 
Perspectives from Emerging Leaders
 Cristina Reyes Smith, OTD, OTR/L
o Medical University of South Carolina (Charleston, SC)
 Arameh Anvarizadeh, OTD, OTR/...
 Rationale and Background
 Focus Group Results and Discussion
 Personal Perspectives
 Moving Toward the Diverse Workfo...

We envision that occupational therapy is a
powerful, widely recognized, science-driven, and
evidence-based profession with...
 di·ver·si·ty
noun də-ˈvər-sə-tē, dī-
: the quality or state of having many different
forms, types, ideas, etc.
: the sta...
Diversity
Age
Education
Gender
Nationality
Race/
Ethnicity
Religion
Sexual
orientation
Socio-
economic
status
 Population (2012): 313, 873, 685
o Under 5 years: 6.4%
o Under 18 years: 23.5%
o 19 to 64 years: 62.8%
o 65 and over: 13...
(U.S. Department of Commerce, 2014)
 AOTA Academic Programs Annual Data Report: 2011-
2012
(AOTA, 2012
 AOTA Faculty Workforce Survey (December 2010)
(AOTA,
2010)
0
10
20
30
40
50
60
70
White Black AIAN Asian NHPI Two or
More
Races
Hispanic
2012
2035
2060
(As cited by U.S. Census Bure...
 AOTA Academic Programs Annual Data Report: 2011-
2012
(AOTA, 201
 AOTA Academic Programs Annual Data Report: 2011-
2012
(AOTA, 201
 AOTA Faculty Workforce Survey (December 2010)
(AOTA, 2010)
 B.1.3: Demonstrate knowledge and understanding of the concepts
of human behavior... including but not limited to introdu...
 B.4.7: Consider factors that might bias assessment results, such as
culture, disability status, and situational variable...
 ―Occupational therapy practitioners have the responsibility to
intervene with individuals and communities to limit the e...
Benefits and drawbacks to diversity:
o Pros: Increased creativity and innovation
o Con: increased conflict through a varie...
 ―Minorities receiving care in hospitals with a less diverse
inpatient population may face greater barriers to health
car...
 ―Diversity will only be achieved if the primary focus is on:
what is happening within the pipeline…Emphasizing
talent de...
 Imbed cultural competency training into OT curriculums
(Nochajski, & Matteliano, 2008)
 Fieldwork education with unders...
 Podsiadlowski et al., 2013:
o Organizational paradigms to diversity
• Discrimination and fairness
• Access and legitimac...
 Dynamic between client and provider can be compromised by
sociocultural mismatches
 Competence connotes a theory that c...
 …transculturally competent therapists are skilled at working
with the client to:
o identify how meanings are created and...
 Cultural fluidity (Shippy, 2009):
o Able to adapt to different cultures--expert and learner
 Cultural humility (Tervalo...
 ―Another promising strategy might be to make use of
―influential‖ therapists….In our opinion, knowledge
brokers could be...
 Therapists value interactive and hands-on continuing
education but rely most heavily on their peers when
accessing, eval...

1. What does diversity mean to you?
2. How do you define diversity?
3. What are 2-3 things that you have observed, done or...
Focus Group Results
17 (23%) 21 (28%)
Participants by region (n=75):
32 (43%)
1 (1%)
Not reported 3 (4%)
Yes 33%
No 67%
20-29 41%
30-39 23%
40-49 17%
50-59 13%
60-69 5%
Student 33%
OTR/L 49%
COTA 3%
Research 7%
Educator 8%
 ―I am reminded that we as a profession need to keep our eyes
fresh to continually adjust our modes of operation. Only th...
 Its important for patients of different cultures to see we have
employee diversity as well
 ―Equality does not equal di...
Politically-
correct
Phenomeno
n vs.
Problem
Changing
terminology

Lived Experiences of Emerging Leaders

1. What does ―diversity‖ mean to you? How does
diversity relate to your workplace?
2. What are some strategies that you ha...
1. What were some of the perspectives discussed
by your group? Were there any insights or
epiphanies you would like to sha...
 Invest in people—it can make all the difference
 Tell people who you are and what you do. Advocate for
what you are doi...
Move Beyond
Cultural
Competenc
e

 Cristina Reyes Smith, OTD, OTR/L; Medical University of South
Carolina (Charleston, SC); (843) 814-7917; smithcris@musc....
 American Association of Family Physicians. (n.d.). Cultural Proficiency.
Retrieved from http://www.aafp.org/patient-care...
 American Occupational Therapy Association. (2010). Faculty Workforce
Survey. Retrieved from http://www.aota.org/-
/media...
 Dreachslin, J. L., Weech-Maldonado, R., & Dansky, K. H. (2004). Racial and
ethnic diversity and organizational behavior:...
 Ketelaar, M., Russell, D.J., & Gorter, J.W. (2008). The challenging of moving
evidence-based measures into clinical prac...
 Nkansah, N. T., Youmans, S. L., Agness, C. F., & Assemi, M. (2009).
Fostering and managing diversity in schools of pharm...
 Suarez-Balcazar, Y., Balcazar, F., Taylor-
Ritzler, T., Portillo, N., Rodakowski, J., Garcia-Ramirez, M., & Willis, C.
(...
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders
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2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders

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This presentation was conducted at the 2014 American Occupational Therapy Association Conference in Baltimore, MD on April 5, 2014.

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  • The data on race were derived from answers to the question on race that was asked of individuals in the United States. The Census Bureau collects racial data in accordance with guidelines provided by the U.S. Office of Management and Budget (OMB), and these data are based on self-identification. The racial categories included in the census questionnaire generally reflect a social definition of race recognized in this country and not an attempt to define race biologically, anthropologically, or genetically. In addition, it is recognized that the categories of the race item include racial and national origin or sociocultural groups. People may choose to report more than one race to indicate their racial mixture, such as “American Indian” and “White.” People who identify their origin as Hispanic, Latino, or Spanish may be of any race. OMB requires five minimum categories: White, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander.
  • The significance of age and sex data:Slide shows: Population by Sex and Selected Age Groups: 2000 and 2010 (SUMMARIZE CHART)Focusing on a population’s age and sex composition is one of the most basic ways to understand population change over time. In general, the U.S. population continues to grow older with a median age over 40 years old in many states. At the same time, increases in the number of men at older ages are apparent. Understanding a population’s age and sex composition yields insights into changing phenomena and highlights future social and economic challenges.
  • Not knowing lived experiences, health beliefInherent is the patient focused interview and client centered language
  • 2014 (AOTA Diversity in the Workforce: Perspectives from Emerging Leaders

    1. 1.   Perspectives from Emerging Leaders
    2. 2.  Cristina Reyes Smith, OTD, OTR/L o Medical University of South Carolina (Charleston, SC)  Arameh Anvarizadeh, OTD, OTR/L o California Children’s Services (Los Angeles, CA)  D’Andre Holland, OTD, OTR/L o Every Child Achieves (Los Angeles, CA)  Catherine Hoyt Drazen, OTD, OTR/L o Washington University in St. Louis (St. Louis, MO)  Nadine Kwebetchou, MS, OTR/L o VA Palo Alto (Palo Alto, CA)  Stacy Wilson, MS, OTR/L o WakeMed Health and Hospital (Raleigh, NC)
    3. 3.  Rationale and Background  Focus Group Results and Discussion  Personal Perspectives  Moving Toward the Diverse Workforce of the Centennial Vision
    4. 4. 
    5. 5. We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs. (AOTA, 2007)
    6. 6.  di·ver·si·ty noun də-ˈvər-sə-tē, dī- : the quality or state of having many different forms, types, ideas, etc. : the state of having people who are different races or who have different cultures in a group or organization (Merriam Webster, Inc., n.d.)
    7. 7. Diversity Age Education Gender Nationality Race/ Ethnicity Religion Sexual orientation Socio- economic status
    8. 8.  Population (2012): 313, 873, 685 o Under 5 years: 6.4% o Under 18 years: 23.5% o 19 to 64 years: 62.8% o 65 and over: 13.7% o Female: 50.8% o White, alone: 63.0% o Black/African American, alone: 13.1% o American Indian/Alaska: 1.2% o Asian, alone: 5.1% o Two or more races: 2.4% o Hispanic/Latino: 16.9% (U.S. Department of Commerce, 2014)
    9. 9. (U.S. Department of Commerce, 2014)
    10. 10.  AOTA Academic Programs Annual Data Report: 2011- 2012 (AOTA, 2012
    11. 11.  AOTA Faculty Workforce Survey (December 2010) (AOTA, 2010)
    12. 12. 0 10 20 30 40 50 60 70 White Black AIAN Asian NHPI Two or More Races Hispanic 2012 2035 2060 (As cited by U.S. Census Bureau, Population Division in Census.gov, n.d., p. 4 AIAN=American Indian and Alaska Native; NHPI=Native Hawaiians and Other Pacific Islanders
    13. 13.  AOTA Academic Programs Annual Data Report: 2011- 2012 (AOTA, 201
    14. 14.  AOTA Academic Programs Annual Data Report: 2011- 2012 (AOTA, 201
    15. 15.  AOTA Faculty Workforce Survey (December 2010) (AOTA, 2010)
    16. 16.  B.1.3: Demonstrate knowledge and understanding of the concepts of human behavior... including but not limited to introductory sociology or introductory anthropology.  B.1.4: Apply knowledge of the role of the sociocultural, socioeconomic and diversity factors and lifestyle choices in contemporary society to meet the needs of individuals and communities.  B.1.5: Demonstrate an understanding of the ethical and practical considerations that affect the health and wellness needs of those who are experiencing or are at risk for social injustice, occupational deprivation and disparity in the receipt of services.  B.2.9: Express support for the QOL, well being and occupation of the individual, group or population...considering the context (cultural, personal, temporal, virtual). (AOTA, 2011)
    17. 17.  B.4.7: Consider factors that might bias assessment results, such as culture, disability status, and situational variables related to the individual and context.  B.5.20: Effectively interact through written, oral, and nonverbal communications with the client, family, significant others, communities, colleagues, other health providers and the public.  B.5.33: Provide population-based occupational therapy intervention that addresses occupational needs as identified by the community.  B.6.3: Integrate current social, economic, political, geographic and demographic factors to promote policy development and the provision of OT services.  B.7.9 (OTD only): Demonstrate knowledge of and the ability to write program development plans for provision of services to individuals and populations. (AOTA, 2011)
    18. 18.  ―Occupational therapy practitioners have the responsibility to intervene with individuals and communities to limit the effects of inequities that result in health disparities. Practitioners have knowledge and skills in evaluating and intervening with individuals and groups who face physical, social, emotional, or cultural challenges to participation. Further, the American Occupational Therapy Association (AOTA) supports advocacy to increase access to health services for persons in need, and efforts to lessen or eliminate health disparities are consistent with the Occupational Therapy Code of Ethics and Ethics Standards (2010) (AOTA, 2010).‖ (AOTA, 2013)
    19. 19. Benefits and drawbacks to diversity: o Pros: Increased creativity and innovation o Con: increased conflict through a variety of ideas and beliefs presents o Mediating factors to negative effects of diversity are: 1. Leadership 2. Communication (Dreachslin, Weech-Maldonado, & Dansky, 2004)  ―Leaders who are able to validate alternative realities and appreciate different perspectives appear to moderate the potential negative effects of racial diversity on team communication processes and strengthen the positive aspects of diversity‖ (Dreachslin, Hunt, & Sprainer, 2000, p. 1403)
    20. 20.  ―Minorities receiving care in hospitals with a less diverse inpatient population may face greater barriers to health care than those receiving care in hospitals with a more diverse patient population.‖ (Weech-Maldonado et al., 2012, p. 821) ―There is a need for occupational therapy to deepen its understanding of how the experience of being a minority group client within a therapeutic relationship intersects with the process and outcomes of occupational therapy.‖ (Kirsh, Trentham, & Cole, 2006)
    21. 21.  ―Diversity will only be achieved if the primary focus is on: what is happening within the pipeline…Emphasizing talent development opens up many new approaches for science training outside of traditional degree programs.‖ (McGee, Saran, & Krulwich, 2012)  Literature is scarce on the long-term benefits of workplace diversity in OT: o (Kirsh, Trentham, & Cole, 2006) o (Trentham, Cockburn, Cameron, & Iwama, 2007)
    22. 22.  Imbed cultural competency training into OT curriculums (Nochajski, & Matteliano, 2008)  Fieldwork education with underserved populations and international fieldwork opportunities (Kirsh et al., 2006)  Promote self-reflection into OT students’ own cultural identities (Kirsh et al., 2006)  Explore qualitative literature which depicts the experiences of minority groups who receive OT (Kirsh et al., 2006)  Include discussions in academia of discrepancies in Westernized versus non Westernized cultural values (Iwama, 2003; Kinebanian & Stomph, 1992)
    23. 23.  Podsiadlowski et al., 2013: o Organizational paradigms to diversity • Discrimination and fairness • Access and legitimacy • Learning and effectiveness  Suarez-Balcazar et al., 2011: o Self-reflection o Integrating culture in the occupational therapy process o Developing organizational support for change  Dass and Parker, 1999: o Resistance to organizational support for change
    24. 24.  Dynamic between client and provider can be compromised by sociocultural mismatches  Competence connotes a theory that can be mastered  Cultural humility indicates: o Lifelong commitment to self-evaluation and self-critique o Addressing power imbalances in the provider/client dynamic o Developing partnerships with communities  Focus on student education to examine individual patterns of unintentional and intentional racism, classism, homophobia (Tervalon & Murray-Garcia, 1998)
    25. 25.  …transculturally competent therapists are skilled at working with the client to: o identify how meanings are created and/or expressed through occupation o acknowledge systemic barriers to inclusion and are able to advocate for their amelioration o open to learning about the lived experience of their clients o knowledgeable about their {clients} values and health beliefs o insightful about their own values and assumptions regarding what are good and right and true o can monitor their own tendency towards ethnocentricity (Trentham, Cockburn, Cameron, & Iwama, 2007)
    26. 26.  Cultural fluidity (Shippy, 2009): o Able to adapt to different cultures--expert and learner  Cultural humility (Tervalon & Murray-Garcia, 1998): o Every interaction is multicultural; must be aware of personal bias  Transcultural competence (Kirsh et al., 2006): o Ability to function effectively within a given role with a diversity of individuals whose cultural perspectives differ from one’s own • Cultural sensitivity is viewed as one aspect of transcultural competence.  Cultural proficiency (AAFP, n.d.): o Knowledge, skills, and attitudes which enable people to work well with, effectively respond, and support people in cross- cultural settings
    27. 27.  ―Another promising strategy might be to make use of ―influential‖ therapists….In our opinion, knowledge brokers could be very important, especially in the last stages of implementation—change and maintenance.‖ (Ketelaar, Russell, & Gorter, 2008)  ―For research findings to effectively influence health services’ delivery of care needs an intermediary…an emerging role therefore exists for knowledge brokers, supported by knowledge brokering resources and agencies, to fill the gap.‖ (Lomas, 2007)
    28. 28.  Therapists value interactive and hands-on continuing education but rely most heavily on their peers when accessing, evaluating, and implementing new knowledge.  Trials involving educationally influential therapists are indicated.  Continuing education research is needed to identify organizational conditions conducive to therapists’ learning and knowledge translation. (Rappolt & Tassone, 2002)
    29. 29. 
    30. 30. 1. What does diversity mean to you? 2. How do you define diversity? 3. What are 2-3 things that you have observed, done or could do to promote diversity in the workforce? 4. What do you feel is the importance of diversity in the workforce? 5. Is there anything else you would like to share?
    31. 31. Focus Group Results 17 (23%) 21 (28%) Participants by region (n=75): 32 (43%) 1 (1%) Not reported 3 (4%)
    32. 32. Yes 33% No 67% 20-29 41% 30-39 23% 40-49 17% 50-59 13% 60-69 5% Student 33% OTR/L 49% COTA 3% Research 7% Educator 8%
    33. 33.  ―I am reminded that we as a profession need to keep our eyes fresh to continually adjust our modes of operation. Only then can we provide the best patient care and more fully promote a richer QOL.‖  ―Diversity tends to be boxed into groups, but it is a really broad concept on more than race, gender, religion and sexuality.‖  It is extremely important. No pt is the same meaning having diversity in the workforce helps us as OTs provide more pt centered practice and increases the comfort and relatability pts feel with us.
    34. 34.  Its important for patients of different cultures to see we have employee diversity as well  ―Equality does not equal diversity -> makes working together interesting.‖  I realize there are many types of diversity, as we discussed. Some areas, such as rural may only have 1 OT for hundreds of miles. In these cases there is not a lot of opportunity for a diverse professional pool. I feel the therapist needs to be diverse in their understanding of cultures that they do not belong to. There is such an opportunity to learn from our clients too. Maybe this is considered cultural sensitivity, but we also need to be diverse in our own self to be effective.
    35. 35. Politically- correct Phenomeno n vs. Problem Changing terminology
    36. 36.  Lived Experiences of Emerging Leaders
    37. 37. 
    38. 38. 1. What does ―diversity‖ mean to you? How does diversity relate to your workplace? 2. What are some strategies that you have observed, implemented, or could do to promote diversity in the workforce? 3. Discuss the concepts of cultural competence, cultural humility, cultural fluidity, and trans-cultural care. Why are these different? Do they matter? Why or why not?
    39. 39. 1. What were some of the perspectives discussed by your group? Were there any insights or epiphanies you would like to share? 2. Are there any other supports or barriers to promoting diversity in your workplace or university that you have observed?
    40. 40.  Invest in people—it can make all the difference  Tell people who you are and what you do. Advocate for what you are doing, and look for teachable moments  Be an advocate in/for your community. Look for volunteer opportunities to speak at local schools or career fairs  Create volunteer/observation opportunities for youth  Do not underestimate the one minute elevator speech. You can change a life in a minute  Provide opportunities for structured and unstructured mentorship on multiple organizational levels  Provide financial support for Conference and/or Conclave  Strategize inclusion of OT in career interest tools/events
    41. 41. Move Beyond Cultural Competenc e
    42. 42. 
    43. 43.  Cristina Reyes Smith, OTD, OTR/L; Medical University of South Carolina (Charleston, SC); (843) 814-7917; smithcris@musc.edu  Arameh Anvarizadeh, OTD, OTR/L; California Children’s Services (Los Angeles, CA); (213) 820-3260; anvariza@gmail.com  D’Andre Holland, OTD, OTR/L; Every Child Achieves (Los Angeles, CA); (317) 445-8573; deehollandOT1209@gmail.com  Catherine Hoyt Drazen, OTD, OTR/L; Washington University in St. Louis (St. Louis, MO); (301) 467-0177; hoytc@wusm.wustl.edu  Nadine Kwebetchou, MS, OTR/L; VA Palo Alto (Palo Alto, CA); (443) 562 -3774; nadine.kwebetchou@gmail.com  Stacy Wilson, MS, OTR/L; WakeMed Health and Hospital (Raleigh, NC); (336) 847-0093; mrstacywilson@gmail.com
    44. 44.  American Association of Family Physicians. (n.d.). Cultural Proficiency. Retrieved from http://www.aafp.org/patient-care/public-health/cultural- proficiency.html  American Occupational Therapy Association. (2013). AOTA’s societal statement on health disparities. American Journal of Occupational Therapy, November/December 67, 6 (Supplement), 57-58.  American Occupational Therapy Association. (2012). Academic Programs Annual Data Report: Academic Year 2011-2012. Retrieved from http://www.aota.org/- /media/Corporate/Files/EducationCareers/Accredit/47682/2011-2012- Annual-Data-Report.pdf  ˜ American Occupational Therapy Association. (2011). ACOTE Standards. Retrieved from http://www.aota.org/- /media/Corporate/Files/EducationCareers/Accredit/Draft-Standards/2011- Standards-and-Interpretive-Guide-August-2013.pdf
    45. 45.  American Occupational Therapy Association. (2010). Faculty Workforce Survey. Retrieved from http://www.aota.org/- /media/Corporate/Files/EducationCareers/Educators/OTEdData/2010%20F aculty%20Survey%20Report.pdf  American Occupational Therapy Association. (2007). AOTA’s centennial vision and executive summary. American Journal of Occupational Therapy, 61, 613–614.  ˜ ˜ Census.gov. (n.d.). Methodology and Assumptions for the 2012 National Projections. Retrieved from http://www.census.gov/population/projections/files/methodology/methodstat ement12.pdf  Dass, P., & Parker, B. (1999). Strategies for managing human resource diversity: From resistance to learning. Academy of Management Executive, 12, 68–80.  Dreachslin, J. L., Hunt, P. L., & Sprainer, E. (2000). Workforce diversity: implications for the effectiveness of health care delivery teams. Social Science & Medicine, 50, 1403-1414.
    46. 46.  Dreachslin, J. L., Weech-Maldonado, R., & Dansky, K. H. (2004). Racial and ethnic diversity and organizational behavior: a focused research agenda for health services management. Social Science & Medicine, 59, 961-971.  ˜ Gates, M. G., & Mark, B. A. (2012). Demographic diversity, value congruence, and workplace outcomes in acute care. Research in Nursing and Health, 35(3), 265-276.  Halime, C., Abma, T. A., Klinge, I., & Widdershoven, G. A. M. (2012). Process evaluation of a diversity training program: The value of a mixed method strategy. Evaluation and Program Planning, 35, 54-65.  ˜ ˜ Hildebrand, K., Lewis, L.J., Pizur- Barnekow, K., Schefkind, S., Stoffel, A., & Wilson, L.S. (2013). Frequently asked questions: How can occupational therapy strive towards culturally sensitive practices. Retrieved from http://www.aota.org/media/Corporate/Files/Secure/Practice/Multicultural/FA QCulturalSensitivity.pd1f  Iwama, M. (2003). Toward culturally relevant epistemologies in occupational therapy. American Journal of Occupational Therapy, 57, 583–589.
    47. 47.  Ketelaar, M., Russell, D.J., & Gorter, J.W. (2008). The challenging of moving evidence-based measures into clinical practice: Lessons in knowledge translation. Physical and Occupational Therapy in Pediatrics, 28(2), 191- 206.  Kinébanian, A. & Stomph, M. (1992). Cross-cultural occupational therapy: a critical reflection. American Journal of Occupational Therapy, 46, 751–757.  Kirsh, B., Trentham, B., & Cole, S. (2006). Diversity in occupational therapy: Experiences of consumers who identify themselves as minority group members. Australian Occupational Therapy Journal, 53, 302-313.  ˜ Lomas, J. (2007). The in-between world of knowledge brokering. British Medical Journal, 334, 129–132.  McGee, R., Saran, S. & Krulwich, T. A. (2012). Diversity in the biomedical research workforce: Developing talent. The Mount Sinai Journal of Medicine New York, 79(3), 397-411.  ˜ Merriam-Webster, Inc. (n.d.). Diversity. Retrieved from http://www.merriam-webster.com/dictionary/diversity
    48. 48.  Nkansah, N. T., Youmans, S. L., Agness, C. F., & Assemi, M. (2009). Fostering and managing diversity in schools of pharmacy. American Journal of Pharmaceutical Education, 7.  Nochajski, S., & Matteliano, M. (2008). A guide to cultural competence in the curriculum: Occupational therapy. Retrieved from Center for International Rehabilitation Research Information and Exhange (CIRRIE) website: http://cirrie.buffalo,edu  Nunez-Smith, M., Pilgrim, N., Wynia, M., Desai, M. M., Jones, B. A., Bright, C., Krumholz, H. M., & Bradley, E. H. (2009). Race/ethnicity and workplace discrimination: results of a national survey of physicians. Journal of General Internal Medicine, 11, 1198-1204.  ˜ Rappolt, S., & Tassone, M. (2002). How rehabilitation therapists gather, evaluate, and implement new knowledge. Journal of Continuing Education in the Health Professions, 22, 170–180.  Shippy, M.A. (2009). Cultural Fluidity: How multicultural leaders adapt in the US business environment. Verlag, Germany: VDM Verlag.
    49. 49.  Suarez-Balcazar, Y., Balcazar, F., Taylor- Ritzler, T., Portillo, N., Rodakowski, J., Garcia-Ramirez, M., & Willis, C. (2011). Development and validation of the cultural competence assessment instrument: A factorial analysis. Journal of Rehabilitation, 77, 4–13.  Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved. 9(2).  Trentham , B., Cockburn, L., Cameron, D., & Iwama, M. (2007). Diversity and inclusion within an occupational therapy curriculum. Australian Occupational Therapy Journal, 54, S49-S57.  Weech-Maldonado, R., Elliott, M. N., Pradhan, R., Schiller, C., Dreachslin, J., & Hays, R. D. (2012). Moving towards culturally competent health systems: Organizational and market Factors. Social Science & Medicine, 75, 815-822.  U.S. Department of Commerce. (2014). United states census bureau: State and county quickfacts. Retrieved from: http://quickfacts.census.gov/qfd/states/00000.html

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