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Article

A course designed for undergraduate biochemistry students to learn about cultural diversity issues

Authors

  • Marilee Benore-Parsons

    Corresponding author
    1. Department of Natural Sciences, University of Michigan at Dearborn, Dearborn, Michigan 48128
    • Dept. of Natural Sciences, University of Michigan at Dearborn, 4901 Evergreen Rd., Dearborn, MI 48128
    Search for more papers by this author

Abstract

Biology, biochemistry, and other science students are well trained in science and familiar with how to conduct and evaluate scientific experiments. They are less aware of cultural issues or how these will impact their careers in research, education, or as professional health care workers. A course was developed for advanced undergraduate science majors to learn about diversity issues in a context that would be relevant to them, entitled “Diversity Issues in Health Care: Treatment and Research.” Learning objectives included: developing awareness of current topics concerning diversity issues in health care; learning how research is carried out in health care, including pharmaceutical research, clinical trials, and social research; and learning about health care practices. Lectures and projects included readings on laboratory and clinical research, as well as literature on legal, race, gender, language, age, and income issues in health care research and clinical practice. Exams, papers, and a service learning project were used to determine the final course grade. Assessment indicated student understanding of diversity issues was improved, and the material was relevant.

Biochemistry and biology majors graduate with the knowledge and skills necessary to begin careers in research or enter into fields such as health care. However, they know very little about, and have less appreciation of how, the diversity of the human population will impact their work. This is in large part due to the highly structured and difficult coursework they must take to complete their undergraduate education. There is often not time for science students to consider classes such as gender or cultural diversity unless they are required. Currently, cultural diversity is rarely a topic in biochemistry and chemistry courses, although species diversity is a fundamental part of a biology curriculum.

The term “diversity” is usually considered part of a mechanism to train and recruit minorities to generate a diverse workforce. (Unfortunately, for some, diversity has developed a negative connotation as administrative and political mandates require efforts deemed as annoying, unnecessary, and unfair.) Those issues, although important, are not the basis for this course, which has a different aim. This course is designed so that students understand the broad ramifications as well as potential limitations of their work [1]. Diversity training is already required in many professional fields, such as medicine, and in volunteer positions, such as scout leadership, so it is important to also incorporate it into undergraduate education [2].

There are several reasons students should learn more about cultural diversity. Our students will be better citizens if they understand these issues and how they will impact their lives, work, and research. An appreciation of how research is performed in other areas such as social science is necessary for science students to be able to communicate and work effectively with other researchers, as indicated in the document Bio2010 [3]. Students must be prepared to enter the workforce and be able to succeed in an interdisciplinary teamwork approach. Laboratory, clinical, and managerial positions will all require an understanding of how to work in a diverse workplace. Finally, many research grants require considerations about gender, race, and age [4].

A course on diversity issues was developed so that biochemistry students could learn about cultural diversity in a course that was relevant to their major and simultaneously reinforce their biochemical knowledge by placing it in a case-oriented context. Topics included gender, age, race, culture, income, and religion. We did not spend time discussing the philosophical arguments of defining the various categories but focused on how differences and inequities impacted scientific research and health care.

COURSE DESCRIPTION

The following section was used to support the rationale for a course that met the university's requirement for a three-credit diversity course that could also be used as a general upper division science requirement. To satisfy both diversity and science stipulations, specific goals were included in the rationale. Prerequisites required that students be juniors or seniors and have completed the introductory biology courses for science majors [5].

INFORMATION REQUIRED FOR COURSE APPROVAL

Course Description—

This course addresses the effect of race, age, gender, religion, and economic status on medical research and health care. Students will learn how medical research is performed in the United States and what health care treatments and options for patients are available. Medical treatment and disease topics will be selected and will be evaluated as to how they are influenced by the criteria listed. The examples will focus on both cultural differences and inequity, in national and global settings.

Rationale—

This course will allow students to examine issues in diversity on a topic that is of particular interest to them: health care. Diversity issues are an important part of medical research and training and are currently a primary focus of the American Medical Association and scientific research societies. The focus will be on both cultural diversity and inequity and will examine national and global issues.

The students need to learn how research is done and how treatments are developed within the scientific and legal community. They will learn that the research design is not easy as many cultural and other differences arise that are not immediately obvious. They will also learn about bias and inequity in the research, such as when certain groups are deliberately ignored by study groups or excluded for scientific or safety reasons. Students will evaluate for themselves whether cultural differences or inequities compromise patient care or whether cultural statutes affect medical diagnosis and prescribed treatment.

Students will examine the literature of clinical trials and case studies. Statistical analyses will be used to help evaluate whether cultural differences or inequity compromises patient care or whether cultural statutes affect medical diagnosis and prescribed treatment.

Learning Methods and Objectives for Achieving Them—

The overall course goal is to raise awareness of cultural differences, as well as issues concerning inequity and bias, in research, diagnosis, and treatment in health care. Although the focus will be national, issues of cultural diversity will require examining the history of cultural practices in health care, lending a global perspective. Students will be taught theory of research design and medical practice, examples will be discussed, and individual projects will be assigned for research and critical evaluation.

At the end of the course, students should be able to demonstrate:

  • Knowledge of the process of medical research, epidemiological studies, and drug development.

  • An understanding of how medical treatment options are chosen by physicians and presented to patients.

  • An ability to critically evaluate research and treatment choices and to be able to identify inequity due to gender, age, religion, race, economic status, or cultural differences.

COURSE TOPICS AND FORMAT

No text was available, and internet searches revealed that there were few courses coupling biochemistry and cultural diversity, although similar courses existed in nursing programs. Discussions with physicians, social workers, clinical researchers, and faculty teaching cultural and gender courses and others, as well as internet research on courses in diversity in health care and personal experience teaching gender and health, formed the basis for topic selection.

A variety of web sites, reviews, research articles, and case studies were utilized in lieu of a text. The aim was to learn about the diversity topics combining reading and lectures on science and clinical research, with extensive time to understand and discuss the impact of the topics on research and health care.

Lecture topics required extensive introduction to the material. The science of the health issue was presented in lecture format, and relevant web sites and/or articles were assigned for reading and discussion. The level of topics presumed that students understood biochemistry at an undergraduate level, and lectures introducing topics used resources taken from undergraduate and graduate texts in biochemistry and biology as well as medical texts. (See Tables I and II for detailed topic examples.) After the science was understood, the health issues, treatment, and research were discussed. Assignments included short essays, group discussions, assigned interviews and data collection, and class presentations.

Group discussion is an important part of this course. To facilitate discussions, students were often assigned, in teams, to present parts of lectures or to be team leaders. In many instances, the expertise of students was drawn upon to facilitate discussion. For example, students with more coursework in psychology and statistics were able to explain the significance of certain studies or to discuss typical treatments for psychological disorders. Students who worked in pharmacies had input about drug costs and patient needs related to the new prescription drug law.

Following are the types of topics covered, with some web site links and references to a few of the research papers used. (Some of the topics were in response to student's interests and their personal and family experiences.)

Introduction

  • Introduction to healthcare equity terminology [6].

  • Discussion and comparison of laboratory and clinical research.

  • How to develop drugs for a specific disease or illness, carry out clinical trials, and bring the therapy to market [7–9].

  • The impact of the Human Genome Project, single nucleotide polymorphisms, and genetic diseases on pharmacogenomics and health care research and treatment [10–12].

Gender Issues

  • The Women's Health Initiative. This ongoing and huge study, begun 15 years ago, was an excellent resource to examine cutting edge issues in how health care, laboratory, and clinical and social research mesh [13].

  • Other government research and trials to study disease and infection in women [14].

  • African-American men and myths about lung cancer therapy [15].

Legal Issues

  • Legal issues about the rights of consumers and the obligations of health care providers with respect to linguistic and cultural competence [16–18].

  • NIH11 research requirements for diversity in laboratory and clinical research [4].

  • Prisoners/inmates (the only group guaranteed medical coverage by the federal government through the 8th amendment) [19].

Age Issues

  • Ethnogeriatric studies [20].

  • Alzheimer disease.

  • Prescription drug laws.

  • Women's Health Initiative [13].

Race, Ethnicity, and Culture

  • Diabetes and statistics related to various American minority groups.

  • NIH-Pima Indian project [21].

  • Genes impacting disease susceptibility and predisposition (mental illness, AIDs, diabetes).

Global Issues

  • AIDS/HIV in a global setting [22].

Financial Issues

  • The Oregon Health Plan [23].

  • Medicaid/Medicare program.

  • Social services and mental health care options for citizens living in poverty.

Myths and Alternative Therapies

  • Research papers on myths and how they interfere with and limit care [15].

  • Alternative therapy and non-Western treatments.

Guest Speakers

  • A deaf science faculty member described the ordeals and successes he had as a deaf individual in the community, in schools, and in scientific research and professional interactions in the workplace.

  • A social worker addressed the impact of poverty on social and psychological care and treatment and presented case studies.

  • An M.D./Ph.D. researcher discussed research on the leptin receptor and its impact on obesity and health.

  • A visiting scholar from Africa discussed the social implications of HIV, particularly the impact on young women, in Africa.

As expected, many issues span several areas in diversity. For example, the AIDS epidemic can be evaluated by race, gender, age and poverty, social behavior and responsibility, and myths and legal issues, in both global and national settings (Table I). The laboratory and clinical research, drug development, and treatment and educational dissemination can all be discussed. Students were required to “design” a drug target and propose a mechanism to study effectiveness based on their understanding of how the virus gained cell entry and replicated. Financial resources, including private and government funds, and limitations on aid as determined by political issues such as abortion and AIDS were included. (Interestingly, this was one of the areas in which students were divided, with many students believing that care should be determined by the way the disease was contracted, with risky lifestyle choices negatively viewed and those patients deemed as less deserving of support.) Each student was assigned a country to research and had to make an information sheet about the incidence of AIDs in that country, including a map and other vital information about politics and treatment; these mini-posters were all discussed in class and assembled in a collage for public display.

Similar topics were explored studying other diseases, such as diabetes. Students learned about metabolic processes, including glucose regulation, and the role of insulin and glucagon through lectures and reading review articles. Student teams were assigned American minority groups to study, including Asian/Pacific Americans, African-Americans, Hispanics, and Native American Indians. They studied genetic predisposition as well as the cultural issues that caused increases in the disease. In studying Alzheimer disease, students read OMIM articles that connected possible genetic linkages with the disease. Each student was assigned a drug in clinical trial and had to present to the class the drug, the category, and the mechanism of action (if known).

It was apparent that many students were unaware of what prejudice and racism meant, and many perceived themselves as being “victims” of affirmative action. We used the exercise developed by Peggy McIntosh, “White Privilege: Unpacking the Invisible Knapsack,” to explore privilege and racism [24], using this understanding to move into discussions about what situations might lead to inequity in health care.

ASSESSMENT OF STUDENT PERFORMANCE

Students in this course were all undergraduates, with declared majors in biochemistry, biology, chemistry, and social sciences. Career goals included medicine and other health care professions, research, and social work. Grades were determined by exams, assignments, class discussion, a service learning project, and a research paper. Homework assignments were assigned and collected, and students were required to participate in class and bring in relevant news articles to post and share.

The service learning project (worth 10% of the grade) was a semester-long project. The project had to be related to the course goals and had to be something “new,” not a current volunteer project in which the student was already participating. Oral progress reports were presented mid-semester, and a final written report was turned in the last week. Some students chose and carried out excellent projects, whereas others did perfunctory work (such as make copies of handouts for clinics). Good examples included:

  • Organizing a seminar for college students on the cardiovascular health of young adults.

  • Flyers and educational literature written by the student and distributed to the community. Topics included the dangers of tanning, proper diet and nutrition, the hazards of accutane, the dangers of smoking the arghila (hookah), and the prescription drug program.

  • Fund-raising and developing educational awareness information for shelters and for cancer prevention and patient support.

  • Becoming a translator for the deaf and Arabic-speaking patients in emergency rooms.

  • Scientific updates and references added to Wikipedia. (en.wikipedia.org/)

A 10-page research paper on a topic related to diversity was written over the course of the semester. Deadlines included choosing a topic (first month), a full annotated literature search (second month), a rough draft (third month), and the final paper due (with all reference papers collated in a binder) the last week of the course.

Exams were primarily essay. Questions combined scientific information and social issues. One question was designed to determine student ability to read and interpret science policy essays; an article by Lewis Thomas on ethics and science and health care was selected, and students were graded using a rubric [25].

OUTCOMES AND STUDENT ASSESSMENT

Overall, the course was successful in meeting its objectives. Students reported better awareness of health issues and understanding of clinical and social research and how they impact health care and research. Students learned about the “big picture” of clinical research, as well as how other issues (gender, age, scientific myths, legal issues, and poverty) will impact their research and health practices. In some cases, the information was stunning to them, as revelations about our health care systems and patients' use and response to systems was explored. The emotional influence of patient attitude, family intervention, legal ramifications, and communication issues was surprising to many students.

A number of challenges had to be overcome as shown below.

  • Students did not understand the terminology used in social science papers and research.

  • Students did not believe (initially) that social and clinical research is as valid as laboratory research.

  • Students were shocked and dismayed by the potential barriers to proper health care.

  • Students had a difficult time outlining the major steps necessary to address major health issues.

This last issue is not inconsistent with the difficulty observed in science classes, when students are required to propose research plans. They had a difficult time understanding how to go about evaluating and coordinating the scientific, social, behavioral, and research issues necessary to make changes. For example, in a group exercise, teams were asked to determine what steps were necessary for treating a major health care issue such smoking or obesity. Students had to understand the health problem, cause of the disease, and social and medical factors influencing the issues, and once those were established, they had to outline a strategy that encompassed the medical and psychological treatment plans, consumer education, and basic (drug development) and clinical (evaluation of programs) necessary. This big picture problem was difficult for many to solve without extensive guidance.

Student assessment of the course was positive. In addition to the end of semester evaluations, a survey was sent to all students 18 months following the end of the course after the first course offering in 2003 to determine whether they still felt positive about their experience and to determine whether some of the course objectives were met. (A sample survey is shown in Table III.)

Many (nearly 50%) of the students returned the survey. On a scale of 1–5, with a 1 indicating strong agreement, the scores indicated that students found the material relevant (1.2) and would recommend it to other students (1.2) They reported that it integrated scientific principles and diversity topics (1.4), that the course changed the way they think about diversity and health care issues (1.3), and that it increased their awareness of diversity issues (1.4). They agreed that they would be able to use and apply the course material in their professional career (1.3). Comments indicated that discussions, speakers, women's health topics, and the process of drug discovery and development were interesting. The only negative comments included one from a student who did not like service learning and from a student who did not want to learn about the diseases, only treatments. Many listed topics that surprised them, of which they were previously unaware (women's health, prison rights, legal issues). One was grateful that in an undergraduate class, they were able to discuss science and politics, something that they rarely encounter as undergraduate students. Specific comments on course evaluations and survey included:

“This class has been one of my favorites … I think that it should be made a requirement for ”Pre-Med“ students … It was truly a great experience.”

“The class was indeed fun, entertaining, informative, and educational. I walked away with a much better understanding of my society, particularly healthcare … ”

RIGOR AND ADAPTABILITY

The University of Michigan-Dearborn campus initiated the diversity requirement in 2002, and thus students are just beginning to fulfill the requirement. Initially, the course drew about 20–25 students, and these students were not required to have the course but were simply interested in the topic. Similar numbers took the course in 2005, and the course is offered in alternate years due to faculty availability. Students entering as freshmen in 2003 would not have the required junior status until 2005 or 2006, so we expect to see an increase in student numbers. A large number of courses are options for the diversity requirement; however, this is the only science course. Students are allowed to use a diversity course toward their degree requirements; thus “double-dipping” is allowed.

The students enrolled in this course were typical of the science student population at UM-Dearborn. Although we have few Hispanic or African-American students, over half of our students are of Arabic descent as our metropolitan area is home to the largest Middle-Eastern population in the U.S. Therefore, nearly half the students were of Indian or Arabic descent, with many of these “first generation” or immigrants.

The course rigor for students at this level was determined to be appropriate for students with experience in upper division courses such as biochemistry, cell biology, genetics, or microbiology. Biochemistry majors are required to take upper level math or statistics, but not all students in the course were familiar with statistics. Lectures contained supplemental information as needed for students to understand and interpret research papers. As an example of the rigor, it should be noted that students used research databases such as the National Center for Biotechnology Information (NCBI) OMIM data base [10]. For illustration, as part of the discussions on HIV and AIDS, we examined the history of the disease and polymorphisms in genes that are linked to reduced susceptibility to acquiring disease while we covered the details of viral entry via the host cell receptor CD4 protein.

Although this class is designated for upper division students, it is possible that similar courses could be developed for freshman seminar-type courses. If the level of rigor were lowered and more review articles were assigned, it could serve as an excellent introduction to health studies at the interface of social and science research. There are numerous government web sites that contain an abundance of information linked to social aspects and scientific research that could be used.

SUPPLEMENTAL INFORMATION

The course syllabus, UM-Dearborn course description, link to the UM-Dearborn diversity requirements, and other information can be obtained by writing to the author at mparsons@umich.edu or at a link from the author's home page at this web site: www-personal.umd.umich.edu/∼mparsons.

  • Descriptions of AIDS (acquired immune deficiency syndrome), ARC (AIDS-related complex) and HIV.

  • Information about HIV and how the virus causes AIDS.

  • History of the disease and its spread.

  • Pharmacology and treatments.

  • The cost to cure AIDS.

  • Politics influencing AIDS research and treatment (government, religious, and gender issues).

  • National and global efforts to cure this disease (prevention and eradication).

  • Confusion and myths about the disease and the cause of HIV.

  • Assignment: Each students was assigned a country and had to research AIDS in that country: prevalence, treatment, and other statistics.

  • Genetics: Genes and DNA polymorphisms related to disease resistance studied.

  • WHI project [13]

    What is it? Why was it done?

    Who was involved?

    What agencies are involved?

    What is being tested

  • Basic biochemistry

    What are estrogen and progesterone? How many types are there?

    How are they related to other steroid hormones?

    How do steroid hormones function (biochemistry and physiology)?

    Why do steroid hormones influence so many cells and tissues and the regulation of so many genes?

  • Clinical science

    Recruiting subjects for studies.

    Types of data being recorded.

    Observational data versus active laboratory and clinical research and treatment.

    Time course of the study.

    Number of centers and studies.

  • How is the treatment of a major disease organized?

    What are the options to improve health (education, prevention, interference, medications, gene therapy, etc)?

  • NIH research guidelines and laws

    Legislation and guidelines for research.

  • Pervasive myths

    What are some of the myths about women's health [26]?

    How to determine if a myth is widespread.

    How to dispel myths.

  • Evaluation of results

    Study results using research papers studying hormone mechanism of action.

    Study clinical results by using WHI to link to clinical research papers [26, 27].

Rate each of the following statements on a scale of 1–5, with 1 being in strong agreement and 5 being in strong disagreement.
  • 1The course material was relevant to current issues in diversity and health care.
  • 2This course effectively integrated scientific principles with topics involving diversity.
  • 3This class has changed the way I think about issues involving diversity in the health care system.
  • 4I will use some of the material that I learned in this course and apply it in my professional career.
  • 5This course made me more aware of diversity issues in general.
  • 6I would recommend this course to others.
Please answer the following questions.
  • 1What topics covered during the semester were of most interest to you? Least interest?
  • 2Were there any topics that you found surprising? What topics, and why were they surprising to you?

Acknowledgements

I thank Karole Kuslack, Creigh Milford, and Christopher Maksimovski for literature research used to develop case studies.

Footnotes

  1. 1

    The abbreviations used are: NIH, National Institutes of Health; OMIM, Online Mendelian Inheritance in Man; HIV, human immunodeficiency virus; UM, University of Michigan.

Ancillary

Article Information

DOI

10.1002/bmb.2006.494034052631

Format Available

Full text: HTML | PDF

Copyright © 2006 International Union of Biochemistry and Molecular Biology, Inc.

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Publication History

  • Issue online:
  • Version of record online:
  • Manuscript Revised:
  • Manuscript Received:

Funded by

  • Office of the Dean, College of Arts Sciences and Letters, University of Michigan at Dearborn
  • ASBMB National Meeting in San Diego

Keywords

  • Cultural diversity;
  • health care;
  • interdisciplinary course

REFERENCES

  • 1Office of Minority Health; available on-line at !www.omhrc.gov.
  • 2Women's Health Care Competencies for Medical Students; available on-line at wheocomp.apgo.org.
  • 3 Bio2010 Transforming Undergraduate Biology Education for Future Research Biologists (2003) Committee on Undergraduate Biology Education to Prepare Research Scientists for the 21st Century, National Academies Press, Washington, D. C.
  • 4NIH Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research; available on-line at grants.nih.gov/grants/funding/women_min/women_min.htm.
  • 5University of Michigan at Dearborn Course Catalog; available on-line at www.umd.umich.edu.
  • 6B. L. Lewis, F. D. Parent (2001) in Healthcare Equity, in Handbook of Clinical Sociology (Howard M.Rebach, J. G.Bruhn, eds.) Second Edition, pp. 293–312, Kluwer Academic/Plenum Publishers, New York.
  • 7Pharmafocus; available on-line at www.pharmafocus.com.
  • 8D. Morgan (1990) Primer offered for scientists bringing drugs to market, The Scientist4, 7.
  • 9Obesity Meds and Research News; available on-line at www.obesity-news.com.
  • 10NCBI Science Primer, Books, OMIM, Pub Med; available on-line at www.ncbi.nlm.nih.gov.
  • 11S. B. Haga, J. C. Ventner (2003) Genetics: FDA races in the wrong direction, Science25, 466.
  • 12Center for Disease Control; available on-line at www.cdc.gov.
  • 13Women's Health Initiative; available on-line at www.nhlbi.nih.gov/whi.
  • 14Society for Womens' Health Research; available on-line at www.womenshealthresearch.org.
  • 15M. L. Margolis, J. D. Christie, G. A. Silvestri, L. Kaiser, S. Santiago, J. Hansen-Flaschen (2003) Racial differences pertaining to a belief about lung cancer surgery, Ann. Intern. Med.139, 558–563.
  • 16Kaiser Family Foundation; available on-line at www.kff.org.
  • 17Diversity Rx; available on-line at www.diversityrx.org/HTML/LEGAL.htm.
  • 18Bridging Language Barriers in Health Care, California Immigrants Surveyed in Multiple Languages on Language Access in Health Care; available on-line at www.medmall.org/∼landon/BridgingLanguage/bridginglanguagebarriers.htm.
  • 19H. Haft (2003) Is health care a right or a privilege? -Health policy, Physician Executive29, 26–29.
  • 20Curriculum in Ethnogeriatrics, Core Curriculum and Ethnic Specific Modules; available on-line at www.stanford.edu/group/ethnoger.
  • 21The Pima Indians, Pathfinders for Health; available on-line at diabetes.niddk.nih.gov/dm/pubs/pima/index.htm.
  • 22The Joint United Nations Programme on HIV/AIDS, UNAIDS; available on-line at www.unaids.org.
  • 23L. Jacobs, T. Marmor, J. Oberlander (1999) Report from the field, The Oregon Health Plan and the political paradox of rationing: What advocates and critics have claimed and what Oregon did, J. Health Polit. Policy Law24, 1–27.
  • 24P. McIntosh, White Privilege: Unpacking the Invisible Knapsack; available on-line at www.wcwonline.org/seed/unpacking.html.
  • 25L. Thomas (1992) Obligations, The Fragile Species, Scribner's, New York.
  • 26J. E. Manson, J. Hsia, K. C. Johnson, J. E. Rossouw, A. R. Assaf, N. L. Lasser, M. Trevisan, H. R. Black, S. R. Heckbert, R. Detrano, O. L. Strickland, N. D. Wong, J. R. Crouse, E. Stein, M. Cushman (2003) Estrogen plus progestin and the risk of coronary heart disease, N. Engl. J. Med.349, 523–534.
  • 27C. Gorman (2003) The No. 1 killer of women, Time, April 23, 2003, 60–66.

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