Previous research has recognized the clinical and ethical imperative of considering socio-cultural contexts in developing healthcare interventions for various populations [41, 42]. The need for culturally sensitive interventions is especially crucial during and after an emergency due to the increased vulnerability of ethnic minorities and other underserved populations to disasters' physical, psychological, and economic effects . Research examining cultural competence training programs suffered from methodological constraints, such as weak study designs (e.g., lack of RCTs), low or no reporting of consent rates, and non-validated measurement instruments, limiting rigorous evaluations on the effectiveness of interventions [3, 4].
The current study used a randomized controlled design to examine the effectiveness of an online intervention in increasing nursing students' cultural competence in emergencies.
Overall, our results supported the use of an online program incorporated in the curriculum for increasing students' cultural competence. Specifically, participants in the intervention group were more likely to report increased knowledge of socio-cultural characteristics, health disparities, and health risks experienced by particular racial and ethnic groups, as well as of alternative healing traditions and methods . The effect of the intervention in increasing participants' ability to translate this knowledge into their daily practice (skills) approached significance. However, participants did not present increased confidence (encounters) in their ability to empower patients from diverse backgrounds or increased awareness of their own cultural background, stereotypes, or biases. These findings are consistent with previous studies [45–47] and systematic reviews [48, 49] showing that cultural competence training is especially effective in facilitating cultural-competence knowledge. For instance, a systematic review of 16 studies by Jongen et al.  found that cultural competence training improved knowledge in 9 of 16 studies, skills in 7 of 16, attitudes/beliefs in 5 of 16 studies, and confidence in 5 studies.
Several explanations may be proposed but warrant further exploration. First, focused intervention programs incorporated in the curriculum context are more likely to enhance
the cognitive aspect of cultural competence (especially at the basic knowledge and understanding levels) than other domains. From an education perspective, culturally- diverse knowledge is easier to learn and teach than practical skills or attitudes (affective learning domain) . Second, changes in culturally competent knowledge are easier to measure than changes in other domains . The gains in culturally competent knowledge may also be attributed to the course delivery mode . While different cultural competence training was delivered by professional trainers , sometimes from diverse backgrounds , our intervention was provided in two online sessions. Such delivery mode, especially in academic settings, may focus on the acquisition of facts rather than encouraging affective engagement or self-reflection. It is possible that longer courses that include active participation (e.g., students' presentations, classroom discussions, simulations) would increase the practical and affective domains of cultural competence.
A further explanation for our findings is related to the considerable overlap between the control and the intervention programs in content and structure. Given that the control program was incorporated within the curriculum, it was necessary to develop a course that consists of relevant educational content. The control program addressed the pivotal role of healthcare services during emergencies and emphasized the importance of social communication and networks. While not explicitly addressing culturally related topics, this program may encourage a patient-centered approach and promote sensitive and empathic attitudes among students. Indeed, our results showed that, compared to the pre-intervention assessment, both the intervention and the control groups showed an increase in their CCCQ scores. Such similarity between the intervention and control programs may explain why the culturally related knowledge was the most prominent gain from the intervention. Because most cultural competency training studies did not include a comparison group or used a non-intervention control group [3, for review], there is a need for a systematic investigation of what could be considered a "comparison condition.” For example, Genao et al. , who examined a cultural competence curriculum for third-year medical students, presented a control program that included lectures on clinical preventive medicine, alternative medicine, and domestic violence, taught by faculty with expertise in those areas. This program, however, did not necessarily encourage a patient-centered approach, and therefore might be more distinguished from the intervention group than in our study.
The limited differences between the intervention and control group might also be attributed to the demographic nature of our sample, which consisted of a high proportion of immigrants (30%). Previous studies suggested that compared to white therapists, cultural and linguistically diverse professionals were more likely to be involved with ethnic minority communities, to use a cultural framework in their clinical practice, and to perceive their agencies as culturally sensitive . Ethnic minority healthcare professionals often share patient's experiences of racism and prejudice , motivating them to provide more culturally competent care. It is possible that healthcare students of immigrant backgrounds were already aware of the importance of culturally- competent care and familiar with the concepts of cultural competence . Therefore, the only effect of the intervention program was evident in the practical skills domain, where training was necessary.
Our findings provide further support for the usefulness of online learning in health education. Recent studies that examined the effects of online learning on nursing assessment skills and knowledge supported its effectiveness [56, for a systematic review], especially in facilitating practical skills . Online learning was found to be effective in increasing medical capacity in rural settings and low- and middle-income countries, as it provides greater educational opportunities for students while simultaneously enhancing faculty effectiveness and efficiency . Our study had several notable strengths. First, the study used a theory-based intervention that incorporates universal as well as local understating of crisis responses and resilience. Second, the current study is built on the model of methodological excellence in educational studies  that advocates for the use of blind RCTs with valid instruments and appropriate statistical analyses of subgroups. This research is also one of the few studies that examined the efficacy of cultural competence training programs outside the United States.
The reported findings should be considered under several limitations. First, this study relied on self-report measures of cultural competence and did not include an objective evaluation method, such as health outcomes [60, for a systematic review] or patient satisfaction [61, for a systematic review]. Self-report measures are also vulnerable to various biases, including social‐desirability or response‐shift bias, that may confound the intervention effect with bias recalibration . Second, because the post-intervention assessment did not include a follow-up phase, it is difficult to determine whether the intervention's advantage would be stable over time. Third, because this study was based on healthcare students, our ability to generalize our results to other healthcare populations and setting is currently limited. Finally, due to the high attrition rate, the sample size was limited.