The Impact of Cross Cultural Training and Environmental & Personal Factors

on the Cultural Competence of Staff of Centers for Independent Living

Jun-Yuan Tung, MS, OTRMachiko R. Tomita, PhDJohn Stone, PhDSusan M. Nochajski, PhD, OTR/LDouglas Usiak

Department of Rehabilitation ScienceState University of New York at Buffalo

BackgroundCulture is increasingly recognized as an important factor that affects outcomes in human services.

More than 1/10 Americans (31.1 million in 2000) was born outside U.S. and 25-30% of U.S. population are ethnic minorities.

Cultural insensitivity or ignorance is a significant barrier between service providers and consumers.

CIRRIE is offering training workshops to remove cultural barriers.

Purpose of Research

To investigate whether the workshops have an impact on the participants’ cultural competence.

To explore the impact of personal characteristics and/or work environments on cultural competence.

To identify whether the personal and work environmental factors are modifiers of the impact of the workshops.

What is Culture? The way a group of people live

The way people perceive, adapt to and structure their internal and external environment

A blueprint or framework to guide people’s daily behaviors

A system of learned and shared patterns of behaviors

Literature Review

(Iannone,1987;Jezewski et al.,2001;Krefting,1991;McGruder,1996)

Cultural CompetenceAn awareness of, sensitivity to, and knowledge of the meaning of culture

The ongoing process in which the service provider continuously attempts to accomplish the capability to offer effective and efficient services to persons of different cultures

Personnel who have moved from being culturally unaware to being sensitive to their own cultural issues and to how their values and biases affect culturally diverse consumers

Literature Review…cont’d

(Bartol et al,1998;Campinha-Bacote,1998;Fitzgerald et al,1996;Forwell et al,2001; Jezewski et al,2001;McCormack,1987; Small et al,1999;Smith,1998;Wells,1995)

Methods to Improve Cultural Competence

Literature Review…cont’d

Direct contact with people with culturally diverse backgrounds

(Fitzgerald et al.,1997;Forwell et al.,2001;Robins et

al., 2001; Scheiderer et al.,1995)

The generic approach, such as seminars and workshops, that establish the awareness of cultural concerns by stimulating discussion and activities.

(Anthony,1997;Forwell et al.,2001;Goddard et al., 1998; Lindgren et al.,1993; Smedley et al.,1998)

Culture Brokering Model

Bridging the Cultural Gap Between

Foreign-Born Consumers and

Services Providers

Literature Review…cont’d

(Jezewski,1993;Jezewski et al.,2001;McElroy et al.,2000)

See Culture Brokering Model

Centers for Independent Living (CILs)

Community Based: Centers are located throughout the nation in local communities.

Consumer Controlled: Centers are run by a board of directors, more than half of whom are people with disabilities.

Available to All People with Disabilities: Staff, board members, volunteers, and people served represent a broad cross-section of disabilities.

Literature Review…cont’d

1) Do CIL staff who serve in culturally diverse environments have higher cultural competence at the pretest than those who serve in culturally homogeneous environments?

2) Do CIL staff who are cultural minorities have higher cultural competence at the pretest than staff from cultural majorities?

3) Do CIL staff improve their cultural competence and culture brokering knowledge after attending the culture brokering workshop?

Research Questions

4) Among CIL staff attending workshops, do those who serve in culturally diverse environments improve their cultural competence more than those who serve in culturally homogeneous environments?

5) Among CIL staff attending workshops, do those from cultural minorities improve their cultural competence more than the cultural majorities?

6) Does a testing effect exist in the self-assessment tool, Promoting Cultural Diversity and Cultural Competency for Personnel Providing Services in Centers of Independent Living (PCDCC-CIL)?

Research Questions…cont’d

Study DesignPretest - Posttest Control Group Design

Methods

Pre Time Post

RQ 1 Diverse Environment (DE) O

Homogeneous Environment (HE)

O

RQ 2 Cultural Majority (MA) O

Cultural Minority (MI) ORQ 3 Treatment Group (T) O X O

Control Group (C) O O

Study Design…cont’d

Methods…cont’d

Pre Time Post

Among Treatment Group:

RQ 4 Diverse Environment (DE-T) O X O

Homogeneous Environment (HE-T)

O X O

Among Treatment Group:

RQ 5 Cultural Majority (MA-T) O X O

Cultural Minority (MI-T) O X O

RQ 6 Control Group (C) O O

Participants

Treatment Group:Staff of CILs in California who attended the workshop in July, 2002.

Control Group:Staff of CILs in New York State with similar working environment.

Methods…cont’d

VariablesIndependent Variables:

Participation in workshops

The level of cultural diversity in participant's working environments

Participants’ personal cultural characteristics

Dependent Variables:Scores of instruments

Methods…cont’d

Instruments

Demographic Information Questionnaire

Methods…cont’d

Gender

Age

Education

Cultural Background

Working Regions

Disability

Cultural Diversity in

Working Environments

Time of Working

Experience with

Foreign-born

Consumers

Instruments…cont’d

Promoting Cultural Diversity and Cultural Competency for Personnel Providing Services in Centers of Independent Living (PCDCC-CIL)

Adapted from 4 similar self-assessment checklists but for different service providers

Intended to heighten the awareness and sensitivity of personnel to the importance of cultural competence in human service settings

Methods…cont’d

Instruments…cont’d(PCDCC-CIL)

Three Domains• physical environment, materials & resources• communication styles • values & attitudes

36 items (8, 9, & 19 items for each domain respectively)

Each item from A (Things I do all the time, 100%) to E (Things I never do, 0%)

Methods…cont’d

Instruments…cont’d

Workshop Questionnaire (WQ)

For treatment group only

To assess knowledge acquired during the workshops

Questions were developed based on the previous workshop

24 items with true and false answers1 fill-in question with five blanks

Methods…cont’d

Procedure

Treatment Group

Methods…cont’d

All materials, including PCDCC-CIL & WQ were given to participants and completed before the workshops.

Participants were asked to finish WQ again at the end of the workshops.

The posttest of PCDCC-CIL was filled out approximately two months after the workshops.

Procedure…cont’d

Methods…cont’d

Control GroupAll materials, including PCDCC-CIL were given to participants and collected through mail, email or in person.

The posttest of PCDCC-CIL was completed approximately two months after the pretest.

Data Analysis

Cronbach’s Alpha

Factor Analysis

Two-way ANOVA

ANCOVA

Wilcoxon Signed-Rank

McNemar Test

Independent t-test

Paired t-test

Methods…cont’d

ResultsCharacteristics of Participants

N = 92CA: 50 (54%); NY: 42 (46%)Female: 64 (70%); Male: 28 (30%)Age: 23-64 (mean: 41 years old)With Bachelor’s or higher degree: 56 (61%)With disability: 56 (61%)Cultural minorities: 26 (28%)Culturally diverse environment: 32 (35%)Working years for foreign-born consumers< 1: 30 (33%); 1-5: 30 (33%); >5: 32 (35%)

Cronbach’s Alpha

Physical Environment, Materials & Resources: α = 0.88

Communication Styles: α = 0.83

Values & Attitudes: α = 0.95

Results…cont’dInternal Consistency

Results…cont’dConstruct Validity

Factor analysisPhysical Environment, Materials & Resources (8 items)

Communication Styles (9 items)• Language Barrier (3 items)• Using Alternatives (3 items)• Self Changes (3 items)

Values & Attitudes (19 items)• Appreciation of Other Cultures (10 items)• Advocacy for Information (5 items)• Avoiding the Inappropriateness (4 items)

Two-way ANOVA

Results…cont’d

Domain/Factor Variable Mean F p d

Communication Style

DE 732.84.29 0.041 0.43

HE 611.7

Using Alternatives

DE 251.66.57 0.012 0.53

HE 191.3

RQ1: Diverse VS Homogenous Environments

(cultural competence)

Results…cont’d

Two-way ANOVA

Domain/Factor Variable Mean F p d

Physical Environ- ment, Materials & Resources

MI 498.13.99 0.049 0.42

MA 377.3

Self Changes MI 226.9

6.45 0.013 0.53MA 168.6

RQ2: Cultural Minorities VS Majorities (cultural competence)

Results…cont’dRQ3: Treatment VS Control Groups

ANCOVADomain/Factor Variable Mean F p d

Physical Environment, Materials & Resources

T 548.86.02 0.017 0.61C 472.0

Language Barrier T 280.4 6.09 0.016 0.62C 261.8

Using Alternatives T 247.6

5.13 0.026 0.56C 211.8

Values & Attitudes T 1633.5 7.54 0.008 0.70C 1531.6Appreciation of Other Cultures

T 950.012.04 0.001 0.88C 880.6

(cultural competence)

Results…cont’dRQ3: Pre-test VS Post-test(knowledge

gained)Wilcoxon signed-rank testMcNemar test

Participants increased their scores on 21 of the 25 items (84%)

41 out of 49 participants (84%) increased their scores

Results…cont’dRQ4: Diverse VS Homogenous Environments

(Improvement of cultural competence)Independent t-test

Domain/Factor Variable Mean t p d

Communication StyleDE-T 5.4

-2.47 0.009 0.77HE-T 119.7

Language Barrier DE-T 16.3-1.41 0.083 0.44

HE-T 40.8

Using Alternatives DE-T 5.4-1.69 0.049 0.52

HE-T 50.0

Self Changes DE-T -16.3-1.93 0.031 0.59

HE-T 29.0

Results…cont’dRQ4…cont’d

Domain/Factor Variable Mean t p dPhysical Environment, Materials & Resources

DE-T 73.9-2.16 0.018 0.67

HE-T 197.4

Values & AttitudesDE-T 126.1

-1.55 0.065 0.50HE-T 275.0

Appreciation of Other Cultures

DE-T 73.9-1.37 0.090 0.45

HE-T 144.4

Avoiding the Inappropriateness

DE-T 15.2-1.45 0.077 0.45

HE-T 61.1

Results…cont’dRQ5: Cultural Minorities VS Majorities (Improvement of cultural competence)Independent t-test

Domain/Factor Variable Mean t p dCommunication Style

Language Barrier MI-T 44.21.30 0.100 0.42

MA-T 19.8

Using Alternatives MI-T 59.61.74 0.045 0.63

MA-T 10.3

Self Changes MI-T -23.1-1.54 0.066 0.53

MA-T 16.4

Results…cont’dRQ6: Testing Effects

Paired t-test8 items (22%) showed testing effects

Physical Environment, Materials &

Resources: 3 items (38%)

Communication Styles: 4 items (44%)

• Self Changes: 3 items (100%)

Values & Attitudes: 1 item (5%)

Culture brokering workshops had positive effects Follow-up for long-term effects

The influence of participants’ cultural background and working environments

Pre-workshop cultural competenceImprovement of competence

Modify workshops for factors

The presence of testing effects Revise the items

DiscussionsSummary of Main Findings

Discussions…cont’dMajor Shortcomings

Possible ceiling effect of the questionsIn WQ, 9 items with 80-96% correct answerIn PCDCC-CIL, Appreciation of Other Cultures factor reached 84% max scores

The workshop and the instrument are not based on the same theory

The sampling methods of the studyFor treatment group: Self-selection biasFor control group: Investigators’ bias

Discussions…cont’dPotential Factors

Characteristics of staff positions

Completion of the post-test or not

Education

Experience for working with foreign-born consumers

Conclusions

This study was the first research for CILs staff and culture brokering workshops

Findings supported the benefits of workshops

The need of the more appropriate instrument and the consideration of relevant factors are indicated