Discussion Acquire, apply, and activate knowledge: A pyramid model for teaching and integrating cultural competence in medical curricula Costas S. Constantinou a, *, Alexia Papageorgiou b , George Samoutis c , Peter McCrorie d,e a Medical Sociology, University of Nicosia Medical School, Cyprus b Clinical Communication, University of Nicosia Medical School, Cyprus c Primary Care, University of Nicosia Medical School, Cyprus d Medical Education, St George’s, University of London, UK e Medical Education, University of Nicosia Medical School, Cyprus A R T I C L E I N F O Article history: Received 8 June 2017 Received in revised form 1 December 2017 Accepted 19 December 2017 Keywords: Cultural competence Pyramid model Medical curricula Health care A B S T R A C T The importance of cultural competence in health care has been more acknowledged since modern societies are becoming increasingly multi-cultural. Research evidence shows that cultural competence is associated with improved skills and patient satisfaction, and it also seems to have a positive impact on adherence to therapy. Based on this evidence, the acknowledged importance of cultural competence and its poor integration into medical curricula, we present a pyramid model for building cultural competence into medical curricula whereby medical students can enhance their skills through acquiring, applying and activating knowledge. © 2017 Elsevier B.V. All rights reserved. 1. Introduction Contemporary societies are increasingly becoming multi- cultural [1], and medical practitioners encounter patients who bring to medical consultations their own views about health and illness, and are expected to understand the impact of various sociocultural factors on medical conditions [2]. As a result, medical practitioners are faced with the challenge of understanding their patients holistically [3] and communicating with them effectively in order to provide good quality care and improved health outcomes. To achieve a good relationship with their patients and positive health outcomes such as patient satisfaction, adherence to therapy and health improvement, medical practitioners need to be culturally competent [4]. We are presenting below the reasons why cultural competence has been acknowledged as an important skill in medical practice, and whether it is effective in terms of a number of outcomes, such as enhanced skills and attitudes, patient satisfaction, adherence to therapy and health improvement. We also discuss the existing frameworks and models of cultural competence and propose a pyramid model for teaching and integrating cultural competence skills in medical curricula in order to fill into an identified gap in medical education. 2. The need for, and effectiveness of, cultural competence Betancourt et al. [4](p.297) explained that cultural competence refers to “understanding the importance of social and cultural influences on patients’ health beliefs and behaviours; considering how these factors interact at multiple levels of the health care delivery system and, finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations”. This definition reflects the fact that modern societies are increasingly becoming multi-cultural and medical practitioners are faced with the challenge to establish good relationships with their patients from different cultures in order to improve patient satisfaction and achieve positive health outcomes. On this note, there is evidence to suggest that some cultural groups are not satisfied with health care [5], while medical practitioners may find that some cultural groups are difficult to work with because these groups may not speak the language of the host country, lack financial resources and have poor understanding of the existing health care services [6]. Therefore, as Waxler-Morrison et al. [5](p.6) explained, we need to adopt cross cultural care in order to deal with such “problems with health care”. Along similar lines, Betancourt et al. [7] outlined three reasons why cultural * Corresponding author. E-mail address: constantinou.c@unic.ac.cy (C.S. Constantinou). https://doi.org/10.1016/j.pec.2017.12.016 0738-3991/© 2017 Elsevier B.V. All rights reserved. Patient Education and Counseling xxx (2017) xxx–xxx G Model PEC 5857 No. of Pages 5 Please cite this article in press as: C.S. Constantinou, et al., Acquire, apply, and activate knowledge: A pyramid model for teaching and integrating cultural competence in medical curricula, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2017.12.016 Contents lists available at ScienceDirect Patient Education and Counseling journal homepage: www.else vie r.com/locate /pateducou