Cultural competency

文化能力
  • 文章类型: Journal Article
    跨文化护理是一门强调对不同人群的文化胜任护理的学科,认识到文化对健康信念的影响,值,实践,和结果。它要求护士尊重文化的差异和相似性,但是在课程设计方面面临挑战,教师发展,和学生评估。本文探讨了跨文化护理教育的现状和未来发展方向,向美国护理学院协会致辞,将文化内容纳入护理课程,回顾马德琳·莱宁格的跨文化护理理论,多样性,股本,和包容性概念,并讨论了跨文化护理教育的主要挑战,包括缺乏学生多样性,培训,和资源。克服这些挑战的策略包括跨专业合作,文化沉浸,和循证实践。本文最后介绍了急诊科护士应如何将其纳入实践。
    Transcultural nursing is a discipline that emphasizes culturally competent care for diverse populations, recognizing the influence of culture on health beliefs, values, practices, and outcomes. It requires nurses to respect cultural differences and similarities, but faces challenges in curriculum design, faculty development, and student assessment. This paper explores transcultural nursing education\'s current state and future directions, addressing the American Association of Colleges of Nursing essentials for integrating cultural content into nursing curricula, reviewing Madeleine Leininger\'s transcultural nursing theory, diversity, equity, and inclusion concepts, and discussing the main challenges of transcultural nursing education, including lack of student diversity, training, and resources. Strategies to overcome these challenges include interprofessional collaboration, cultural immersion, and evidence-based practice. The paper concludes with how emergency department nurses should incorporate this into practice.
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  • 文章类型: Systematic Review
    背景:社区驱动的初级医疗保健(PHC)研究可能会减少土著人民的慢性病负担。本系统综述评估了来自四个具有相似殖民历史的国家的土著人民使用PHC研究报告的文化安全性。
    方法:Medline,从2002年1月1日至2023年4月4日,对CINAHL和Embase进行了系统搜索。如果论文是原始研究,以英文出版,并包括数据(定量,定性和/或混合方法)关于慢性疾病(慢性肾脏疾病,心血管疾病和/或糖尿病),来自西方殖民地国家的土著人民。研究筛选和数据提取由两名作者独立进行,其中至少有一个是土著人。论文的基线特征采用描述性统计分析。使用两种质量评估工具对研究论文的文化安全方面进行了评估:CONSIDER工具和CREATE工具(子集分析)。本系统评价是根据评估系统评价的方法学质量(AMSTAR)工具进行的。
    结果:我们确定了来自澳大利亚的35篇论文,新西兰,加拿大,和美国。大多数论文是定量的(n=21),包括42,438人的数据。纳入论文的文化安全性差异很大,在充分报告研究伙伴关系方面存在差距,在整个研究过程中提供参与者和土著研究治理的明确集体同意,特别是在传播方面。大多数论文(94%,33/35)指出,研究目标来自社区或经验证据。我们还发现,71.4%(25/35)的论文报告说,通过考虑定植对减少初级医疗保健的影响,使用基于优势的方法。
    结论:关于土著PHC使用的研究应采用更文化安全的方式,通过在整个研究过程中赋予土著声音特权,提供与社区需求相关的护理和研究成果,包括传播。土著利益攸关方应在整个过程中更正式和明确地参与,以指导研究实践,包容土著价值观和社区需求。
    BACKGROUND: Community-driven research in primary healthcare (PHC) may reduce the chronic disease burden in Indigenous peoples. This systematic review assessed the cultural safety of reports of research on PHC use by Indigenous peoples from four countries with similar colonial histories.
    METHODS: Medline, CINAHL and Embase were all systematically searched from 1st January 2002 to 4th April 2023. Papers were included if they were original studies, published in English and included data (quantitative, qualitative and/or mixed methods) on primary healthcare use for chronic disease (chronic kidney disease, cardiovascular disease and/or diabetes mellitus) by Indigenous Peoples from Western colonial countries. Study screening and data extraction were undertaken independently by two authors, at least one of whom was Indigenous. The baseline characteristics of the papers were analyzed using descriptive statistics. Aspects of cultural safety of the research papers were assessed using two quality appraisal tools: the CONSIDER tool and the CREATE tool (subset analysis). This systematic review was conducted in accordance with the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) tool.
    RESULTS: We identified 35 papers from Australia, New Zealand, Canada, and the United States. Most papers were quantitative (n = 21) and included data on 42,438 people. Cultural safety across the included papers varied significantly with gaps in adequate reporting of research partnerships, provision of clear collective consent from participants and Indigenous research governance throughout the research process, particularly in dissemination. The majority of the papers (94%, 33/35) stated that research aims emerged from communities or empirical evidence. We also found that 71.4% (25/35) of papers reported of using strengths-based approaches by considering the impacts of colonization on reduced primary healthcare access.
    CONCLUSIONS: Research on Indigenous PHC use should adopt more culturally safe ways of providing care and producing research outputs which are relevant to community needs by privileging Indigenous voices throughout the research process including dissemination. Indigenous stakeholders should participate more formally and explicitly throughout the process to guide research practices, inclusive of Indigenous values and community needs.
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  • 文章类型: Journal Article
    当每个人都有平等的机会实现其最高水平的健康时,就存在健康公平。有效的沟通对于确保治疗关系至关重要。英语水平有限(LEP)的患者遇到沟通障碍,导致较差的结果。联邦法规要求医院提供受过医学培训的口译员;但是,这并不总是发生。我们确定了三个广泛的研究领域:沟通障碍,结果,和成本。研究结果强调了LEP患者在医疗保健系统中面临的挑战,以及需要有针对性的干预措施来加强语言的获取,提高卫生保健专业人员的文化能力,并确保所有人的公平结果。
    Health equity exists when everyone has an equal opportunity to achieve their highest level of health. Effective communication is essential to ensure a therapeutic relationship. Patients with limited English proficiency (LEP) experience communication barriers, leading to poorer outcomes. Federal regulation requires hospitals to provide medically trained interpreters; however, this does not always occur. We identified 3 broad areas of research: communication barriers, outcomes, and costs. Findings highlight the challenges patients with LEP face in the health-care system, and the need for targeted interventions to enhance language access, improve cultural competence among health-care professionals, and ensure equitable outcomes for all.
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  • 文章类型: Journal Article
    目标:尽管美国外国出生人口有所增加,移民和难民健康(IRH)方面的医学教育机会仍然有限。我们总结了已发布的IRH课程的发现,并提供了将IRH纳入儿科住院医师计划的建议。
    方法:我们对描述设计的文章进行了文献综述,实施,或评估美国本科和研究生医学学员的IRH课程。
    结果:文献综述确定了来自21个机构的36篇文章,描述了37个独特的课程。三个课程包括儿科住院医师计划。通常教授的主题包括文化谦逊,解释器使用,和移民身份是健康的社会决定因素。连续性诊所存在以移民为重点的培训经验,难民或寻求庇护者诊所,和专门的选修/轮换。课程最常被描述为独立的选修课/轮换。
    结论:IRH课程提供了发展临床护理技能的机会,倡导,以及与移民人口的社区伙伴关系。儿科住院医师计划应将IRH课程与现有的学习重点保持一致,支持和聘请具有IRH专业知识的教师,并与具有专业知识的社区组织合作。课程还可以考虑如何最好地支持对专注于移民人口的职业感兴趣的学习者。需要进一步的工作来建立能力和经过验证的工具,以衡量IRH课程的受训者满意度和临床能力。
    OBJECTIVE: Despite increases in the US foreign-born population, medical education opportunities in immigrant and refugee health (IRH) remain limited. We summarize findings for published IRH curricula and offer recommendations for integrating IRH into pediatric residency programs.
    METHODS: We performed a literature review of articles describing the design, implementation, or assessment of IRH curricula for US-based undergraduate and graduate medical trainees.
    RESULTS: The literature review identified 36 articles from 21 institutions describing 37 unique curricula. Three curricula included pediatric residency programs. Commonly taught topics included cultural humility, interpreter use, and immigration status as a social determinant of health. Immigrant-focused training experiences existed at continuity clinics, clinics for refugees or asylum seekers, and dedicated electives/rotations. Curricula were most frequently described as stand-alone electives/rotations.
    CONCLUSIONS: IRH curricula provide opportunities to develop skills in clinical care, advocacy, and community partnerships with immigrant populations. Pediatric residency programs should align the IRH curriculum with existing learning priorities, support and hire faculty with expertise in IRH, and partner with community organizations with expertise. Programs can also consider how to best support learners interested in careers focusing on immigrant populations. Further work is needed to establish competencies and validated tools measuring trainee satisfaction and clinical competency for IRH curricula.
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  • 文章类型: Journal Article
    背景:几个因素导致手术结果差异,包括结构性种族主义和隐性偏见。关于外科住院医师计划如何通过教育干预文化并发症的研究仍然很少。我们回顾了有关外科住院医师计划如何利用教育来对抗员工和患者接触文化并发症的文献。
    方法:我们搜索了PubMed,Scopus,和谷歌学术课程旨在提高外科住院医师的文化能力。OBGYN课程包括在内。非美国研究被排除在外。
    结果:研究按干预类型组织:教育,大回合,M&M最常见的干预措施是教育,大回合是最不常见的。目标措施提高了20-88%。
    结论:文化能力课程的常见类型是明确的,某些干预措施显示受训者的教育有所改善。这些课程数据的稀缺性并不一定表明它们缺乏存在,但确实表明需要对课程干预措施以及它们如何解决文化并发症进行更多研究。
    BACKGROUND: Several factors contribute to surgical outcome disparities, including structural racism and implicit bias. Research into how surgical residency programs intervene on Cultural Complications via education remains sparse. We review the literature for how surgical residency programs use education to combat staff and patient exposure to Cultural Complications.
    METHODS: We searched PubMed, SCOPUS, and Google Scholar for curricula aimed at improving cultural competency in surgical residencies. OBGYN curricula were included. Non-US studies were excluded.
    RESULTS: Studies were organized by intervention type: Didactic, Grand Rounds, and M&M. The most common interventions were Didactics, with Grand Rounds being the least common. Target measures improved anywhere from 20-88%.
    CONCLUSIONS: The common types of cultural competency curricula are clear, and certain interventions show improvement in trainees\' education. Scarcity of data on these curricula does not necessarily indicate their lack of existence but does suggest additional research is needed into curricular interventions and how they may address cultural complications.
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  • 文章类型: Journal Article
    背景:提供对多样性敏感的护理是减少健康差异的一种有希望的方法。最近的批评和科学差距表明,需要从患者的角度看待多样性敏感的护理。本系统综述旨在描述患者的观点,包括病人的经历,期望,以及对医疗保健提供者提供的多样性敏感护理的满意度。
    方法:2022年12月,MedlineALL,Embase,WebofScience核心合集,Cochrane中央控制试验登记册,CINAHL,搜索了PsycINFO和GoogleScholar,以寻找描述或测量患者期望的原始研究,经验,和/或满意度,特别关注医疗保健提供者的文化或多样性能力。使用基于主题综合的会聚混合方法设计对收集的数据进行分析。
    结果:从最初的5,387篇文章中,117人被选中进行全文筛选,最终,这项研究包括34篇文章。观察到多样性敏感性护理的概念包括三个组成部分。第一部分侧重于以患者为中心的护理,包括清晰和直接的沟通等能力。共同决策,个性化护理,同理心,和考虑。第二个组成部分的中心是提供文化定制的信息,根据文化需求调整护理,与口译员一起工作,allyship,社区伙伴关系,自我意识,文化知识,并建立在第一个组件上。在多样性敏感护理的前两个组成部分中,患者报告说,他们的医疗保健提供者遇到了不满和缺点,有时会导致与提供者护理有关的第三个也是最后一个组成部分。这一部分强调了语言的重要性,民族,文化,以及在提供优质护理方面的性别一致性。
    结论:结论:患者对多样性敏感护理的观点包括多个组成部分,从以患者为中心的护理到和谐护理。这些组件包括各种能力作为沟通技巧,同理心,自我意识和调整照顾文化需求。患者报告说,医疗保健提供者提供的多样性敏感护理的所有组成部分都存在不满和缺点。
    BACKGROUND: The provision of diversity-sensitive care is a promising approach towards reducing health disparities. Recent criticism and a scientific gap demonstrate the need for the patient perspective on diversity-sensitive care. This systematic review aims to describe the patient perspective, including patient experiences, expectations, and satisfaction with diversity-sensitive care provided by healthcare providers.
    METHODS: In December 2022 the Medline ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO and additionally Google Scholar were searched for original studies that described or measured patient expectations, experiences, and/or satisfaction, specifically focusing on cultural or diversity competence of healthcare providers. Analysis of the collected data was performed using a convergent mixed-methods design based on thematic synthesis.
    RESULTS: From initially 5,387 articles, 117 were selected for full-text screening, and ultimately, 34 articles were included in this study. The concept of diversity-sensitive care was observed to comprise three components. The first component is focused on patient-centered care and includes competencies such as clear and direct communication, shared decision-making, individualized care, empathy, and consideration. The second component centers on providing culturally tailored information, adjusting care to cultural needs, working with interpreters, allyship, community partnerships, self-awareness, and cultural knowledge, and builds upon the first component. Across the first two components of diversity-sensitive care, patients have reported experiencing dissatisfaction and encountering shortcomings in their healthcare providers, sometimes resulting in the third and final component pertaining to provider care. This component underscores the importance of linguistic, ethnic, cultural, and gender concordance in delivering quality care.
    CONCLUSIONS: In conclusion, the patient perspective on diversity-sensitive care encompasses multiple components, from patient-centered care to concordant care. The components incorporate various competencies as communication skills, empathy, self-awareness and adjusting care to cultural needs. Patients reported experiencing dissatisfaction and shortcomings across all components of diversity-sensitive care provided by healthcare providers.
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    文章类型: Journal Article
    英国联合卫生专业公共卫生战略框架概述了他们将疾病预防和公共卫生嵌入到联合卫生实践中的承诺。然而,关于如何最好地将公共卫生付诸实践,尚无明确的指导。这项研究的目的是研究在专职卫生专业人员(AHP)中嵌入公共卫生实践的国际方法。鉴于本研究的探索性,进行了快速范围审查。报告69项研究的70份独特参考文献被纳入,代表了广泛的国家,广泛的时间表(1987-2022)和不同的AHP。全球,AHP涉及英国联合卫生专业公共卫生战略框架模型中概述的所有四个公共卫生领域。最佳实践以精心设计的研究(n=21)的形式得到证明,这些研究报告了AHP公共卫生实践的有效性。确定了将公共卫生方法纳入AHP实践的九个关键成功因素。嵌入公共卫生实践应涉及针对AHP行为改变的干预措施和针对AHP公共卫生实践的障碍和促进者的行为改变技术。多/跨学科工作,创新的设置/角色,还应鼓励文化定制的公共卫生干预措施以及作为核心技能的文化能力。
    The UK Allied Health Professions Public Health Strategic Framework outlines their commitment to embed disease prevention and public health into allied health practice roles. Yet there is no clear guidance on how best to embed public health into practice. The aim of this study was to examine international approaches which embed public health practices amongst allied health professionals (AHPs). Given the exploratory nature of this study, a rapid scoping review was conducted. Seventy unique references reporting 69 studies were included representing a breadth of countries, extensive timeline (1987-2022) and different AHPs. Worldwide, AHPs are involved in all four domains of public health outlined in the UK Allied Health Professions Public Health Strategic Framework model. Best practice was evidenced in the form of well-designed studies (n=21) which reported the effectiveness of AHPs public health practice. Nine key success factors for embedding public health approaches within AHP practice were identified. Embedding public health practice should involve interventions targeting AHPs\' behaviour change and behaviour change techniques targeting barriers to and facilitators for AHPs\' public health practice. Multi/interdisciplinary working, innovative settings/roles, culturally tailored public health interventions along with cultural competence as a core skill should also be encouraged.
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  • 文章类型: Journal Article
    背景:在社会中,人们生活在一个社会现实中,多元文化主义在他们的环境中是一个越来越相关和普遍的话题。面对这个,由于复杂性,在急诊服务或重症监护病房中照顾多元文化患者需要高水平的文化能力,病人的脆弱性,血液动力学状态的快速变化,家庭的参与,他们的信息需求。
    目的:探讨危重患者多元文化护理对策。
    方法:根据乔安娜·布里格斯研究所的建议进行了范围审查,研究问题:危重患者的多文化护理策略是什么?该研究由PRISMA指导。这项研究是通过EBSCOHost平台进行的,SciELO,葡萄牙的开放获取科学知识库,虚拟健康图书馆和灰色文献搜索。这是通过结合描述DECS/MESH来实现的:文化能力;重症监护;急诊室;重症监护;和自然词:文化护理;nurs*干预;nurs*策略;在2012年至2024年的时间范围内。这项研究筛选是由三名独立审稿人通过阅读标题进行的,摘要和全文,应用排除标准。然后对研究结果进行内容分析,从哪个类别出现。
    结果:所选文章重点介绍了有助于改善危重患者多文化护理的各种策略,专注于护士和护生的护理实践和文化多样性培训。
    结论:具有文化能力的护士拥有更多的知识和策略,可以为多元文化的危重患者提供量身定制的护理。从而提高所提供护理的质量,并为医疗保健的人性化做出贡献。
    结论:护士需要了解现有的多文化危重患者护理策略。
    没有患者或公众对审查的直接贡献。
    BACKGROUND: In society, people live in a social reality where multiculturalism is an increasingly relevant and prevalent topic in their contexts. Facing this, caring for multicultural patients in an emergency service or intensive care unit setting requires a high level of cultural competence due to the complexity, vulnerability of the patient, rapid changes in hemodynamic status, involvement of the family, their informational needs.
    OBJECTIVE: To map the strategies for nursing care of critically ill multicultural patients.
    METHODS: A Scoping Review was conducted following the Joanna Briggs Institute\'s recommendations, with the research question: What are the strategies for nursing care of critically ill multicultural patients? The study was guided by PRISMA. The research was conducted through the EBSCOHost platform, SciELO, Portugal\'s Open Access Scientific Repository, the Virtual Health Library and a search in grey literature. This was achieved by combining the descriptors DECS/MESH: cultural competence; critical care; emergency room; intensive care; and natural words: cultural care; nurs* interventions; nurs* strategies; within the time frame from 2012 to 2024. The study screening was performed by three independent reviewers through the reading of titles, abstracts and full texts, applying exclusion criteria. The study results were then subjected to content analysis, from which categories emerged.
    RESULTS: The selected articles highlight various strategies that contribute to the improvement of nursing care for critically ill multicultural patients, focusing on care practice and cultural diversity training for both nurses and nursing students.
    CONCLUSIONS: Nurses with cultural competence possess more knowledge and strategies to provide tailored care for multicultural critically ill patients, thereby enhancing the quality of care delivered and contributing to the humanization of healthcare.
    CONCLUSIONS: Nurses need to have knowledge of existing strategies for caring for multicultural critically ill patients.
    UNASSIGNED: No direct patient or public contribution to the review.
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  • 文章类型: Journal Article
    目的:确定具有临床意义的文化主题,以纳入牙科课程以发展跨文化能力。
    方法:使用PRISMA标准进行系统审查,从WebofScience导出了216篇文章,Scopus,和2012年至2022年的SciELO数据库,其中40个被选中。纳入标准是理论和实证科学文章,定量的,定性,或混合方法自然,关于文化主题。
    结果:数据分析允许将信息组织成四个文化主题:专业跨文化自我意识的发展,个人,家庭,和文化含义,跨文化治疗关系的构建,和具体的临床方面,每个都有特定的内容要在牙科课程中开发。然而,一些临床问题还有待深入探讨,将研究的可能性开放给牙科的所有学科。此外,有必要分析一些评论文章的讨论和结论中的文化偏见,因为它们是从种族中心主义的角度进行的。因此,这些主题的科学期刊和研究人员的同行审稿人必须接受跨文化能力方面的适当培训。
    结论:这篇综述提供了应纳入牙科课程以实现跨文化能力的文化主题的指南和教学顺序,它还强调了在建立适当的治疗关系时需要考虑的广泛相关方面。明确的认证标准有助于在课程中建立跨文化能力;然而,在缺乏法规的国家,有道德和伦理责任纳入这一主题,以便未来的专业人士能够管理和建立包容性的医疗保健。
    OBJECTIVE: To identify cultural topics with clinical implications to be incorporated into the dentistry curriculum to develop Intercultural Competence.
    METHODS: Systematic review with PRISMA criteria that exported 216 articles from the Web of Science, Scopus, and SciELO databases from 2012 to 2022, of which 40 were selected. The inclusion criteria were theoretical and empirical scientific articles, of quantitative, qualitative, or mixed methods nature, on cultural topics.
    RESULTS: The data analysis allowed the organization of information into four cultural topics: Development of professional intercultural self-awareness, Individual, family, and cultural implications, Construction of intercultural therapeutic relationships, and Specific clinical aspects, each with particular contents to be developed in the dentistry curriculum. However, some clinical issues have yet to be explored in-depth, leaving research possibilities open to all disciplines in dentistry. Additionally, it is necessary to analyze the cultural bias in the discussion and conclusion of some reviewed articles, as they were conducted from an ethnocentric perspective. Thus, peer reviewers of scientific journals and researchers in these topics must have appropriate training in Intercultural Competence.
    CONCLUSIONS: This review provides a guide and pedagogical sequence of the cultural topics that should be incorporated into the dentistry curriculum to achieve Intercultural Competence, it also highlights a wide range of relevant aspects to consider in establishing an adequate therapeutic relationship. Explicit accreditation criteria contribute to the establishment of Intercultural Competence in the curricula; however, in countries that lack regulations, there is a moral and ethical duty to incorporate the subject so that the future professional can manage and establish inclusive healthcare.
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  • 文章类型: Journal Article
    UNASSIGNED: To identify the entry-level curricular content related to Indigenous health recommended for entry-level physiotherapy (PT) programs in Canada and other similar countries.
    UNASSIGNED: Design: Scoping review. Procedures: Four electronic databases were searched using the terms physiotherapy, Indigenous health, entry-level curriculum, and their derivatives. Grey literature sources were hand searched and included Canadian PT professional documents, PT Program websites, Truth and Reconciliation Commission (TRC) sources, and a Google search. Data related to curriculum characteristics, methods of delivery, and barriers and facilitators to implementation were extracted from relevant references. Stakeholders reviewed study findings.
    UNASSIGNED: Forty-five documents were included. Documents focused on Indigenous peoples in Canada, Aboriginal and Torres Strait Islanders in Australia, and Māori in New Zealand. Canadian PT programs appeared to rely on passive teaching methods while programs in Australia and New Zealand emphasized the importance of partnering and engaging with Indigenous people. Barriers to incorporating indigenous health curriculum included an overcrowded curriculum and difficulty establishing relevance of Indigenous content (i.e., meaning).
    UNASSIGNED: Similarities and differences were found between curricula content and approaches to teaching IH in Canada and the other countries reviewed. Strategies to promote greater engagement of Indigenous people in the development and teaching of IH is recommended.
    UNASSIGNED: déterminer le contenu du cursus en santé autochtone recommandé pour les programmes d’entrée en pratique en physiothérapie au Canada et dans des pays semblables.
    UNASSIGNED: étude exploratoire. Méthode : les chercheurs ont fouillé quatre bases de données électroniques à l’aide des termes physiotherapy, Indigenous health, entry-level curriculum et leurs dérivés. Ils ont fouillé manuellement les sources de documentation parallèle et y ont inclus des documents professionnels canadiens sur la physiothérapie, les sites Web des programmes de physiothérapie, les sources de la Commission de vérité et réconciliation (CVR) et une recherche dans Google. Les données liées aux caractéristiques du cursus, aux modes de prestation et aux obstacles et incitatifs à la mise en œuvre provenaient de références pertinentes. Les intervenants ont examiné les résultats des études.
    UNASSIGNED: au total, 45 documents ont été retenus. Ils portaient sur les Autochtones du Canada, les Aborigènes et les insulaires du détroit de Torres en Australie et les Māori de la Nouvelle-Zélande. Les programmes de physiothérapie canadiens semblaient reposer sur des méthodes d’enseignement passives, tandis que ceux de l’Australie et de la Nouvelle-Zélande faisaient ressortir l’importance des partenariats et des relations avec les peuples autochtones. Les obstacles à l’intégration du cursus sur la santé autochtone incluaient un cursus surchargé et la difficulté à déterminer la pertinence du contenu sur les Autochtones (c’est-à-dire le sens).
    UNASSIGNED: les chercheurs ont constaté des similarités et des différences de contenu entre les cursus et les approches d’enseignement de la santé autochtone au Canada et les autres pays analysés. Il est recommandé de trouver des stratégies pour favoriser une plus grande participation des peuples autochtones à la création et à l’enseignement de la santé autochtone.
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