to develop rapport and connection. Four semi-structured opportunities for interaction between student pairs and families were provided: (1) an orientation meeting, (2) rapport developing meeting, (3) a grocery store tour, and (4) a cultural cooking session. Dietetic students were initially introduced to partner families through an informal evening event. Students were instructed to plan rapport developing meetings with their partner family to allow students to gain a better understanding of assigned families’ culture and food preferences/choices. For the purpose of observation and guidance, students accompanied assigned families during a grocery shopping trip. Students were encouraged to be open-minded and aware of their own biases (e.g., avoid making or verbalizing judgments about food choices); however, students were encouraged to assist them in selecting healthy, budget conscious foods. Finally, at the project end, students and partner families prepared a dish celebrating the family’s culture together.

For most dietetic students, this was their first experience with service-learning and the first opportunity for meaningful interaction with culturally diverse immigrant and refugee families. Learning objectives for the dietetic students were to: (1) gain skills in intercultural communication, (2) understand the challenges, particularly those related to food and nutrition, faced by newcomers to Canada, and (3) participate in the practical application of theories learned in class related to the roles of culture, religion, nutrition transition, and acculturation in shaping the diet of immigrants and refugees.

Change in cultural competence was assessed using a pre- and post-survey on cultural competency [10]. Students completed this survey at the start of the semester before meeting their partner families, and for a second time after finishing all components of Project LINK. The survey was adapted with permission from the Clinical Cultural Competency Questionnaire developed by Robert Like, which has been used in previous projects [11, 12]. The survey was composed of multiple-choice questions, which used a five-point Likert scale design (responses of very, quite a bit, somewhat, a little, or not at all) and assessed five competence areas: knowledge, skills, encounters, attitudes, and cultural awareness. The response data from both the pre- and post-surveys were extracted, anonymized, and coded into a Microsoft Excel spreadsheet (Microsoft Office, Microsoft Corporation, Redmond, WA, USA, 2013).

Additionally, to enrich our understanding of the processes and experiences that aided or detracted from the goals of the project, at semesters end, guiding questions were provided and each student wrote a reflection in response.

Descriptive statistics were computed to determine the percent change in student cultural competency areas before and after participating in Project LINK. Further, a cumulative logistic regression model was developed to analyze the association between project participation and cultural competency. Model assumptions were tested and satisfied, and fulfillment of the proportional odds assumption confirmed employing the score test (p-value >5%). Spearman correlation coefficient between pre- and post-cultural competencies showed ignorable within-individual correlations (≤ 0.214) and, therefore, biased estimation or inference was unlikely. This was confirmed by comparing results of the generalized estimating equations method and logistic regression. Pearson and Deviance goodness-of-fit statistics were used to evaluate the adequacy of the final model. All the statistical analyses and data cleaning were performed in SAS 9.3 (SAS Institute Inc., Cary, NC, USA. 2011).

Student reflective essays were analyzed by inductive thematic analysis (SF). Names were removed from reflection papers before analysis. New and recurrent ideas were recorded, and each reflection paper was examined several times to reduce missed ideas. These ideas were then summarized into categories and analyzed to produce cohesive themes. Exemplar quotes were chosen to illustrate each sub-theme; care was taken to ensure these quotations remain applicable out of the context of original sources. Two neutral researchers (HV, CH) confirmed the analysis and the absence of bias.

Paired pre- and post-surveys were obtained from 107 students. The students who participated in Project LINK were second-year dietetic students, predominantly White and female. Before Project LINK, only two students identified themselves as having professional experience interacting with people of different cultures. The families who participated in Project LINK were recent immigrants to Saskatoon, Saskatchewan (less than 2 years). The countries which participants migrated from varied over the years of Project LINK and reflected the global situation at the time and the resulting migration patterns, and included Karen, Afghan, and Iraqi refugees.

Table 1 presents the odds of increasing one level in cultural competence areas from pre- to post-intervention. Odds of increasing one level knowledge after Project LINK were approximately 110 (95% CI: 32.4–378.4) times of that prior (Table 1). Such substantial significant increases were not seen in the other four areas: however, participants improved cultural competence skills, encounters, and attitudes. Results did not change year by year, confirmed by no interaction between pre- and post-indicator year.

Figure 1 shows the percentage of students who rated themselves within the highest two competence levels in both the pre- and post-intervention for each competency area (see Supplemental Figure 1¹ for percentage of students who rated themselves within the lowest two competence levels). A larger percentage of students rated overall cultural competence as higher after completion. Only the competence areas of knowledge and skills showed statistically significant increases, but the data show a trend of increasing competence in the areas of encounters, attitudes, and cultural awareness (Figure 1).

Table 2 and Supplemental Table 1¹ represent findings illustrating the thematic analysis of reflection papers. Four major themes (application of classroom learning, student perceptions, benefits to immigrant and refugee families, challenges faced by students) along with sub-themes were identified. These four themes and their sub-themes exemplify the impact of Project LINK both in the context of student learning and the benefits provided to recent immigrants and refugees. Processes to improve the operation of Project LINK were also captured. Overall, the themes identified from reflections demonstrate how students benefited in many aspects of cultural competence.