Disability, Diversity and Dissemination: A Review of the Literature on Topics Related to Increasing the Utilization of Rehabilitation Research Outcomes among Diverse Consumer Groups

A Look Back to Part 1: Theoretical Framework

The review of the literature presented here and in the previous issue (Volume 4, Number 1 of The Research Exchange) was prepared to help researchers better understand the interaction of disability, diversity and dissemination.

Part 1: Theoretical Framework presented a discussion of the relationship of constructs such as race, ethnicity, culture, disability, and power. Influences within the rehabilitation system were presented, as well as descriptions of "mainstream" and "ethnic" cultures in the United States.

Part 2 focuses on the characteristics of effective systems and how to build relationships within "culturally competent" organizations. The concepts about culture and diversity that were discussed in Part 1 are related to issues in conducting research as well as issues in dissemination and utilization (D&U). Organizational, research, and D&U recommendations are also presented.

PART 2: Applying the Concepts to Research and D&U

Characteristics of effective systems and relationships

How is all of the information presented in Part 1: Theoretical Framework linked to the process of increasing the utilization of rehabilitation research outcomes? Addressing diversity in the knowledge utilization process is not merely a matter of translating materials into Spanish or broadening dissemination channels to include, for example, churches in predominantly African American communities. For most research and development organizations, and for the service agencies that often serve as dissemination channels for them, addressing diversity requires fundamental changes in perspective in order to become knowledgeable about, responsive to, and credible to a diverse set of potential users. There are implications for organizational policy, structures, procedures, and staffing; for what research is conducted, for what purposes, and according to what methodologies; and for strategies for "packaging" and disseminating research outcomes. These implications are discussed in the following sections.

Building "culturally competent" organizations. Most of the literature addressing organizational issues related to diversity focuses on service agencies rather than on research agencies and organizations. However, many of the principles and characteristics described for service agencies also appear relevant to a variety of institutional contexts. This literature includes recommendations for organizational approaches that are variously described as "culture-compatible" (Flaskerud, 1986) or "multicultural" (Duarte & Rice, 1992; Ehiobuche, 1995). A number of authors use the term "cultural competence," a concept derived from the work of Cross et al. (cited in Benjamin, 1992; see also Schaller, Parker, & García, 1998; Soriano, 1995; and Mason, 1994).

Soriano defines cultural competence as "a set of congruent behaviors, attitudes, beliefs, and values that… enable [people] to work effectively in a cross-cultural situation" (p. 67). Benjamin notes that developing "culturally competent systems of care" requires "congruence" among policymakers, administrators, practitioners, and consumers; he lists five "essential elements" that characterize culturally competent organizations. With slight variations, this list is echoed by Soriano:

• valuing diversity "for its own sake" (Soriano, p. 68);
• having "the capacity for cultural self assessment" within the organization (Benjamin, p. 39);
• institutionalizing knowledge about various cultural groups;
• fosteringconsciousness among all staff as to "the dynamics inherent when cultures interact" (Benjamin, p. 39); and
• having the "willingness and ability to adapt to a diverse and continuously changing cultural mosaic in society" (Soriano, p. 68).

Benjamin and his colleagues conducted a nationwide study to assess organizational characteristics that help to operationalize these elements of cultural competence. They found:

Empowerment vs. assistance. The most critical element of cultural competence, according to some authors, is "empowerment," an orientation toward partnership with clients or consumers rather than assistance that is "bestowed" upon a passive recipient. As Kalyanpur and Rao (1991) explain,

Wolff (1995), citing the work of Chavis and Florin, summarizes major differences between traditional approaches, in which research, services, or information are provided by outside "experts" to an essentially passive recipient audience or clientele, and an empowerment approach, in which providers and clients work as partners. Wolff uses the term "community based" to describe traditional approaches and "community development" to describe empowerment strategies:

FIGURE 1 Differences between traditional and empowerment approaches
[ FIGURE 1 Text description ]

Traditional/Community based	Empowerment/Community development
Problems defined "by agencies, government and outside institutions"	Problems defined by the community
Primary vehicles for change are "information, education, and… capacity"	Primary vehicles for change are "building community control and increasing community services"
Professionals "are the key and central decision makers"	Professionals "are a resource to the community's problem solving"
Primary decisionmakers are "agency and government representatives and other appointed leaders"	Primary decisionmakers are "the indigenous, informal and elected leaders from the community" (p. 2-17)

Some authors also discuss the need for service agencies to shift their orientation from that of solely addressing the needs of individuals to including a focus on underlying social, institutionalized inequities. For example, Ehiobuche (1995), describes a "multicultural rehabilitation modality" as requiring "an equally balanced focus on the environment and on the individual because disability may stem as much from environmental barriers (cultural racism, poverty, and disadvantaged status) as from the individual's functional limitation" (p. 53). Similarly, Atkins (1988), in discussing mental health services for African American clients, quotes Raphael (1972), who notes that "the counselor is caught between efforts to ameliorate the immediate problems of a particular client and an awareness that only deeper social reform can eliminate the general conditions creating the problems" (Atkins, p. 45). And Brodwin, Orange, and Brodwin (1995), pointing out that people with disabilities are stigmatized in U.S. society, argue that "it is the responsibility of the rehabilitation counselor to tactfully and artfully stimulate various aspects of our society to address the anti-discrimination regulations of the ADA" as well as other provisions designed to prevent discrimination against particular groups (p. 87).

Addressing organizational policy as well as practice. Mason (1994) notes that "the policy element is an often overlooked — yet very important — area" of cultural competence within organizations. "Culturally competent staff attitudes and program practices need to be upheld by policy lest they ebb and flow on the trends of the times" (p. 6). Similarly, O'Brien and Rhoades (1996), in discussing outreach and rehabilitation services for non-English speakers, recommend that agencies that are "serious about improving services to non-English-speaking clients must begin with an organized outreach plan." They stress that "the plan should not be placed solely on the shoulders of one person — for example, the bilingual staff member — but should be a cohesive teamwork effort to which all staff members are committed" (p. 8). Duarte and Rice also address the importance of aligning policy and practice:

The VR agency should be an organization which values diversity and emphasizes that value in its mission, policy, principles, procedures, and practices. It is critical that organizational leaders demonstrate a commitment to this value in theory and practices which guide agency activity. The integration of this value into the organization is not a "quick fix" process achieved by brief training programs. (p. 43)

Diversifying staff. Perhaps more than any other single characteristic, the literature stresses the need for the staff of culturally competent organizations to reflect the racial, ethnic, and cultural diversity of intended consumers. For example, Atkinson and Lowe (1995), who reviewed research studies on mental health counseling, found "strong evidence" that pairing clients with "ethnically similar" counseling professionals is "associated with more positive counseling process and outcome" than if the client and professional are "ethnically dissimilar" (p. 405). Flaskerud (1986) identified "nine major components of a culture-compatible approach recommended by researchers to the mental health care of Asian, Hispanic, and Black American clients" and then conducted a study to assess the influence of each component on the dropout rate among minority clients within mental health service organizations. The study found that, "of the individual components, language match of therapist and client, ethnic/racial match of therapist and client, and agency location in the ethnic/racial community were the best predictors of dropout status" (p. 136).

McFarlane, Farley, Guerrero, and Galea'i (1996) also emphasize the importance of having staff members who can speak the native language of intended clients or consumers. They quote Vash (1994):

Language is a critical factor in understanding culture. When you try to understand and analyze beliefs, ethical values, and convictions, there are deep concepts that are very much tied to language. When you rely on translators, you lose a great deal. Individuals who can speak two languages are almost essential. (McFarlane, et al., p. 23)

One strategy that has been used successfully in several contexts is training and employing paraprofessionals drawn from the client community (McFarlane & Fehir, 1994). D'Alonzo, Giordano, and Oyenque (1996) report on a rehabilitation services project in New Mexico which used paraprofessionals drawn from local American Indian tribes to work with American Indian clients. Over a one-year period, the employment rate of American Indian rehabilitation clients more than doubled, from 14 percent to 31 percent, and the unsuccessful termination rate dropped by more than 20 percent. Locust and Lang (1996) report on a similar outreach effort with potential American Indian clients in Florida, a "Native American Technician" program in which "tribal people are employed via a subcontract with a tribe or tribal entity to provide outreach to American Indian people with disabilities" (p. 11). Via this program, the number of American Indian clients in Florida increased from only one to 260 over a four year period. Ultimately, however, as Schaller, Parker, and García (1998) point out, using paraprofessionals is an incomplete answer to the need for greater numbers of rehabilitation professionals from culturally diverse backgrounds.

Diversifying marketing and service strategies. Backer (1994) discusses "social marketing," a strategy drawn from corporate marketing concepts; he notes that "social marketing provides a management framework for systematic efforts to understand a target audience for change" (p. 17). He describes key elements as follows:

Audience segmentation, a key concept of social marketing, involves subdividing the targets (e.g., teachers in a large school district) into both "demographic" and "psychographic" groups, based on an understanding of what personal or group characteristics have a bearing on their behavior with respect to [adopting an innovation]… Learning what the individual differences are requires audience analysis, frequently using marketing techniques such as "focus groups." (p. 17)

Similarly, Yamashiro and Matsuoka (1997) describe the need for "culturally sensitive marketing strategies" for mental health service providers. Elements of such strategies, as they describe them, include:

• "removing impediments to services" by assuring procedures that address cultural needs, for example, confidentiality measures that families perceive will protect them from losing "face" (p. 183),
• adopting culturally inclusive perspectives on disability and dysfunction, and
• conducting research and needs assessments to "determine who the prospective clients are and where they reside," so that outreach efforts can be tailored to the concerns and needs of specific audiences (p. 184).

Schaller, Parker, and García (1998), among others, describe changes in practice that contribute to cultural competence. These include showing respect for cultural values and mores, addressing families as well as individual clients, locating services within the client community, assuring language accessibility via both print materials and interpreters, and using culturally sensitive assessment tools.

---

Top