Background

Although acceptance of the Lesbian, Gay, Bisexual, Transgender, Queer or Questioning and others (LGBTQ+) population has increased in recent years, health disparities for LGBTQ+ individuals continue to exist [1, 2]. Disproportionate access to healthcare services among this population can be partially attributed to the lack of cultural competence among healthcare providers.

Lack of cultural competence has been found in the literature to be a significant barrier in providing appropriate gender affirming care [3–5]. To create a clinically and culturally responsive workforce, national organizations like the Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health have developed protocols to direct healthcare organizations in this regard [6]. As per the Health Quality Index report, only 36% of institutions that pursued organizational accreditation met the standards to be “LGBTQ + Healthcare Equality Leaders” [7]. Several LGBTQ+ advocacy organizations focus on education and training of healthcare providers. The Inaugural State of LGBTQ+ Health National Survey, administered by the National Coalition for LGBTQ+ Health (2022), highlighted the importance of integrating sexual health histories into routine clinical care and providing enhanced LGBTQ+ education, training, and support for healthcare personnel to deliver more personalized care [4]. The National Institute of Health, Sexual and Gender Minority Research Office also recommends mandatory inclusion of LGBTQ+ specific education for healthcare professionals to offer more individualized care and a more inclusive and welcoming environment to the LGBTQ+ population [8].

LGBTQ+ cultural competence training incorporates methodologies for healthcare providers and learners that include theory-driven, evidence-based, interprofessional, and multimodal approaches (1). More specifically, cultural competence training in health professions institutions underscore the importance of creating inclusive curricula and learning environments for the future healthcare workforce [9–12]. Within the last five years, there has been an increased emphasis on four main constructs of LGBTQ+-focused cultural competency training programs among healthcare professionals: knowledge, skills, behavior, and attitude [1, 13]. In some regions, such as Washington, DC, LGBTQ+ competence training is even required by law for renewals of healthcare providers’ licenses [14].

While there have been sporadic efforts to enhance LGBTQ+-specific education in healthcare curricula, there remains a gap in literature exploring the integration of an interprofessional perspective with LGBTQ+ instruction. Literature notes dental students report little interest in formal LGBTQ+ health education which may be attributable to the minimal exposure dental students receive as part of their training [14]. Dental students also report inadequate resources and support, as well as insufficient LGBTQ+ specific information at dental schools [15]. However, implementing LGBTQ+ competency training in dental education has been shown to improve implicit and explicit biases among future oral health care providers. Salter et al., focused on clinical cultural competency training for dental students using the Lesbian, Gay, Bisexual, Transgender Development of Clinical Skills Scale (LGBT-DOCSS), and found an increased feeling of clinical preparedness in treating LGBTQ+ patients, decreased bias toward LGBTQ+ patients, and increased knowledge of health disparities in the LGBTQ+ population after students were able to complete the training [16]. Another systematic review focused on training in dental, medical and nursing residents showed bias-focused educational interventions were effective at increasing knowledge; experiential learning interventions were effective at increasing comfort levels; and intergroup contact was effective at promoting more tolerant attitudes toward LGBTQ patients [9].

This study used a novel interprofessional model of three different LGBTQ+ focused educational interventions within a group of dental and pharmacy students. Therefore, the aim of this study was to evaluate the impact of the model in improving cultural competence and clinical preparedness among dental and pharmacy students for providing LGBTQ+ specific care.

Methodology

Results

Since portions of this project were voluntary, many students did not participate in all three interventions. For this article’s purpose, we included data relevant to each intervention.

“S1 Fig” shows the number of students participating in each of the interventions.

This study included 154 students who participated in the ECHO sessions. The participant population is described in “Table 1”. The majority were enrolled in the PharmD program (86%); the median age of the participants being 22 years, with an interquartile range from 21 to 32 years. Most participants identified as White (67%) and were not of a Hispanic (94%) origin. In terms of sexual orientation, the predominant group was straight (heterosexual) individuals, constituting 82% of the sample with 63% of the participants identifying as cisgender female.

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Table 1. Demographic characteristics of the study participants.

https://doi.org/10.1371/journal.pone.0313492.t001

LGBTQ+ inclusivity in climate and curriculum at the educational institution

“Table 2” presents different aspects of climate and curricular inclusivity at the educational institution. Most students (54%) agreed that their school had processes or mechanisms to address gender discrimination and to help patients address such discrimination. Less than half (40%) agreed the LGBTQ+ community was well represented and part of all conversations within the institution. When asked about the total hours dedicated to LGBTQ+ specific instruction, more than a third (38%) reported 3–5 hours; with lectures and presentations being the most common method of instruction (35%).

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Table 2. LGBTQ+ inclusivity in climate and curriculum at the educational institution.

https://doi.org/10.1371/journal.pone.0313492.t002

Learning on topics in health equity

86% of dental participants agreed on the importance of learning about stigma before the ECHO sessions which increased to 94% after the intervention (p = 0.7). These results contrasted with pharmacy participants in that 75% of participants were interested in learning about stigma before the intervention, which decreased to 65% post-intervention (p = 0.061). Similarly, 86% of dental participants agreed on the importance of learning about cultural humility pre-intervention, increasing to 94% post-intervention (p = 0.7). This change was much smaller for the pharmacy participants, increasing from 75% to only 76% post intervention (p = 0.7). None of these changes were statistically significant “(Table 3)”.

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Table 3. Learning on topics in health equity.

https://doi.org/10.1371/journal.pone.0313492.t003

Participation in gender health clinic experiential activities and iOSCEs

A total of 19 dental and 2 pharmacy students completed the AITCS-II (Student) survey which was distributed post participation in the gender health clinic experiences and the iOSCE. Seven (7) out of these 21 students completed both the above activities while 12 attended the gender health clinic only and 2 participated in the iOSCEs only.

Students participating in gender health clinic experiences (n = 12) generally had higher mean scores on all aspects than those that participated in iOSCE (n = 2), except for teamwork. However, these differences were not statistically significant. Similarly, students involved in both activities (n = 7) had higher mean scores than those in a single activity, but again, the differences were not statistically significant “(Table 4)”.

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Table 4. Comparison of mean scores by activity.

https://doi.org/10.1371/journal.pone.0313492.t004

Dental students (n = 19) perceived better cooperation, partnership, teamwork, and coordination within their teams compared to pharmacy students (n = 2). However, these differences were not statistically significant. Thus, the type of program did not significantly impact these aspects of team dynamics “(Table 5)”.

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Table 5. Comparison by degree.

https://doi.org/10.1371/journal.pone.0313492.t005

As per the results from TOSCE “(Table 6)” descriptive statistics indicated that one of the teams, (Team 3) performed the best out of the three teams, performing above expected in five of the six competencies and an above expected Global Rating. Overall, each team and member performed at or above expected in the Team Functioning competency. Kruskal-Wallis tests determined a significant difference in the Team scores for Roles and Responsibilities (p = 0.039) and Patient Centered Approach (p = 0.039). A moderate difference was found between Teams 1 and 3 in these two categories based on the pairwise Wilcox Test (p = 0.074).

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Table 6. Median TOSCE scores by category.

https://doi.org/10.1371/journal.pone.0313492.t006

No significant differences were found in individual scores by the Friedman Test, implying all students w ere performing at the same level and the educational content was received effectively by this group of participants (p = 0.18).

Discussion

The study results align with broader trends in literature that indicate a growing but uneven commitment to LGBTQ+ inclusivity and education in educational institutions. While progress is being made, especially in providing training and affirming spaces, there remain significant gaps in representation, explicit mission alignment, and comprehensive educational offerings on LGBTQ+ issues.

The study results did indicate a majority of the respondents believed having received some training or instruction specific to LGBTQ+ content at their institution, which compares to research by Sharma et al. (2021), while many healthcare education programs include some level of LGBTQ+ related training, the depth and comprehensiveness of this training often vary [26]. Comprehensive training is crucial for improving the quality of care provided to LGBTQ+ patients [26]. Although there is no ideal way to train future oral health providers, at a minimum, complying with the standards of Commission on Dental Accreditation requires delivering content on the following topics: 1. Sexual orientation, gender identity, and LGBTQ+ terminology 2. Health needs and risks 3. The potential impact of LGBTQ+ related discrimination on health inequities 4. Provision of inclusive care [11]. Similarly, the Accreditation Council for Pharmacy Education (ACPE) Standards require pharmacy graduates be able to 1) describe how population-based care influences patient-centered care and the development of practice guidelines and evidenced-based practices; and 2) recognize social determinants of health to diminish health disparities and inequities in access to quality care [27].

The literature on LGBTQ+ experiences in professional education predominantly addresses the medical environment. Per a report published in 2014 by the Association of American Medical Colleges (AAMC) Advisory Committee on Sexual Orientation, Gender Identity, and Sex Development, 30 competencies within 8 domains to address the needs of LGBTQ+ patients in medical education were recommended [28]. These competencies are built within eight existing competency domains: 1. Patient Care 2. Knowledge for Practice 3. Practice-Based Learning and Improvement 4. Interpersonal and Communication Skills 5. Professionalism 6. Systems-Based Practice 7. Interprofessional Collaboration 8. Personal and Professional Development. The intervention, being one of the few addressing both dental and pharmacy education curricula with its multi-intervention approach, touched upon all the above-mentioned recommended domains. Per a recent systematic review, majority of studies exploring inclusion of LGBTQ+ specific content in medical curriculum involved preclinical interventions [29]. Our program offered both preclinical and clinical interventions in the form of ECHO sessions which focused on didactic topics and case discussions, followed by interactive observational experiences with patients from the LGBTQ+ community and the iOSCE sessions that included simulated patients and providers representing the LGBTQ+ community.

The ECHO survey results align with literature in highlighting that while lectures and presentations are the most common methods for teaching LGBTQ+ content, there is growing recognition of the value of more interactive and diverse teaching methods. The hours of instruction reported in the survey reflect a range that is consistent with findings from a recent systemic review by Yu et al. (2023), who advocate for more extensive and comprehensive training [12]. Interactive sessions and small group discussions have been also found to be particularly effective for engaging students and facilitating deeper understanding, although these methods were less commonly reported in the survey [30, 31]. While both programs showed shifts in attitudes toward learning more about stigma and cultural humility, the trends observed in the dental and pharmacy programs differed in magnitude and direction. This difference likely indicated a desire by dental students to continue to learn more about these topics as they progress in their education and training, but pharmacy students appeared to be content with where their knowledge was related to these topics at that stage in their education. ECHO survey results also showed most students agreed their school provides the spaces and infrastructure for gender affirming practices. Research by Keuroghlian et al. (2017) shows that affirming environments, including visible support materials, significantly enhance the well-being and academic success of LGBTQ+ students [32].

Our study also indicated improved interprofessional collaborative outcomes, especially for dental students. This aligns with study conducted by Prasad et al. (2023), that suggested that an interprofessional case-based learning approach for students across different healthcare professions significantly enhanced cultural competence to provide collaborative and standardized care for LGBTQ+ individuals [33]. Collaborative health care teams are found to be leading to increased quality of patient care, safety, and positive outcomes; reduced health care costs; and greater satisfaction among patients and providers [34, 35]. Students that participated in both clinical experiences and iOSCEs had better scores than those that participated in only one. While the differences were not statistically significant, the higher mean scores suggest that participating in multiple activities may enhance specific team dynamics and planning processes, likely due to increased exposure and interaction in diverse settings. The literature supports the importance of clinical rotations in building interprofessional team-based care skills [36].

Significant improvements in participants’ collaborative skills and knowledge related to LGBTQ+ health equity post cultural competence training was noted by a study by Leslie et al,. These findings complement our study where the educational model did improve the cultural competence for the participants, especially with respect to treating patients from the LGBTQ+ community [37]. Our multipronged approach aligned with studies like the one by Sekoni et al. (2017) which demonstrated significant improvements in knowledge, attitudes, and clinical skills related to LGBTQ+ health among healthcare students and professionals following targeted educational curricula and training, particularly emphasizing the effectiveness of experiential learning methods and the need for ongoing education to sustain these improvements [11]. While it is ideal for students to be able to get clinical experiences specific to the care of LGBTQ+ patients, getting students in these settings can be logistically difficult. If these experiences were not available, the results of this study show that directed education related to LGBTQ+ care can still lead to improvements.

Findings from the TOSCE align with existing literature on team-based clinical assessments, emphasizing the critical role of effective teamwork and communication in achieving superior performance outcomes [38]. The observation from study results (Table 6) indicates that Team 3, scored high (3) in all domains which aligns with the evaluators positive feedback about effective handoffs, clear roles, and a strong rapport with the patient. This resonates with studies highlighting the impact of cohesive team dynamics leading to better performance in clinical settings [39]. Team 1 displayed effective listening and teamwork skills which is consistent with their median TOSCE score of 2.5 in communication and collaboration categories. Though these scores were not the highest, the evaluators highlighted the team’s effective listening and collaborative skills. Additionally, the identification of individual performance discrepancies within the team highlights the significance of individual contributions within a team context, reflecting broader literature on teamwork and collaboration in healthcare [40]. For instance, in Team 1, even though communication and collaboration scores were moderately high (2.5), other categories were scored low (2) which could be due to inconsistencies in how each individual in the team contributed to the team’s performance. The significant differences in scores for patient-centered care across teams, underscore the importance of patient-centered approaches in contemporary healthcare delivery models, emphasizing the need for targeted interventions to optimize patient outcomes and satisfaction [41, 42]. Overall, the feedback from evaluators indicated that although the team members displayed empathy for the patients, there was still room for improvement in terms of cooperation and including patient’s social determinants of health in patient care. This is supported by literature suggesting that improving patient outcomes when addressing social determinants of health is essential with a collaborative approach in addition to efficient communication [43, 44].

The positive feedback about the year-long intervention from student participants supports the usefulness of such programs and serves as an example for educators to look for opportunities to include this type of focused education and training in their curricula. In a similar study by McCave et al. (2019) an interprofessional simulation training was implemented for 2 years, and 90% of the student participants felt the training prepared them better in the interprofessional competencies [45]. Future studies should evaluate long-term retention of LGBTQ+ cultural competence trainings across diverse student body at multiple healthcare institutions, measure its impact and its practical application in clinical settings [45]. Supporting our work, recent studies like the one by Bass et.al reaffirm that, better patient outcomes for LGBTQ+ patients are achieved when providers use inclusive language, understand specific healthcare risks, and offer tailored, knowledgeable care [46]. It’s important to note that our study, like several studies, measured the impact of the program by using pre and post surveys, however program effectiveness measurements without long-term evaluation is still fragmented [46, 47]. Further evaluation of the long-term program impact should be explored with future studies [46, 47]. Also, since this intervention was offered only once as an elective course, the impact of the educational interventions should be reviewed by offering such programs more frequently in the curriculum [46, 47].

Conclusion

This program was a novel intervention that aimed at improving cultural competence for health professional students in an interprofessional environment. Further research in the direction can be useful in creating replicable models. Health professions programs offer a unique opportunity to shape the future healthcare workforce. With them embracing diversity, equity and inclusion, specific to LGBTQ+ instruction, significant improvements in health equity for this vulnerable group can be expected.

Supporting information