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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
https://doi.org/10.1186/s12939-024-02309-x International Journal for Equity
in Health
*Correspondence:
Stijn Schelfhout
stijn.schelfhout@ugent.be
Full list of author information is available at the end of the article
Abstract
Objective Measuring intercultural attitudes can aid in understanding and addressing persistent inequities in
healthcare. Instead of creating new instruments, several sources call for a more rigorous revalidation of existing
instruments towards a more broad population. As an example of such an existing instrument, the EMP-3 (Ethnic
Minority Patients) focuses on the attitudes of physicians towards ethnic minority patients. Starting from a robust
theoretical underpinning and a rigorous methodological setup, the present study revalidates the EMP-3 instrument
for physicians towards the REMP-3 instrument for graduate healthcare practitioners.
Methods We assessed the reliability and validity of the old EMP-3, which we then updated to a new REMP-3
instrument. We used structural equation modeling to model the framework of intercultural eectiveness on two
waves of independent data, N2021 = 368 and N2022 = 390. Within this framework, we tested the new REMP-3 instrument
as an operationalization of intercultural attitudes. We conducted a conrmatory factor analysis on the rst wave, after
which we made adaptations to the original EMP-3 instrument to obtain a new REMP-3 instrument. The new REMP-3
instrument was then cross-validated using the data of the second wave.
Results The new REMP-3 instrument is a psychometric upgrade compared to the EMP-3. The REMP-3 now has
a cross-validated structure, with three subscale dimensions (i.e., task perception, background perception and the
perceived need to communicate) and an overarching higher-order, full-scale dimension. Both the subscales as well
as the full instrument show acceptable to good internal consistency reliability, with a reduced number of items from
eighteen to ten. As theoretically predicted, the REMP-3 also functions as a measure of intercultural attitudes in an
intercultural competence framework.
Conclusion Ultimately, the REMP-3 instrument can contribute to more equity in healthcare by concisely and reliably
assessing and monitoring attitudes in healthcare practitioners. This attitude assessment represents the potential of
learning new skills and knowledge to address interactions with ethnic minority patients, which is especially useful
during training situations like an internship.
Keywords Intercultural traits, Intercultural attitudes, Intercultural competence, Intercultural eectiveness,
Intercultural capabilities, EMP-3, REMP-3
Measuring attitudes towards ethnic minority
patients: the revalidated REMP-3 instrument
for graduate healthcare practitioners
StijnSchelfhout1,3*, RobinVandecasteele2, SaraWillems2,4, EvaDerous1 and StéphanieDeMaesschalck2
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
Background
According to the World Health Organization, equity
in healthcare embodies the absence of unfair, avoid-
able or remediable dierences among groups of people
[1]. Recent review research indicates that ethnic minor-
ity patients are one of those groups that still experience
healthcare disparities in important areas like emergency
healthcare [2], safety of healthcare [3], diabetes treatment
[4], and organ transplants [5].
To improve this equity in healthcare, research already
focuses on investigating intercultural attitudes of health-
care practitioners towards ethnic minority patients. For
instance, the study of such attitudes can aid in under-
standing equity related problems ranging from general
social and ethnic dierences in healthcare systems [6] to
more specic problems like racism in healthcare [7].
However, empirical data collection on healthcare prac-
titioners’ intercultural attitudes towards ethnic minority
patients remains inconsistent [8], with limited attention
towards sucient methodological rigor [9, 10]. Often,
research exclusively focuses on standalone self-report
instruments, without the validating power of an under-
lying theoretical framework or without linking attitude
instruments results to real life outcomes. For instance,
Osmancevic and colleagues scrutinized 44 studies and 21
instruments in a systematic review, of which only three
instruments1 showed sucient levels of psychometric qual-
ity to assess the intercultural competence of nurses [10–13].
Although we considered these instruments as valid can-
didates for the present study, we decided against targeting
these instruments for mainly two reasons. First, we assessed
the instruments’ items as too nurse-specic and thus less
suited to generalize towards a more broad target popula-
tion. And second, the instruments are not exclusive atti-
tude instruments, but also include items that cover other
constructs like motivation and knowledge. Such composite
instruments are less compatible with the setup of the pres-
ent study as we operationalize each component of inter-
cultural competence separately by using the framework of
intercultural competence by Leung and colleagues [14].
e framework of Leung and colleagues can provide a
robust theoretical underpinning for intercultural com-
petence (revalidation) studies [14–16], as the framework
facilitates a more structured approach. Figure1 shows a
summary of the framework. Intercultural competence
is described as a combination of three components that
represent dispositions on (a) personality traits, (b) atti-
tudes and (c) knowledge and skills needed to perform
1 e Cultural Competence Health Practitioner Assessment, the Cultural
Competence Assessment and the Transcultural Self-Ecacy Scale.
Fig. 1 The framework of intercultural competence. Note. The gure is adapted from Schelfhout et al., 2022. The framework features four hypotheses that
need conrming in order for the data to t the framework. H1 = A high disposition on intercultural traits predicts a more ethnorelative disposition, H2 = A
high disposition on intercultural traits predicts a higher cultural intelligence, H3 = A more ethnorelative disposition predicts a higher cultural intelligence.
H4 = A higher cultural intelligence predicts more intense cultural contacts
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
eectively in intercultural interactions [17]. First, inter-
cultural personality traits represent persevering personal
dispositions that can explain eectiveness in intercultural
situations [18, 19]. Second, intercultural attitudes repre-
sent world views individuals have regarding the ethno-
centric – ethnorelative continuum [20]. An ethnocentric
view represents a world view in which the own culture
is seen as superior, while an ethnorelative view acknowl-
edges the co-existence of many dierent cultures, all of
equal value. And third, intercultural capabilities repre-
sent the skills and knowledge an individual has acquired
to address intercultural situations [21].
e three components interact in a specic way: Traits
trigger attitudes and capabilities, attitudes trigger capa-
bilities, and capabilities lead to intercultural eective-
ness. As Fig.1 shows, intercultural attitudes function as
a central component of intercultural competence [22].
Due to this central function, attitudes directly aect the
acquisition of capabilities like knowledge and skills [23].
Indeed, a more ethnorelative view in a healthcare practi-
tioner will facilitate the learning of skills and knowledge,
while a more ethnocentric view will hamper such learn-
ing. An intercultural attitude measure during training
situations like (pre -or postgraduation) internships can
thus prove key to explore to which extent attitudes can
aect the learning of knowledge and skills. In conclusion,
the framework posits that the central attitudes do not
exert a direct inuence on the outcomes of intercultural
eectiveness. Instead, their impact is mediated indirectly
through the acquisition of capabilities like skills and
knowledge (see also Fig.1).
Osmancevic and colleagues advise that selecting an
intercultural competence instrument should depend on
the purpose of the study and the targeted population
[10]. For the present study, we thus aim at revalidating an
instrument that could specically measure intercultural
attitudes in a more broad population of graduate health-
care practitioners. For this purpose, the present study
chooses to target the EMP-3 instrument, which mea-
sures the perceptions and attitudes of physicians towards
ethnic minority patients [24]. is EMP-3 instrument
featured three subscales on (a) task perception (b) the
attitude towards physician–patient communication and
(c) perception of minority patients’ need for communica-
tion (see Table1). e EMP-3 instrument showed valid-
ity as the subscales correlated with proven scales like the
Jeerson’s Empathy scale [25] and the Patient Practitio-
ner Orientation scale [26]. However, De Maesschalck and
colleagues called for further revalidation studies to inves-
tigate the use of the EMP-3 instrument in more broad
groups of healthcare practitioners [24].
Despite the instrument’s obvious qualities, we also
observe that the original EMP-3 study underexplored
four important aspects regarding the validity of the
results that hold back the instrument’s further dissemina-
tion. First, the original EMP-3 intends to cover attitudes
of physicians towards ethnic minority patients. Yet, the
original EMP-3 does not have a physician–specic nature
as the current instrument does not involve specic pro-
cedures, exclusively known to physicians. As such, the
instrument could be suited for use in a broader popula-
tion of healthcare practitioners like nurses and medical
assistants. Second, the original EMP-3 instrument study
does not report the correlations between the subscales,
while the possibility of a higher-order factor is also not
investigated. A higher-order structure should at least be
investigated in the present study to further strengthen
the internal structure of the instrument. ird, the
instrument is not based on a formal theoretical frame-
work. For construct validity purposes, the present study
therefore proposes to integrate instrument as a measure
of intercultural attitudes into the framework of Leung
and colleagues [23]. As an instrument that measures
intercultural attitudes, a revalidated EMP-3 could there-
fore be integrated as a central component of intercul-
tural competence (see also Fig.1), in between traits and
capabilities. e hypothesized relations of the framework
have to be tested in order to evaluate if the framework
holds given the data used. Fourth and nally, the origi-
nal study did not link the EMP-instrument to any specic
medical outcomes like the eectiveness of the care or the
patient experience to show criterion validity. As the pres-
ent study aims for a use of the instrument in a broader
population, a general outcome like the intensity of inter-
cultural contacts is suited for the present study’s revali-
dation purposes. Indeed, an individual that has a higher
intercultural competence, generally shows a higher inten-
sity of intercultural contacts [27].
e present study revalidates the original EMP-III
instrument towards a more broad REMP-3 instrument
that measures the intercultural attitudes of graduate
healthcare practitioners. For this revalidation, we t the
present study’s empirical data on traits, attitudes (i.e.,
the EMP-III results) and capabilities to the intercultural
competence framework of Leung and colleagues [23].
Four eects need to be tested in order to evaluate if inter-
cultural attitudes as measured by the REMP-3 can indeed
function as the central component of intercultural com-
petence (see also Fig.1). As suggested by Schelfhout and
colleagues [22], the hypotheses are directly drawn from
the theoretical model (see also Fig.1).
First, a high disposition on intercultural traits predicts
more ethnorelative attitudes or less ethnocentric atti-
tudes. For instance, Talay & De Coninck reported that
openness, agreeableness, and honesty-humility were
negatively associated with ethnocentricity in the form of
refugee prejudice [28].
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
H1 A high disposition on intercultural traits predicts a
more ethnorelative disposition.
Second, a high disposition on intercultural traits should
predict higher intercultural capabilities like cultural
intelligence. For instance, Li and colleagues showed that
open mindedness is positively related to cultural intel-
ligence but only when individuals also have a high dis-
position on agreeableness [29]. Instead of focusing on
single traits, the authors therefore advocated to use an
integrative approach by taking a full spectrum of traits
into account when studying the eects on a construct
like cultural intelligence. Also in healthcare specically,
researchers are already aware of the eects intercultural
traits can have on intercultural intelligence. For instance,
Wang and colleagues used the open mindedness trait as
a controlling covariate to test the eects of an overseas
intervention on the cultural intelligence of undergraduate
healthcare students [30].
H2 A high disposition on intercultural traits predicts a
higher cultural intelligence.
ird, a more ethnorelative attitude should predict
higher intercultural capabilities. For instance, Majda and
colleagues reported that emergency healthcare profes-
sionals with a positive (or ethnorelative) attitude towards
culturally divergent people showed a higher cultural
intelligence [31].
H3 A more ethnorelative disposition predicts a higher
cultural intelligence.
Fourth and nal, higher intercultural capabilities should
predict more intercultural eectiveness. For instance,
Schwarzenthal and colleagues demonstrated that a
higher intercultural intelligence can result in benecial
outcomes like increased intercultural contacts and coop-
eration [27].
Table 1 Item List for EMP-3 and REMP-3
Nr Items EMP-3 EMP-
3 TP
EMP-
3
PPC
EMP-
3
PNC
REMP-3 REMP-
3 TP
REMP-
3 BP
REMP-
3 PNC
1 Physicians should accept culturally bound illness practices of the
patients, provided that it does not put the patient’s health at risk.
x x
2 Physicians should be aware of the cultural identity of each patient. x x x x
3R Physicians should feel free to refuse a patient merely on the basis
of his or her cultural background.
x x x x
4 Physicians have a moral duty toward taking care of refugees. x x x x
5 Physicians should be empathic toward every patient, even if they
have completely dierent opinions.
x x x x
6 Physicians should have a broad knowledge of social and human
sciences.
x x x x
7 Physicians should be trained in cultural and social dierences in
health.
x x x x
8 Patients’ social background determines their health. x x x x
9 Physicians should treat every patient equally no matter what his or
her social or cultural background is.
x x
10 The community to which someone belongs is important for the
way this person deals with his/her health.
x x x x
11 The communication between physicians and patients is facilitated
when they share the same cultural background.
x x
12 More physicians belonging to minority groups will gain better
health care for minority patients.
x x
13 Patients’ social background determines the way they communicate
with physicians.
x x
14 The communication between physicians and patients is facilitated
when they share the same social background.
x x
15 The communication with patients with a dierent social or cultural
background is worse.
x x
16 Physicians’ social background determines the way he or she com-
municates with patients.
x x
17R Minority patients prefer a paternalistic consulting style. x x x x
18R Some patients don’t need information, because they wouldn’t
understand it.
x x x x
Note. (R)EMP-3 = (Re validated) at titude towards Et hnic Minorit y Patients, TP = Task Perceptio n, BP = Background Percep tion, PNC = Perceived Ne ed for Communic ation,
PPC = Physician – Patient Comm unication
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
H4 A higher cultural intelligence predicts more intense
cultural contacts.
On a nal note, the framework by Leung and colleagues
does not predict a direct eect of attitudes on intercul-
tural eective behavior [23].
Methods
Data
e data were obtained from the regionwide Flemish (i.e.,
large region in Belgium with about 6.8 million inhabit-
ants) EdisTools (i.e., E-antidiscrimination Tools) project
that aims to chart and remedy discrimination in four key
domains of human interaction: education, healthcare,
housing and work. As such, the project focuses on the
interaction between the ethnic majority service providers
(e.g., healthcare practitioners) and the ethnic minority
clients (e.g., patients). For the present study, participants
were recruited from the pre-Master Program in Man-
agement and Organization of Healthcare and from the
pre-Master Program in Health Promotion, both from
the Faculty of Medicine and Health Sciences of a large
Flemish university. e main target audience consists
of graduate healthcare practitioners that want to master
their healthcare training to further degree. e data was
collected online in two waves. e rst wave ran from
February 2021 to May 2021 (N2021 = 368, age M = 22.69,
age SD = 4.37), where about 29% of the participants iden-
tied with a male gender orientation, 70% identied with
a female gender orientation and 1% identied with a dif-
ferent gender orientation. About 68% of the participants
indicated they already had some form of experience in
working as a healthcare practitioner, ranging from one
week to twenty-three years. Such a diverse graduate stu-
dent population with already some experience in various
subelds of healthcare seems appropriate for the present
study, as the REMP-3 aims to become an instrument that
can measure intercultural attitudes in a broad population
of graduate healthcare practitioners. As an additional
illustration, some participants added a job description
to their accumulated experience, indicating a wide scope
of working environments, ranging from an internship
or general nursing aid, to very specic descriptions like
operating room assistant or psychiatric nurse. e vast
majority (97%) of the participants indicated they were
born in the country were the study was conducted. About
6% indicated they had a father who was born in another
country, about 7% indicated they had a mother that was
born in another country and about 8% indicated they had
a grandmother that was born in another country.
e second wave ran from February 2022 to May 2022
(N2022 = 390, age M = 22.71, age SD = 4.48), where about
23% of the participants identied with a male gender
orientation and 77% identied with a female gender ori-
entation. One participant indicated a dierent gender
orientation. About 65% of the participants indicated they
had some form of experience in working as a healthcare
practitioner, ranging from one week to thirty years. Ana-
logue to the rst wave, some participants added a job
description to their accumulated experience, indicating
a wide scope of working environments. e vast major-
ity (i.e., 95%) of the participants indicated they were born
in the country were the study was conducted. About 10%
indicated they had a father who was born in another
country, about 9% indicated they had a mother that was
born in another country and about 11% indicated they
had a grandmother that was born in another country.
Note that both datasets are independent (i.e., each stu-
dent only participated in one wave).
Measures
Intercultural traits
We measures intercultural traits using the Short Form
Multicultural Personality Questionnaire or SF-MPQ [32,
33]. We used this questionnaire, as the SF - MPQ features
a specic intercultural iteration of the Big Five personal-
ity traits, that explains intercultural eectiveness above
and beyond the original Big Five. For instance, the SF-
MPQ was recently administered to a population of West-
ern and non-Western, male and female students [33].
Results showed that all ve subscales (i.e., cultural empa-
thy, exibility, social initiative, emotional stability and
open mindedness) could be reliably used in both com-
parative as well as longitudinal designs, for Western and
non –Western students alike. Five traits are measured,
including cultural empathy (CE), exibility (FX), social
initiative (SI), emotional stability (ES) and open minded-
ness (OM). Each trait subscale features eight items (e.g.,
Pays attention to the emotions of others, CE), measured
on a ve-point Likert scale, anchored between totally not
applicable (1) to completely applicable (5). For reliability,
we refer to the Results section.
Intercultural attitudes
Intercultural attitudes are measured using the original
attitude towards Ethnic Minority Patients instrument or
EMP-3 [24]. Participants had to indicate to which extent
they agreed with a set of eighteen statements, on a ve-
point Likert scale from totally not agree (1) to totally
agree (5). e original three subscales are measured
including (1) ten items on task perception or TP (e.g.,
Physicians should be aware of the cultural identity of
each patient), (2) six items on the attitude towards phy-
sician – patient communication or PPC (e.g., Patients’
social background determines the way they communi-
cate with physicians) and (3) two items on the perception
of minority patients’ need for communication or PNC
(e.g., Minority patients prefer a paternalistic consulting
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
style, reverse coded). For reliability, we again refer to the
Results section.
Intercultural capabilities
We measured intercultural capabilities using cultural
intelligence or CQ [27]. Multiple studies already use
CQ to validate intercultural capabilities as a part of the
intercultural competence framework [15, 22]. Although
a multimodal measure is possible, the present study only
uses the overarching scale for reasons of parsimony to
limit the risk of inating the results our SEM analyses.
CQ is measured using 24 items (e.g., If there is a misun-
derstanding between people from dierent cultures, I
try to clear it up) on a ve-point Likert scale, anchored
between strongly disagree (1) and strongly agree (5). For
reliability, we again refer to the Results section.
Intercultural eectiveness
We measured intercultural eectiveness using the inten-
sity of intercultural contacts or IOIC, which is an adap-
tation from the operationalization of Schwarzenthal and
colleagues [27]. Literature already features studies that
use this concise measure to validate intercultural compe-
tence constructs [15]. Indeed, the measure has one ques-
tion and probes for the intensity of intercultural contacts
(i.e., How would you characterize your contacts with peo-
ple that have a migration background? ). e responses
were anchored on a four-point Likert scale ranging from
(1) I only have anonymous contacts with people that have
a migration background, over (2) I have vague acquain-
tances with people that have a migration background and
(3) I have friends or close colleagues/fellow students with
a migration background, to (4) I have close relatives or
close friends with a migration background. e analyses
with the continuous Likert scale were also repeated with
an ordinal scale, rendering analogue correlation patterns.
Analyses
We have included two measures of internal consistency
reliability common to literature. First, the Cronbach’s
alpha is used as a measure of internal consistency, with
α > 0.70 indicating an acceptable reliability and α > 0.80
indicating a good reliability [34]. However, Cronbach’s
alpha is sensitive to the length of a (sub)scale and the
alpha does not measure homogeneity as such [35, 36].
As the present study features (sub)scales with a lower
number of items (i.e.,< 11 items), we have followed the
suggestions of Clark and Watson to include the average
inter-item correlation (AIIC) as a measure of internal
consistency reliability as the AIIC is independent of scale
length and does cover homogeneity [37]. Clark and Wat-
son recommend that the AIIC should fall into the 0.15
− 0.50 range, with more general scales (e.g., CQ) showing
a relatively lower AIIC and more specic scales showing
a relatively higher AIIC (e.g., MPQCE) [37].
e revalidation and framework integration analyses
are conducted using structural equation models or SEM
[38], using the lavaan package [39]. Evaluating SEM is
usually executed by using a battery of t indices. For the
present study, a battery of three indices common to lit-
erature are included to complement the conservative chi-
squared test including the Comparative Fit Index or CFI
(> 0.90 for an adequate t, > 0.95 for a good t), the Root
Mean Square Error of Approximation or RMSEA (90%
condence interval or CI should have a lower bound no
higher than 0.05 and a higher bound lower than 0.08) and
the Standardized Root Mean square Residual or SRMR
(< 0.08 for a good t). For a complete discussion on t
indices, we refer to measuring model t by David Kenny
[40]. Note that the cuto values are not absolute, as an
evaluation of goodness-of-t should always regard a full
index pattern. e SEM analyses consist of two major
parts: a conrmatory factor analyses or CFA on the orig-
inal EMP-3 subscales and a latent SEM analyses on the
framework of intercultural competence. For both parts,
an adequately tting model is derived from the data from
the rst wave (N2021) and cross-validated on the data from
the second wave (N2022). e construction and netuning
of the models were executed using modication indices
(MI), that indicate how the t of a model can change if
variables or regressions are added or omitted [39]. e
Results section also contains a summarizing table featur-
ing all variables, including the original EMP-3 instrument
and the revalidated REMP-3 instrument respectively. On
a nal note, analyses were also controlled for the eects
of age (year of birth), gender (male − 1, female − 0) and
(months of ) healthcare experience. To avoid ination of
model t by adding a multitude of additional variables,
we opted to act conservatively and therefore conducted
the analyses for each hypothesis separately, moving away
from SEM towards linear regression analyses.
Results
e variable descriptive statistics for both datasets N2021
and N2022 are highly similar regarding means, standard
deviations and reliability (see also Additional File 1 for
additional analyses). For reasons of parsimony, Table 2
therefore reports the pooled variable descriptive statis-
tics of N2021 and N2022. Table2 thus reveals that the reli-
ability of the original three EMP-3 subscales is at least
acceptable. However, the reliability of a presumed over-
arching construct is lackluster as the AIIC is too low (i.e.,
< 0.15). Moreover, we also observe a negative correlation
between the PPC and PNC subscale, which is problem-
atic as both scales intend to measure dierent compo-
nents of the same intercultural attitude construct and
thus should be positively correlated. e EMP-3 and its
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
subscales do seem to be correlated to a number of MPQ
scales and CQ, as is also predicted by the hypotheses. e
(negative) correlations between the subscales and the
reliability are further assessed using a CFA. e hypoth-
esized correlations are further assessed using a full SEM
on the framework of intercultural competence.
Conrmatory factor analyses
We conducted a CFA on the data of the rst wave
(N2021 = 368), and cross-validated the results on the
data of the second wave (N2022 = 390). First, a model
on the data of 2021 was constructed in which all items
were loaded on one overarching latent EMP-3 con-
struct. e model showed a poor t, with χ²(135,
N2021 = 368) = 839.19, p < .001, CFI = 0.43, RMSE A = 0.12
with 90% CI [0.11, 0.13] (i.e., the null-hypothesis of an
RMSEA below 0.05 is rejected) and SRMR = 0.12. Second,
we constructed a model analogous to De Maesschalck
and colleagues [24] in which the EMP-3 items are loaded
on their respective (i.e., three) latent subscales (see also
Table1). Again, the model showed a poor t with χ²(132,
N2021 = 368) = 487.00, p < .001, C FI = 0.71, RMSEA = 0.09,
p < .001 with 90% CI [0.08, 0.09] and SRMR = 0.12. Note
that the relation between the latent constructs of PPC
and PNC showed a negative loading of -0.27. As a conse-
quence, the model did not converge any more if we added
an overarching (i.e., over the three subscales) EMP-3
higher order latent construct.
Following these results, we decided to remove the PPC
subscale. Moreover, we also observed that items 1 and 9
loaded poorly on the TP scale. We therefore decided to
remove these items as well. Further inspecting the MI of
the last tested model, items 8 and 10 were related closely
to the extent we considered a new subscale Background
Perception or BP. Finally MI also indicated that item 3R
had a stronger loading on PNC compared to TP.
Taking these results into account, we constructed a new
Model2021 1 with items 2, 4, 5, 6 and 7 loading on the TP
latent subscale, items 8 and 10 loading on the BP subscale
and items 3R, 17R and 18R loading on the PNC subscale.
Finally, we also added an overarching latent construct
representing a higher order REMP-3 factor for intercul-
tural attitudes. e model showed an adequate to good
t, with χ²(27, N2021 = 368) = 53.88, p = .002, CFI = 0.96,
RMSEA = 0.05, p = .41, 90% CI [0.03, 0.07] (i.e., the null-
hypothesis of an RMSEA below 0.05 cannot be rejected)
and SRMR = 0.04. Figure 2 shows the nal Model2021 1.
To cross-validate the CFA, we applied the model struc-
ture from Model2021 1 to the 2022-wave data. Model2022
1 again showed an adequate to good t, with χ²(27,
N2022 = 390) = 60.97, p < .001, CFI = 0.96, RMSE A = 0.06,
p = .26, 90% CI [0.04, 0.08] and SRMR = 0.04. Figure 3
shows the nal Model2022 1. In sum, our CFA analyses
indicated that Model 1 provides cross-validated evidence
Table 2 Variable summary and correlation matrix
n of items M SD α AIIC EMP-TP EMP-PPC EMP-PNC EMP-3 MPQCE MPQFX MPQSI MPQES MPQOM CQ IOIC REMP-TP REMP-BP REMP-PNC REMP-3
EMP-TP 10 4.04 0.42 0.70 0.21 1.00
EMP-PPC 6 3.44 0.52 0.71 0.29 0.14** 1.00
EMP-PNC 2 3.96 0.60 --- 0.28 0.26** − 0.16** 1.00
EMP-3 18 3.83 0.32 0.70 0.12 0.85** 0.60** 0.31** 1.00
MPQCE 8 4.20 0.42 0.80 0.33 0.31** − 0.04 0.12** 0.22** 1.00
MPQFX 8 2.52 0.71 0.87 0.46 − 0.03 − 0.09** 0.06 − 0.06 − 0.05 1.00
MPQSI 8 3.34 0.64 0.86 0.44 0.04 − 0.01 − 0.06 0.01 0.24** 0.11** 1.00
MPQES 8 3.09 0.71 0.85 0.41 − 0.14** − 0.06 − 0.04 − 0.14** − 0.09*0.26** 0.30** 1.00
MPQOM 8 3.51 0.51 0.77 0.30 0.24** − 0.06 0.11** 0.17** 0.40** 0.17** 0.29** 0.22** 1.00
CQ 24 3.49 0.37 0.84 0.19 0.39** 0.01 0.09*0.31** 0.38** 0.04 0.12** 0.01 0.47** 1.00
IOIC 1 2.41 0.98 --- --- 0.09*− 0.04 0.06 0.05 0.11** 0.03 0.07*0.06 0.35** 0.25** 1.00
REMP-TP 5 4.12 0.52 0.73 0.36 0.88** 0.07 0.24** 0.73** 0.28** − 0.01 0.04 − 0.13** 0.27** 0.42** 0.11** 1.00
REMP-BP 2 3.83 0.68 --- 0.44 0.52** 0.32** 0.06 0.56** 0.11** − 0.10** 0.06 − 0.06 0.08*0.10** 0.01 0.26** 1.00
REMP-PNC 3 4.01 0.57 0.53 0.27 0.44** − 0.17** 0.87** 0.41** 0.18** 0.07 − 0.04 − 0.05 0.13** 0.13** 0.08*0.35** 0.080*1.00
REMP-3 10 4.03 0.41 0.72 0.21 0.92** 0.08*0.54** 0.82** 0.29** − 0.01 0.03 − 0.13** 0.25** 0.36** 0.11** 0.87** 0.53** 0.66** 1.00
Note. (R)EMP-3 = (Revalidated) attitude towards Ethnic Minority Patients, TP = Task Perception, BP = Background Perception, PNC = Perceived Need for Communication, PPC = Physician – Patient Communication,
MPQ = Multicultural Personality Questionnaire, CE = Cultural Empathy, FX = Flexibil ity, SI = Social Ini tiative, ES = Emotional Stabilit y, OM = Open Mindednes s, CQ = Cultural Intelligence, IOIC = Intensity Of Inte rcultural Contac ts,
AIIC = average interitem correlation. * p < .05, ** p < .01
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
for the REMP-3 instrument as a measure of intercultural
attitudes.
Structural equation modeling: the Intercultural Framework
of Intercultural competence
We started from Model2021 1 and added the hypoth-
esized relations as already introduced in Fig. 1, sup-
plemented with the possible direct eects of MPQ
and REMP-3 scales on the IOIC outcome variable.
Model2021 2 showed an adequate to good t, with χ²(90,
N2021 = 368) = 154.40, p < .001, C FI = 0.93, RMSEA = 0.04,
p = .79 with 90% CI [0.03, 0.06] and SRMR = 0.04. e
model showed an explained variance for CQ of R² =
0.32 and for IOIC of R² = 0.14. We further explored the
somewhat lower CFI. Analyses thus revealed that the
baseline model for Model2021 2 (i.e., the model it is com-
pared against to obtain relative t measures like a CFI)
has a low RMSEA = 0.139. Literature shows that in case
of a low RMSEA (< 0.158) of the base model, incremen-
tal t indices like the CFI have a practical maximum of
0.95 and should be interpreted with care [41]. Cross-
validating the model, we applied the model structure
from Model2021 2 to the 2022-wave data. Model2022
2 again showed an adequate to good t, with χ²(90,
N2022 = 390) = 151.60, p < .001, C FI = 0.94, RMSEA = 0.04,
p = .88 with 90% CI [0.03, 0.05] and SRMR = 0.04. e
model showed an explained variance for CQ of R² = 0.39
and for IOIC of R² = 0.14. e RMSEA = 0.149 of the
baseline model was again lower than 0.158. Table3 shows
the nal Model2022 2. As Model2022 2 does still feature a
lot of non-signicant eects, these eects could arti-
cially improve the t indices. As a control, we removed
these non-signicant eects in Model2021 3 (see Fig.4)
and Model2022 3 (see Fig. 5). Both models still showed
an adequate to good t, with χ²(76, N2021 = 368) = 138.87,
p < .001, C FI = 0.93, R MSEA = 0.05, p = .62, 90% CI [0.04,
0.06] and SRMR = 0.04 for Model2021 3 (note that the
RMSEA = 0.155 of the baseline model was again lower
than 0.158) and χ²(76, N2022 = 390) = 125.81, p < .001,
CFI = 0.95, RMSEA = 0.04, p = .88, 90% CI [0.03, 0.05] and
SRMR = 0.04 for Model2022 3. For Model2022 3 the base-
line model reached an RMSEA = 0.164, which is above
the 0.158 threshold, explaining the now slightly improved
CFI value. In sum, the nal revalidated REMP-3 has three
Fig. 2 Model2021 1: CFA of REMP-3 using the data from wave 2021. Note. (R)EMP-3 = (Revalidated) attitude towards Ethnic Minority Patients, TP = Task
Perception, BP = Background Perception, PNC = Perceived Need for Communication. The observed variables are depicted as squares, the latent variables
are depicted as circles. The items are annotated using the numbers from Table1. Items annotated with an R are scored reversely
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
subscales (i.e., TP, BP and PNC) and a higher-order fac-
tor that can be integrated as a measure of intercultural
attitude into the framework of intercultural competence.
Hypothesis testing
e hypothesis testing was conducted conservatively, as
we opted to use the cross-validated Model2022 2 described
in Table3. In such a way, the eects of one variable are
controlled for the eects of the other (relevant) variables,
while the full model is constructed on a dierent dataset.
First, we have found at least partial evidence for H1, as
a high disposition on the two intercultural traits of CE
and OM predicts a more ethnorelative disposition on the
REMP-3 (i.e., a higher score). Note that the ES disposi-
tion showed a reverse eect. Such an eect is not uncom-
mon, but is addressed in the Discussion. Second, we have
found at least partial evidence for H2, as a high disposi-
tion on the intercultural traits of CE and OM predicts a
higher cultural intelligence, measured by CQ. ird, we
have found evidence for H3, as a more ethnorelative dis-
position measured by the REMP-3 predicts a higher cul-
tural intelligence measured by CQ, while controlling for
the eects of intercultural traits. Finally, we have found
evidence for H4 as a higher cultural intelligence as mea-
sured by CQ predicts more intense cultural contacts as
measured by IOIC, showing criterion validity.
In sum, all hypotheses were (at least partially) con-
rmed. ese conclusions are further supported by an
acceptable to good internal consistency reliability as
shown by Table2. As such, we conclude that the REMP-3
functions as a valid and reliable measure of the central
intercultural attitudes component in the framework of
intercultural competence (see Fig.1).
Controlling for gender, age and experience
irty-four participants chose to not disclose informa-
tion on their age or experience, three participants indi-
cated a dierent gender orientation. ese participants
were not included in the analyses. Analyses were con-
ducted on the pooled dataset of N2021 and N2022. All
eects were standardized. Regressing the REMP-3 score
on age, gender and healthcare experience rendered a
signicant linear model, F(3, 717) = 13.29, p < .001, R² =
0.05, with a non-signicant eect of experience (β = 0.01,
Fig. 3 Model2022 1: CFA of REMP-3 using the data from wave 2022. Note. (R)EMP-3 = (Revalidated) attitude towards Ethnic Minority Patients, TP = Task
Perception, BP = Background Perception, PNC = Perceived Need for Communication. The observed variables are depicted as squares, the latent variables
are depicted as circles. The items are annotated using the numbers from Table1. Items annotated with an R are scored reversely
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
p = .93), a possible trending eect of age (β = 0.09, p = .12),
with younger participants obtaining higher scores, and
a signicant eect of gender (β = − 0.22, p < .001), with
a lower average score for the male gender. As experi-
ence rendered a non-signicant eect, experience was
removed from further control analyses. For H1, the
REMP-3 score is regressed on MPQCE, MPQOM,
MPQES, age and gender. e linear model was signi-
cant, F(5, 749) = 28.04, p < .001, R² = 0.16, with signicant
eects of MPQCE (β = 0.16, p < .001), MPQOM (β = 0.23,
p < .001), MPQES (β = − 0.09, p = .02), age (β = 0.09, p = .01)
and gender (β = − 0.18, p < .001). Although age and gender
have a signicant eect, both variables do not change the
conclusions for H1. For H2 and H3, CQ was regressed on
MPQCE, MPQOM, REMP-3, age and gender. e linear
model was again signicant, F(5, 749) = 64.91, p < .001,
R² = 0.30, with signicant eects of MPQCE (β = 0.17,
p < .001), MPQOM (β = 0.34, p < .001) and REMP-3
(β = 0.22, p < .001). e eects of age (β = 0.02, p = .49) and
gender (β = 0.02, p < .49) were not signicant (even in the
Table 3 SEM Model2022 2 and hypotheses Testing
Latent Observed E SE z pML
TP
EMP3_2 1.00 0.55
EMP3_4 1.27 0.17 7.33 < 0.001 0.53
EMP3_5 1.03 0.14 7.58 < 0.001 0.56
EMP3_6 1.35 0.17 7.80 < 0.001 0.62
EMP3_7 1.55 0.18 8.42 < 0.001 0.68
BP
EMP3_8 1.00 0.58
EMP3_10 1.07 0.25 4.35 < 0.001 0.81
PNC
EMP3_17R 1.00 0.35
EMP3_18R 1.13 0.35 3.25 0.001 0.43
EMP3_3R 1.84 0.55 3.33 0.001 0.57
REMP3
TP 1.00 1.10
BP 0.50 0.15 3.40 0.001 0.38
PNC 0.39 0.12 3.18 0.001 0.57
Hypothesis Dependent Independent(s) E SE z pML
H1 REMP3
MPQCE 0.03 0.01 3.94 < 0.001 0.24
MPQFX 0.00 0.00 1.20 0.23 0.06
MPQSI -0.00 0.00 -0.71 0.48 -0.04
MPQES -0.01 0.00 -3.13 0.002 -0.18
MPQOM 0.02 0.01 3.79 < 0.001 0.23
H2 & H3 CQ
REMP3 12.39 3.15 3.94 < 0.001 0.30
MPQCE 0.81 0.25 3.30 < 0.001 0.16
MPQFX -0.02 0.19 -0.20 0.84 -0.01
MPQSI -0.22 0.15 -1.54 0.12 -0.07
MPQES 0.19 0.14 1.43 0.15 0.07
MPQOM 1.57 0.21 7.62 < 0.001 0.37
H4 IOIC
CQ 0.01 0.00 2.51 0.01 0.15
REMP3 0.03 0.15 0.20 0.84 0.01
MPQCE -0.02 0.02 -1.21 0.23 -0.07
MPQFX -0.00 0.01 -0.38 0.70 -0.02
MPQSI -0.01 0.01 -0.65 0.52 -0.03
MPQES -0.00 0.01 -0.12 0.91 -0.01
MPQOM 0.08 0.02 4.95 < 0.001 0.30
Note. ( R)EMP-3 = (Revalidated ) attitude towa rds Ethnic Minor ity Patients , TP = Task Perception, BP = Background Per ception, PNC = Perceived N eed for Communi cation,
PPC = Physician – Patient Communication, MPQ = Multicultural Personality Questionnaire, CE = Cultural Empathy, FX = Flexibili ty, SI = Social Initiative, ES = Emotional
Stabilit y, OM = Open Mindedn ess, CQ = Cultural Intelligence, IOIC = Intensity O f Intercultural Cont acts. The ite ms are annotated using t he numbers from Table1. Items
annotated w ith an R are scored reversel y
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
absence of MPQCE, MPQOM and REMP-3) and thus
do not change the conclusions for H2 and H3. Finally,
for H4, IOIC was regressed on CQ, OM, age and gender.
e linear model was again signicant, F(5, 749) = 23.29,
p < .001, R² = 0.14, with signicant eects of MPQOM
(β = 0.29, p < .001) and CQ (β = 0.12, p = .003). e eect of
age was not signicant (β = 0.00, p = .98), while the eect
of gender was trending (β = 0.07, p = .06). e eects of
age and gender do not change the conclusions for H4.
Discussion
Answering the call for more, and more rigorous, revali-
dation of existing instruments [8–10], the present study
aimed to revalidate the Ethnic Minority Patients atti-
tude measure for physicians (EMP-3) for use in graduate
healthcare practitioners [24]. To this extent, the present
study aimed to integrate a revalidated EMP-3 instrument
or REMP-3 into the framework of intercultural compe-
tence as a measure of intercultural attitudes. To assess
this reintegration, a number of hypotheses were drawn
from intercultural competence literature regarding the
interplay between traits, attitudes, capabilities and eec-
tiveness. Important to note, all results were cross-vali-
dated using a second, independent sample of graduate
healthcare practitioners.
More specically, the content of the EMP-3 for physi-
cians was revalidated towards the REMP-3 for a broad
graduate healthcare practitioner population by removing
one of three subscales and two poor loading items (see
also Table1). e Task Perception (TP) and the Percep-
tion of Needs in Communication (PNC) were retained,
while the attitude towards Physician – Patient Com-
munication (PPC) was removed entirely as the subscale
correlated negatively with the PNC. Apart from the sta-
tistical arguments, we consider the PPC subscale some-
what ambiguous, as the items probe for both the current
situation as well as the ideal situation. For sure, item 14
“e communication between physicians and patients is
facilitated when they share the same social background.”
is based on empirical ndings [42], but is also contradic-
tory to an ideal world in which social background is no
longer relevant. Participants can experience a conict
Fig. 4 Model2021 3: CFA of REMP-3 using the data from wave 2021. Note. (R)EMP-3 = (Revalidated) attitude towards Ethnic Minority Patients, TP = Task Per-
ception, BP = Background Perception, PNC = Perceived Need for Communication. MPQ = Multicultural Personality Questionnaire, CE = Cultural Empathy,
OM = Open Mindedness, ES = Emotional Stability, CQ = Cultural Intelligence, IOIC = Intensity Of Intercultural Contacts. The observed variables are depicted
as squares, the latent variables are depicted as circles. The items are annotated using the numbers from Table1. Items annotated with an R are scored
reversely.
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
between actual and ideal situations, which could explain
the statistical ndings regarding the PPC subscale.
Considering the results and the possible explanation,
we decided to remove the PPC subscale in the present
study’s iteration of the REMP-3 instrument. We assume
that this removal of the PPC subscale is warranted, as the
SEM analyses indicate a better t of the instrument data
without the PPC subscale, while also allowing a higher
order factor. However, future research can reconsider the
use of the subscale by testing our hypothetical explana-
tion of actual versus ideal situation conict in partici-
pants. Research can compare both situation hypotheses
by adjusting the question that is posed to participants
accordingly.
Moreover, the revalidated REMP-3 instrument was
successfully integrated as an ethnorelative measure of
intercultural attitudes (and world views) into the frame-
work of intercultural competence [22, 23]. Largely in
line with (healthcare) literature, a higher disposition on
intercultural traits predicts a more ethnorelative atti-
tude [28] and a higher cultural intelligence [29]. A more
ethnorelative attitude also predicts to a higher cultural
intelligence [31], while higher cultural intelligence pre-
dicts more intense intercultural contacts [27]. Note that
intercultural attitudes do not have a direct eect on more
intense cultural contacts. is result is actually in line
with literature, as the framework does not presume a
direct link between attitudes and real life outcomes.
Despite not having a direct eect on real life outcomes,
intercultural attitudes are at a central position of inter-
cultural competence, as an ethnorelative disposition
positively aects the ability of enlarging intercultural
capabilities by acquiring new skills and knowledge. We
estimated this positive eect at r = .36. e emerging lit-
erature on intercultural competence framework valida-
tion studies reports similar correlations of r = .40 [15]
and r = .37 [22]. Important to note, these studies used a
dierent operationalization of intercultural attitudes,
which provides additional evidence that the eects of
the REMP-3 measurements are not instrument-specic.
Rather, these REMP-3 eects appear to represent genu-
ine eects of an ethnorelative intercultural attitude.
Fig. 5 Model2022 3: CFA of REMP-3 using the data from wave 2022. Note. (R)EMP-3 = (Revalidated) attitude towards Ethnic Minority Patients, TP = Task Per-
ception, BP = Background Perception, PNC = Perceived Need for Communication. MPQ = Multicultural Personality Questionnaire, CE = Cultural Empathy,
OM = Open Mindedness, ES = Emotional Stability, CQ = Cultural Intelligence, IOIC = Intensity Of Intercultural Contacts. The observed variables are depicted
as squares, the latent variables are depicted as circles. The items are annotated using the numbers from Table1. Items annotated with an R are scored
reversely.
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
Furthermore, an appropriate empathic and open
minded trait disposition also facilitates an ethnorelative
disposition, while too much emotional stability seems to
inhibit an ethnorelative disposition, especially regarding
task perception. As an explanation, we consider that a
lower emotional stability in a graduate healthcare prac-
titioner can also indicate a higher level of involvement
towards patient care and the tasks that need performing.
Indeed, the involvement regarding the patient’s condi-
tion can trigger an emotional reaction. is involvement
hypothesis for emotional stability is further supported by
the negative correlation between emotional stability and
cultural empathy (see Table2). It is also not uncommon
to observe eects that are not featuring in the original
framework. Similar unexpected, minor eects were also
observed in earlier empirical tests of the framework of
intercultural competence [22].
Theoretical implications
Showing ample construct validity, the REMP-3 is a
straightforward psychometric upgrade compared to
the original EMP-3 (see also Tables1 and 2). First, the
REMP-3 now has a clear and cross-validated content
and structure, with three subscale dimensions and an
overarching higher order full scale dimension. Second,
both the subscales as well as the full scale show accept-
able to good internal consistency reliability, even though
the total number of items is reduced from eighteen to
ten. ird, the REMP-3 has stronger correlations to the
related constructs of intercultural competence, while
even showing a positive correlation with the intensity of
intercultural contacts, which the original EMP-3 does
not. As a result, the quality of the REMP-3 structure was
sucient to empirically integrate and cross-validate the
REMP-3 as a measure of intercultural attitudes into the
theoretical framework of intercultural competence [23].
Practical implications
Practically, the cross-validated REMP-3 is suited to ques-
tion graduate healthcare practitioners on their attitudes
towards ethnic minority patients in a concise manner
(i.e., only ten items). As intercultural attitudes are at a
central position of intercultural competence, measuring
the attitudes of graduate healthcare practitioners can give
an indication to which extent the potential to learn new
intercultural capabilities is facilitated (i.e., in case of a
more ethnorelative disposition) or hampered (i.e., in case
of a more ethnocentric disposition) by the practitioner’s
attitudes [31]. Awareness and change of intercultural
attitudes can thus prove to be key in order to understand
and address issues like ethnic dierences and racism in
healthcare systems through learning processes [6, 7].
As an example, supervisors can systematically evalu-
ate and monitor the progress of healthcare internships
or trial periods by administering the REMP-3 assess-
ment at predetermined intervals, such as before the
start of the internship and after its conclusion. is sys-
tematic approach allows for a structured comparison of
the intern’s performance over time. In conjunction with
other evaluative methods, such as direct observations of
interns in clinical settings (e.g., general practices or hos-
pitals), the REMP-3 results enable supervisors to assess
whether there has been a measurable shift in the intern’s
attitudes. Furthermore, the impact of these attitudi-
nal changes on the intern’s eectiveness in intercultural
patient interactions can be analysed, oering further
insights into their acquired skills and knowledge.
Limitations and Future Research
e present study revalidates the REMP-3 for use in a
broad population of graduate healthcare practitioners.
However, the participants for the present study were
all still studying albeit with various amounts of experi-
ence in a wide range of medical settings, which does
seem appropriate for the present study’s goals. Still,
future studies should focus on replicating the results of
the present study in more specic samples of health-
care practitioners, preferably over a wide range of work
settings like general nursery, psychiatric nursery and
surgery assistance. We are cautiously optimistic that
the REMP-3 results will be replicated, especially as the
results were cross-validated on independent data samples
while showing no eects of previous healthcare experi-
ence on the REMP-3 score. We attribute this non-eect
to the more general approach of the instrument, further
strengthened by using non-specic, non-medical ques-
tionnaires to operationalize intercultural competence
[21] and intercultural eectiveness [27].
e present study does show that younger (i.e., age)
and female (i.e., gender) practitioners can score higher
on the REMP-3. However, age and gender do not seem
to have an eect on acquiring intercultural capabili-
ties as an ethnorelative attitude combined with cultural
empathy and an open mind are predictive of the already
learned cultural capabilities. We do acknowledge that
the research line regarding the eects of covariates like
gender, age and experience on the components of inter-
cultural competence is quite complex and requires more
research. Such future research on components like eth-
norelativism as measured by the REMP-3, should always
include a full framework of intercultural competence to
assess the validity of the (sub)scales, as the validity of an
instrument’s results is function of both the instrument as
well as the population [43].
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Schelfhout et al. International Journal for Equity in Health (2024) 23:226
Conclusions
e cross-validated REMP-3 attitude instrument con-
cisely and reliably measures intercultural attitudes of a
broad population of healthcare practitioners towards eth-
nic minority patients. e instrument can be used in full
or split out in three subscales of task perception, back-
ground perception and the perception of needs in com-
munication. e REMP-3 instrument is therefore suited
to assess and monitor the attitude of graduate health-
care practitioners, even over longer periods of time like
the stages of an internship. Future research can evaluate
the impact of this attitude assessment and monitoring
in other settings like general practices and with a dier-
ent, more experienced target population including but
not limited to nurses and medical assistants. Ultimately,
the REMP-3 instrument can contribute to more equity
in healthcare by assessing and monitoring attitudes in
healthcare practitioners, as these attitudes indicate the
potential of acquiring new skills and knowledge to prop-
erly address interactions with ethnic minority patients.
Abbreviations
AIIC Average Inter-Item Correlation
CFA Conrmatory Factor Analysis
CFI Comparative Fit Index
CI Condence Interval
CQ Cultural Intelligence
MPQ (SF) Multicultural Personality Questionnaire (Short Form)
CE Cultural Empathy
ES Emotional Stability
FX Flexibility
OM Open Mindedness
SI Social Initiative
(R)EMP-3 (Revalidated) attitude towards Ethnic Minority Patients
TP Task Perception
BP Background Perception
PNC Perceived Need for Communication
PPC Physician – Patient Communication
RMSEA Root Mean Square Error of Approximation
SEM Structural equation modelling
SRMR Standardized Root Mean square Residual
Supplementary Information
The online version contains supplementary material available at h t t p s : / / d o i . o r
g / 1 0 . 1 1 8 6 / s 1 2 9 3 9 - 0 2 4 - 0 2 3 0 9 - x .
Supplementary Material 1
Acknowledgements
Not applicable.
Author contributions
SS: conceptualization, data collection, data curation, methodology, formal
analysis, investigation, supervision, validation, visualization, original
draft, review & editing. RV: investigation, review & editing. SW: funding
acquisition, data collection, investigation, supervision, review & editing.
ED: funding acquisition, investigation, supervision, review & editing. SDM:
conceptualization, data collection, investigation, supervision, review & editing.
Funding
This research was funded by Research Foundation-Flanders grant number
[Strategic Basic Research – S004119N]. The sponsors had no role in the design,
execution, interpretation, or writing of the study.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
The study was conducted according to the guidelines of the Declaration
of Helsinki, and approved by the Institutional Review Board (or Ethics
Committee) of UZGent, in collaboration with Ghent University (BC-07577,
22nd of April, 2020).” Informed consent was obtained from all subjects
involved in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1Faculty of Psychology and Educational Sciences, Department of Work,
Organisation and Society, Research Group Vocational and Personnel
Psychology, Ghent University, H. Dunantlaan 2, Ghent 9000, Belgium
2Faculty of Medicine and Health Sciences, Department of Public Health
and Primary Care, Research Group Equity in Health Care, Quality & Safety
Ghent, Ghent University, University Hospital, Campus entrance 42, C.
Heymanslaan 10, Ghent 9000, Belgium
3Faculty of Psychology and Educational Sciences, Department of
Experimental Psychology, Ghent University, Henri Dunantlaan 2,
Ghent 9000, Belgium
4Centre for the Social Study of Migration and Refugees, Ghent University,
H. Dunantlaan 2, Ghent 9000, Belgium
Received: 5 August 2024 / Accepted: 21 October 2024
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