potential pattern interdisciplinary health science...

Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-343

Journal of Allied Health, Winter 2006

2006; 35:e343—e358.

© 2006 ASAHP, Washington, DC

POTENTIAL PATTERN

Interdisciplinary Health Science Education to Promote Cultural Competence

Beverly P. Horowitz, PhD, LMSW, OTR/L 1

Elizabeth Vanner, MS 2

Tosin Olowu, MS, OTR/L

1 Clinical Associate Professor, Occupational Therapy Department, School of Health Technology

and Management, Stony Brook University, Stony Brook, NY.

Email: [email protected]

2 Clinical Assistant Professor, Occupational Therapy Department, School of Health Technology

and Management, Stony Brook University, Stony Brook, New York

Date received: 10/12/2004; accepted: 12/21/2005

Acknowledgments

This program was supported by a Stony Brook University Presidential Grant for

Departmental Diversity Initiatives and the Stony Brook University Long Island Geriatric

Education Center. This paper builds upon Strategies to Promote Culturally Competent

Occupational Therapy Practice, presented at the 2003 National Annual Conference of the

American Occupational Therapy Association in Minneapolis, MN. Special thanks are extended

to Dr. Pamela Block for her insights and assistance with this research.


J Allied Health 2006; 35(4):e-343–e-358.

The 2000 United States Census confirmed that the United States has become increasingly

racially, ethnically and culturally diverse, with implications for healthcare. 1-4

Increasing ethnic

and cultural diversity, coupled with recognition of health status disparities among sub-

populations (racial, ethnic, gender), has spurred recognition that cultural competence is “an

essential ingredient for quality, access and the elimination of disparities” and is necessary to

meet legislative and regulatory requirements, including Federal requirements for language-access

services. 5-9

Cultural competence is a process, requiring respect for individual and family differences

and, in health care, requires the ability to provide effective, quality services to culturally,

ethnically, linguistically, and otherwise diverse populations, tailoring care to clients needs.1, 10-12

Diverse populations encompass the full range of multicultural distinctions, including racial;

religious; immigrant; gay, lesbian and transgender; individuals with disabilities; and

nontraditional families.10,13

Cultural competence is recognized as necessary for quality healthcare by the U.S.

Department of Health and Human Services, 14

including the Bureau of Primary Health Care, 7 the

Office of Minority Health 9, 15

, and the National Committee for Quality Assurance. 16

The Joint

Commission on Accreditation of Healthcare Organizations recognizes an individual’s right to

healthcare services that consider individual culture and language, and the relationship between

culturally competent practice and healthcare “safety and quality.” 17

Similarly, the American

Medical Association 18

and Institute of Medicine highlight the importance of “culturally


responsive medical care,” and effective cross-cultural communication to reduce health

disparities.19

The American Occupational Therapy Association affirms the right of each individual to

actively participate in healthcare decision-making to attain personally meaningful goals. 20

Professional guidelines for culturally competent occupational therapy highlight the need to

appreciate one’s own culture, biases and values; to respect diversity; and to use “culturally sensitive

interventions.”21

Cultural competency requires that practitioners are aware of their personal values

and biases, appreciate the ways in which culture can impact attitudes, behavior and lifestyle, and

have communication skills to support effective cross-cultural interactions.11, 22-23

Implicit in

“becoming culturally competent” is recognition of one’s heritage, respect for each individual’s

cultural practices and beliefs, and appreciation of the risk of stereotyping groups.10, 24-25

U.S. Census and healthcare data show disparities in life expectancy and the prevalence of

chronic illness and disability between genders and among Blacks, Whites, Asian Americans, and

Hispanics.11, 26-27

The Institute of Medicine’s 2002 report Unequal Treatment found that patients

of different cultural backgrounds do not consistently receive equal medical treatment and clinical

procedures, and that “racial differences” are insufficient to fully explain healthcare disparities.8,

28 The causes of these marked disparities in life expectancy, chronic illness, and disability are not

fully understood. In addition to linguistic, transportation, and financial barriers, there are

concerns that provider bias and misperceptions hinder effective communication, negatively

influencing medical care quality.5, 8, 28-29

Fadiman’s The Spirit Catches you and You Fall Down (1997) tells the story of cultural

clash and misunderstanding between an immigrant Hmong family and American healthcare and

social service organizations in which the family was erroneously accused of sabotaging their


daughter’s health. 30

Similarly, Ratliff (1999) reports a cultural clash involving a Hmong infant

diagnosed with retinoblastoma, requiring removal of the eye. Both cases resulted in loss of

parental custody. Miscommunication, language barriers, and lack of knowledge about Hmong

religion and beliefs contributed to a law enforcement manhunt after the family abducted their

child from the hospital to prevent surgery. The situation was resolved after social service

personnel enlisted assistance from a local Hmong shaman who calmed fears and encouraged

needed surgery. 31

Effective cross-cultural communication and client-centered approaches can avert

unintentional personal, community and institutional conflict. 11, 32-35

One successful occupational

therapy example involved collaborative treatment planning between a French-speaking Haitian

woman who sustained a stroke, with resulting moderate aphasia, while visiting her American

daughter. Despite medical challenges and language barriers, the patient’s goal of returning home

to Haiti was achieved through a client-family-centered partnership. This partnership supported a

treatment plan that focused on the patient’s specific needs and goals to maximize self-efficacy,

functional self-care capabilities, and quality of life. 33

Community-based health care and prevention programs are more successful when they

recognize culturally meaningful interventions. John, Hennessy and Denny (1999) provide an

example of the Zuni Diabetes Project, an exercise and weight reduction program that addresses

obesity and diabetes within Native American populations. Although successful outcomes depend

upon multiple factors, health care programs for Native Americans were found to be more

successful when in accord with traditional, holistic health care approaches.36


Cultural Competence Interdisciplinary Program

This paper reports on an interdisciplinary educational intervention with goals that

included increasing: cultural self-awareness; knowledge and understanding of diverse cultures,

including how culture can influence health behaviors and service utilization; communication

skills with diverse populations; and clinical skills for culturally competent practice. 22

It expanded

upon existing coursework to support culturally competent practice within occupational therapy

and other healthcare education programs. The program was funded by a Stony Brook University

grant and by the university’s multidisciplinary Long Island Geriatric Education Center and was

approved by the University’s Office on Research Compliance.

This initiative was embedded within a sequence of occupational therapy, physician

assistant, and physical therapy courses, was an elective for nursing, social work, and medical

students, and was offered to all students and faculty within these disciplines. Part one, “Moving

Toward Cultural Competency”, included a four-hour program using lecture, small-group self-

exploration activities, and case studies. Part two, “Addressing Diverse Client Needs,” used a

two-hour interactive community forum. In this forum panelists shared their personal perspectives

and experiences with students, faculty and members of the health care community. They

included individuals from the Hispanic, Black, Asian and Muslim communities, gay, lesbian, and

transgender adults, parents of disabled children, physically disabled adults. Facilitated dialog

between participants and forum speakers personally explored how bias, miscommunication, and

cultural insensitivity affected healthcare interventions, utilization, and speakers’ attitudes and

behaviors toward healthcare providers and institutions (Table 1).


Table 1. Cultural Competence Interdisciplinary Program

Program Description Learning Objectives

Part 1. Moving Toward Cultural Competency

Guest faculty Roxie Black and Shirley Wells provided a 4-hour

lecture and interactive case-based program to increase knowledge

and skills for culturally competent health care practice. Black and

Wells used materials from their text Moving Toward Cultural

Competency including their Cultural Competency Educational

Model focusing on:

1. Self-exploration to build an awareness of one’s individual

cultural heritage

2. Increasing knowledge about diverse cultures and recognition of

individual and group differences and similarities

3. Developing strategies and skills to more effectively communicate

and interact with persons from different cultures

The session included skill-building small-group cased-based

simulation activities. For example, one case focused developing a

care plan for a 72- year old Somali woman with specific religious

dietary and modesty requirements and strong cultural views

concerning gender and family roles.

1. To increase participants self-

awareness and recognition of

personal biases, attitudes, and

prejudices

2. To increase knowledge of

how culture can impact health

beliefs, behaviors, and service

utilization

3. To promote clinical

communication skills

4. To increase knowledge of

the benefits of culturally

competent practice for

effective health care services

Part 2. Cultural Competence: Addressing Diverse Client Needs

A multimedia musical and slide presentation, developed with the

assistance of Stephen Larese, Stony Brook University Slide

Librarian, set the tone for this 2 hour forum. The program brought

together a diverse group of 10 individuals from the Long Island

community and New York City metropolitan area to share their

experiences as health care consumers. Panelists were asked to share

a personal story and participate in a discussion on how students and

clinicians can increase understanding of diverse client values and

concerns to optimally address their health care needs.

The themes of these stories focused on concerns about respect,

privacy, prejudice, ignorance, and paternalism. One story, told by a

63- year old transgender women, spoke of the emotional toll of

coping with cancer treatment and insensitive, disrespectful hospital

staff. Another panelist shared her experiences as a young woman

with paraplegia determined to live her life, enjoy sports (i.e., scuba

diving), and have a family, and her search to locate physicians who

would recognize her goals and capabilities as well as her

limitations.

1. To increase knowledge

regarding the health care

concerns and needs of

culturally diverse consumers.

2. To increase knowledge

about the impact of client-

provider communication on

heath care utilization and

outcomes.

3. To promote culturally

competent communication

skills and clinical practice.


Methodology

Participants

Program evaluation research utilized pre and post-program tests to determine if there

were changes in perceived levels of cultural competency among occupational therapy students,

who were required to attend both parts of this program. Twenty-six students took the pre-

program test; twenty-five students completed the post-program test. Due to coding difficulties,

only 15 of the post-program tests could be matched to their corresponding pre-program tests.

All participants completed The Long Island Geriatric Education Center’s 9-item program

evaluation at the conclusion of part one and part two of this interdisciplinary program. Fifty-six

students, faculty, and guests attended part one “Moving Toward Cultural Competency;” 81

participants attended part two ” Addressing Diverse Client Needs.” Two items from this program

evaluation were analyzed to assess perceived changes in knowledge level before and after

attending each session.

Instruments

The primary outcome measures included, Promoting Cultural and Linguistic

Competency: Self- Assessment Checklist for Personnel Providing Primary Health Care Services,

designed to facilitate reflection and dialogue about cultural competency, by Georgetown

University’s National Center for Cultural Competence (NCCC), and one open-ended question

that asked how the program influenced attitudes, values, and communication styles.37

The

checklist was selected as a recognized, standardized instrument that promotes self-examination;

with the knowledge that “there was no process, nor any intent to determine the psychometric

properties of the tool” and that NCCC does not consider this tool “the most appropriate for

quantitative measurement of changes in self-report over time.” (W Jones, personal


communication, May 24, 2005). It was then adapted with permission to enable use by students.

The Physical Environment and Resources section was deleted since it is suitable only for

practicing clinicians. The entire two sections on Communication Styles and Values and

Attitudes remained, and the response scale was expanded from a 3-point scale (Things I do

frequently, Things I do occasionally, and Things I do rarely or never) to a 5- point scale geared

to student needs, adding: Things I need to do frequently and Things I need to do occasionally.

Lower scores indicate higher cultural competence self-assessment.

The Long Island Geriatric Education Center’s standardized 9-item program evaluation,

using a 5-point Likert scale (1 the lowest rating; 5 the highest), was completed by participants to

rate their knowledge-level of the subject before (item 1) and after (item 2) each session. The

remaining seven items (not analyzed here) were about the program’s methodology rather than

the program’s content (speaker quality, meeting course objectives, teaching methods, physical

facilities, personal objectives’ satisfaction, recommendation, and overall program quality.)

Data Analysis

Quantitative data analysis was conducted using SPSS (Version 13.0), Microsoft Excel

(2003), and the University of Colorado at Colorado Springs’ web site 38

for calculation of

Cohen’s d. Cronbach’s alpha reliability analysis was performed to determine the appropriateness

of creating overall scores for the modified Promoting Cultural and Linguistic Competency: Self-

Assessment Checklist for Personnel Providing Primary Health Care Services. Two scores were

calculated for each person: Communications (8 questions) and Values & Attitudes (20

questions). Cronbach’s alphas were 0.63 for the Communications scale and 0.89 for the Values

& Attitudes scale . These indicate a high degree of reliability for the Values & Attitudes scale


and a lesser degree of reliability for the Communications scale. Item responses were summed to

create these two separate scores.

The data included 26 pre-program and 25 post- program tests, of which 15 were paired.

Collectively, these tests had 34 missing responses, 17 were in two tests. These were eliminated

from the analysis (both unpaired pre-program tests). The remaining missing responses were

replaced with the median (appropriate for ordinal data) response for the cohort (pre or post).

A paired-samples t-test was used to analyze differences between occupational therapy

students’ paired pre-program and post- program test scores (n =15). An independent-samples t-

test was used to analyze unpaired data (pre- program tests n = 9; post- program tests n = 10). The

open-ended question was analyzed qualitatively for common themes. Scores on the university

program evaluation were also analyzed to assess the change, for all participants, for each of the

two sessions regarding knowledge of subject matter before and after each session using paired t-

tests (session one, N= 56; session two, N= 81).

Results

For the OT students the paired tests (n = 15), the mean pre-program Communications and

Values & Attitudes scores were M = 15.13 (SD =4.49) and M = 39.33 (SD =12.66), respectively

while the mean post-program Communications and Values & Attitudes scores were M = 14.67

(SD = 3.37) and M = 32.53 (SD =7.18), respectively. Results of the paired-samples t-tests

indicated a marginally significant improvement for occupational therapy students’ Values &

Attitudes mean scores [t(14) = 2.14, p = 0.05054 (two-tailed), d = 0.66] and no significant

difference in the mean Communications scores [t(14) = 0.38, p = 0.71 (two-tailed), d = 0.12].


For the unpaired tests, the mean pre-program (n = 9) Communications and Values &

Attitudes scores were M =16.33 (SD=2.00) and M =29.89 (SD=4.40), respectively while the

mean post-program (n = 10) Communications and Values & Attitudes scores were M =15.2

(SD=6.09) and M =32.20 (SD=10.94), respectively. Results of the independent-samples t-test

showed no significant differences in any of the mean scores [Communications scores: t(11.1

equal variances not assumed) = 0.56, p = 0.59 (two-tailed), d = 0.25 and Values & Attitudes

scores: t(17 equal variances assumed) = -0.59, p = 0.56 (two-tailed), d = -0.28.

The marginally significant difference in the Values & Attitudes mean scores, found in the

paired analysis but not the unpaired analysis, is probably due to the fact that the paired tests were

from predominantly first-year students while the un-paired tests were predominantly second-year

students. The second-year students had already been exposed to issues of cultural competence

during their initial clinical experience. The mean of the Values & Attitudes scores for the pre-

program paired tests is high (lower perceived competence), whereas the mean of the Values &

Attitudes scores for the post-program paired tests is comparable to the means of the Values &

Attitudes scores for both the pre- and post-program un-paired tests.

Program evaluation forms were completed by all participants for both parts one (n = 56)

and two (n = 81) of the program. Based on the program evaluation forms, significant differences

in mean perceived knowledge scores were found for both part one and part two (ps < 0.000, two-

tailed). For part one, the pre and post mean scores were M = 3.54 (SD = 0.95) and M = 4.14 (SD

= 0.72), respectively, t(55) = -6.69, d = 0.72. For part two, the pre and post mean scores were M

= 3.68 (SD = 0.85) and M = 4.38 (SD = 0.70), respectively, t(80) = -7.38, d = 0.90.

Qualitative data, from occupational therapy students responses to an open-ended question

(n =26), showed that 22 students reported increased insight and understanding of other cultures.


Four students specifically indicated that the program influenced how they will communicate with

diverse client populations and two students stated that the program “opened their eyes” and

helped them value diversity. Specifically, one student reported that hearing directly from health

care consumers was “ informative, eye opening,… and made me more aware of other cultural

practices”, another stated that the program increased “understanding … of different cultures”,

“the values of different cultures,” and “made me value diversity.”

Summary

Cultural competence is recognized across healthcare disciplines as a critical aspect of

healthcare delivery and a necessary component of healthcare education. Within occupational

therapy education, accreditation standards require curricula to address the influence of culture,

socio-cultural, and lifestyle factors on human behavior, and their potential impact upon

healthcare outcomes.22

Increasingly, legislative, accreditation and regulatory requirements also

emphasize culturally competent practice. 22, 34

To prepare healthcare providers for culturally competent practice, students need multiple

opportunities to explore their personal values, increase knowledge of diverse cultures, and

develop cross-cultural communication and clinical skills in the classroom and in clinical

education. This 6-hour, two-day program was established to provide a supplemental opportunity

within the confines of extensive, prescribed curricula to support self-exploration, and increase

knowledge, skills, and interdisciplinary dialog to advance the process of becoming culturally

competent practitioners. Although this program included only one university, with small

numbers of students, results found this educational initiative, combining traditional teaching

methodologies, case studies, and a participatory community forum, indicated possible heightened

awareness among occupational therapy students of how their values and attitudes can impact


practice and increased perceived knowledge for all participants, confirming the value of this

interdisciplinary program for students from many health disciplines.

This initiative can be replicated and/or adapted by other institutions to provide

opportunities for experiential learning, including community and interdisciplinary dialog, and

opportunities to build skills for culturally competent practice. Clinical education is a backbone of

healthcare education to ensure that students competently use and apply knowledge and skills in

practice settings. Currently, the challenge for healthcare educators is to infuse their extensive

curricula with opportunities for understanding the complex relationships between culture and

health care, enabling students to build the interpersonal, communication, and clinical reasoning

skills necessary to provide quality healthcare services to diverse populations. While health care

professions educators also face challenges meeting accreditation standards and the demands of

21st century practice, 21

st century practice requires all disciplines to acknowledge the importance

of cultural competence to provide effective health care for increasingly diverse populations.

However, educational institutions seeking to document educational outcomes need to appreciate

the difficulties of quantifying perceived changes in cultural competency, in order to properly

evaluate these curriculum initiatives.


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