Jun-Yuan Tung, MS, OTR Machiko R. Tomita, PhD John Stone, PhD Susan M. Nochajski, PhD, OTR/L Douglas Usiak Department of

1. 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, OTR Machiko R. Tomita, PhD John Stone, PhD Susan M. Nochajski, PhD, OTR/L Douglas Usiak Department of Rehabilitation Science State University of New York at Buffalo

2. Background • Culture 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.

3. 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.

4. Literature Review 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 • (Iannone,1987;Jezewski et al.,2001;Krefting,1991;McGruder,1996)

5. Literature Review…cont’d Cultural Competence • An 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 • (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)

6. Literature Review…cont’d Methods to Improve Cultural Competence • 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)

7. Literature Review…cont’d Culture Brokering Model • Bridging the Cultural Gap Between Foreign-Born Consumers and Services Providers • (Jezewski,1993;Jezewski et al.,2001;McElroy et al.,2000) See Culture Brokering Model

8. Literature Review…cont’d 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.

9. Research Questions • Do CIL staffwho serve in culturally diverse environments have higher cultural competence at the pretest than those who serve in culturally homogeneous environments? • Do CIL staffwho are cultural minorities have higher cultural competence at the pretest than staff from cultural majorities? • Do CIL staff improve their cultural competence and culture brokering knowledge after attending the culture brokering workshop?

10. Research Questions…cont’d • Among CIL staffattending workshops, do those who serve in culturally diverse environments improvetheir cultural competence more than those who serve in culturallyhomogeneous environments? • Among CIL staffattending workshops, do those from cultural minoritiesimprovetheir cultural competence more than thecultural majorities? • 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)?

11. Methods Study Design • Pretest - Posttest Control Group Design

12. Methods…cont’d Study Design…cont’d

13. Methods…cont’d 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.

14. Methods…cont’d Variables • Independent Variables: • Participation in workshops • The level of cultural diversity in participant's working environments • Participants’ personal cultural characteristics • Dependent Variables: • Scores of instruments

15. Demographic Information Questionnaire Methods…cont’d Instruments • Gender • Age • Education • Cultural Background • Working Regions • Disability • Cultural Diversity in Working Environments • Time of Working Experience with Foreign-born Consumers

16. Methods…cont’d 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

17. 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%)

18. 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 answers 1 fill-in question with five blanks

19. Methods…cont’d Procedure • 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. • Treatment Group

20. Methods…cont’d Procedure…cont’d • Control Group • All 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.

21. Methods…cont’d Data Analysis • Cronbach’s Alpha • Factor Analysis • Two-way ANOVA • ANCOVA • Wilcoxon Signed-Rank • McNemar Test • Independent t-test • Paired t-test

22. Results Characteristics of Participants • N = 92 • CA: 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%)

23. Results…cont’d Internal Consistency • Cronbach’s Alpha • Physical Environment, Materials & Resources: α = 0.88 • Communication Styles: α = 0.83 • Values & Attitudes: α = 0.95

24. Results…cont’d Construct Validity • Factor analysis • Physical 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)

25. Results…cont’d RQ1: Diverse VS Homogenous Environments (cultural competence) • Two-way ANOVA

26. Results…cont’d RQ2: Cultural Minorities VS Majorities(cultural competence) • Two-way ANOVA

27. Results…cont’d (cultural competence) RQ3: Treatment VS Control Groups • ANCOVA

28. Results…cont’d RQ3: Pre-test VS Post-test (knowledge gained) • Wilcoxon signed-rank test • McNemar test • Participants increased their scores on 21 of the 25 items (84%) • 41 out of 49 participants (84%) increased their scores

29. Results…cont’d RQ4: Diverse VS Homogenous Environments (Improvement of cultural competence) • Independent t-test

30. Results…cont’d RQ4…cont’d

31. Results…cont’d RQ5: Cultural Minorities VS Majorities(Improvement of cultural competence) • Independent t-test

32. Results…cont’d RQ6: Testing Effects • Paired t-test • 8 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%)

33. Discussions Summary of Main Findings • Culture brokering workshops had positive effects • Follow-up for long-term effects • The influence of participants’ cultural background and working environments • Pre-workshop cultural competence • Improvement of competence • Modify workshops for factors • The presence of testing effects • Revise the items

34. Discussions…cont’d Major Shortcomings • Possible ceiling effect of the questions • In WQ, 9 items with 80-96% correct answer • In 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 study • For treatment group: Self-selection bias • For control group: Investigators’ bias

35. Discussions…cont’d Potential Factors • Characteristics of staff positions • Completion of the post-test or not • Education • Experience for working with foreign-born consumers

36. 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