TECHNICAL BRIEF NO. 31 2011 A Publication of the National Center for the Dissemination of Disability Research (NCDDR) Do Cultural Competency Interventions Work? A Systematic Review on Improving Rehabilitation Outcomes for Ethnically and Linguistically Diverse Individuals with Disabilities Rooshey Hasnain, EdD, Diane M. Kondratowicz, PhD, Eugene Borokhovski, PhD, Chad Nye, PhD, Fabricio Balcazar, PhD, Nelson Portillo, PhD, Katherine Hanz, MA, MLIS, Tim Johnson, PhD, and Robert Gould, MS This issue of FOCUS describes a systematic review and answers (see http://www.ncddr.org/pd/ that was conducted to address a critically important courses/2007course.html). research question about cultural competency by The goal of the online training was to engage taking stock of the current literature and evidence. researchers from NIDRR-funded projects around the The review examined whether cultural competency United States in conducting a high-quality systematic interventions improve rehabilitation outcomes for review of disability-related empirical research on a ethnically and linguistically diverse individuals with topic of interest to them. As one of its organizational disabilities, and if so, for tools, the program required whom and under what participants to form a review conditions. “No one seems to agree with anyone’s team and commit to actively approach. But more distressing: no one contributing to the project Integrating Evidence- seems to know what works.” activities, including assignments Based Research on an (Light & Pillemer, 1984, p. viii) that would require them to Unresolved Issue apply ideas from the webinars. The project described The organizers knew the in this issue began when the National Center for researchers would need this kind of collegial support the Dissemination of Disability Research (NCDDR), to complete what was known to be a lengthy and funded by the National Institute on Disability and challenging task. Rehabilitation Research (NIDRR), offered its first online training workshop on developing high- A total of 31 individuals, organized into nine teams, quality systematic reviews, including a meta- signed up for the training. The lead instructors analysis component. The training was offered in were Chad Nye, PhD, of the University of Central a webinar format for 2 hours once a month from Florida, and Herb Turner, PhD, of the University of September 2007 through April 2008, with additional Pennsylvania. In addition, guest presenters focused on 1-hour sessions between webinars that provided specific methodological topics needed to complete consultations, updates, and time for questions a review. All the instructors and presenters were The National Center for the Dissemination of Disability Research (NCDDR) is a project of SEDL. It is funded by the National Institute on Disability and Rehabilitation Research (NIDRR). FOCUS: Technical Brief no. 31 | 2011 members of the Campbell Collaboration’s Education followed to complete the systematic review and Coordinating Group (ECG). meta-analysis report. We also summarize our findings to date and offer several thoughts on The program began with an orientation webinar the policy, practice, and research implications of outlining the review production process. Then, these findings. a series of eight instructional webinars covered the basic tools and methods needed to conduct Overview and Background each phase of a systematic review: (1) formulating There is growing recognition that ethnic review questions, (2) defining inclusion and minorities, immigrants, and refugees with exclusion criteria, (3) locating studies, (4) selecting disabilities in the United States need rehabilitation studies, (5) assessing study quality, (6) extracting and disability services (National Council on data, (7) analyzing and presenting results, and (8) Disability, 2003). Moreover, those individuals with interpreting results. disabilities who most need rehabilitation and The authors of this issue of FOCUS constituted health care services may be least able to access one of the review teams that participated in and use culturally-adapted services because of the workshop. various barriers— Team members cultural, institutional, The goal for our systematic review was to understand were recruited structural, better the effects of rehabilitation interventions that are from the United environmental, States, Canada, and sensitive to and inclusive of the cultural and linguistic economic, political, Norway. Our team backgrounds of individuals with disabilities who are and societal— was supported in which may further receiving rehabilitation or community-based services. part by the Center undermine their for Capacity Building health, well-being, on Minorities with Disabilities Research at the or participation in life activities (Balcazar, University of Illinois at Chicago (see http:// Suarez-Balcazar, Taylor-Ritzler, & Keys, 2009). disabilityempowerment.org). The goal for Until relatively recently, little attention has been our systematic review was to understand better paid to the roles of ethnicity, culture, language, the effects of rehabilitation interventions that and disability in influencing the efficacy and are sensitive to and inclusive of the cultural effectiveness of rehabilitation service delivery, and linguistic backgrounds of individuals with despite the growing amount of culturally disabilities who are receiving rehabilitation or relevant research in both the United States community-based services (e.g., at hospitals, at and abroad (Palsbo & Kailes, 2006; Vyas et al., mental health and rehabilitation centers, or in 2003). In fact, various disability groups and community-based settings; Shin & Lukens, 2002). organizations, including projects sponsored under For this purpose, we selected intervention studies the NIDRR Section 21 initiatives, the National that focused on historically underserved and Council on Disability, the Rehabilitation Services hard-to-reach populations of various cultures and Administration (RSA), and the National Association languages, including individuals with minority, of Multicultural Concerns (NAMC), are working, immigrant, and refugee backgrounds (e.g., Hinton both independently and collaboratively, to find et al., 2004). As a result of our review, we found culturally appropriate ways to work effectively evidence from several studies that support the with U.S.-based minority and new immigrant construct that culture plays an important role population groups (Lewis, Shamburger, Head, in client-level rehabilitation outcomes. In this Armstrong, & West, 2007). technical brief, we describe the process we 2 SEDL | National Center for the Dissemination of Disability Research FOCUS: Technical Brief no. 31 | 2011 Defining Cultural Competency. Given the size of producing better outcomes” (“Defining Cultural the underserved population and its multiple needs, Competence,” para. 3). disability and rehabilitation professionals can Presently, a limited amount of empirical evidence improve client-level experiences and outcomes by supports the assertion that cultural competence integrating cultural competence into their practice. in service delivery reduces service disparities and Many researchers have urged that traditional improves rehabilitation outcomes, including the rehabilitation treatments be modified to better well-being of the diverse client populations (Geron, match clients’ cultural contexts using a concept 2002; Goode, Dunne, & Bronheim, 2006). However, of cultural competency or competence, also known we could not find any systematic review of the as cultural responsiveness or multiculturalism. research evidence that provided a measure of The concept emerged through rather simplistic how or the extent to which cultural competency attempts to increase provider-level cultural interventions improve the rehabilitation outcomes awareness and knowledge of other groups’ unique of individuals with disabilities from diverse cultural values, beliefs, and differences in regard to disability and ethnic backgrounds. and rehabilitation (Sue, Zane, Hall, & Berger, 2009). More recently, the concept has evolved to Thus, we used a systematic review methodology resemble an anthropological, community-based to address our primary research question for this approach (Kleinman & Benson, 2006), in which unresolved issue: Do culturally adapted competency providers and practitioners are encouraged to interventions improve rehabilitation outcomes for integrate their clients’ cultural backgrounds, family ethnically and linguistically diverse individuals with members, and experiences into their rehabilitation disabilities? If so, for whom and under what conditions care and follow-up plans. Davis, 1997 (as cited in do they work? National Association of School Psychologists, n.d.), The Review Process offers a useful operational definition of cultural competence as “the integration and transformation Before we initiated our search for empirically based of knowledge about individuals and groups of intervention studies, we established eight criteria to people into specific standards, policies, practices, determine whether to include studies in the review. and attitudes used in appropriate cultural settings To be included, a study would have to meet all to increase the quality of services; thereby eight criteria, as listed in Table 1. Table 1: Criteria for Inclusion 1. Be published since 1980 in any language 2. Include participants aged 18 and older identified as having a disability 3. Use a culturally adapted competency intervention 4. Conduct the intervention in a rehabilitation, health-care, or community-based setting 5. Include consumer outcome measures, as exemplified in Table 2 6. Use a randomized controlled trial (RCT) research design 7. Report data that could be used to calculate effect size 8. Explain cultural competency strategies reported Note: In this brief, individuals with a disability/disabilities refers to a collection of descriptors including consumer, client, customer, and patient. SEDL | National Center for the Dissemination of Disability Research 3 FOCUS: Technical Brief no. 31 | 2011 Additionally, we decided to exclude studies lists of all included studies and other relevant that focused on individuals who smoke or use documents/studies to determine if the cited recreational drugs and alcohol. We reasoned works might be relevant to our topic. Finally, we that given the differences in their behavior and conducted a general Web-based search in both motivation, they may take a different approach the Google and Yahoo search engines using a to disability management and healthy living variety of terms that reflect the three key concepts compared with others in this review. We also listed above. excluded studies whose primary units of analysis Study Selection and Data Extraction were family-, provider-, organizational-, or Procedures. Once we judged that a study had system-level outcomes. Finally, we excluded satisfied our initial inclusion criteria, we obtained studies that conducted interventions for non- its full text. Two independent coders (the first two English-speaking participants in their country of authors of the review) then reviewed the study origin; for instance, a study of Korean-speaking to determine its eligibility. In some cases, we had participants in Korea. to obtain additional information about a study from its author(s) before we could determine Locating Studies: The Information Retrieval and inclusion in the review. If we disagreed or were Search Strategy. We identified databases relevant unsure of our decision, we sought input from to the rehabilitation, disability, health care, mental our third reviewer (N. Portillo) regarding study health, and social science fields and created search inclusion. Once we had the full text of a study, strings using key terms and subject headings we extracted specific information about its identified in the thesaurus of each database. The participants, interventions, outcomes, and design terminology varied in each database, but the characteristics using a coding scheme specifically terms chosen reflected the following concepts: developed for that study. We then compared (1) cultural competency, (2) educational notes and resolved any differences in our coding intervention, and (3) disability. In addition to U.S.- responses through discussion of each study, as based databases, we also searched Australian, described above. Figure 1 shows the process of British, and Canadian databases to ensure that our database search. the scope of the research would not be limited to the United States. Our searches included Study Findings interdisciplinary databases, such as Academic We identified a total of 3,022 titles and abstracts Search Premier and ProQuest Dissertations and of potentially relevant studies. After judging these Theses, as well as those that focus specifically publications, we retrieved 179 full texts and found on health care, disability, mental health, 22 studies that met the inclusion criteria and were rehabilitation, and the social sciences, such as selected for systematic review and meta-analysis. MEDLINE/PubMed, CINAHL®, PsycINFO®, Social Work Abstracts, Health Source®, and REHABDATA. Study Characteristics. All of the studies were Additionally, we conducted searches in ERIC published in scholarly peer-reviewed journals and print-based subject indices. To ensure between 1981 and 2009; the majority (77%) comprehensiveness, we examined the reference were published since 2000. Most studies were Davis, 1997, offers a useful operational definition of cultural competence as “the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services; thereby producing better outcomes." 4 SEDL | National Center for the Dissemination of Disability Research FOCUS: Technical Brief no. 31 | 2011 Figure 1: Flow of Included Studies Number of studies assessed for eligibility (Total N=3022) Studies excluded after judging the study titles and abstracts (n=2,800) • Children and/or youth under 18 • Participants are identified as substance abusers (those who smoke and/or use recreational drugs) • No culturally adapted intervention and/or obvious control group • No disability • No quantitative outcomes to enable us to conduct a meta-analysis • Cross-sectional, one subject-design, correlation, or secondary studies Potentially relevant studies • Conducts a pilot, baseline study, or an identified and screened evaluation for full-text retrieval Inclusion Criteria Exclusion Criteria • Published in any language between • Has no culturally adapted intervention and/ 1980 and the present or control group • Involve participants 18 and older who have a • Uses one-group pre- and post-design or disability quasi-experimental design • Provide adequate explanation of the • Data are missing or inadequate to enable culturally-adapted (CC) competency meta-analysis intervention • Outcomes are at the level of provider or • A rehabilitation outcome of any kind (except system rather than client physiological/biological outcomes) • Uses only biological/physiological outcomes • Adequate data that allow us to conduct a • Health promotion/preventative studies meta-analysis • Unit of analysis is at the family, provider, • RTCs (where the control received treatment organizational, or systems level as usual and the treatment group received a • Inadequate data are provided to calculate an culturally adapted intervention) effect size Dropped Studies: n=157 Total Studies Included for Meta-Analysis: n=22 conducted in the United States (86%), followed mental health, nursing, ethnic studies, and by two in the United Kingdom (9%) and one in public health. Canada (5%). Given the multidisciplinary nature of the topic, the studies selected for the meta- Participant Characteristics. The majority of analysis represented multiple disciplines with participants were females (73%) with ages the majority in medicine/health care, followed by ranging between 31 and 63 years. All 22 studies SEDL | National Center for the Dissemination of Disability Research 5 FOCUS: Technical Brief no. 31 | 2011 reported the race/ethnicity of participants, with a by African-American participants (13.7%); Khmer breakdown of 41% Latino, 27% Asian, 23% Black/ (9.1%); Punjabi, Hindi, and Urdu (9.1%); and Korean, African-American, and 9% Other (i.e., Portuguese- Vietnamese, and Portuguese (4.5% each). speaking). Taken together, 64% of all participants Another culturally relevant strategy included the had chronic health conditions (e.g., diabetes, participation of family members or community HIV/AIDS, lupus) and disabilities as defined by members––almost 41% of the studies included the World Health Organization’s International them. It is worth noting that a large proportion of Classification of Functioning, Disability and Health these studies (68%) were conducted by a team of (ICF) (see http://www.who.int/classifications/ professionals, family members, and community icf/en/). Thirty-six percent of the participants were members working together to support the identified as having mental health conditions individual, rather than a team of professionals (e.g., schizophrenia, depression, post traumatic working alone (32%). Consistent with cultural stress disorder). Not all studies reported the socio- competency strategies, the majority of studies economic status (SES) (55%) had what we of the individual All of the studies included in the review were RCTs, with considered a high to participants, but very high percentage a treatment and control group. All treatments were almost 60% of those of client-provider that were described culturally relevant interventions, and all the control ethnic match, while were of low to middle group participants were provided care that 36% had a low to SES. Regarding was considered standard for individuals with moderate match, and education level, disabilities of diverse cultures. 9% did not report this 77% of participants information. had a high school education or less, and 5% had attended college. About half of the interventions took place However, 18% of the studies did not report the at hospitals or clinics, followed by 32% in educational levels of the clients who participated. community-based settings and 18% at mental Similarly, of the studies that reported employment health facilities. Exactly half of the interventions information, 46% of the study participants lasted less than 3 months, 36% lasted more than 3 were unemployed or underemployed, 5% were months, and the remaining 14% of studies failed employed, and the remaining studies did not to report treatment duration. report employment information. Another critical factor we assessed was the use of Intervention Characteristics. As described culturally adapted competency interventions. We earlier, all of the studies included in the review identified 14 cultural adaptations that were utilized were RCTs, with a treatment and control group. All in the 22 studies and examined in our meta-analysis. treatments were culturally relevant interventions, Next, we classified the adaptations into three and all the control group participants (even those general categories: (a) education and behavioral controls who were wait-listed for a culturally changes, such as health promotion and prevention, adapted intervention) were provided care that was health literacy, partnership elements, and condition considered standard for individuals with disabilities management; (b) language and communication of diverse cultures. To ensure that the interventions accommodations, such as the use of interpreters, would be culturally relevant, all interventions language matching, and translated materials; and used the native language of participants. The (c) cultural adaptations, such as client-provider majority of the 22 studies provided interventions match, adapted interventions, media tools, and in Spanish (54.6%), followed by English spoken immersion in a multicultural environment. 6 SEDL | National Center for the Dissemination of Disability Research Focus: Technical Brief no. 31 | 2011 Based on our coding scheme, 73% of the studies into five major categories reflecting the effects of used seven or more adaptations, and 27% used the treatments on participants. These categories fewer than seven. All of these variables, both and the measures utilized for each one across individually and collectively, are important in the 22 studies consisted of various standardized understanding the overall outcomes of our analysis. instruments and rating scales, which are presented in the full report. Looking at client-level rehabilitation outcomes, the Whenever more than one measure addressed the majority of studies (55%) used a combination of same outcome type within a given category, we measures to assess the status of individuals with averaged individual effects so that one comparison disabilities after the intervention rather than rely produced a single effect size for each category on a single indicator (45%). Among the 22 studies, of outcomes. As a 59% used behavioral result, the number outcomes, followed by Another critical factor we assessed was the use of of effect sizes in measures of disability culturally adapted competency interventions. We each category was knowledge (50%), identified 14 cultural adaptations that were utilized in reduced substantially. symptoms related to disability (41%), the 22 studies and examined in our meta-analysis. Ultimately, these efforts produced the psychosocial outcomes following results: (27%), and attitudes (a) 11 effect sizes in Category 1, disability symptom- and health beliefs pertaining to disability (22%). All related measures; (b) 11 in Category 2, measures but one study reported attrition rates that ranged of client-level knowledge of their disability; (c) from 0% to 49% for the treatment group, with a 15 in Category 3, behavioral measures, including median attrition rate of 0%, and 0% to 51% for disability self-management and treatment the controls, with a median rate of 4%. Overall, we compliance; (d) 6 in Category 4, psychosocial found no consistent pattern of attrition differences measures of well-being, self-efficacy, and quality of between treatments and controls. life; and (e) 7 in Category 5, measures of attitudinal As shown in Table 2, we classified the original and health beliefs pertaining to disability, impact outcome measures reported in individual studies on job, and/or supports. Table 2: outcome categories and Measures Total Number of Effect sizes outcome categories and Measures originally Derived 1. Measures of disability-related symptoms 34 2. Measures of client-level knowledge of their disability 19 3. Behavioral measures, including disability self-management and 37 treatment compliance 4. Psychosocial measures of well-being, self-efficacy, and quality of life 9 5. Measures of attitudinal and health beliefs pertaining to disability, 17 impact on job, and/or supports SEDL | National Center for the Dissemination of Disability Research 7 FOCUS: Technical Brief no. 31 | 2011 Table 3: Summary of Average Effect Sizes by Outcome Category Outcome Category g 95% CI 1. Disability-related symptoms 0.90 0.58–1.22* 2. Client-level knowledge of their disability 0.41 0.20–0.61* 3. Behavioral self-management and treatment compliance pertaining to disability 0.22 -0.07–0.50 4. Psychosocial outcomes of well-being, self-efficacy, and quality of life 0.78 0.22–1.34* 5. Attitudinal and health beliefs pertaining to disability, impact on job, 0.13 -0.80–0.33 and/or supports * p < .05 We present an analysis based on a random The results from our meta-analysis indicate that effects model that is summarized in Table 3. In culturally adapted interventions do improve three of the five categories, the average effect rehabilitation outcomes for minority and immigrant sizes (expressed in Hedges’ g) were positive and individuals with a wide variety of disabilities, statistically significant (p < .05). Category 3— especially in three major areas: disability-related which contained a higher number of studies— symptoms; client knowledge of their disability; and produced a nonsignificant average effect size psychosocial outcomes of well-being, self-efficacy, (g) of 0.22, while Category 5—which contained and quality of life. These findings have several only three studies—produced a nonsignificant implications for further research and practice. average effect size (g) of 0.13, when examined First, culturally adapted interventions can play in both fixed and random models. (See full a useful role in reducing service disparities and review for details.) Given the small number of improving rehabilitation outcomes for culturally studies examined within this category, we cannot diverse individuals with disabilities. Future make firm conclusions regarding these types of research could explore the critical components or outcome measures. Each outcome had a different mechanisms that make cultural adaptations work. magnitude of impact. As mentioned, we identified three broad categories Implications for Research and Practice of adaptations—educational and behavioral skills development (e.g., training, cultural immersion); Among the studies reviewed, we found that language/communication supports (e.g., linguistic scholars and service practitioners have proposed, match, translators); and cultural adaptations (e.g., developed, and implemented a range of cultural adapted interventions, ethnic match). At this competency initiatives. These initiatives include point, we do not know if the categories are equally cultural awareness and sensitivity training necessary to attain the desired outcomes. for providers; racial and ethnic concordance between provider and client/patient; the use of Second, we identified several variables that language interpreters in the service provision; the significantly moderated intervention effects; thus, incorporation of the beliefs, values, practices, and more research is needed to understand better traditions of clients/patients; collaboration with their effects when developing and implementing community and faith-based organizations; and future interventions. These moderator variables including family members in the decision-making included the involvement of family members, the or rehabilitation processes. magnitude of the intervention (number and types 8 SEDL | National Center for the Dissemination of Disability Research FOCUS: Technical Brief no. 31 | 2011 of adaptations), the duration of the intervention, practitioners from the field and the community to the marital status of participants, and the ethnic assist with treatment interventions. Interestingly, characteristics of the participants, especially for none of the intervention studies required outside Latinos and Asians. The full report of our review interpreters or translators because the teams of contains the details of these moderator analyses. bicultural and bilingual researchers, practitioners, and community members in these programs came Third, as cultural competence appears to have from ethnically or culturally similar backgrounds. an impact on the delivery of services to minority and immigrant individuals with disabilities, Additionally, our review does not allow us to make researchers need to account for this phenomenon any inferences about cost-effectiveness issues when evaluating programs or services. Examples related to culturally competent interventions. of intervention characteristics that warrant Certainly this is a substantial element in examination are the cultural adaptations of understanding the efficacy and effectiveness of the intervention culturally adapted or program, the The results from our meta-analysis indicate that interventions, and future availability of research should address culturally adapted interventions do improve translators or this critical aspect. rehabilitation outcomes for minority and immigrant translated materials individuals with a wide variety of disabilities, We conclude that and information, and culturally adapted the level of cultural especially in three major areas: disability-related competency competence training symptoms; client knowledge of their disability; and interventions can provided to the psychosocial outcomes of well-being, self-efficacy, improve rehabilitation individuals delivering and quality of life. service outcomes for services. ethnically and culturally Finally, it also seems diverse persons with appropriate to consider the level of cultural disabilities who reside in Western cultural contexts. competence of the researchers themselves as Our meta-analysis of the available literature on well as the diversity of the research team, a factor experimentally controlled interventions revealed seemingly demonstrated in all 22 of the studies positive effects for three of the five categories examined in our meta-analysis. Minority individuals of rehabilitation outcomes for ethnically and often experience mistrust, particularly regarding linguistically diverse individuals with disabilities. participation in services and research (Alston, 2003), We also identified a set of program and individual and their willingness to participate and continue characteristics that moderate these effects, which in research projects is related at least in part to are key to increasing our understanding of how the skills and characteristics of the researchers, these outcomes are obtained. In summary, our providers, and interviewers (Shavers, Lynch, & findings inform future research priorities as we Burmeister, 2002). seek to learn more about the multifaceted and In many of the studies reviewed here, great care multilayered processes and mechanisms through was taken to make the intervention culturally which cultural competency improves outcomes for relevant with regard to ethnicity, culture, and diverse individuals with disabilities in the context of language, particularly in those studies that focused rehabilitation, mental health, and disability services. on Asian and Latino American communities. In fact, the researchers often recruited staff and SEDL | National Center for the Dissemination of Disability Research 9 FOCUS: Technical Brief no. 31 | 2011 References references marked with an asterisk indicate studies included in the meta-analysis. Please note the complete listing of studies included in our meta-analysis will be available in our full review. alston, r. J. (2003). racial identity and cultural national association of School Psychologists. mistrust among african-american recipients of (n.d.). Defining cultural competence. retrieved rehabilitation services: an exploratory study. from http://www.nasponline.org/resources/ International Journal of Rehabilitation Research, culturalcompetence/definingcultcomp.aspx 26(4), 289–295. doi:10.1097/00004356-200312000- national council on Disability. (2003, november 00006 20). Outreach and people with disabilities from Balcazar, f. f., Suarez-Balcazar, Y., Taylor-ritzler, T., diverse cultures: A review of the literature. retrieved & Keys, c. B. (2009). Race, culture, and disability: from http://purl.access.gpo.gov/GPo/lPS97235 Rehabilitation science and practice. Boston, Ma: Palsbo, S. e., & Kailes, J. i. (2006). Disability- Jones and Bartlett Publishers. competent health systems. Disability Studies Geron, S. M. (2002). cultural competency: how is it Quarterly, 26(2), 1–10. retrieved from http://www. measured? Does it make a difference? Generations, dsq-sds.org/article/view/674/851 26(3), 39–45. retrieved from http://eric.ed.gov/ Shavers, V. l., lynch, c. f., & Burmeister, l. f. (2002). ericWebPortal/detail?accno=eJ658683 racial differences in factors that influence the Goode, T. D., Dunne, M. c., & Bronheim, S. M. willingness to participate in medical research (2006). The evidence base for cultural and linguistic studies. Annals of Epidemiology, 12(4), 248–256. competency in health care (fund report). available doi:10.1016/S1047-2797(01)00265-4 from the commonwealth fund Web site: http:// *Shin, S. K., & lukens, e. P. (2002). effects of www.commonwealthfund.org psychoeducation for Korean americans with *hinton, D. e., Pham, T., Tran, M., Safren, S. a., chronic mental illness. Psychiatric Services, 53(9), otto, M. W., & Pollack, M. h. (2004). cBT for 1125–1131. doi:10.1176/appi.ps.53.9.1125 Vietnamese refugees with treatment-resistant Sue, S., Zane, n., hall, G. c. n., & Berger, l. K. PTSD and panic attacks: a pilot study. Journal (2009). The case for cultural competency in of Traumatic Stress, 17(5), 429–433. doi:10.1023/ psychotherapeutic interventions. The Annual B:JoTS.0000048956.03529.fa Review of Psychology, 60, 525–548. retrieved from Kleinman, a., & Benson, P. (2006). anthropology http://www.annualreviews.org/doi/abs/10.1146/ in the clinic: The problem of cultural competency annurev.psych.60.110707.163651 and how to fix it. PLoS Medicine, 3(10), e294. *Vyas, a., haidery, a. Z., Wiles, P. G., Gill, S., roberts, doi:10.1371/journal.pmed.0030294 c., & cruickshank, J. K. (2003). a pilot randomized lewis, a. n., Shamburger, a., head, c., armstrong, trial in primary care to investigate and improve a. J., & West, S. l. (2007). Section 21 of the 1992 knowledge, awareness and self-management rehabilitation act amendments and diversity among South asians with diabetes in Manchester. articles. Journal of Vocational Rehabilitation, 26(2), Diabetic Medicine, 20(12), 1022–1026. doi:10.1046/ 89–96. available from http://iospress.metapress. j.1464-5491.2003.01082.x com/content/v731032j77t87038/ light, r. J., & Pillemer, D. B. (1984). Summing up: The science of reviewing research. cambridge, Ma: harvard University Press. 10 SEDL | National Center for the Dissemination of Disability Research