A Curricular Model of Cross-Cultural Sensitivity

Journal of Physical Therapy Education, Fall 2007 by Shore, Susan

Background and Purpose. As the ethnic diversity of the US population continues to increase, the likelihood that students will interact with patients or supervisors from a cultural heritage different from their own becomes certain. Preparing students for culturally successful interactions in clinics is paramount. The purposes of this article are to present a model of preparation in cross-cultural sensitivity and to evaluate its effectiveness in a curricular setting.

Method/Model Description and Evaluation. The model consists of 3 phases: understanding cultural differences through classroom presentations, simulated classroom application through group projects, and clinical application through provision of physical therapy services to patients of various cultures. The model was evaluated by use of the Cross-Cultural Adaptability Inventory (CCAI) administered to 2 consecutive groups of professional (entry-level) physical therapist students before and after the curricular unit. Outcomes. In the first group of students, there was no difference in pre versus postinstruction CCAI scores, but the second group of students showed a significant increase. The most valued topics of discussion included global health belief systems and cross-cultural communication. Students unanimously voted to make these discussions a permanent part of the curriculum.

Discussion and Conclusion. A structured 3-phase model of instruction on multiculturalism for students may result in increased potential for cross-cultural effectiveness, as measured with the CCAI.

Faculty members revising cross-cultural content may wish to consider this model.

Key Words: Cross-cultural sensitivity, Model, Physical therapy education, Cross-Cultural Adaptability Inventory.

We live in a global society. According to the 2000 US population census, 75.1% of the US population is white, a noticeable decrease from 80.3% in 1990.1 In keeping with this population shift, physical therapy professionals are treating patients from culturally diverse backgrounds. To be successful in this environment, a practitioner must be skilled in cross-cultural interactions in order to ensure patient cooperation and well-being.

"Culture" represents an intangible set of acquired societal mores that acts as a filter through which people perceive and respond to daily life.2,3 The physical therapy environment, the therapist-patient relationship, and the intervention process all pass through this filter of perception and response-the filters of both the therapist and the patient. A person's health belief system influences not only that person's understanding of the cause of disease and disability but also that person's expectations from and participation in the intervention process.4 Verbal and nonverbal communications, including the expression of symptoms,5 are tied inextricably to a cultural understanding of the roles of the professional and the patient.6 A physical therapist who does not understand these concepts may not receive complete patient cooperation and therefore may reach erroneous conclusions about treatment effectiveness. Educators strive to prepare students to be technologically and methodologically ready to enter practice. However, are they prepared to face issues of multiculturalism? Azusa Pacific University students returning from clinical affiliations in southern California estimated that their average caseload included 62% patients in minority groups, consistent with California demographics.1 Although there is variability in cultural composition across the United States, cross-cultural sensitivity in all clinical settings is necessary.

Physical therapy professionals are gradually becoming aware of their responsibility in this domain. Information on cross-cultural issues in rehabilitation has begun to emerge in the physical therapy literature. There have been reports of short-term student assignments abroad7-9 and of physical therapist experiences in Mexico,10 Romania,11,12 Estonia,13 Saudi Arabia,14 Zimbabwe,15 and Jamaica16,17 and with Palestinians.18 There has been research about the influence of race and ethnicity on the incidence of disease,19 on attitudes toward disability,20 on the development of motor behavior,21 and on the cooperation and satisfaction of parents with regard to the rehabilitation of their children.22,23 Thus, physical therapy professionals are interacting on a global scale.

In keeping with this trend, the physical therapy literature has addressed methods by which professionals can develop cross-cultural competence. Black and Purnell24 applied the Purnell model for cultural competence to the physical therapy profession in the areas of cross-cultural communication, health care practices, and health care practitioners. The American Physical Therapy Association Continuing Education Series Developing Cultural Competence in a Multicultural World25,26 includes a synthesis of relevant cross-cultural information for physical therapists, with applications to the clinical setting. Included is an overview of collectivistic versus individualistic cultural value systems, as well as cultural views of disease, disability, and intervention. Lynch27 used cultural continua with opposing values at the extremes to explain 7 societal values to rehabilitation professionals; these values included interdependence versus individuality, use of time, and harmony versus control. Brice and Campbell6 applied individualistic versus collectivistic values to cross-cultural communication and conflict resolution. Padilla and Brown3 applied cultural understanding to patient education. Emphasized throughout these discussions is the importance of exploring one's own cultural heritage in order to understand how personal cultural biases influence patient care.