METHOD

This study was conducted in two phases: the first phase was conducted to analyze the concept by evolutionary approach. In the second phase, interview with faculty members was conducted to determine appropriate formulation in the present context. Following steps was used for evolutionary analysis (13):

1- identify and select appropriate realm (setting and sample) for data collection
2- collect relevant data to identify: a) the attributes of the concept b) the contextual basis of the concept, including interdisciplinary. Socio-cultural, and temporal (antecedent and consequential occurrences) variations.
3- analyze data regarding above characteristics of the concept.
At the end of the first phase of study we analyzed codes in categories: antecedents, attributes, consequences, and surrogate term. In the second phase, based on gained results, semi-structured interviews with faculties were conducted to determine the appropriate approach in the present context.

A) Search sources and strategy for data collection: we used electronic resources and databases: PubMed, Google scholar, Science Direct, Scopus. OVID, Web of Science, by 2016, which resulted in more than 1500 articles. We limited results to documents that focused-on definition, concepts, and models of cultural competency so that there remained 350 articles and after reading the abstracts 135 articles were introduced into the study.

B) Data analysis (first phase): Coding was conducted in regard to antecedents, attributes, consequences, and surrogate terms.

C) Interview: in order to determine appropriate approach to context of Medical University, semi-structured interviews with 10 faculties in different groups were carried out, and after preparing the transcript of interviews, data were analyzed.

D) Data analysis (second phase): Data of first stage and second stage of study were compared and formulation of concept was determined according to context.

RESULTS AND FINDINGS

A) History
Records about cultural competency go back to the 1980s. Social work and psychology were among the first areas that paid attention to this issue. Sue in psychology and Cross in social work presented their models (38,40),but utilizing this topic in medical science was by Lininger in the nursing profession. Leininger presented her first model of cultural competency in 1980s (14 ) and completed it within two decades. Medical anthropology in medicine studied relationship between culture, health and disease (15), although, because of the dominant paradigm of Bio-Medicine in the medical profession, culture was not in focus of this profession. In the last decades in medicine, registry organizations such as ACGME, LCME introduced cultural competency into their requirements (16,17), due to increasing awareness of physicians learning knowledge and skills in this area and its effect on patient adherence, lead to establishment of training courses, mandatory or optional, at many universities in the U.S (18) Also among different countries, those who accept more immigrants such as America, Australia and New Zealand are involved with this issue. According to the latest statistics, rank of Iran in reception of immigrants /refugees is 5 and the largest group of these are from Afghanistan (19). Iran is in southwest of Asia in the heart of the Middle East. This region is composed of different races: Arabs, Turkish and Persians. Also, this country consists of more than 32 states and several ethnicities such as: Turks, Baluch, Kurds, Arabs, Fars etc., and each of them have their own culture and language (20). This rich variation of culture causes diversity of believers and behaviors in health and disease and also different treatment choices: Traditional medicine, herbal medicine and western medicine. Education of health and medicine professions in Iran is integrated in the health system and medical universities deliver health services and training of the needed workforce for their services (21).

B) Antecedents
Antecedents are those instances that precede the concept (13). Antecedents of cultural competency varies in different studies. SUH in an analysis that was conducted in nursing in 2004 categorized it in four domains: cognitive, emotional, behavioral, and environmental that consisted of cases such as knowledge, sensitivity, awareness, skills, and cultural exposure (22). Also, other researchers offered cases such as: cultural diversity, cultural encounter (23, 24, 25).
Inability to communicate with other cultures, lack of attention to interests and beliefs of another culture, desire to reject people from other cultures result from lack of cultural competency such as globalization of societies, health inequalities, cultural arousal (25) cultural diversity, racial diversity, ethnic, economic and social status, education, religion, language, etc. Reductions in the quality of health care due to cultural differences between health care providers and recipients of services (26) have been recorded. In this study, these cases extracted as antecedents of cultural competency are decreasing in: quality of physician – patient communication, effectiveness of care, patient compliance occurrences, and also cultural competency as: a requirement for customer satisfaction, patient safety, and as a requirement for professional, moral and ethical competency, as a requirement for enhance effectiveness of health organizations, and as a legal requirement.

Cultural diversity and encounter between them result in the need for cultural competency training in communities that are in globalization process. This encounter (without necessary competency) results in lack of effective and efficient communication and also stereotypes and prejudice in dealing with people from different and “other” cultures.

In order to explain antecedents of cultural competency in this study, we classified them into:

1- Values: Political systems and social values impact on formation of concepts widely .in this document analysis, values of justice, equality, and ethics are at the basis for demands in various spheres including in health. In fact, this term applies to these values in the health field.
2- Legal: Philosophical views, values and also needs of society, are foundations for definition of “right” in terms of human rights and civil rights. Cultural competency is influenced by laws and social attitudes, as superior structures of the health system. Different people from various cultures have the “right” to receive appropriate and effective health services, and be safe in front of stereotypical thoughts and prejudice of health care teams. This right leads to formation of the term “cultural safety” which emphasizes on “right” of patients to be safe of malfunctions caused by lack of understanding and recognition of cultural differences. Terms such as racism, minority rights and social accountability strengthen the legal approach to cultural competency. Cultural competency as a solution and also a response to avoidance of discrimination in services is a legal assumption in defining cultural competency.
3- Professional level: after Legislation for meeting “social needs”, different professions apply superior rules and laws to their specific needs. Education, leadership, social services and sociology, anthropology and psychology have performed measures on cultural competency. Undoubtedly, the first step in each of these actions is definition. Actually, profession is the location that superior needs (values and laws) meet with inferior needs (social and costumer needs) and Theoretical bases. So, this term has been defined in each profession or specialty according to their theoretical foundations and paradigms. Sometimes professions borrow some elements of definition from adjacent professions and cause a variety of different approaches to the concept. For example, customer-oriented approach, quality improvement approach, managerial approach, business approach, etc. In medical and health professions, according to share issue of “health”, concepts are close together, the main focus of these professions are: patient safety, professional capabilities and best practice, patient-centered services, professional ethics, physician – patient communication form professional needs of this concept.
4- The nearest factors are in last level as: “encounter factors”, cultural diversity and encounter between them. As long as there is no diversity, cultural competency will not be needed, therefore, cultural diversity and exposure to it, is a direct antecedent in this level, factors such as globalization, immigration and development of communications and media can be effective in increasing diversity and cultural encounter.

C: Attributes
Attributes of the concept constitute a real definition, it is the cluster of attributes that makes it possible to identify situations that can be characterized appropriately using the concept of interest (13).\

In previous studies that conducted conceptual analysis, the following features are mentioned:

Ability - Openness - Flexibility - (22) - knowledge awareness - understanding - sensitivity - Interaction - Skills - competence - a dynamic process – desire-(26,23,24) domains: affective, cognitive, behavioral - characteristics: sensitive, justice, activity. Three dimensions of consciousness, openness, and integrity (25)

Three dimensions: awareness, attitude and behavior, and a key way: dynamic and continuous process (26) - awareness, ability to take care of people, openness, long-term and continuous process.

We summarize attributes as below:
1- Ability- Openness- flexibility (22)
2- C. Awareness- C. Knowledge- C. Understanding- C. Sensitivity- C. Interaction- C. Skill- C. Proficiency (27)
3- C. Awareness- C. Sensitivity- C. Knowledge- C. Skill- C. Dynamic process (23)
4- C. Awareness- C. Knowledge- C. Skill- C. Encounter- C. Desire (24)
5- Three Domains: Cognition- affection. Behavior Attributes: sensitivity-equality-activity. Three dimension: awareness-openness-coherence (25)
6- Three dimension: awareness, attitudes, behaviors a key aspect: there is no end point to achieve. As a fluid dynamic process from the point of unconscious incompetence to unconsciously competent (26)
7- Awareness - Ability to care for individuals- Non-judgmental openness- C.C as a long term continuous process (28).

Consequences
Consequences: it is of interest to note the consequences that result from the concept that is under study (13).

According to values, assumptions and antecedents and attributes, expected consequences are different. Overall, the results are listed below;

- Equality and reduce discrimination in health services (29)
- Improving the quality and effectiveness of care (31)
- Increased satisfaction with services (31)
- Increased patient compliance and increased employee effectiveness of care (31)
- Ensure justice and equality in service
- Promotion of attitudes, knowledge and skills of individual employees.
- Participation of social, political, historical processes, on the health of people (32)
- Improving physician - patient communication (31)
- improving accessibility and acceptability and effectiveness of services for people of diverse communities (33 and 34)
- Improve clinical outcomes and reduce discrimination of health (31)
- Improving cultural responsiveness and appropriateness (30)
- Awareness of the prejudices and assumptions and stereotypes (35)
- Accountability of services to cultural features (36)
- Flexibility in relations with “different” people (32)
- Increased cultural awareness in practice, good practice in fair access to care and treatment for patients, equal opportunities of education and employment, employee promotion, and protection of forces and minority groups (37)

For ease of explanation results can be classified as follows:

Based on target group:
Service provider - recipient of the service - the organization / society
Based on antecedents:
Values - rights laws - professional - cultural encounter
Based on attributes:
Cognitive - Attitudes - Skills – meta-competencies (reflection on competencies)

D) Surrogate Term
Multicultural competencies (38 and 39) – transcultural care -Civil competencies (37) - Culturally Sensitive Care - Critical cultural care (36) - cultural safety, cultural sensitivity (36) Cultural understanding (35) - cross-cultural interaction (39) intercultural competency (refers to the interaction between two cultures) (40) - cultural sensitivity (41) - language ability (42) - cultural knowledge (35) - cultural awareness (35) cross-cultural communication (35) - cultural humility (43) - culture safety (44) - cross cultural competence (36)
These terms are used according to specific scope or need of programs or researchers or societies to cultural competency. Multicultural competency focuses on knowledge and understanding different cultures in society (45), while cultural special care refers to create settings for specific cultures such as hospital for Hispanics or Asians. Cross-cultural encounter focuses on communication skills that are applied to handle cultural differences(39). Language competency focuses on interpreter services for reduction of language barrier between service providers and customers(44) Cultural safety refers to patient’s right for receiving services without discrimination and without prejudice and judgment(46). Also, other terms of cognitive, affective, cultural competency emphasize on special skills. In different contexts, based on condition and situations each of these terms is used. Consequently, targets and methods and educational content are prepared in relevant terms.

Exemplars:
The identification of exemplars in some form is a common and useful part of concept analysis. Because the evolutionary method is an inductive technique, exemplars should be identified rather than constructed by the investigator. The purpose of an exemplar is to provide a practical demonstration of concept in relevant context (13). In most resources these cases are mentioned: minority groups (race and ethnicity, religious), gender, disabilities, sex orientation, and elderly (30).

In our context:
In interview with medical faculties of TUMS:
Appropriate term is defined as cultural competency and antecedents of this term in our context is: fair service, professional values and increasing encounter factors such as: globalization, international education, international service, development of new media. Unfortunately, there is no law or requirement for implementing programs of cultural competency.

Attributes of the term are classified as:
a) what : it contains domains of cognitive, attitudes and skills in different degrees
b) how: quality of articulation of the constructs is an important factor in achieving it, fluidity, non-judgmental openness, dynamic process, flexibility, long term continuous process, can explain way of arrangement of constructs. c) Areas: individual, organization, society.

Consequences: improvement of: quality of care, adherence of patient, communication of physician and patient, effectiveness of treatment, cost-effectiveness, fairness in service, accessibility to health service, are main consequences of cultural competency.

Exemplars: in our interviews, all of the exemplars in review are accepted except sex orientation that in Muslims is a taboo of course, there is different emphasis and priorities in them.

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Table 1: some of antecedents, attributes, consequences, and surrogate terms for cultural competency

CONCLUSION

During four decades, multiple models of cultural competency in different professions have been developed. These models are based on various contexts and professions that are affected by their ultra-structure and also regulation systems. LCME in U.S introduced it in their standards: ED-22. Medical students must learn to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery (17). ACGME outlined general or common program requirements for specialty as the basis for accreditation of programs (16). In New Zealand indeed indigenous Maoris, a large number of immigrants with various cultures live and cause diversity of population because more health care providers are from new residents, regulatory bodies authorized laws for delivery of appropriate cultural services in terms of cultural safety (47). In US, Native Americans and coloured people are more suppliant for these programs. Here in RAN historical and geographical situation of our country is a source of diversity and seems to be a priority for our society and also educational and professional structures for designing and implementing relevant programs.

Acknowledgement:
This project was supported by a grant from the Tehran university of medical science as a PhD project” Developing medical students’ cultural competency conceptual model in TUMS”, approved in medical education department of educational development center of TUMS.