Abstract
Culture is intrinsic to the health care process, because it affects the practitioner, the person seeking care, and the context in which care is provided. It is essential for practitioners to understand how culture influences the choices their clients make and the beliefs that drive them (Betancourt et al., 2003). Cultural diversity is estimated to increase in the coming years mainly because of unstable political and economic situations around the globe that lead to increasing numbers of refugees and asylum seekers (Darawsheh & Chard, 2015). Cultural competence is an awareness of differences in cultures and “a process that is built up gradually through experience” (Darawsheh & Chard, 2015, p. 1). It is characterized by awareness and knowledge of one’s own culture and other cultures; attitude toward and value for different beliefs and behaviors; and ongoing acquisition of skills to interpret culture and relate to and interact with people of different cultures. Cultural competence includes cultural knowledge, awareness, and skills (Darawsheh & Chard, 2015).
Cultural awareness may be a building block that leads to cultural competence. According to Darawsheh and Chard (2015), cultural awareness is the first step toward cultural competence in occupational therapy practitioners and is described as the time when they become aware of differences in culture and how their own culture interacts with other cultures. Although these stages of cultural competence are not discrete levels of development, they provide a basis for students to acquire cultural competence through experiences and education aimed at moving them from one stage to the next (Darawsheh & Chard, 2015). Castro et al. (2016) described cultural awareness as the “affective dimension of cultural competence,” which includes exploration and reflection of one’s own culture, one’s professional culture, and the impact of culture on clients (p. 197). In combination, the constructs of cultural competence and awareness set the stage for this study in which we attempted to identify where students are starting in their cultural learning and where additional education and experience can be added to enhance the learning and application of cultural competence in practice.
Cultural awareness, knowledge, and sensitivity as well as cultural and transcultural competence need to be deliberately incorporated into occupational therapy education to ensure the development of competent practitioners. In a way, the actual process of becoming an occupational therapy practitioner should be an enculturating one (Castro et al., 2014). Even though cultural competence is considered a necessity in occupational therapy education (World Federation of Occupational Therapists, 2014), to date, many higher education institutions have failed to accomplish internationalization of the curricula (Barker et al., 2010). Some occupational therapy programs use fieldwork, travel abroad, and “cultural visits” to facilitate multicultural education. These approaches are often difficult to implement because of cost and time constraints. Moreover, such mobility may not be accessed by all students, especially when the learning outcomes accomplished are uncertain (Humbert et al., 2012). Previous studies have reported that although students valued the importance of cultural differences, they had limited knowledge and skills to meet the needs of people with variable cultural backgrounds (Murden et al., 2008; Rasmussen et al., 2005).
Internationalization at Home (IaH) has been introduced as an alternative to internationalization abroad; IaH can be integrated within the curriculum and be available to all students on the home campus through communication technologies. Synchronous online collaborative learning offers the opportunity for direct, verbal, and immediate communication between students and may be effective for cultural reflection (Yang et al., 2014). Aldrich and Grajo (2017) summarized the experiences gained by a combination of asynchronous and synchronous cross-cultural online collaborations (SCCOC) between students and suggested that repeated SCCOC with diverse cultural groups can influence students’ willingness to have multicultural experiences. Cabatan and Grajo (2017) reported positive feedback from students after web-based, cross-cultural conversations between occupational therapy and occupational science students in the United States and the Philippines.
An SCCOC between U.S. undergraduate occupational science students and Swedish undergraduate occupational therapy students was reported by Aldrich and Johansson (2015). Technical problems (such as internet and audio quality), preinteraction preparation, language barriers, and the degree to which sessions should be student led were identified as basic issues to consider for future development. Similar problems were reported by other studies (Cabatan & Grajo, 2017). Communication between institutions across time zones, different institutional policies, and matching of proficiency levels between students might be some of the challenges that could affect the outcome of an SCCOC (Yang et al., 2014).
Many studies have not provided details about how IaH programs were designed or specific outcomes that were used. Evidence of the best methods toward implementation of such programs within occupational therapy education remains scarce. In addition, the potential impact on occupational therapy students’ cultural competence is underexplored. Although language barriers and technological issues have been reported, little has been done to mitigate these concerns in previous collaborations. In this study, we have added a unique approach to initiating IaH by using translation services, enhanced video technology equipment, and information technology support services during the collaboration in an attempt to take an active approach to reducing known barriers. This study approach is also unique, because the synchronous engagement between the two groups of occupational therapy program students was limited to 1 hr, whereas most previous studies have included extended periods of interaction, which can increase the complexity of planning, scheduling, and resource allocation.
The purpose of this study was to address the need for sustainable and effective methods for enhancing cultural competence, with a focus on developing cultural awareness as a component of cultural competence, in occupational therapy students through IaH by exploring the use of SCCOC between two international occupational therapy programs. This study had the following three objectives:
Determine perceived supports and barriers in an SCCOC according to student participants
Identify opportunities and challenges for implementing an SCCOC according to student participants
Examine the impact of SCCOC on the development of students’ cultural competence, specifically the dimension of cultural awareness.
Method
The collaboration evolved between the University of St. Augustine for Health Sciences (USAHS; St. Augustine, FL, campus) and the European University Cyprus (EUC; Nicosia, Cyprus) from an initially experimental attempt to develop mutually beneficial cross-cultural learning experiences. Over a period of months before the initial implementation, the authors of this study met using video conferencing to discuss and exchange information on courses we taught, the universities’ policies, and learning objectives; we also brainstormed ways to develop cross-cultural learning experiences for our students. Instructors at both universities had previously engaged in a set of SCCOC between programs as an educational activity to reinforce course content. On the basis of literature, prior experience, and informal student feedback (Zadnik et al., 2018), we designed the SCCOC in a way that could potentially enhance student learning with the least number of barriers.
Design
A convergent, parallel mixed-methods design was used to analyze and merge the qualitative and quantitative data (Creswell, 2013). A self-assessment survey was conducted to test the development of cultural competence for occupational therapy students after the SCCOC. Students’ experiences of participating in this SCCOC were explored through written self-reflections and focus groups. The institutional review and research ethics boards of both universities approved the study.
Participants
The purposive sample was composed of students of the master of occupational therapy program at USAHS (n = 32) and the bachelor of science (BSc) in occupational therapy program at EUC (n = 56). Students from USAHS and EUC were enrolled in the first-year courses “Scholarly Design” and “Occupational Science,” respectively. Despite the degree-level difference between the USAHS and EUC students, the foundational knowledge of the occupational therapy profession, including occupational justice, was relatively similar. Both USAHS and EUC students had previously taken courses that included an introduction to occupational therapy principles, ethics, and professional issues as well as basic science and clinical skill courses. A comparison between the EUC and USAHS study programs is outlined in Table 1. Participation in the study was voluntary, and all students signed an informed consent.
Comparison of EUC and USAHS Study Programs
Note. EUC = European University Cyprus; USAHS = University of St. Augustine for Health Sciences.
Denotes the course in which the synchronous cross-cultural online collaboration occurred.
Instrument and Outcome Measures
Cultural competence was measured by the Cultural Awareness Scale for Occupational Therapy Students (CASOTS), which was developed and validated by Castro et al. (2017). This scale has demonstrated good test–retest reliability and internal consistency. The CASOTS was translated into Greek and slightly modified to fit the study’s needs after obtaining permission from the authors. Back-translation and all recommended procedures were followed (Beaton et al., 2000). After its translation, the tool was pilot tested with colleagues who had a high level of competency in the Greek language and teaching Greek students, resulting in minor changes. The survey was administered to students in hard copies. On the basis of the curricular timing of our SCCOC, we assumed that the students would start in the lower stages of cultural development, and we decided to focus on cultural awareness. The CASOTS was chosen to measure changes in cultural awareness that, in combination with qualitative responses from students’ written reflections, would illustrate a potential impact on the overarching construct of cultural competence.
Additional outcome measures included focus groups and students’ written reflections on their experience. Focus groups centered on Objectives 1 and 2 of the study, which include supports and barriers as well as opportunities and challenges. Written reflections allowed further assessment of student cultural competence that may not have been captured by the CASOTS.
Procedure
Students on each campus were divided into 10 groups of no more than 5 students. At the beginning, students were given the CASOTS to complete. Each group was given a topic related to a potentially vulnerable population of clients (older adults; lesbian, gay, bisexual, transgender, and questioning clients; clients with mental disabilities, physical disabilities, or low socioeconomic status; women; immigrants; and refugees). Students were given 2 wk to prepare for the SCCOC, including readings and relevant lectures that were part of their coursework. In addition, they had to perform an online search and discuss with relevant people or organizations to gather information related to
Cultural views of the vulnerable population they were assigned,
What was currently being done in their country to address the needs of this population and what else could be done, and
Existing supports and barriers for practicing occupational therapy to address the needs of this population in their country.
A private Facebook group was created to offer the opportunity for introductions and informal information exchange between students. This page has since remained open to allow for continuation of interactions.
The SCCOC took place over 3 days, during which each group was given 1 hr for discussion. One faculty member along with technicians were present from each campus to assist with technical challenges and organizational needs. The two faculty members, along with a third one who was not part of either course but was acting as the moderator of the sessions, kept faculty involvement to a minimum to allow for more peer-to-peer exchange. The moderator’s role was to prompt students and pose questions when needed and to ensure discussions were kept within the planned timeline.
On the session day, each group met in a room on their campus, equipped with a video screen through which groups could see each other and a 360° camera and microphone set in the middle of the table. Communications were conducted through Zoom (Zoom Video Communications, San Jose, CA). A translator was present to translate from English to Greek and vice versa for the students of both campuses. The translator was seated in a separate room on the EUC campus. Students could hear the translation of what was spoken 2–3 s after the original statement, which kept delays to a minimum. The use of video allowed students to see the nonverbal body language of students in the opposite group in real time, which gave context to the translated statements.
At the conclusion of all SCCOC, students completed the CASOTS for the second time. A 1-hr focus group was held on each campus to discuss
What worked well and supported the experience,
What was a barrier or challenge, and
Suggestions for future implementation and expansion of SCCOC.
Students provided a written reflection based on specific questions about their personal feelings and views as well as thoughts of how this experience might fit within occupational therapy education in the future.
Data Analysis
The constant comparative and constructivist method for qualitative data analysis was used to code the focus groups’ transcripts (Glaser & Strauss, 1967). Qualitative data analysis was done by hand, separately on each campus, following line-by-line open coding with axial coding. Categories were developed from the findings and driven by the data. During this iterative process, new codes and categories emerged from the data. After each investigator had coded and analyzed their campus-specific data, congruencies were reviewed collaboratively between the programs. Survey data were analyzed with IBM SPSS Statistics (Version 25; IBM Corp., Armonk, NY). Descriptive statistics were used in combination with analysis of variance (ANOVA) and Pearson’s correlation to identify trends between institutions.
Results
A total of 56 EUC and 32 USAHS students participated in the SCCOC. Students from both universities were primarily female and represented multiple nationalities and cultures.
Student Reflections
EUC students reported the following major themes:
Occupational therapy has a role in providing services to refugees, and this population could be included in students’ practical placements.
Issues of race and gender inequality are present in both cultures.
The two countries have differences in socioeconomic statuses.
Occupational therapists specializing in neurological rehabilitation are needed in Cyprus.
It feels awkward to not have any understanding of the political climate of another country.
These themes represent the students’ awareness of the differences and similarities between the two countries, a burgeoning awareness of gaps in the practice of occupational therapy in their country, and a personal reflection of their cultural competence.
Thematic analysis of the USAHS students’ reflections revealed the following major themes:
Realization of how diverse the occupational therapy profession is
Sadness for the magnitude of occupational injustice worldwide and an increased drive to advocate for occupational justice issues in their future profession
Similarity of the two cultures at their roots, although seemingly so different on a surface level
More connected to the profession of occupational therapy after this experience.
These themes represent the students’ feelings of connectedness to the occupational therapy profession and development of personal values regarding advocacy for occupational justice issues. In addition, the USAHS students noted a deeper awareness of the similarities and differences between the countries.
Focus Groups
Within each transcribed set of focus group data, we identified common themes, revealing that students found SCCOC to be more interesting than traditional in-class teaching and appreciated the organization of the sessions, including the mediator, translator, prereadings, and their participation as groups rather than in one-to-one discussions. Technical issues and issues related to time availability before and during the sessions were identified as the strongest barriers. Students’ suggestions were mainly on the following topics:
More preparation time and information exchange through prior asynchronous communications
Smaller groups
More cross-cultural opportunities with variant topics, occurring more frequently and with diverse cultures and professions
Recording of synchronous sessions to make them accessible to other groups of students.
To ensure trustworthiness of data collection and analysis regarding the focus group data, we used a multiphase approach as described by Nowell et al. (2017). Phase 1 of the thematic analysis included all researchers documenting initial thoughts about potential codes and themes (Nowell et al., 2017, p. 4). Phases 2 and 3 involved generating initial codes and searching for themes. Researcher triangulation and documentation of all team meetings were used, along with detailed notes about the development of themes. Through Phase 4 (reviewing themes) and Phase 5 (defining and naming themes), researcher triangulation was still used, vetting the themes through team members, returning to the raw data, establishing team consensus, and documenting theme naming to establish trustworthiness (Nowell et al., 2017, p. 4). Although credibility, dependability, and confirmability throughout the first phase of thematic analysis were established, improved processes could have been used in Phase 6 (producing the report). In future studies, member checking and peer debriefing could be used to ensure that the final report accurately reflects the full scope of the potential themes developed from data analysis.
Cultural Awareness Scale for Occupational Therapy Students
Questionnaires with incomplete data were removed from analysis, resulting in 49 EUC and 25 USAHS presurveys and 40 EUC and 17 USAHS postsurveys. Statements 5, 8, 23, 27, 29, and 30 were reverse coded before data analysis. Descriptive statistics showed that the total pretest mean difference was 89.08 (standard deviation [SD] = 6.53) for EUC and 100.58 (SD = 5.06) for USAHS. The total posttest mean difference was 89.42 (SD = 6.49) for EUC and 99.83 (SD = 5.11) for USAHS. Many EUC students did not answer Statements 13 (“I think some occupational therapy concepts and values come from one particular culture”) and 17 (“I think the current theories in occupational therapy are culturally relevant, independent of the context in which they are used”).
A one-way ANOVA within groups revealed no significant difference for either country (EUC: F[1, 87] = 0.29, p = .59; USAHS: F[1, 40] = 1.21, p = .28). ANOVA comparison assuming nonequal variance using a Dunnet’s C post hoc analysis indicated that USAHS students had significantly higher pre- and posttest scores compared with EUC students.
Pearson’s correlations revealed that EUC students’ responses to Statements 8 and 10 demonstrated a significant correlation to time (pre–post experience). A positive correlation was found for Statement 8, “I think cultures can exert a certain degree of power over other people or groups” (r[87] = .27, p = .01), indicating less agreement on posttest. Surprisingly, a negative correlation was found for the statement, “To understand a culture, I think it is good to share their festivities, to know the traditional jobs and the typical objects used by the members of that culture” (r[87] = −.25, p = .02), indicating stronger disagreement postintervention.
Several significant correlations were found between the USAHS students’ responses and time (pre–post experience). The only positive correlation was associated with Question 15, “I need to adjust the occupational therapy models of practice so that I can use them in my local culture” (r[40] = .39, p = .00).
Discussion
In agreement with previous researchers (Aldrich & Johansson, 2015; Yang et al., 2014), this study identified a positive attitude from both EUC and USAHS students, who found SCCOC to be interesting and helpful in discovering issues that relate to occupational therapy. Students expressed their desire to be included in such experiences more often, with diverse cultures and topics. Although this study was based on previous experience of SCCOC (Zadnik et al., 2018) and the findings of other researchers, barriers were still present and pointed out by students.
Themes of professionalism, advocacy, and cultural awareness were present in student reflections. Professionalism included comments about students’ feelings of connection to the profession and drive to advocate for populations who are affected by occupational injustice. Cultural awareness reflected the students understanding of the similarities and differences between their cultures and the potential ways culture may influence their future client encounters. Themes resulting from the qualitative data highlight the students’ positive influence by the SCCOC experience. Results indicated that through the experience, the students enhanced their understanding of how different populations could be affected by social justice issues, how culture can influence client experiences, and where advocacy can play a role in access to care. Interestingly, it appears that USAHS students may have developed more personal and professional cultural awareness, whereas the EUC student reflections indicate only personal cultural awareness.
The cultural competence tool used did not reflect any changes. The CASOTS was originally designed with the intent to reverse code some questions, which may have affected the students’ responses. Skepticism has been expressed over the use of self-report instruments, particularly as the sole method, to measure the outcomes of an intervention (Deardorff, 2006). However, it is not surprising that a single session may not have been influential. Moreover, to test the results on cultural competency, follow-up reassessments may need to take place with a broader perspective on all components of cultural competence, beyond cultural awareness.
The reason why many EUC students declined to answer Questions 13 and 17 might have been that they that were not truly familiar with the cultural relevance of concepts and theories in occupational therapy because they were only in their first year of a BSc program. The USAHS students’ higher pre- and posttest scores compared with those of the EUC students reflect the difference in educational level between them. It might be more appropriate in the future to include students who are at similar degree levels. Potential correlations between time (pre–post experience) indicated that there may have been some emerging impact on students’ feelings of cultural awareness for both the EUC and USAHS cohorts. The positive correlations found may support the themes developed from the qualitative data analysis. Specifically, EUC students’ increased disagreement with Statement 8 and USAHS students’ increased agreement with Statement 10 support the theme of cultural awareness that was indicated in the qualitative findings.
Although students appreciated the way the SCCOC were organized and the major issue of internet connectivity did not come up, challenges still occurred. Despite having an automatic translation, delays affected the dialogue at times. Moreover, because this type of translation is expensive, such a method is not sustainable. In agreement with others (Aldrich & Johansson, 2015; Chen et al., 2006; Garrett & Cutting, 2012), the language barrier seemed to affect communication significantly. Students requested more time during the SCCOC, for preparation beforehand and for each person within the group. Indeed, cross-cultural learning takes more processing time for effective communication, especially given communication context differences (Chen et al., 2006). Perhaps the formation of smaller groups (n < 5) may be beneficial (Aldrich & Johansson, 2015). Having more than one interaction has been suggested to be associated with significant changes (Aldrich & Grajo, 2017; Yang et al., 2014).
One major limitation of this study is that each student’s responses (pre–post experience) were not coded; thus, an individual analysis could not be performed, which would be very informative especially by adding individual demographic data. These data should be incorporated with caution because of the considerable difference in the sample size between the two groups and the significant number of pre- and posttests that could not be used because of incomplete data.
Implications for Occupational Therapy Education
The results of this study have the following implications for occupational therapy education:
SCCOC enhance students’ self-learning process and offer an opportunity for cultural awareness.
SCCOC might be more beneficial if combined with multiple asynchronous sessions beforehand or embedded throughout the curriculum.
The success of SCCOC may depend on proper selection of similar-level students and handling of technical problems. The language barrier is perhaps the most challenging factor.
Conclusion
The purpose of this study was to develop and implement a potentially sustainable solution for enhancing cultural competence in occupational therapy students by using IaH principles. With a specific focus on cultural awareness, we attempted to establish best practices in IaH and measure the effectiveness of IaH between two international occupational therapy programs. Using a pretest–posttest, parallel mixed-methods design, the study involved student participation in video collaboration sessions to discuss social justice issues that affect occupational therapy practice. Focus groups, reflective writing, and pre- and postsurveys were used to determine perceived supports and barriers, opportunities and challenges, and the impact of SCCOC from the student’s perspective.
The results indicated that although there was no discernable change in occupational therapy students’ cultural awareness on the basis of the CASOTS, the students’ comments reflected a desire to increase engagement in these types of experiences. Themes of professionalism, advocacy, and cultural awareness were present in the comments. Although the researchers were able to develop solutions to several barriers related to technology and organization, language barriers were not as successfully overcome and affected the student experience.
The findings from this study can help inform future implementation of IaH experiences to broaden students’ opportunities to engage in cultural collaborations while overcoming barriers that have made IaH experiences challenging in the past. In addition, future studies should explore integration of IaH experiences throughout the curriculum and measure the effectiveness of these experiences using different measures of cultural competence to determine the impact on student outcomes.
Footnotes
Acknowledgments
This work was supported by the Digital Teaching and Learning Research Grant of Laureate Education.