Cultural competence in healthcare professionals, specialised in diabetes, working in primary healthcare— A descriptive study

Self-care is the most important cornerstone of diabetes treatment. As self-care is affected by cultural beliefs, it is important for healthcare professionals to be able to adapt their educational approach and to be culturally competent. The aim of this study was to describe the cultural competence in Swedish healthcare professionals, specialised in diabetes care and to examine related factors for cultural competence. The healthcare professionals’ perceived level of cultural competence was measured across three domains— Openness and awareness, Workplace support and Interaction skills— in 279 Swedish healthcare professionals from all 21 regions of Sweden, using the Cultural Competence Assessment Instrument (Swedish version— CCAI-S). Descriptive statistics were used to describe cultural competence in healthcare professionals, and linear regression was conducted to examine factors related to cultural competence. Of the healthcare professionals studied, 58% perceived that they had a high level of Openness and awareness, 35% perceived that they had a high level


| INTRODUC TI ON
Type 2 diabetes constitutes a global public health problem that is rapidly increasing.Today, over 463 million people are affected by type 2 diabetes representing 9.3% of the world's population.It is predicted that, by 2045, the number will have risen to 700 million people (IDF, 2019;Saeedi et al., 2019).Type 2 diabetes particularly affects vulnerable populations, such as migrants living in developed countries (Guariguata et al., 2014;IDF, 2019;Testa et al., 2016).
Migrants include foreign-born people who have moved to another country, either voluntarily as immigrants or involuntarily as refugees (IOM, 2017).In addition, migrants with type 2 diabetes have been shown to have limited knowledge about diabetes (Pettersson et al., 2019) and to be at increased risk of high blood glucose levels (Chambre et al., 2017).Furthermore, migrants find that diabetes care is not tailored to their expectations and cultural needs (Jager et al., 2019).
Type 2 diabetes is a progressive condition that can involve micro and macrovascular complications.These can have an adverse effect on health and possibly lead to high healthcare costs and suffering for the individual (IDF, 2019).Although serious complications can develop, the condition can be managed, complications can be prevented and the deterioration can be delayed by practicing adequate self-care (Cefalu et al., 2016;IDF, 2019;Saeedi et al., 2019).
Self-care is of great importance in improving the health of persons with a chronic condition and can be seen as a process of maintaining health through health-promoting practices, symptom monitoring and the managing of symptoms when they occur (Riegel et al., 2009).Active participation in self-care, based on knowledge of the condition, is the most important cornerstone of treatment for type 2 diabetes (IDF, 2019).Self-care for chronic illness is directly affected by several factors, such as knowledge of the condition, experience, skills, motivation, habits, cultural beliefs and values, functional and cognitive abilities, support and access (Jaarsma et al., 2017).The way in which an individual responds to healthcare advice is partly based on their cultural backgrounds, and so it is important to consider a person's cultural beliefs in healthcare (Hjelm & Bard, 2013).Culture consists of knowledge, values, beliefs, assumptions, perspectives, attitudes, norms and the customs people inherit when participating in a society or a certain group (Hammell, 2013).It may include people of the same religion or origin and it influences attitudes and behaviours in relation to lifestyle and activities to promote health, which may subsequently lead to differences in self-care performance (Becker et al., 2004).Good communication between clients and healthcare professionals is important and the knowledge obtained by a person with diabetes influenced by the way the professional responds to the person with diabetes during a consultation or clinical interview (Capone, 2016;Foronda et al., 2016).
Due to global migration, different cultural backgrounds in society have increased and healthcare professionals interact with a great number of clients from different cultural backgrounds and with different cultural needs (Alizadeh & Chavan, 2016).Cultural diversity can constitute a major barrier to effective healthcare, and so cultural competence and cultural awareness are becoming important skills for healthcare professionals (Alizadeh & Chavan, 2016;Leininger & McFarland, 2006) to enable them to provide effective and culturally responsive healthcare services (Campinha-Bacote, 2002;Papadopoulos et al., 2004).Cultural competence can be defined as healthcare professionals' understanding on how culture affects an individual's beliefs and behaviours and adapts their strategies to meet clients' individual needs, thus increasing the possibility of effective healthcare for people from various cultural backgrounds (Balcazar et al., 2010).Cultural awareness is an important aspect of cultural competence and involves the recognition of one's biases, prejudices and assumptions about individuals who are different (Balcazar et al., 2010;Jirwe et al., 2009).Cultural competence and cultural humility support health educators and professionals when working with diverse individuals, groups and communities (Greene-Moton & Minkler, 2020).Cultural humility is an integrated part of cultural competence when the health professionals question the assumptions, beliefs and biases they have and in the interaction with the client respect differences and reduce power disparities (Danso, 2018).
Previously, cultural competence has been measured at primary healthcare services to identify barriers in diabetes care.The result reported cultural diversity related to languages and strong cultural traditions around food were the most common cultural barriers to culturally competent healthcare service (Domenech Rodríguez et al., 2019;Zeh et al., 2018).In order to enhance the quality of healthcare, there is a need for further knowledge

What is known about the topic
• The cultural background in persons with diabetes may constitute a barrier for healthcare professionals when providing optimal diabetes care.
• Cultural competence is an important skill for healthcare professionals.
• In order to optimise the quality of healthcare, there is a need for further knowledge about the cultural competence of healthcare professionals.

What this paper adds
• Healthcare professionals perceive a lack of feedback from managers on how to improve their interactive skills to be culturally competent when working with persons with diabetes with different cultural background.
• Healthcare professionals perceive high levels of cultural openness and awareness.
• The cultural openness and awareness in the clinic is high among the healthcare professionals when there is a high percentage of migrant clients with diabetes receiving care in a primary healthcare clinic.
about the cultural competence of healthcare professionals (Berlin et al., 2010) The aim of this study, therefore, is to describe the cultural competence of primary healthcare professionals that specialise in diabetes care and to examine related factors that affect cultural competence.

| Design
This was a cross-sectional study involving a questionnaire measuring the cultural competence in healthcare professionals specialised in diabetes, working in primary healthcare.

| Sample selection and procedure
Data were collected between January 2020 and July 2020.All 21 regions in Sweden were contacted and informed about the study and e-mail addresses were obtained for all managers of primary healthcare clinics (n = 957).Every region has healthcare clinics, responsible for the care of persons with diabetes.Most healthcare clinics have special diabetes teams.Included in a diabetes team are, e.g., nurses, general practitioners, podiatrists, physiotherapists, social workers and dieticians.
Each manager was given information about the study and asked to provide contact details for healthcare professionals working with diabetes care.The healthcare professionals (n = 500) were contacted by e-mail including an encrypted web-based survey provided by Linköping University.The participants were informed that consent was implied through completion of the survey.A paper survey was provided for any professional that requested one.If there was no response approximately 2 weeks after the survey had been sent out, a reminder was sent.A second reminder was sent after approximately 4 weeks.During the Covid-19 pandemic, we realised that non-respondence was not due to an unwillingness to participate but to a lack of time, and we sent a third and a fourth request for responses.We aimed to include healthcare professionals from all regions as we wanted the results to be representative for the whole of Sweden.The 21 Swedish counties/regions are quite large by area and differ with regard to population density.There are differences in the rural or metropolitan lay out of each county and the composition of the population, e.g., related to economy, age of the population and number of immigrants (SCB, 2020).
The sample size calculated using the rule of thumb of Pedhazur and Schmelkin (1991) that states that good power to study relationships requires 50 participants for each factor measured.We, therefore, aimed to include over 150 healthcare professionals (three domains in the cultural competence instrument).
The study was conducted in accordance with the Helsinki Declaration (WMA, 2013).However, the regional ethical committee waived the requirement for this study to gain ethical approval since no sensitive personal data were collected nor information from medical records (registration no./decision no.2019-05093).

| Measurement
Cultural competence was measured using the Swedish version of the Cultural Competence Assessment Instrument (CCAI-S; Holstein et al., , 2020).The CCAI-S is a self-report instrument aiming to measure perceived cultural competence in healthcare professionals.As cultural competence is not a commonly used concept, we provided the healthcare professionals with a description of cultural competence (Balcazar et al., 2010) before filling in the instrument.The instrument includes13 items and response options on a 6-point scale, where 6 corresponds to "strongly agree" and 1 to "strongly disagree".
It contains three domains: Openness and awareness (measured by six items including respect for differences in cultural background) Workplace support (including four items measuring learn from peers) and Interaction skills (measured by three items including effective verbal and non-verbal communication).In this study, for each domain, a mean score lower than 3 was treated as low, 3-4 was treated as medium and a mean score higher than 4 was treated as high.For every item in the domains, response options 1 and 2 were recoded as strongly disagree/disagree, 3 and 4 as neutral and 5 and 6 as agree/strongly agree.The reliability of CCAI-S has been tested in a previous study (Holstein et al., 2020); Cronbach's alpha for the instrument as a whole was 0.81, and for the domains was: Openness and awareness 0.79; Workplace support 0.64; Interaction skills 0.69.In our study, the Cronbach's alpha was 0.82 for the total scale and for the three domains was: Openness and awareness 0.72; Workplace support 0.73; and Interaction skills 0.59.In addition, demographic information was collected on gender, education, place of birth, profession, length of practice in healthcare and diabetes care in particular, self-reporting of attitudes towards working with various cultures and various types of disabilities and previous experience of cultural competence training.We also asked participants to estimate the percentage of migrants registered with their practice.

| Data analysis
Data were analysed using SPSS version 26.To describe the data, we used numbers and percentage, mean (SD) and median (range).It was only possible to submit fully completed questionnaires meaning that we did not need to address missing data in our analysis.For the associations among the three domains of cultural competence, we performed correlation analyses.In order to analyse sociodemographic factors associated with the three domains, we performed univariate analyses with bivariate correlations, independent Student's t test or one-way ANOVA, where appropriate.When conducting linear regression analyses, with the three domains as dependent variables, it is common to observe a change in several predictive variables' significance level, and therefore, we included sociodemographic factors in the linear regression analyses when a p-value < 0.15 was observed in the univariate analyses.

| RE SULTS
Of the 500 healthcare professionals invited, a total of 279 responded to the questionnaire (response rate 56%).Healthcare professionals from all 21 regions in Sweden were represented in the results.The majority of the healthcare professionals were female (91%) with a mean age of 50 years (SD 10).Most of them were born in Sweden (80%).In terms of academic achievement, 91% of the healthcare professionals had a university bachelor's degree or higher.The healthcare professionals were mainly registered nurses (74%); other professions represented were, in descending order, general practitioners (GPs), podiatrists and dieticians.The healthcare professionals reported widely differing lengths of practice, from 2 to 48 years with a median of 23 years of practice (Table 1).

| Development of cultural competence
Healthcare professionals stated that they had developed their cultural competence through practical experience in their professional practice (78%, n = 218), by obtaining information for themselves (37%, n = 103) and through basic education (21% n = 58).Eight per cent stated that they had not developed any cultural competence (Table 2).

| Cultural competence
The mean score in the Openness and awareness domain was 4.98 (0.70), in the Workplace support domain 3.30 (1.07) and in the Interaction skills domain 4.40 (0.85).The majority of the healthcare professionals (n = 162, 58%) reported high perceived Openness and awareness (>4) while 35% (n = 98) had high perceived Interaction skills and 6% (n = 17) had high perceived Workplace support in relation to cultural competence (Table 3; Figure 1).The lowest score was found in the Workplace support domain, where 37% of the healthcare professionals reported low perceived Workplace support (n = 104), 4% reported low perceived Interaction skills (n = 10) and 2 (1%) reported low perceived Openness and awareness (Table 3; Figure 2).
Considering the responses at item level (Table 3), the items showing the lowest score referred to feedback from supervisors on how to improve practice skills with clients from different cultural backgrounds, where 56% (n = 156) of the healthcare professionals reported that they did not receive feedback about cultural competence from their workplace.A total of 61% (n = 170) reported that their verbal communication with clients whose culture is different from theirs was effective, while 9% of the healthcare professionals (n = 24) found effective non-verbal communication difficult.
Difficulties in working competently with minority ethnic clients were reported by 10% (n = 27) of the healthcare professionals, and 9% (n = 26) did not openly discuss issues about multicultural awareness or examine their own biases around ethnicity.None of the healthcare professionals reported that they were not sensitive to the need to value and respect differences between their own cultural background and their clients' cultural heritage (Table 3; Figure 3).

| Sociodemographic factors related to cultural competence
Univariate analysis showed that neither age (Openness and aware-    a Scoring: 1 and 2 were recoded as strongly disagree/disagree, 3 and 4 as neutral and 5 and 6 as agree/strongly agree. was associated with Openness and awareness (F = 0.63, p = 0.03) but not with Workplace support (F = 4.75, p = 0.13) or Interaction skills (F = 1.11, p = 0.30; Table 4).
Only the percentage of migrant clients at the healthcare clinic was independently related to Openness and awareness in relation were not found to be related factors in the linear regression analysis of Interaction skills (ß: 0.023, p: 0.718 and ß: 0.005, p: 0.099; Table 4).

| Correlation between the domains
All three domains were positively correlated to each other, with the strongest correlation between Openness and awareness and Interaction skills (r = 0.47, p-value □0.01;Table 5).

| D ISCUSS I ON
To our knowledge, this is the first study to measure, and report perceived cultural competence in healthcare professionals working in diabetes care within primary healthcare.It certainly exists studies measuring cultural competence in primary healthcare but with a focus on the general practise teams (Balcazar et al., 2010;Kirk et al., 2014;Zeh et al., 2018).Our main finding is that a considerable proportion of healthcare professionals (58%) perceived themselves to be open The first factor was that healthcare professionals working at healthcare clinics with a high percentage of migrants showed significantly higher levels of Openness and awareness and Workplace support.
The second factor positively affecting self-assessed cultural competence was whether the healthcare professionals had developed cultural competence through practical experience, obtained information themselves and/or through education.
In this study, the healthcare professionals were rated as having a high level of Openness and awareness, indicating that they recognise their biases, prejudices and assumptions about individuals with various cultural backgrounds (Balcazar et al., 2009;Campinha-Bacote, 2002), which is an important aspect in cultural competence.
None of the healthcare professionals reported that they were not sensitive to the need to value and respect differences between their cultural background and the cultural heritage of their clients.These findings strengthen previous research findings that have showed high self-rated levels of cultural awareness among healthcare professionals (McElroy et al., 2016;Suarez-Balcazar et al., 2009).To achieve cultural competence in practice, it is essential to be culturally aware and have an open attitude and a respect for cultural differences (Darawsheh et al., 2015).
A major finding was the reported lack of support for cultural competence at the workplace.Only 9% of all healthcare professionals perceived that they received input from supervisors on how to improve their practice skills with clients from different culturally backgrounds.Workplace support has been found to be important tain feedback from colleagues about cultural skills (Holstein et al., 2019).Support from the organisation is also important when defining the capacity of individual healthcare professionals to supply culturally relevant services (Anderson et al., 2003).Further, cultural competence training seems to be essential for developing these skills.The cultural competence of general practices providing diabetes services depends mostly on cultural awareness of practice staff, general practices' understanding with staff ethnicity and the language skills (Zeh et al., 2018).In the current study, there was low Workplace support in relation to materials that reflected the culture of the clients.Healthcare organisations should provide patient information materials that meet clients' needs, for instance, on health literacy and language during assessment, treatment and discharge (Seeleman et al., 2015).
There seems to be a need of studies comparing cultural competence between different healthcare professionals.This study reported significantly higher scores in the Openness and awareness and Interaction skills in nurses compared to GPs, while other research has reported no significant difference in cultural competence between professionals; however, sensitivity and knowledge regarding cultural competence were found to be higher in GPs compared to nurses (Pedrero et al., 2020).
We were unable to identify any factors that were strongly related to the three domains.Neither age nor length of practice affected cultural competence in any of the three domains, while other studies have shown that length of practice is a related factor for cultural competence (Leininger & McFarland, 2006;Lin et al., 2015;Suarez-Balcazar et al., 2009).This may be partly explained by the fact that the healthcare professionals included in our study had quite extensive practical experience, with a median of 23 years of practice.Further, there was no significant difference in self-assessed cultural competence if the healthcare professionals were migrants themselves, in any of the three domains, although in previous

Openness and awareness
Workplace support

Interaction skills
Openness and awareness -Workplace support 0.42 a -Interaction skills 0.47 a 0.42 a research cultural competence has been found to be positively associated with healthcare professionals from minority backgrounds (Repo et al., 2017).Diversity among staff members is desirable for furthering responsiveness to client diversity (Seeleman et al., 2015).
However, the percentage of migrant clients at the healthcare clinic and if the healthcare professionals stated that they had developed cultural competence, particularly by practical experiences but also by education, were found to be related to perceived cultural competence assessed with CCAI-S.This result strengthens previous studies showing that frequency of caring for clients from different culturally backgrounds improves cultural competence in cultural encounters (Chen et al., 2018;Lin et al., 2015;Repo et al., 2017).The result is also in line with studies reporting that the experience of cultural education is a predictor of cultural competence in healthcare professionals (Holstein et al., 2019) and that there is a need to highlight the importance of cultural competency education in healthcare (Abrishami, 2018;Chae et al., 2020).Thus, it is essential to provide cultural competence training to healthcare professionals at different levels in the healthcare system to increase their awareness of cultural differences (Kaihlanen et al., 2019).Future research needs to examine other factors to identify additional related factors in respect of cultural competence in healthcare professionals.Teaching and learning methods of cultural competence can, for instance, comprise cultural self-awareness and intercultural communication skills, understandings of socio-cultural barriers in professional-patient encounter and in leadership and workforce at the organisational level (Horvat et al., 2014).
However, even if the healthcare professionals in this study perceived that they had developed cultural openness and awareness, they did not necessarily have Interaction skills relating to cultural competence when working with clients.Thus, healthcare professionals might need more support from their workplace to improve their cultural competence in Interaction skills when working with clients from a cultural background different to their own.

| Strengths and limitations
One of the limitations of this study was that out of the 957 healthcare clinics that were contacted, only 188 approved participation in this study.Although we were able to include healthcare professionals from all regions, this low response rate (20%) may have affected the results.On the other hand, the results are based on healthcare clinics from every region of Sweden, giving a good spread.Another limitation of this study is that most of the healthcare professionals included were nurses (80%) and 91% were female.Although this is representative of a diabetes healthcare team (Socialstyrelsen, 2019), the results cannot be generalised to all healthcare professionals working with persons with diabetes or to male healthcare professionals.Future studies should aim to include a greater variety of healthcare professionals.Although we included all the regions of Sweden and the results reflect Sweden as a whole, the sample size included in this study has not enough power to make comparisons between the regions and therefore we could not make comparison in, for example, differences in rural or metropolitan areas in Sweden according to the cultural competence in healthcare professionals.
The result showed a high score for cultural Openness and awareness which might be indicative of a selective sample (e.g. only those with cultural competence responded to the questionnaire) but it also reflects a high rating of Openness and awareness in those who did respond.A person rating themselves as very confident may possess real qualities of Openness and awareness, but they could also be lacking awareness of their limitations, which might suggest overconfidence (Gozu et al., 2007).However, cultural awareness includes the ability to reflect on cultural interactions.This involves self-exploration and the ability to recognise when the judgemental self affects the capacity to be open-minded (Wells et al., 2016).

| Conclusion
Although most healthcare professionals had practical experiences with cultural diversity in caring for persons with diabetes, only onethird of healthcare professionals perceived to have interaction skills needed to be culturally competent.The healthcare professionals felt that they did not receive support from their workplace to improve their interaction skills.Cultural competence-related education could support the healthcare professionals to develop interaction skills.
Most healthcare professionals perceived that they had developed cultural openness and awareness.

ACK N OWLED G EM ENT
We thank primary healthcare professionals who participated in this study.This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

CO N FLI C T O F I NTE R E S T S
The authors declare that they have no conflict of interest.

AUTH O R CO NTR I B UTI O N S
SP, LK, TJ were involved in study design, data collection, analysis, drafting and re-drafting of the article.JH was involved in analysis, drafting and re-drafting of the article.MJ was involved in drafting and re-drafting of the article.

D at a Av a i l a b i l it y St ate m e nt
The data that support the findings of this study are available from the corresponding author upon reasonable request.

Sara
ness r = −0.04p = 0.55, Workplace support r = −0.01p = 0.83, Interaction skills r = 0.04 p = 0.48) nor length of practice of the healthcare professionals (Openness and awareness r = −0.06p = 0.30, Workplace support r = −0.01p = 0.81, Interaction skills r = 0.03 p = 0.66) were significantly related to any of the three domains in cultural competence.Neither was there a statistically significant relationship between if the healthcare professionals themselves being a migrant and any of the three domains (Openness TA B L E 1 Sociodemographic characteristics for the healthcare professionals n = 279 Age (years; mean ± SD) 50 (±10) and awareness; F = 1.22 p = 0.22), Workplace support (F = 4.13 p = 0.20) and Interaction skills (F = 1.53 p = 0.66; Table4).In the univariateanalyses p-values < 0.15 were marked bold.In multivariate analyses p-values< 0.05 were marked bold.The Openness and awareness (F = 2.65, p < 0.05) and Interaction skills (F = 3.85, p = 0.01) differed between professions.Nurses scored higher than GPs in Openness and awareness (5.03 ± 0.66 vs. 4.69 ± 0.82, p = 0.01) and Interaction skills (4.43 ± 0.83 vs. 4.03 ± 0.78, p = 0.01) while no significant differences between professions in Workplace support were found (F = 0.53, p = 0.67).The self-estimated percentage of migrants in the healthcare clinic correlated significantly with Openness and awareness (r = 0.26, p = 0.01) and with Workplace support (r = 0.26, p = 0.01) but not with Interaction skills (r = 0.11, p = 0.10).Cultural competence developed through education, practical experience or personal learning TA B L E 2 Healthcare professionals' development of cultural competence N = 279 a n (%) to developed cultural competence (ß = 0.26 p > 0.01), explaining 7% of the variance.Percentage of migrant clients at the healthcare clinic (ß = 0.26 p > 0.01) and developed cultural competence (ß = 0.14 p = 0.03) were significant predictors of Workplace support, explaining 8% of the variance in Workplace support in relation to cultural competence.No predictors were found for Interaction skills.Although profession and percentage of migrant clients in the healthcare clinic were associated with Interaction skills in the univariate analyses, these and aware in regard to clients with other cultural backgrounds and a third (36%) of the healthcare professionals perceived that they had good Interaction skills in relation to cultural competence.Further, fewer than 10% (6%) reported having received support from their workplace in relation to cultural competence.Another important finding was that only two factors were identified affecting selfassessed cultural competence among the healthcare professionals.

F
Mean score, measured as a percentage, for each of the three domains Openness and awareness, Workplace support and Interaction skills Health care professionals' responses for each item, within the three domains Openness and awareness, Workplace support and Interaction skills, measured as a percentage in improving cultural competence.One way to feel supported by the workplace is by being given opportunities to learn and to ob- Pettersson https://orcid.org/0000-0003-1406-0349R E FE R E N C E S Abrishami, D. (2018).The need for cultural competency in health care.Radiologic Technology, 89(5), 441-448.
Univariate and multivariate analyses for sociodemographic factors related to Openness and awareness, Workplace support and Interaction skills TA B L E 4