Graphic Medicine Activity Impacts Cultural Awareness in Athletic Training Students

Study Design

We conducted a cross-sectional study in which athletic training students were surveyed before and after participating in a GM activity. The variables of interest were scores on the modified Cultural Awareness Scale (mCAS) and preference of pedagogy.¹⁰

Participants

A total of 87 athletic training student participants, the majority (77.0%) White, who identified as female and woman (73.6%), with a mean age of 22.03 ± 2.60 years, participated in this study. Participant demographics are presented in Table 1.

Table 1.Survey Participant Demographic Characteristics (N = 87)

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Intervention

We used the GM activity previously described by Carlson et al.¹¹ Before the activity, a sense of community within each cohort was considered essential to facilitating a safe and brave space for students to share their experiences and openly receive information from classmates. The topic of each GM and corresponding discussion focused on bias and stereotyping.

Instruments

The Cultural Awareness Scale (CAS) was modified to measure athletic training students’ cultural awareness.¹⁰ The CAS is a 35-item survey with 3 subscales. Subscale 1, General Attitudes, consists of 27 questions exploring “general experiences at this school,” “general awareness and attitudes,” and “classes/clinicals.” Subscale 2, Research Attitudes, includes 4 questions; and Subscale 3, Clinical Experiences, relates to working with patients from diverse cultural groups in clinical practice and contains 4 questions. The reliability of the CAS is strong for General Attitudes and Research Attitudes (α = .80 and .89, respectively), whereas the reliability for Clinical Experiences is .70.¹⁰ Construct validity for the CAS supports its applicability to cultural awareness in nursing students.¹⁰ With permission, the CAS was modified to use athletic training–specific language. In addition, questions about general experiences with the school, instructors, or research were eliminated to focus on questions relative to the in-class activity. Rather than evaluating others, students were asked to evaluate their own thinking and beliefs. Therefore, the mCAS used in this study had 2 subscales, General Attitudes, which included 8 questions, and Clinical Experiences, which included 4 questions.

The postintervention survey consisted of retaking the mCAS with additional questions regarding enjoyment, benefits, and relatedness to real-world medical practice of the activity (Figure 1) using a 100-point Likert scale, with higher points reflecting more favorable outcomes. Preference for the activity over more traditional pedagogies and open-ended feedback were also collected. Preference for the GM activity over more traditional pedagogies was analyzed by asking participants, “If given the choice, which learning method(s) do you prefer?” Multiple options included (1) reading and discussing a graphic novel case, (2) reading and discussing a traditional case (paragraph form), (3) role-playing, (4) watching a video, (5) writing a paper, and (6) listening to a lecture.

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Procedures

Athletic training professors at Commission on Accreditation of Athletic Training Education–accredited institutions were recruited to facilitate the GM activity at their respective athletic training programs. Facilitators were recruited via a sample of convenience via email and word of mouth. Before the activity, a meeting with the lead author (LMC and facilitator explained the institutional review board (IRB)–approved study protocol. A letter of support from each institution was provided to the IRB. Facilitators agreed to spend 1 to 1.5 hours completing the activity and agreed that students would not be graded or forced to participate in the activity or surveys. Facilitators chose from four 4-panel GM strips. The general theme of each graphic narrative was exploring bias and stereotyping. “More Than Meets the Eye” discussed bias and stereotyping relative to appearance, “Disability = Adaptability” (Figure 2) discussed biases relative to people with disabilities, “Flag on the Play” discussed biases surrounding sexual orientation, and “Express Yourself” discussed gender identity and expression biases. Discussion questions and take-home points were provided for each GM to help facilitate a safe and brave discussion, but each facilitator was tasked with managing the discussion.

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The first 5 to 10 minutes of the activity began with students being invited to participate in the study by completing an online survey (Redcap), which included the IRB-approved informed consent form, demographic information, and the mCAS. The survey was integrated into the in-class activity, but students could opt out by not completing the online survey without penalty or affecting their grade. Names were not collected from participants; rather, self-selected codes were used to match preintervention and postintervention scores.

Next, the facilitator and students were asked to agree to group norms to cultivate a safe and brave environment, as described by Carlson et al.¹¹ After consensus on the group norms was achieved, the first narrative was projected for students to read silently. Then, facilitators spent 15 to 20 minutes leading a discussion on the interpretation of the GM, tying in how bias and stereotyping may impact patient care. Next, a second narrative was projected, and the discussion was repeated with a new storyline. Between 4 and 7 days after the GM activity, facilitators provided the postintervention survey, again inviting students to complete the survey to participate in the study without impacting student grades. The 4- to 7-day window was selected because the mCAS includes questions about clinical practice. Delaying the posttest allowed students to integrate and reflect on the lessons learned during the GM activity.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics (version 28IBM Corp). Descriptive statistics were computed for background variables and the Likert scale data. Paired-sample t tests were conducted to compare mCAS scores before and after the GM activity.

A 100-point Likert scale was used to evaluate enjoyment, benefit, and relatedness to real-world medical practice (Figure 1). To streamline the output for data analysis, the 100-point Likert scale was condensed to a 5-point scale (strongly positive [100–80], positive [79–60], neutral [59–40], negative [39–20], and strongly negative [19–0]).

Individual Survey Questions

When looking at individual questions of the mCAS scale, scores on 2 items significantly increased and scores on 2 items significantly decreased postintervention. The survey items with significantly increased scores were “I often reflect on how culture affects beliefs, attitudes, and behaviors” and “If I need more information about a patient’s culture, I would use resources available on site.” The survey items with significantly decreased scores were “I feel comfortable working with patients of all ethnic groups” and “I typically feel somewhat uncomfortable when I am in the company of people from cultural or ethnic backgrounds different from my own.” There are several reasons to explain our findings. The postintervention survey was taken 4 to 7 days after the GM activity. The intent of delaying the postsurvey (versus taking the survey immediately after the activity) was to allow students to reflect on the activity and resulting discussions. However, enough time may not have passed to allow students to begin implementing action relative to our topics, therefore resulting in only a limited impact on overall cultural awareness. When evaluating the language of the survey items that improved, participants expressed an increase in reflecting on cultural beliefs, attitudes, and behaviors and seeking additional information about a patient’s culture. These are promising signs that students are moving toward understanding how culture impacts patient care and how they would pursue learning more about people of a different culture than their own. When evaluating the language of the survey items for which scores decreased, participants expressed feeling uncomfortable working with patients of all ethnic groups or cultural backgrounds. After the activity, the students may be more aware of differences, making them feel uncomfortable so as not to make a mistake and offend patients of different cultural backgrounds. Also, there is a potential for unintended consequences from this activity to include making students more aware of biases and stereotyping, instead of embracing differences and encouraging gaining knowledge about cultural differences. Another possibility is that although students were not required to attend and participate in this activity, they may have felt pressure to participate, making this activity feel mandatory. When mandatory, DEI training can be accompanied by feelings of “blaming and shaming.”^17,18 In addition, the second question had double-negative language that may have been confusing to the reader, causing inaccurate responses.

Impact of Sex and Gender Identity

Female participants scored significantly higher on the mCAS scales compared with male participants both before and after the GM activity. All female participants self-identified as women. Female participants demonstrated a significantly higher preintervention Clinical Experience score versus male participants. Prior research suggests that female health care providers are more likely to possess patient-centered communication styles,^19,20 which may be more conducive to cross-cultural care.³ The mCAS Clinical Practice subscale incorporates questions regarding patient-centered communication, which may explain our findings. Educators should be aware that sex and gender cultural awareness differences may be present across a cohort, resulting in different student-centered needs.

Utility of GM

Learners in our study enjoyed and benefited from the GMs and found them to be relevant to real-world medical practice. Today’s learners possess elevated expectations concerning their educational experiences, given their considerable financial cost, personal sacrifices, and time and energy investment for advancing their education. Therefore, students need to be engaged in the learning process. Graphic medicine has several advantages as an active learning strategy, as it has been demonstrated to be preferred over more traditional pedagogies, such as lecturing, which agrees with our study that found 74% of participants preferred the GM activity over more traditional pedagogies.^8,15 Maatman et al, discussed earlier, reported 90% of participants found the activity enjoyable and 98% found the activity engaging, also in agreement with our study.⁸

As undergraduate athletic training programs give way to graduate programs, our cohorts may include adult learners. Adult learning theory, which was first introduced by Malcolm Knowles in the 1970s, illustrates the unique way adults learn compared with children. Adult learners thrive in educational settings that both celebrate creative thinking and support the freedom to explore ideas independently.²¹ Further, embracing creativity is vital for nurturing an ability to adapt, remain open-minded, and manage uncertainty.²² When learners participate in a more playful and relaxing educational atmosphere, they can tackle serious subjects with less severity. This lighter approach, modeled through GM, helps alleviate some of the stress associated with the need to constantly maintain a professional atmosphere.

Participants expressed a strongly positive or positive benefit from completing the GM activity, possibly because of their perceived connection to how this information relates to their medical practice. This may be explained by the very design of graphic narratives. Graphic narratives use both sight and mental imagery to portray a story, blending elements of visuals and written words. Readers practice perspective taking by reading the expressions of characters, identifying feelings, and interpreting how the words sound as these characters speak. This process can be a means for helping learners imagine differences. Perspective taking with GM is a safe way to help evaluate how a graphic character with a radically different point of view or set of life experiences might move through the world or approach a particular set of circumstances. Additionally, participants may find this activity beneficial and relevant because critical thinking skills are used by helping the reader move the story across the white spaces between 2 panels, called the gutter.⁶ The gutter is where human imagination takes 2 separate images and transforms them into a single idea.²³ Because our activity included self-reflection followed by group discussion, learners were given the opportunity to hear how others interpreted the gutter and discuss how a group of people can view the same images but interpret them differently.

Limitations and Future Research

One limitation of this study is that facilitators were selected via a sample of convenience, which may not represent the average ability of faculty to lead a discussion about bias and stereotypes. Intergroup dialogue suggests that facilitators should be trained for a successful learning experience for participants.²⁴ Our facilitators were not formally trained, which may have impacted our results. However, the goal of this activity is to make discussing difficult conversations easier. Facilitators were encouraged to only provide prompt questions and see in what direction the students took the discussion. They were also encouraged to say, “I don’t know,” allowing for the idea that facilitators don’t have to have all the answers because everyone is learning together and from one another.

Another limitation of the study is the ability to capture growth in cultural awareness. There is a wide variety of instruments, each with its own assumptions about what constitutes cultural humility.²⁵ We used the mCAS, but there were issues with the reliability of the scale, making it difficult to evaluate the construct of cultural awareness. Other studies have used the Cultural Competence Assessment,^5,26,27 the Transcultural Self-Efficacy Tool,²⁸ or the California Brief Multicultural Competence Scale,²⁹ among others, but there is no consensus on the best measurement tool for athletic training students. Continued efforts should focus on developing valid and reliable ways to measure cultural growth over time in athletic training students.

Future directions include expanding the GM activity to certified athletic trainers and preceptors. We would also like to make the activity available to athletic training education programs across the nation. Also, gaining formal insight from facilitators of this activity can provide valuable information on the ease of facilitating dialogue without fear of having to “have all the answers.” This activity may also expand into asking learners to create GM, as described by Green.³⁰