|Year : 2022 | Volume
| Issue : 1 | Page : 4-9
Culturally competent occupational therapy practice for south asians in the United States of America: A narrative review
Shivani Bharti Vij, Michelle L Webb
Rocky Mountain University of Health Professions, Utah, USA
|Date of Submission||25-Aug-2021|
|Date of Acceptance||13-Feb-2022|
|Date of Web Publication||25-Mar-2022|
Shivani Bharti Vij
42291 Ashmead Terr, Brambleton, VA 20148
Source of Support: None, Conflict of Interest: None
Background: The concept of cultural competence in health care has gained significant attention in the past few decades due to increased diversity in the United States (US) population. However, studies suggested that occupational therapists in the US are not prepared for this cultural shift. Several research articles indicated that practicing clinicians are either not aware of the need for culturally competent practices or need the training to enhance knowledge on cultural competence to cater to people from South Asian backgrounds. Objectives: This study aims to understand cultural beliefs, the perception of health and illness, the meaning of occupations from the viewpoint of the South Asian clients to help explore culturally competent strategies for occupational therapy (OT) professionals in the US to ensure they provide applicable and culturally appropriate services to South Asian clients. Study Design: A narrative review. Methods: Keyword searches of databases such as PubMed and EBSCO, and the American Journal of OT were performed. The literature search identified and reviewed qualitative/quantitative studies (n = 13) and other articles/resources (n = 9) on cultural competency for South Asians in the United States of America from 2009 to 2021 in English language literature. Manual searches of other relevant journals and reference lists of primary articles were also done. Results: Analysis of the results of studies reviewed revealed three main themes, (1) role of critical thinking and self-awareness that promote or inhibit the use of culturally competent interventions, (2) prior experiences of OT practitioners with ethnically diverse communities, (3) cultural considerations such as common belief, family hierarchy, traditional medicines, and the use of educational material or therapy resources in the native language that may improve therapy outcomes for South Asian clients. Conclusion: Empowering cultural competency requires complex skills such as critical thinking, self-awareness, problem-solving, understanding the dynamics of discrimination, and understanding the service delivery systems. The background information on common behaviors, beliefs, and cultural considerations of South Asians will help devise meaningful client-centered interventions that match the social and cultural norms of South Asian clients, which can improve OT practice for this clientele in the US.
Keywords: Cultural Competency, Culture-Sensitive Strategies, Diversity, Occupational Therapy Practice, South Asians
|How to cite this article:|
Vij SB, Webb ML. Culturally competent occupational therapy practice for south asians in the United States of America: A narrative review. Indian J Occup Ther 2022;54:4-9
|How to cite this URL:|
Vij SB, Webb ML. Culturally competent occupational therapy practice for south asians in the United States of America: A narrative review. Indian J Occup Ther [serial online] 2022 [cited 2022 May 29];54:4-9. Available from: http://www.ijotonweb.org/text.asp?2022/54/1/4/340897
| Introduction|| |
The importance of cultural competency in health-care professions such as nursing and psychology has been studied for decades; however, this concept is relatively new in occupational therapy (OT). The United States (US) Department of Health and Human Services (HHS) defined culturally competent services as “the client-centered services that are respectful and responsive to the needs of a diverse group of patients.” The 2019 American OT Association (AOTA) workforce survey indicated that more than 84% of OT practitioners are Caucasian. As per the US Census Bureau, more than 18 million Asian Americans live in the US. However, only 37% of occupational therapists had worked with Asian clients in their clinical practice. Due to the Asian Americans being a minority but rapidly growing population, the majority of occupational therapists in the United States of America who are primarily Caucasians may need skills in cultural competency for optimum therapy outcomes when working with Asian American clients.
| Methods|| |
English language studies included in the review were identified by keyword searches of databases such as PubMed, EBSCO, and the American Journal of OT. The search period was from 2009 to 2021 in these three resources. Manual searches of other relevant journals such as Disability and Rehabilitation, OT International, Med Care, Journal of Occupational Science, International Review of Psychiatry, Health and Social Care in the Community, Journal of OT, Schools, and Early Intervention, and Canadian Journals of OT were conducted as well from 2009 to 2021. These searches retrieved 732 articles, of which 13 were comparative qualitative/quantitative studies undertaken primarily in the US. A further nine resources from relevant websites and government webpages such as the AOTA, OT Practice, Asia Society, US Department of HHS, Center for International Rehabilitation Research Information and Exchange (CIRRIE), The Georgetown University National Center for Cultural Competence, and US Census Bureau were identified and discussed in this study. Specific keywords and phrases used were OT, cultural competency, Asians, South Asians, and diversity. Numerous iterative searches were performed in the databases mentioned above, resulting in over 732 potential references. Articles were discarded if they did not have a health connection, were in a language other than English, were a duplication, and/or did not have all the reference material needed to find the articles. The data analysis is primarily through a narrative review, and the summary is discussed in the results section. A PRISMA chart for the selection and identification process is reported in [Figure 1].
|Figure 1: PRISMA Flow Diagram of the Identification Process for the Articles Included in this Review|
Click here to view
| Results|| |
The Asian Perspective to Health, Disability, and Rehabilitation
The data analyses generated a few themes, and the following section will elaborate on them. Immigration challenges immigrants' health and occupational engagement; it can affect their routine, lifestyle, and social connectivity. South Asian society follows collectivism, where family hierarchy and interdependence guide clients' occupational engagement instead of the individualistic style observed in Western culture. South Asian clients can significantly depend on their families but may still feel very independent due to their lifestyles and attitudes. They also prefer using specific terminology, which aligns more with a counseling style, as these clients prefer to give control of the session to the therapist. In addition to the above factors, clients' level of education, family dynamics, cultural adaptation, religious and spiritual views can majorly influence the rehabilitation process.
Several researchers also reported that using the family as a resource for commitment to the home program and paying attention to nonverbal cues are essential to developing holistic therapy programs for these clients. Many South Asian clients still believe in traditional medicines and alternative therapies. During health-care service delivery, these clients' primary concerns are lack of conventional medicine options, limited availability of patient education material in their native language, and lack of support groups to facilitate community reintegration. Religious and dietary restrictions often prioritize these clients' health practices. Overall, the values and cultural beliefs derived from the country of origin can play a vital role in occupational engagement and health-promoting behaviors in South Asian clients.
Learning through Self-Reflection
Cultural differences can significantly affect the client and the therapist relationship. Focus on Western norms may amplify this issue if a therapist is not culturally competent. Understanding the critical awareness of personal biases and the cultural outlook is an essential step in a culturally competent practice. The therapists can utilize validated assessment tools such as the Cultural Competence Assessment Instrument (CCAI) and the Cultural Competence Health Practitioner Assessment (CCHPA) by the Georgetown University National Center for Cultural Competence to gain an understanding of their cultural orientation and biases toward different cultures. There are few established and validated instruments to assess cultural competency; however, CCAI and CCHPA have validated tools with good psychometric properties., Some other self-awareness strategies include being more receptive and flexible in learning from clients and therapists from South Asian backgrounds and being informed about culturally relevant resources in the community.
| Utilizing the Sociocultural Variables in Therapy|| |
In addition to understanding different practices, beliefs, and cultural norms, it is also vital to consider the meaning of occupations and the family's role when working with South Asian clients. Family interdependence and social norms play a significant role in how these clients engage in occupations. The family hierarchy plays a vital role in the rehabilitation process of South Asian clients. In a qualitative study utilizing a descriptive interpretative approach, the authors explored the perspectives of rehabilitation of children with cerebral palsy from a cross-cultural approach. The authors concluded that South Asian parents play a passive role in their child's recovery. They tend to follow a wait and watch approach and rely solely on the clinician in the whole process. South Asian parents also deal with negative societal attitudes and stigmas toward disability. Clinicians must focus on client advocacy and empowerment for optimum health outcomes for such families.
Besides focusing on advocacy and family-centered care, the culturally competent strategies should also include attitudinal barriers and cultural beliefs while working with a specific population. Knight and Hawkins examined families with young children with special needs in the Commonwealth of the Northern Mariana Islands, where Asian ethnic groups comprise the island's population. This study signified that being considerate of the family's beliefs and cultural norms is essential for developing culturally appropriate therapy goals.
Another similar study shared similar findings by using the grounded theory approach to find the parenting experiences of Indians in New Zealand. They discussed the challenges of raising children in a different country of origin. The differences in the cultural contexts, social dynamics, and influence of Westernization were the primary challenges for these immigrants in the new region.
Another study explored occupational engagement and health beliefs in South Asian older immigrants in the US using a qualitative study with a grounded theory approach. This study provided information that individuals of different cultural ethnicities adapt their routines in a new environment to improve occupational engagement and health. The themes that emerged from the review were interdependence and control and how it affects their social dynamics. The authors pointed out that immigration and the resettlement process often led to economic challenges, disrupted lifestyles, barriers to accessing health services, and interventions should consider all these factors while working with South Asian clients.
| Inclusion of Culturally Sensitive Curriculum in Formal and Informal Training|| |
In addition to improving critical thinking, clinical reasoning, and collaboration skills, as concluded from the previous studies, another powerful method to prepare health-care professionals to provide culturally responsive services is through formal and informal training. In one qualitative research, the authors utilized focus groups to explore cultural immersion course experience on occupational therapists' practice. These researchers found that formal training expanded therapists' awareness and competency when encountering culturally diverse clients. Other methods include simulation experiences to bridge the gap between theory and clinical practice CIRRIE Another great initiative by CIRRIE is Culture in the Curriculum; this program develops modules that can fit into the existing OT curricula while still meeting the requirements of discipline-specific accreditation standards.
| Use of Culturally Competent Tools in Practice|| |
The literature review suggested that finding appropriate instruments is challenging for South Asian clients. Most OT assessment and intervention tools are designed under Western cultural norms and values. In a mixed-method study, researchers explored the home health interventions in South Asian clients to examine their beliefs on parenting using Western parent‒child interactions assessments with a pretest‒posttest design. They found that there was a cultural mismatch. The researchers emphasized that Western parent‒child interaction assessment tools were inefficient for Asian clients. A qualitative approach is preferable for assessing these clients when Western tools do not provide relevant information.
In such situations, therapists can utilize resources from organizations such as the Office of Minorities Health: U. S. Department of HHS and the Asia Society to develop tools for health-care providers that integrate their sociocultural norms, treatment preferences, and related topics pertinent to the health care of the culturally diverse population in the US. Summary of the above review is tabulated [Table 1].
| Discussion|| |
Culturally competent practice improves the understanding and ability to provide effective and client-centered OT services to clients that belong to culturally diverse groups.,, The literature review indicated that practicing clinicians need culturally sensitive strategies to cater to the health care needs of people from diverse backgrounds.
The findings from several studies stated that cultural competency training might influence therapists' critical thinking, clinical reasoning, and sensitivity to cultural diversity, enhancing OT practice.,,,, It was also highlighted that learning experiences in unfamiliar cultures through specific courses may provide crucial information to therapists interested in facilitating changes to integrate culturally competent strategies into everyday practice., Future research should explore the most effective techniques to train occupational therapists in cultural competency and enhance formal and informal training opportunities to prepare the therapists for culturally diverse clients.
The authors acknowledge a few limitations of the study, including limited evidence on the context of cultural competency significant to South Asians and the limited scope of the research articles included in this study. Future research can address these two critical limitations of this article, including finding the best evidence-based practice focused on cultural competency for South Asians and finding specific strategies to improve cultural competency among OT practitioners in the US and other Western countries while working with South Asians.
| Conclusion|| |
Occupational therapists are confronted with adapting their practice to provide effective and client-centered services due to increasing diversity in the US population. With an ever-growing Asian community in the US, cultural competency training is essential to ensure that Asian clients receive appropriate and high-quality health-care services.
Cultural differences can affect the therapeutic relationships between client and therapist, and focusing on Western norms may amplify this issue if a therapist is not culturally competent. The standards of practice developed by the AOTA encourages therapists to fulfill clients' accommodation needs efficiently and demonstrate respect to a client's sociocultural background by providing client-centered services. Cultural competency can majorly improve the therapeutic relationship by facilitating trust and communication. Overall, incorporating the client's cultural preferences in the therapy can promote holistic and client-centered practice matching with the standards of practice for all OT professionals set forth by AOTA.
First of all, I would like to express my sincere gratitude to the Rocky Mountain University of Health Professions Occupational Therapy Department for letting me participate in this incredible journey toward completing this manuscript. Further, I would like to thank our program director and coauthor, Dr. Michelle Webb, for this dissertation's thoughtful comments and recommendations. I am also thankful to my fellow cohort students and staff members for all the support and guidance.
To conclude, I cannot forget to thank my family and friends for all the unconditional support in this process. Most importantly, I am grateful to my loving and supportive husband, Pratik Vij, who provided constant inspiration for completing this manuscript.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
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