Cultural awareness programs

A six-session cultural workshop series and intensive Spanish language classes were offered as either an 8-week class series or 1—3-week integrated immersion program.

Education DVD delivered to healthcare professionals state-wide through conferences, community meetings and clinic training. A life nationwide webcast and satellite conference was also offered, and the training was accessible online. Pharmacists attended an education weekend which included a 4-h cultural awareness session. The health worker education program occurred over 4 sessions ranging from 30 min to 1. Training was provided to nurses working across two major tertiary hospitals.

Intervention was implemented across four diverse health care practice sites. Three modules could be delivered as one half-day training or 3 separate sessions of 1—1. Table 5 Study design, measures and outcomes.

Study Design and Measures Outcomes Abbott [ 39 ] Content analysis to determine the type and detail of the planned feedback, field notes from workshop discussions and participant evaluations to gain insight into participant confidence in cross cultural supervision. A lack of supervisor confidence in providing guidance on cross-cultural consultation with Aboriginal patients was identified. Aboriginal Workforce [ 50 ] Data analysis of training completions to measure the percentage of health staff who completed training components; staff and participant interviews; and, web-based survey of Chief Executives.

Program implementation was found to be slower than anticipated. Brathwaite [ 40 ] Multiple time-series design to measure nurse cultural knowledge as measured by the Cultural Knowledge Scale CKS. Quantitative and qualitative data showed in an increase in participants cultural knowledge following the program. Chapman [ 38 ] Pre and post questionnaire to measure the cultural awareness perceptions and attitudes of staff. Changes in staff perceptions, but not attitudes which remained neutral.

A decrease in ambivalence. Dingwall [ 42 ] Pre and post questionnaire to measure participant knowledge and confidence in delivering e-mental health to Indigenous people.

Significantly improved perceived knowledge and confidence in using e-mental health tools with Indigenous clients after training. Hinton [ 41 ] Pre-post questionnaire to measure participant knowledge and skills. Significant improvement in knowledge of the warning signs and treatment of mental illness and levels of confidence to assess, treat and communicate with Indigenous mental health clients. Khanna [ 46 ] Retrospective post- then pre- evaluation utilising a non-validated Cultural Competency Assessment CCA tool to measure changes in knowledge and skills related to the care of patients from diverse cultural and ethnic backgrounds.

Statistically significant change in participants self-reported knowledge and skills in providing culturally competent care. Total CCAT scores significantly increased for experimental group participants Liaw [ 52 ] Pragmatic pre- and post- evaluation using a practice site audit of cultural respect, health checks and risk factor management for Aboriginal patients in general practice.

A Cultural Quotient CQ questionnaire was used to measure staff cultural strategic thinking, motivation and behaviour. Lopez-Viets Pre- and during intervention evaluation in measures of research productivity, including number of grant applications and awards, publications and professional presentations of mentees. Self-reported increased appreciation of cultural interpretations of health, increased knowledge and consideration of Latino health beliefs and practices, improved ability to interact with patients, and greater respect and appreciation for patients cultural views.

Improvements in blood glucose control as measured by a drop in HbA 1c. McGuire [ 44 ] Pre-post self-report survey measuring practitioner knowledge and confidence. McRae [ 51 ] Repeated measures three-phase questionnaire and semi-structured, face-to-face, in-depth interview post-program to evaluate pharmacists confidence.

A brief survey to measure acceptability of program to AHWs and an audit of attendance. Salman [ 48 ] Pre-post questionnaire to measure practitioner self-reported cultural awareness and competence.

No effect sizes reported. Increases in proportion of participants rated as culturally aware and competent. No significant improvement on any outcome measure for either intervention group. Lack of impact of physician training on health care provision. Wu [ 43 ] Comparative study with historical control measuring parent reported satisfaction with interpreter and healthcare experience.

Measures There was significant diversity in the measurement tools used across studies to measure changes in cultural competence, with no studies using the same measurement tool. Discussion One of the key issues across the cultural competence literature is the lack of consistent terminology and an agreed upon definition of cultural competence and related concepts [ 2 , 54 — 56 ]. Conclusion The studies which informed this review demonstrate a great diversity in approaches taken to address the cultural competence of the health workforce.

Additional files Additional file 1: 1. Additional file 2: K, docx Data extraction table. Acknowledgements The authors acknowledge the contributions of Mary Kumvaj MK in conducting the literature search, Komla Tsey KT for participating in the screening process, and Anton Clifford AC for participating in the screening process and contributing authorship to the larger systematic review which this review is part of.

Availability of data and materials All data generated or analysed during this study are included in this published article and its supplementary information files. United States. Notes Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests and that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes Electronic supplementary material The online version of this article Contributor Information Crystal Jongen, Email: moc. References 1. Napier AD, et al. Culture and health. Cultural competence in health: a review of the evidence. Singapore: Springer Nature; Cross TL, et al. Towards a culturally competent system of care: a monograph on effective services for MinorityChildren who are severely emotionally disturbed.

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Cultural competence among staff nurses who participated in a family-centered geriatric care program. J Nurses Staff Dev. Thom DH, et al. Development and evaluation of a cultural competency training curriculum. Aboriginal Workforce. McRae M, et al. Evaluation of a pharmacist-led, medicines education program for aboriginal health workers.

Rural Remote Health. Liaw S-T, et al. Improving cultural respect to improve aboriginal health in general practice: a multi-methods and multi-perspective pragmatic study. Aust Fam Physician. Viets VL, et al. The event was very successful, drawing 60 park visitors into the theater to watch their presentation packed full of information on various cultural items and customs from around the world. The event was a rousing success and the interns will return to Fairytale Town on April 18th, for an encore!

This year, interns continued the cultural awareness program by visiting local elementary schools to teach children about some of the diverse cultures of the world. The children enjoyed presentations that included colorful artwork, music and craft projects.

New interns have joined the implementation team; as a result, the project has been able to reach more children. The presentations are infused with cultural artifacts from across the globe, information, activities and enthusiasm. The SHARE interns spend most of their time addressing cultural differences and similarities in dress, values, history, and climate. To reinforce these ideals the interns utilize various cultural objects, maps, and music.

The hope is that by educating as well as entertaining the children we will help them develop a cultural relativistic world view. During this program, interns traveled to different elementary schools promoting cultural diversity by providing interactive presentations of different cultures from around the world.

SHARE interns have visited over 40 elementary schools in the local area over the fall and spring semesters. The program has definitely expanded; there are four new interns who joined the implementation team. A thorough behavior analytic intervention may be effective with individuals across various cultures Kauffman et al. However, skilled, thorough, and well-trained behavior analysts may not always consider client culture. However, common functional assessment data collection strategies and interview forms may not thoroughly explore cultural preferences and norms.

Behavior analysts may consider the intersection of a cultural and linguistic context with the terms, concepts, and science of behavior analysis Jones and Hoerger It is possible that, without information about cultural preferences and norms, behavior analysts may unintentionally provide less than optimal service delivery.

Consider an example of a behavior analyst who provided in-home and community services to the family of a child with severe autism. The family, to whom church is very important, attended a weekly three hour church service. Eventually, the family specifically asked the behavior analyst to teach the child the necessary skills to participate in the church service. However, the behavior analyst still did not assign a high priority to teaching the child the skills needed for successful church attendance.

In addition to the previous two examples, being culturally aware may also increase the probability that behavior analysts will engage in behaviors that are socially acceptable to people from diverse cultural backgrounds. These behaviors include selecting culturally appropriate treatments see Rispoli et al.

Finally, increasing cultural awareness may also decrease the probability of behavior analysts expecting the clients they serve to conform to their own cultural and scientific values and contingencies.

The science of applied behavior analysis ABA is a unique cultural system see Glenn Given that the science of ABA inherently embodies a certain set of values such as a Westernized model of science and health care, the cultural values and contingencies of ABA may not always align with those of the client. As Bolling noted,.

Awareness of cultural differences and similarities may allow for programmatic modifications that result in more culturally appropriate models of behavior analytic service delivery. In summary, there may be many important reasons for behavior analysts to develop cultural awareness skills. Although there is a growing interest in conceptual e. Therefore, guidance on how to become culturally aware may be an important resource for behavior analysts.

The purpose of this paper is to offer suggestions that can serve as a starting point for how behavior analysts may further increase their cultural awareness. We believe that cultural awareness, as described herein, reflect Baer et al. Individuals participating in behavior change programs and those who provide significant support for them should determine what is important to them, to their society, and to their culture. Then, we describe strategies for embedding cultural awareness practices into behavior analytic service delivery, supervision, and professional development.

Finally, we conclude with additional discussion and considerations for becoming culturally aware in everyday practice. We will refer to cultural values and contingencies as the cultural system, except where values or contingencies play an independent role in our analysis of developing cultural awareness. We will refer to cultural identity as characteristics that extend beyond individual differences to those traits that members of a given culture share with one another Adler For example, an individual from Africa may express their cultural identity through their belief structure, attire, foods eaten, or hair style.

Even though this individual might identify as African, there are subcultures to which they might further identify with.

Our suggestions are meant to serve as a starting point for furthering a behavior analytic understanding of cultural awareness and how that awareness can be integrated and improved upon in everyday practice. It is recommended that behavior analysts concurrently engage in cultural awareness practices concerning their own behavior as well as those of their clients.

Lastly, our suggestions are not intended to result in a rigid set of rules or practices. Rather, our hope is the suggestions will lead to broad practices that develop and continually refine cultural awareness, which will hopefully allow behavior analysts to be more open and flexible to the various cultures that will be experienced. Openness and flexibility in the presence of various cultures will hopefully result in better outcomes for those we serve. From a behavior analytic perspective, self-awareness can be defined as verbal discrimination of our own behavior Barnes-Holmes et al.

Sugai et al. An understanding of our own cultural system may be an important first step toward correcting biases that affect our interactions with others Lillis and Hayes Developing self-awareness may prevent our biases from impeding how we serve culturally diverse clients. One strategy to enhance cultural self-awareness is talking about our diverse client interactions with a professional community in group discussions, written forums, journals, mentorship meetings, verbal feedback sessions, or self-reflective exercises Tervalon and Murray-Garcia Skinner emphasized the relationship between self-awareness and control over our own behavior,and proposed that talking about our behavior is how we achieve self-awareness.

Recent behavior analytic research indicates that when individuals verbally describe their own behavior, the behavior may change Tourinho Discussion with mentors and colleagues may help behavior analysts learn about themselves and also change their cross-cultural interactions for the better. We recommend practitioners hone their ability to attend closely to clients and self, in context, for two reasons related to self-awareness.

First, such attention may help enhance skills of self-observation and self-description regarding our overt and covert behavior. Also, while we can remain committed to overtly behaving in ways consistent with values of multiculturalism, even in the presence of values and contingencies that create bias, mindfulness may reduce the biases that produce thoughts, feelings, and reactions to culturally diverse people Lillis and Hayes Attending closely to our clients and being active and alert is good practice for building rapport, too.

Clinicians can engage in more culturally aware practice by assessing, collecting data, and testing hypotheses rather than accepting their own experiences and biases as the norm Sue Scientific mindedness is a characteristic of clinicians and human service providers who develop theories about client behaviors by analyzing data rather than by dependence on their personal assumptions Sue , and may reduce bias and foster better understanding of client behavior.

The practitioner may notice, and be able to covertly tact, that this is not the norm of the cultural majority nor congruent with his personal experience or values. Lillis and Hayes recommend practitioners accept that such reactions may be normal, given our cultural systems and the human tendency to evaluate, but remain committed to acting positively based on our values. Through a process of assessment and covert verbal behavior, the practitioner might accept the co-sleeping arrangement to be culturally appropriate for and preferred by the family, and choose to develop an intervention that keeps the arrangement in place.

A blend of both self-awareness and reliance on scientific knowledge is likely to produce the most culturally aware assessment and intervention. Finally, there are several self-assessment tools that behavior analysts can use to become more aware of their own cultural identity. Behavior analysts can then consider how their biases might affect treatment and may consider other courses of action, such as making referrals to other behavior analysts.

A final potentially useful measure is the Multicultural Sensitivity Scale Jibaja et al. This tool was originally used to assess the multicultural sensitivity of teachers and was later adapted to be used by physician assistant students Jibaja-Rusth et al. Altogether, the behavior analyst may find these assessments helpful in further developing their own cultural awareness in order to further develop culturally competent methods of service delivery.

The above section describes strategies for how a behavior analyst may learn about his or her own cultural system. Culturally aware assessment practices may allow behavior analysts to obtain important cultural information about clients in order to understand their worldviews.

Culturally aware assessment may also allow behavior analysts to identify any potential cultural barriers such as modalities of communication and expression of emotions see Garcia et al. To increase the probability that assessment will identify cultural variables, Vandenberghe recommends focusing on functional relations and behavioral principles rather than topography.

For example, Filipino families often live with extended family members, and the household situation can seem chaotic by Western living standards.

If a child has difficulty sleeping, a behavior analyst may advise the parents that they should separate the sleeping room from the living room. However, during the following session, it might be revealed that the parents did not change anything and that the child is still sleep deprived.

In this case, a natural reaction may be to become frustrated with the lack of parental follow through. However, lack of follow through may also be interpreted as an indicator that the intervention recommendation may not have been culturally appropriate. Vandenberghe emphasizes the need for a behavior analyst to be aware of differences that may exist, including cultural differences, between the behavior analyst, client, and their families. Therefore, behavior analysts should be skilled in sending and receiving cultural communications.

Specific recommendations are described below. Our first recommendation, which applies to all phases of assessment and treatment, is that behavior analysts should reflect on the spoken and written language he or she uses and how it will be perceived by the client. We recommend behavior analysts avoid the use of behavior analytic jargon, as it may confuse clients and their families, and possibly lead to their failure to implement interventions.

Avoidance of excessive or complex behavior analytic jargon may eliminate such problems. It is important throughout assessment and treatment to communicate in a manner easily understood, culturally aware, and does not include terms that are culturally inappropriate or confusing Rolider and Axelrod Furthermore, it may be important to consider who will be completing service related forms e.

If a person lacks adequate language comprehension, completing paperwork may be difficult, embarrassing, or intimidating. In such a case, behavior analysts may consider giving the person the opportunity to complete the forms orally or have another person help with the form completion. The cultural identity analysis should inform the assessment process and the designing of interventions. During intake, the behavior analyst may, with proper consent, gather input from key community members familiar with the client, in addition to those whose feedback is typically sought e.

Additionally, the behavior analyst should seek recommendations from the family regarding additional parties e. For example, behavioral patterns may be similar across cultures, while the language and concepts that are used can differ Vandenberghe It is therefore important for behavior analysts to clarify what the client or family actually mean by the terms they use.

The behavior analyst should also consider accounting for what treatments are appropriate, preferable, or considered norms within a culture. As illustrated by the example of the Filipino family at the beginning of this section, identifying cultural norms may be important for successful assessment and effective treatment. For example, the grandparents rather than the parents may be the primary caregivers in an Indian family. Therefore, it would be important to include the grandparents during intake in order to obtain information.

For example, in examining table manners across cultures, French parents may believe that child table manners are the essence of their culture. In Japan, in contrast, many children will leave the table during a meal, and it is acceptable in certain settings for them to run around, even in restaurants. More specifically, during lunch with family friends, a Japanese child might imitate a peer and leave the table during lunch with a smile on his or her face.

For Japanese parents, this is the cultural norm, but French parents often consider this behavior is inappropriate. Our third and final recommendation for this section is for behavior analysts to consider making use of the resources that are already available to help make their practice more culturally aware. Salend and Taylor describe guidelines for creating more culturally aware functional behavior assessments.

They also suggest behavior analysts attend trainings and engage in activities that allow them to reflect on how their culture might impact their belief system Salend and Taylor Another resource that can help behavior analysts enhance their culturally awareness is provided by Sugai et al. The authors discuss how applied behavior analytical terms can be understood within different cultural contexts.

For example, in some cultures, the concept of reinforcement can be illustrated by describing the act of bowing to greet one another. In this exchange, a bow is more likely to be given if a person is first bowed to, thus the initial bowing behavior is reinforced. Like Salend and Taylor , these authors describe how steps in interventions, such as school-wide positive behavior support, can be made more culturally aware—for example, by using activities that are considerate of learning histories and the norms and values of the culture, family, school, and community.

Tanaka-Matsumi et al. Specifically, the authors provide guidelines for conducting a culturally informed functional assessment interview, in which increases in accurate case formulation, decreases in diagnostic errors, decreases in attrition, increases in the credibility of the therapy, and increases in the expectation of positive change, client compliance, and active participation in treatment might be a result.

It should be noted that lack of a cultural match does not necessarily mean that the behavior analyst cannot provide adequate services to the client. For example, a client of the same race and socioeconomic background may not have cultural norms that are strongly similar to those of the behavior analyst. There are various domains of culture e.

In order for behavior analysts to become aware of the cultural values of their clients, as well as their own cultural values, service delivery and training programs must also develop systems of support and encourage professional growth in this area. The following recommendations concern how cultural awareness training can be integrated into clinical organizations and graduate and professional development programs. These recommendations are not all inclusive; rather, they highlight examples of how behavior analysts can institutionalize cultural awareness within their professional and training systems.