One Health – an interdisciplinary approach in combating emerging diseases
POTENTIAL PATTERN Interdisciplinary Health Science...
Transcript of POTENTIAL PATTERN Interdisciplinary Health Science...
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-343
Journal of Allied Health, Winter 2006
2006; 35:e343—e358.
© 2006 ASAHP, Washington, DC
POTENTIAL PATTERN
Interdisciplinary Health Science Education to Promote Cultural Competence
Beverly P. Horowitz, PhD, LMSW, OTR/L 1
Elizabeth Vanner, MS 2
Tosin Olowu, MS, OTR/L
1 Clinical Associate Professor, Occupational Therapy Department, School of Health Technology
and Management, Stony Brook University, Stony Brook, NY.
Email: [email protected]
2 Clinical Assistant Professor, Occupational Therapy Department, School of Health Technology
and Management, Stony Brook University, Stony Brook, New York
Date received: 10/12/2004; accepted: 12/21/2005
Acknowledgments
This program was supported by a Stony Brook University Presidential Grant for
Departmental Diversity Initiatives and the Stony Brook University Long Island Geriatric
Education Center. This paper builds upon Strategies to Promote Culturally Competent
Occupational Therapy Practice, presented at the 2003 National Annual Conference of the
American Occupational Therapy Association in Minneapolis, MN. Special thanks are extended
to Dr. Pamela Block for her insights and assistance with this research.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-344
J Allied Health 2006; 35(4):e-343–e-358.
The 2000 United States Census confirmed that the United States has become increasingly
racially, ethnically and culturally diverse, with implications for healthcare. 1-4
Increasing ethnic
and cultural diversity, coupled with recognition of health status disparities among sub-
populations (racial, ethnic, gender), has spurred recognition that cultural competence is “an
essential ingredient for quality, access and the elimination of disparities” and is necessary to
meet legislative and regulatory requirements, including Federal requirements for language-access
services. 5-9
Cultural competence is a process, requiring respect for individual and family differences
and, in health care, requires the ability to provide effective, quality services to culturally,
ethnically, linguistically, and otherwise diverse populations, tailoring care to clients needs.1, 10-12
Diverse populations encompass the full range of multicultural distinctions, including racial;
religious; immigrant; gay, lesbian and transgender; individuals with disabilities; and
nontraditional families.10,13
Cultural competence is recognized as necessary for quality healthcare by the U.S.
Department of Health and Human Services, 14
including the Bureau of Primary Health Care, 7 the
Office of Minority Health 9, 15
, and the National Committee for Quality Assurance. 16
The Joint
Commission on Accreditation of Healthcare Organizations recognizes an individual’s right to
healthcare services that consider individual culture and language, and the relationship between
culturally competent practice and healthcare “safety and quality.” 17
Similarly, the American
Medical Association 18
and Institute of Medicine highlight the importance of “culturally
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-345
responsive medical care,” and effective cross-cultural communication to reduce health
disparities.19
The American Occupational Therapy Association affirms the right of each individual to
actively participate in healthcare decision-making to attain personally meaningful goals. 20
Professional guidelines for culturally competent occupational therapy highlight the need to
appreciate one’s own culture, biases and values; to respect diversity; and to use “culturally sensitive
interventions.”21
Cultural competency requires that practitioners are aware of their personal values
and biases, appreciate the ways in which culture can impact attitudes, behavior and lifestyle, and
have communication skills to support effective cross-cultural interactions.11, 22-23
Implicit in
“becoming culturally competent” is recognition of one’s heritage, respect for each individual’s
cultural practices and beliefs, and appreciation of the risk of stereotyping groups.10, 24-25
U.S. Census and healthcare data show disparities in life expectancy and the prevalence of
chronic illness and disability between genders and among Blacks, Whites, Asian Americans, and
Hispanics.11, 26-27
The Institute of Medicine’s 2002 report Unequal Treatment found that patients
of different cultural backgrounds do not consistently receive equal medical treatment and clinical
procedures, and that “racial differences” are insufficient to fully explain healthcare disparities.8,
28 The causes of these marked disparities in life expectancy, chronic illness, and disability are not
fully understood. In addition to linguistic, transportation, and financial barriers, there are
concerns that provider bias and misperceptions hinder effective communication, negatively
influencing medical care quality.5, 8, 28-29
Fadiman’s The Spirit Catches you and You Fall Down (1997) tells the story of cultural
clash and misunderstanding between an immigrant Hmong family and American healthcare and
social service organizations in which the family was erroneously accused of sabotaging their
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-346
daughter’s health. 30
Similarly, Ratliff (1999) reports a cultural clash involving a Hmong infant
diagnosed with retinoblastoma, requiring removal of the eye. Both cases resulted in loss of
parental custody. Miscommunication, language barriers, and lack of knowledge about Hmong
religion and beliefs contributed to a law enforcement manhunt after the family abducted their
child from the hospital to prevent surgery. The situation was resolved after social service
personnel enlisted assistance from a local Hmong shaman who calmed fears and encouraged
needed surgery. 31
Effective cross-cultural communication and client-centered approaches can avert
unintentional personal, community and institutional conflict. 11, 32-35
One successful occupational
therapy example involved collaborative treatment planning between a French-speaking Haitian
woman who sustained a stroke, with resulting moderate aphasia, while visiting her American
daughter. Despite medical challenges and language barriers, the patient’s goal of returning home
to Haiti was achieved through a client-family-centered partnership. This partnership supported a
treatment plan that focused on the patient’s specific needs and goals to maximize self-efficacy,
functional self-care capabilities, and quality of life. 33
Community-based health care and prevention programs are more successful when they
recognize culturally meaningful interventions. John, Hennessy and Denny (1999) provide an
example of the Zuni Diabetes Project, an exercise and weight reduction program that addresses
obesity and diabetes within Native American populations. Although successful outcomes depend
upon multiple factors, health care programs for Native Americans were found to be more
successful when in accord with traditional, holistic health care approaches.36
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-347
Cultural Competence Interdisciplinary Program
This paper reports on an interdisciplinary educational intervention with goals that
included increasing: cultural self-awareness; knowledge and understanding of diverse cultures,
including how culture can influence health behaviors and service utilization; communication
skills with diverse populations; and clinical skills for culturally competent practice. 22
It expanded
upon existing coursework to support culturally competent practice within occupational therapy
and other healthcare education programs. The program was funded by a Stony Brook University
grant and by the university’s multidisciplinary Long Island Geriatric Education Center and was
approved by the University’s Office on Research Compliance.
This initiative was embedded within a sequence of occupational therapy, physician
assistant, and physical therapy courses, was an elective for nursing, social work, and medical
students, and was offered to all students and faculty within these disciplines. Part one, “Moving
Toward Cultural Competency”, included a four-hour program using lecture, small-group self-
exploration activities, and case studies. Part two, “Addressing Diverse Client Needs,” used a
two-hour interactive community forum. In this forum panelists shared their personal perspectives
and experiences with students, faculty and members of the health care community. They
included individuals from the Hispanic, Black, Asian and Muslim communities, gay, lesbian, and
transgender adults, parents of disabled children, physically disabled adults. Facilitated dialog
between participants and forum speakers personally explored how bias, miscommunication, and
cultural insensitivity affected healthcare interventions, utilization, and speakers’ attitudes and
behaviors toward healthcare providers and institutions (Table 1).
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-348
Table 1. Cultural Competence Interdisciplinary Program
Program Description Learning Objectives
Part 1. Moving Toward Cultural Competency
Guest faculty Roxie Black and Shirley Wells provided a 4-hour
lecture and interactive case-based program to increase knowledge
and skills for culturally competent health care practice. Black and
Wells used materials from their text Moving Toward Cultural
Competency including their Cultural Competency Educational
Model focusing on:
1. Self-exploration to build an awareness of one’s individual
cultural heritage
2. Increasing knowledge about diverse cultures and recognition of
individual and group differences and similarities
3. Developing strategies and skills to more effectively communicate
and interact with persons from different cultures
The session included skill-building small-group cased-based
simulation activities. For example, one case focused developing a
care plan for a 72- year old Somali woman with specific religious
dietary and modesty requirements and strong cultural views
concerning gender and family roles.
1. To increase participants self-
awareness and recognition of
personal biases, attitudes, and
prejudices
2. To increase knowledge of
how culture can impact health
beliefs, behaviors, and service
utilization
3. To promote clinical
communication skills
4. To increase knowledge of
the benefits of culturally
competent practice for
effective health care services
Part 2. Cultural Competence: Addressing Diverse Client Needs
A multimedia musical and slide presentation, developed with the
assistance of Stephen Larese, Stony Brook University Slide
Librarian, set the tone for this 2 hour forum. The program brought
together a diverse group of 10 individuals from the Long Island
community and New York City metropolitan area to share their
experiences as health care consumers. Panelists were asked to share
a personal story and participate in a discussion on how students and
clinicians can increase understanding of diverse client values and
concerns to optimally address their health care needs.
The themes of these stories focused on concerns about respect,
privacy, prejudice, ignorance, and paternalism. One story, told by a
63- year old transgender women, spoke of the emotional toll of
coping with cancer treatment and insensitive, disrespectful hospital
staff. Another panelist shared her experiences as a young woman
with paraplegia determined to live her life, enjoy sports (i.e., scuba
diving), and have a family, and her search to locate physicians who
would recognize her goals and capabilities as well as her
limitations.
1. To increase knowledge
regarding the health care
concerns and needs of
culturally diverse consumers.
2. To increase knowledge
about the impact of client-
provider communication on
heath care utilization and
outcomes.
3. To promote culturally
competent communication
skills and clinical practice.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-349
Methodology
Participants
Program evaluation research utilized pre and post-program tests to determine if there
were changes in perceived levels of cultural competency among occupational therapy students,
who were required to attend both parts of this program. Twenty-six students took the pre-
program test; twenty-five students completed the post-program test. Due to coding difficulties,
only 15 of the post-program tests could be matched to their corresponding pre-program tests.
All participants completed The Long Island Geriatric Education Center’s 9-item program
evaluation at the conclusion of part one and part two of this interdisciplinary program. Fifty-six
students, faculty, and guests attended part one “Moving Toward Cultural Competency;” 81
participants attended part two ” Addressing Diverse Client Needs.” Two items from this program
evaluation were analyzed to assess perceived changes in knowledge level before and after
attending each session.
Instruments
The primary outcome measures included, Promoting Cultural and Linguistic
Competency: Self- Assessment Checklist for Personnel Providing Primary Health Care Services,
designed to facilitate reflection and dialogue about cultural competency, by Georgetown
University’s National Center for Cultural Competence (NCCC), and one open-ended question
that asked how the program influenced attitudes, values, and communication styles.37
The
checklist was selected as a recognized, standardized instrument that promotes self-examination;
with the knowledge that “there was no process, nor any intent to determine the psychometric
properties of the tool” and that NCCC does not consider this tool “the most appropriate for
quantitative measurement of changes in self-report over time.” (W Jones, personal
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-350
communication, May 24, 2005). It was then adapted with permission to enable use by students.
The Physical Environment and Resources section was deleted since it is suitable only for
practicing clinicians. The entire two sections on Communication Styles and Values and
Attitudes remained, and the response scale was expanded from a 3-point scale (Things I do
frequently, Things I do occasionally, and Things I do rarely or never) to a 5- point scale geared
to student needs, adding: Things I need to do frequently and Things I need to do occasionally.
Lower scores indicate higher cultural competence self-assessment.
The Long Island Geriatric Education Center’s standardized 9-item program evaluation,
using a 5-point Likert scale (1 the lowest rating; 5 the highest), was completed by participants to
rate their knowledge-level of the subject before (item 1) and after (item 2) each session. The
remaining seven items (not analyzed here) were about the program’s methodology rather than
the program’s content (speaker quality, meeting course objectives, teaching methods, physical
facilities, personal objectives’ satisfaction, recommendation, and overall program quality.)
Data Analysis
Quantitative data analysis was conducted using SPSS (Version 13.0), Microsoft Excel
(2003), and the University of Colorado at Colorado Springs’ web site 38
for calculation of
Cohen’s d. Cronbach’s alpha reliability analysis was performed to determine the appropriateness
of creating overall scores for the modified Promoting Cultural and Linguistic Competency: Self-
Assessment Checklist for Personnel Providing Primary Health Care Services. Two scores were
calculated for each person: Communications (8 questions) and Values & Attitudes (20
questions). Cronbach’s alphas were 0.63 for the Communications scale and 0.89 for the Values
& Attitudes scale . These indicate a high degree of reliability for the Values & Attitudes scale
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-351
and a lesser degree of reliability for the Communications scale. Item responses were summed to
create these two separate scores.
The data included 26 pre-program and 25 post- program tests, of which 15 were paired.
Collectively, these tests had 34 missing responses, 17 were in two tests. These were eliminated
from the analysis (both unpaired pre-program tests). The remaining missing responses were
replaced with the median (appropriate for ordinal data) response for the cohort (pre or post).
A paired-samples t-test was used to analyze differences between occupational therapy
students’ paired pre-program and post- program test scores (n =15). An independent-samples t-
test was used to analyze unpaired data (pre- program tests n = 9; post- program tests n = 10). The
open-ended question was analyzed qualitatively for common themes. Scores on the university
program evaluation were also analyzed to assess the change, for all participants, for each of the
two sessions regarding knowledge of subject matter before and after each session using paired t-
tests (session one, N= 56; session two, N= 81).
Results
For the OT students the paired tests (n = 15), the mean pre-program Communications and
Values & Attitudes scores were M = 15.13 (SD =4.49) and M = 39.33 (SD =12.66), respectively
while the mean post-program Communications and Values & Attitudes scores were M = 14.67
(SD = 3.37) and M = 32.53 (SD =7.18), respectively. Results of the paired-samples t-tests
indicated a marginally significant improvement for occupational therapy students’ Values &
Attitudes mean scores [t(14) = 2.14, p = 0.05054 (two-tailed), d = 0.66] and no significant
difference in the mean Communications scores [t(14) = 0.38, p = 0.71 (two-tailed), d = 0.12].
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-352
For the unpaired tests, the mean pre-program (n = 9) Communications and Values &
Attitudes scores were M =16.33 (SD=2.00) and M =29.89 (SD=4.40), respectively while the
mean post-program (n = 10) Communications and Values & Attitudes scores were M =15.2
(SD=6.09) and M =32.20 (SD=10.94), respectively. Results of the independent-samples t-test
showed no significant differences in any of the mean scores [Communications scores: t(11.1
equal variances not assumed) = 0.56, p = 0.59 (two-tailed), d = 0.25 and Values & Attitudes
scores: t(17 equal variances assumed) = -0.59, p = 0.56 (two-tailed), d = -0.28.
The marginally significant difference in the Values & Attitudes mean scores, found in the
paired analysis but not the unpaired analysis, is probably due to the fact that the paired tests were
from predominantly first-year students while the un-paired tests were predominantly second-year
students. The second-year students had already been exposed to issues of cultural competence
during their initial clinical experience. The mean of the Values & Attitudes scores for the pre-
program paired tests is high (lower perceived competence), whereas the mean of the Values &
Attitudes scores for the post-program paired tests is comparable to the means of the Values &
Attitudes scores for both the pre- and post-program un-paired tests.
Program evaluation forms were completed by all participants for both parts one (n = 56)
and two (n = 81) of the program. Based on the program evaluation forms, significant differences
in mean perceived knowledge scores were found for both part one and part two (ps < 0.000, two-
tailed). For part one, the pre and post mean scores were M = 3.54 (SD = 0.95) and M = 4.14 (SD
= 0.72), respectively, t(55) = -6.69, d = 0.72. For part two, the pre and post mean scores were M
= 3.68 (SD = 0.85) and M = 4.38 (SD = 0.70), respectively, t(80) = -7.38, d = 0.90.
Qualitative data, from occupational therapy students responses to an open-ended question
(n =26), showed that 22 students reported increased insight and understanding of other cultures.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-353
Four students specifically indicated that the program influenced how they will communicate with
diverse client populations and two students stated that the program “opened their eyes” and
helped them value diversity. Specifically, one student reported that hearing directly from health
care consumers was “ informative, eye opening,… and made me more aware of other cultural
practices”, another stated that the program increased “understanding … of different cultures”,
“the values of different cultures,” and “made me value diversity.”
Summary
Cultural competence is recognized across healthcare disciplines as a critical aspect of
healthcare delivery and a necessary component of healthcare education. Within occupational
therapy education, accreditation standards require curricula to address the influence of culture,
socio-cultural, and lifestyle factors on human behavior, and their potential impact upon
healthcare outcomes.22
Increasingly, legislative, accreditation and regulatory requirements also
emphasize culturally competent practice. 22, 34
To prepare healthcare providers for culturally competent practice, students need multiple
opportunities to explore their personal values, increase knowledge of diverse cultures, and
develop cross-cultural communication and clinical skills in the classroom and in clinical
education. This 6-hour, two-day program was established to provide a supplemental opportunity
within the confines of extensive, prescribed curricula to support self-exploration, and increase
knowledge, skills, and interdisciplinary dialog to advance the process of becoming culturally
competent practitioners. Although this program included only one university, with small
numbers of students, results found this educational initiative, combining traditional teaching
methodologies, case studies, and a participatory community forum, indicated possible heightened
awareness among occupational therapy students of how their values and attitudes can impact
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-354
practice and increased perceived knowledge for all participants, confirming the value of this
interdisciplinary program for students from many health disciplines.
This initiative can be replicated and/or adapted by other institutions to provide
opportunities for experiential learning, including community and interdisciplinary dialog, and
opportunities to build skills for culturally competent practice. Clinical education is a backbone of
healthcare education to ensure that students competently use and apply knowledge and skills in
practice settings. Currently, the challenge for healthcare educators is to infuse their extensive
curricula with opportunities for understanding the complex relationships between culture and
health care, enabling students to build the interpersonal, communication, and clinical reasoning
skills necessary to provide quality healthcare services to diverse populations. While health care
professions educators also face challenges meeting accreditation standards and the demands of
21st century practice, 21
st century practice requires all disciplines to acknowledge the importance
of cultural competence to provide effective health care for increasingly diverse populations.
However, educational institutions seeking to document educational outcomes need to appreciate
the difficulties of quantifying perceived changes in cultural competency, in order to properly
evaluate these curriculum initiatives.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-355
References
1. Betancourt J, Green A, Carrillo E. Cultural competence in healthcare: emerging frameworks
and practical approaches. 2002, October. Available at:
http:www.cmwf.org/search_results.htm?frame_limit=o&keywords=cultural+competence&x
=13&y=10. Accessed September 27, 2004.
2. Talamantes M, Aranda M. Cultural competency in working with Latino family caregivers.
Available at:
www.caregiver.org/caregiver/jsp/publications.jsp?nodeid=345&expandnodeid=443.
Accessed September 27, 2004.
3. U.S. Census. Demographic trends in the 20th
century. Available at
http://www.census/gov/prod/2002pubs/censr-4pdf. Accessed September 25, 2004.
4. United States Office of Personnel Management. Frameworks underpinning diversity.
Available at: www.opm.gov/Diversity/diversity-2.htm. Accessed September 25, 2004.
5. National Center for Cultural Competence. Why is there a compelling need for
cultural competence? Available at:
http://www.georgetown.edu/research/gucdc/ncc/cultural5.html. Accessed March 17, 2003.
6. National Center for Cultural Competence. Health disparities among ethic and racial groups.
Available at http:// gucchd.georgetown.edu/ncc/cultural6.html. Accessed September 26,
2004.
7. Bureau of Primary Health Care. Cultural competence: An essential ingredient for quality,
access and elimination of disparities. Available at: http:///www.bphc.hrsa.gov.
Accessed November 14, 2002.
8. Institute of Medicine. Unequal treatment: what healthcare providers need to know about
racial and ethnic disparities in healthcare. Available at:
http://www.iom.edu/topic.asp?id=.8007. Accessed September 27, 2004.
9. IQ Solutions. National standards for culturally and linguistically appropriate services in
health care: Final report. Available at:
http://www.omhrc.gov/omh/programs/2pgprograms/finalreport.pdf. Accessed May 26, 2005.
10. Bonder B, Martin L. Miracle A. Culture in Clinical Care. Thorofare, NJ: SLACK; 2002.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-356
11. Wells S, Black R. Cultural Competency for Health Professionals. Bethesda, Md: American
Occupational Therapy Association; 2000.
12. National Center for Cultural Competence. Conceptual frameworks/models, guiding values
and principles. Available at: http:// gucchd.georgetown.edu/ncc/framework.html. Accessed
September 25, 2004.
13. Lynch E, Hanson M. Developing Cross-Cultural Competence. 2nd
ed. Baltimore, Md: Paul H.
Brooks Publishing; 1997.
14. Programs> diversity> other definitions of cultural competence. Available at:
http://bhpr.hrsa.gov/diversity/cultcomp.htm. Accessed May 31, 2005.
15. Carr W, Willis J. (2002, April). Indicators of cultural competence in health care delivery
organizations: An organizational cultural competence assessment profile. Available at: http://
www.hrsa.gov/OMH/cultural1.htm. Accessed May 26, 2005.
16. Cervical cancer screening. Available at:
http://www.ncqa.org.sohc2002/sohc_2002_ccs.html. Accessed May 26, 2005.
17. Joint Commission on Accreditation of Healthcare Organizations. Hospital, language, and
culture. Available at: http://www.jcaho.org/about+us/hlc/index.htm. Accessed May 31, 2005.
18. Ethics Resource Center of the American Medical Association. Culturally responsive
medical care. Available at http://www.ama-assn.org/ama1/pub. Accessed May 26, 2005.
19. Institute of Medicine. Speaking of health: assessing health communication. Available at
http://www.nap.edu/report.asp?id=4471. Accessed May 26, 2005.
20. American Occupational Therapy Association. Occupational therapy’s commitment to
nondiscrimination and inclusion. Available at:
http://wwwaota.org/featured/area2/links/link24.asp. Accessed May 31, 2005.
21. Wells S. A Multicultural Education and Resource Guide for Occupational Therapy
Educators and Practitioners. Rockville, Md: American Occupational Therapy Association;
1994.
22. Horowitz B, Olowu T, Vanner E. Strategies to promote culturally competent occupational
therapy practice. Short course presented at the American Occupational Therapy
Association’s Annual Conference; May 20, 2004 Minneapolis, MN.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-357
23. The provider’s guide to quality and culture. What is cultural competence? Available at:
http://erc.msh.org/mainpage.cfm?file=2.1.htm&language=English&module=provider.
Accessed May 22, 2003.
24. Kreps G, Kunimoto E. Effective Communication in Multicultural Health Care Settings.
Thousand Oaks, Ca: SAGE Publications; 1994.
25. Tripp-Reimer T. Culturally competent care. In Wykle M, Ford A, eds. Serving Minority
Elders in the 21st Century. New York, NY: Springer Publishing; 1999: 235-247.
26. McNeil J. Disability. Available at http:// www.census.gov/population/www/pop-
profile/disabil.html. Accessed August 31, 2004.
27. Arias E. United States life tables, 2001. Available at:
www.cdc.gov/nchs/products/pubs/pubd/hvsr/hvsr/html. Accessed August 31, 2004.
28. The provider’s guide to quality and culture. Did you know…Available at http://
erc.msh.org/mainpage.cfm?file=1.0.htm&module=provider&language=English&ggro.
Accessed May 9, 2003.
29. Epstein H. Enough to make you sick? The New York Times (October 12, 200, p. 75)
(online). Available at Infotrac Web: New York State Newsletters. Accessed September 27,
2004.
30. Fadiman A. The Spirit Catches You and You Fall Down. New York, NY: Farrar, Strauss and
Giroux; 1997.
31. Ratliff S. Waterfalls and geysers: The development of diversity awareness at children’s
hospital. Journal of Nursing Care Quality (online). 1999; 13:1-12. Available at: infotrac-
custom.com. Accessed November 28, 2001.
32. Greene J, Newell K. Community voices: exploring cross-cultural care through cancer
(video). Cambridge, MA: Harvard Center for Cancer Prevention; 2001.
33. Horowitz B. Occupational therapy home assessments: Supporting community living through
client-centered practice. Occupational Therapy in Mental Health. 2002; 18:1-17.
34. Rundle A, Carvalho M, Robinson M, eds. Cultural Competence in Health Care. San
Francisco, CA: Jossey-Bass; 1999.
Journal of Allied Health, Winter 2006, Vol 35, Number 4 e-358
35. Anand R, Shipler L. Multicultural Case Studies: Tools for Training. 2nd
ed. Washington DC:
National Multicultural Institute Publications; 1999.
36. John R, Hennessy C, Denny C. Preventing chronic illness and disability among Native
American elders. In Wykle M, Ford A, eds. Serving Minority Elders in the 21st Century. New
York, NY: Springer Publishing; 1999: 51-71.
37. Goode, T. Self-assessment checklist for personnel providing primary health care services.
Available at http://www.georgetown.edu/research/gucdc/nccc/nccc11.html. Accessed
November 14, 2002.
38. Becker, L. (1999). Effect Size Calculators: Calculate d and r using means and standard
deviations. Available at: http://web.uccs.edu/lbecker/Psy590/escalc3.htm, the University of
Colorado at Colorado Springs web site. Accessed November 3, 2005.