Abstract
This pilot study demonstrates the effectiveness of using a targeted educational module to significantly improve occupational therapy students’ cultural awareness and skills when working with Hispanic families.
The Hispanic community faces increased disparities in health care quality and access, including rehabilitation services, because of language barriers, limited resources, and cultural differences (Arango-Lasprilla et al., 2007; Flores et al., 2020; Grandpierre et al., 2018; Horvat et al., 2014). By 2060, one-third of children in the United States are projected to be Hispanic (U.S. Census Bureau, 2017; Vespa et al., 2018). With this projection, an increase among Hispanic youth receiving pediatric occupational therapy services is expected, the largest area of occupational therapy practice. Despite the national rise in ethnic diversity, the Hispanic occupational therapy workforce has only increased 3.2% to 4.4% over the past decade (American Occupational Therapy Association, 2023). Therefore, it is imperative to prepare occupational therapy students of all backgrounds to promote culturally effective care that addresses the needs of Hispanic families.
Hispanic and Latino are often used interchangeably when referring to Spanish-speaking populations in the United States (U.S. Census Bureau, 2022). Hispanic refers to anyone born in or with descendants from Spanish-speaking countries (U.S. Census Bureau, 2022), whereas Latino/a refers to people from Latin America specifically, regardless of spoken language (Merriam-Webster, n.d.). Despite their nuanced meanings, the preferences of these panethnic labels are dynamic and situated by one’s identity within several sociodemographic contexts (Martínez & Gonzalez, 2021). It is important to note that the Hispanic and Latino/a constructs are composed of ethnic subgroups that are not culturally homogenous or monolithic. Understanding the dynamic nature of cultural context, in this study, we use the term Hispanic to represent people in New York City’s diverse population who share linguistic and cultural heritage of Spanish-speaking countries while respecting individual ethnic identities within this demographic population.
Culturally effective care refers to an ongoing deep reflection of personal and cultural biases to adequately interact and build therapeutic relationships with patients from other cultural backgrounds while considering the impact of the context within interventions (O’Brien & Kuhaneck, 2020; Wells et al., 2016). In this study, we used three constructs that encompass culturally effective care: how we see ourselves (cultural awareness), how we see others (cultural knowledge), and how we use that awareness and knowledge as a skill to interact with others (cultural skills; Muñoz, 2007; Talero et al., 2015). In this study, cultural awareness refers to the self-reflection on one’s culture and how it differs from the culture of others. Cultural knowledge refers to the obtainment and understanding of information about different cultures. Last, cultural skills refer to the ability to interact with patients from different cultures (American Occupational Therapy Association, 2020; Campinha-Bacote, 2002; Kaihlanen et al., 2019).
Course-based training within the occupational therapy curriculum and interprofessional training with other health professional students have been shown to improve cultural competence levels (Davis-Cheshire & Crabtree, 2019; Ozcan Edeer & Rust, 2022). Evidence in other disciplines, including psychology, nursing, and audiology, supports the use of cultural training to improve the clinician’s ability to work with Hispanic patients (Grady, 2014; Reel et al., 2015; Weil, 2010). Formal training (e.g., cultural competency class), informal training (e.g., work experiences), and cultural immersion (e.g., direct interaction with culturally diverse populations) have been associated with higher levels of self-perceived cultural competence, awareness, and sensitivity among occupational therapy students and occupational therapists (Brock et al., 2019; Suarez-Balcazar et al., 2009). Occupational therapy students’ experiences and understanding of cultural competency positively affected the occupational therapy intervention process (Govender et al., 2017).
The occupational therapy field has recognized the value of cultural training programs to assess and improve understanding of these cultural differences to enhance therapeutic relationships (Davis-Cheshire & Crabtree, 2019; Govender et al., 2017; Suarez-Balcazar et al., 2009). However, occupational therapy programs have reported time constraints within the academic curriculum, and the lack of diversity within the field has made it challenging for many programs to incorporate training into their curriculum (American Occupational Therapy Association, 2023; Brown et al., 2011).
The aim of this pilot study was to develop and implement a module in the occupational therapy pediatric curriculum on promoting culturally effective pediatric care for Hispanic families in New York City to improve cultural awareness, cultural knowledge, and cultural skills. On the basis of previous literature, we hypothesized that the implementation of the module in the curriculum would be associated with significant improvements in measures of cultural awareness, cultural knowledge, and cultural skills (Davis-Cheshire & Crabtree, 2019; Govender et al., 2017; Muñoz, 2007; Talero et al., 2015).
Method
Research Design
In this interventional study, we used a pre–post outcome measure mixed-methods design to gather data for assessing changes in cultural awareness, cultural knowledge, and cultural skills after implementing a module for occupational therapy students on promoting culturally effective care for the Hispanic community in New York City. Researchers developed and implemented the intervention module in an occupational therapy program pediatric course. The Cultural Competence Self-Assessment Checklist–Revised (CCSACR) is a valid and reliable tool that was administered to assess the identified constructs of culturally effective care, including cultural awareness, cultural knowledge, and cultural skill levels among occupational therapy students (Argyriadis, Asimakopoulou, et al., 2022; Argyriadis, Patelarou, et al., 2022).
After the module, participants were given a questionnaire with four demographic and six open-ended questions to collect qualitative data. The open-ended questions were used to collect data on self-perceived awareness, knowledge, and skills. The Columbia University Institutional Review Board approved this study.
Participants
The sample consisted of 30 participants recruited through convenience sampling of entry-level occupational therapy master’s students. All participants were enrolled in a pediatric course in their program. Participants spoke English and were physically present in class on the day of implementation. Participants received the interventional module as part of their course requirements. Written consent to participate in data collection was voluntary with the option to withdraw at any time.
Intervention
A cognitive behavioral–based interventional module was delivered in a classroom and taught by Chloë Carames-Foley, who identifies as Hispanic. The module was developed with a cognitive–behavioral framework with evidence-based methods. The module was delivered with an explicit emphasis on considering the unique factors of individual families and the use of contextual and situated cultural information as a guide. Module topics included promoting awareness through self-reflection on personal or cultural bias; improving knowledge on family-centered culturally effective care, barriers, and facilitators as well as strategies for practice; and a discussion focused on skills to become agents of change by creating inclusive work environments, seeking resources to continue to develop culturally effective practices, and continuously advocating for Hispanic families. To mitigate language as a barrier to care, a Spanish medical interpreter reviewed general and developmental pediatric occupational therapy resources in Spanish (what is occupational therapy, fine motor development, sensory processing, social–emotional development, and activities of daily living) for accuracy and shared them with the participants.
Data Analysis
We assessed data from the CCSACR using IBM SPSS Statistics (Version 29). The preset α level was .05. We performed a paired t test to compare differences between CCSACR pre- and posttest scores. We performed analysis of demographic data using descriptive statistics. We analyzed qualitative data using a conventional analysis method (Hsieh & Shannon, 2005). We classified open-ended questions as a coding unit. We independently reviewed each participant’s responses and identified common words or ideas. Data were then categorized into related groups, counted, and summarized.
Results
The participant characteristics are shown in Table 1. The majority of participants were female (93.3%; n = 28), White (53.3%; n = 16), and between ages 21 and 29 yr (90.0%; n = 27). Only 6.7% of participants were fluent in Spanish (n = 2), and 26.7% reported participating in some form of Spanish medical terminology training (n = 8).
Descriptive Demographic Characteristics
Cultural Awareness, Knowledge, and Skills
As shown in Table 2, the paired t test indicated a significant difference in cultural awareness (p = .013) and cultural skills (p = .038) after module implementation. Participants’ cultural awareness pretest mean scores improved from 39.30 (SD = 3.94) to a posttest mean score of 41.33 (SD = 4.41). Participants’ cultural skills mean scores improved from 31.86 (SD = 3.81) to a mean score of 33.59 (SD = 4.62). The results showed that the cultural knowledge mean score (M = 34.83, SD = 3.31) increased (M = 36.00, SD = 3.05). However, this improvement was not significant (p = .55). Additionally, participants’ total CCSACR score significantly improved (p = .004) after participation in the module. Participants’ total CCSACR pretest mean scores improved from 105.62 (SD = 9.07) to a mean score of 111.07 (SD = 10.86).
Paired t Test Pre- and Posttest Results
Note. CI = confidence interval.
aTotal score refers to the sum score of cultural awareness, knowledge, and skills.
Qualitative Results
Participant examples of their responses are listed in Table 3.
Participant Responses
Self-Perceived Skills
Of the participants, 63.3% (n = 19) indicated they felt more ready to work with Hispanic families after this module. In addition, 3.3% (n = 1) of the participants said their preparedness did not change after the module, and 33.3% (n = 10) did not respond.
Self-Perceived Knowledge
Of the participants, 50.0% (n = 15) reported self-perceived improvement in knowledge. In addition, 10.0% (n = 3) of the participants felt that they knew the presented information, and 40.0% (n = 12) did not respond. Three themes emerged in responses on improvements in knowledge: cultural considerations (f = 8), terminology (f = 3), and practice strategies for working with Hispanic families (f = 4).
Self-Perceived Awareness
Of the participants, 26.7% (n = 8) mentioned increased attentiveness to bias. In addition, 20.0% (n = 6) of the participants mentioned awareness of the need for continued learning and ongoing self-reflection, and 53.3% (n = 16) did not respond.
Resources
Of the participants, 73.3% (n = 22) reported that they will use the provided Spanish-translated resources in future clinical experiences. In addition, 26.7% (n = 8) of the participants did not respond.
Discussion
In this pilot study, we examined the effects of implementing a module on promoting culturally effective pediatric care for Hispanic families on a sample of occupational therapy students’ cultural awareness, cultural knowledge, and cultural skills. The results of the CCSACR indicated that occupational therapy students experienced significantly higher cultural awareness and cultural skill score results in the posttest compared with the pretest, indicating that implementation of the module improved cultural awareness and skills. The qualitative data revealed self-perceived improvements in awareness of bias and the need for continued learning and ongoing self-reflection. The results are consistent with previous evidence supporting the effectiveness of cultural course-based training within occupational therapy curriculum in improving levels of overall cultural competence, awareness, and skills (Davis-Cheshire & Crabtree, 2019; Grady, 2014; Ozcan Edeer & Rust, 2022). Overall, the current findings support our hypothesis that implementation of the module was associated with improved occupational therapy student scores on the posttest measures of cultural awareness and cultural skills.
In this study, we found that occupational therapy students improved in cultural knowledge after implementing the module; however, the improvement was statistically insignificant. These findings were inconsistent with previous literature that found a significant improvement in cultural knowledge after implementing a cultural education intervention for occupational therapy students (Davis-Cheshire & Crabtree, 2019; Jamieson et al., 2017). The majority of completed responses to questions on knowledge indicated self-perceived improvement. Participants identified improvements in cultural considerations, terminology, and strategies for practice when working with Hispanic families. The open-ended responses allowed participants to report on occupational therapy–related knowledge, whereas the CCSACR did not measure constructs related explicitly to occupational therapy practice. The majority of participants who responded reported feeling more prepared to work with Hispanic families after this module and indicated plans to use the provided Spanish resources in future clinical experiences.
Strengths and Limitations
This pilot study had several strengths, including measuring constructs of culturally effective care and extending the research on course-based cultural training within the occupational therapy pediatric curriculum. However, some limitations must be acknowledged when interpreting the results. First, the convenience sample of entry-level occupational therapy master’s students was small (N = 30), and no control group was used. Participants who identified as Hispanic or Latino/a were included in the analysis, which may have skewed the results in cultural knowledge. Additionally, the qualitative survey was voluntary for students, and the response rate for completion of open-ended questions in its entirety was low, affecting generalizability.
In future studies, researchers should develop resources that capture the dynamic nature of cultural contexts and occupational therapy–specific assessment measures to measure culturally effective care based on the values and constructs of occupational therapy practice. Moreover, cultural skills could not be adequately measured, and researchers conducting future studies should follow students until they are clinicians to assess long-term ability to carry out culturally effective care in practice with Hispanic families.
Implications for Occupational Therapy Practice
Occupational therapy clinicians are ethically responsible for providing quality care to all pediatric patients, including those who identify as Hispanic (American Occupational Therapy Association, 2020). Results from this study provide further evidence for the significant influence of course-based cultural training on promoting culturally effective care. These findings may be used in the development of occupational therapy academic curriculum, in-services, and continued education. The benefits of implementing cultural-based training in occupational therapy curricula, which targets specific demographic populations to promote culturally effective practice, can prepare students to address the occupational needs of diverse populations.
Conclusion
This study presents compelling evidence of the significant impact of course-based cultural training on the promotion of culturally effective care. Specifically, occupational therapy students demonstrated significant improvements in cultural awareness and skills after completing a module focused on culturally effective care. Qualitative findings also indicate that the module enhanced students’ self-perceived awareness, knowledge, and preparedness to provide culturally effective occupational therapy services to Hispanic families. Overall, the results underscore the importance of integrating cultural training into the occupational therapy curriculum to advance culturally effective practices.
Footnotes
Acknowledgments
We express our gratitude to Dr. Julia Guzman for her generous support and for allowing us to use her class as a platform to deliver the module that served as the focus of this study. We also acknowledge the Programs in Occupational Therapy at Columbia University. Their support, encouragement, and dedication to fostering educational growth were instrumental in the success of this project.