Putting Concepts Into Action: A Brief Description of 2022 BACB Ethics Code Standard 1.07 & Actionable Recommendations for Evolving Practices of Behavior Analysts

For over a decade, behavior analysts have been calling for more culturally responsive practices. Within the newest edition of the Ethics Code for Behavior Analysts, one addition in particular was Standard 1.07 Cultural Responsiveness and Diversity (Behavior Analyst Certification Board, 2020b). The inclusion of this new standard shows positive movement but there is more to unpack. This article seeks to contextualize the relevance and necessity of Standard 1.07 both at a societal level and within the field of applied behavior analysis (ABA). A timeline of previous calls to actions and changes within ABA that align with the inclusion of this standard is discussed along with the obstacles that hindered progress. Lastly, directions are provided for how to make behavior analytic practices more culturally responsive through confronting our personal biases, using culturally responsive pedagogies, updating and adapting our practices regarding the selection of target skills and assessment administration, and collaborating with our clients and their teams. Through an understanding of its urgency and direct applications into our work, this article seeks to aid behavior analysts in shifting our practices to being more culturally responsive.

Cultural Responsiveness in Behavior Analysis: Provider and Recipient Perceptions in Ontario

Cultural responsiveness is critical to providing high-quality behavior analytic services, particularly when providers and recipients have different cultural backgrounds. The purpose of this study was to systematically replicate and extend (Beaulieu et al. (2019) Behavior Analysis in Practice, 12(3), 557-575) by investigating the diversity among applied behavior analysis (ABA) service providers and service recipients in Ontario, service providers' training and experiences in working with diverse families, and service providers' and recipients' perceptions of behavior analysts' cultural responsiveness in practice. Results from 428 participants suggest that service providers and recipients in Ontario differ in demographic characteristics; service providers report having little training in how to serve diverse families; and although service recipients rate providers' skills relatively positively, there is room for improvement. Results suggest a path forward for behavior analysis that includes education and training in cultural responsiveness as well as encouraging and fostering a bidirectional relationship between behavior analysts and the families they serve.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00825-w.

Development and validation of the Cultural Responsiveness Assessment Measure (CRAM): A self-reflection tool for mental health practitioners when working with First Nations people

BACKGROUND

The purpose of this study was to develop and to validate a measure of cultural responsiveness that would assist mental health practitioners across a range of disciplines, in Australia, to work with Indigenous clients.

AIM

The Cultural Responsiveness Assessment Measure (CRAM) was developed to provide a tool for practitioners and students to evaluate their own culturally responsive practice and professional development.

METHOD

Following expert review for face validity the psychometric properties of the measure were assessed quantitatively, from the responses of 400 mental health practitioners.

RESULTS

Confirmatory Factor Analysis yielded a nine factor, 36 item instrument that demonstrated strong convergent and discriminant validity as well as test-retest reliability.

CONCLUSIONS

It is anticipated that the CRAM will have utility as both a learning tool and an assessment measure, for mental health practitioners to ensure that services are culturally responsive for Aboriginal and Torres Strait Islander people.

Vaccine Mandates and Cultural Safety

The issues and problems of mandatory vaccination policy and roll out in First Nations communities are unique and do not concern the safety and effectiveness of vaccines. These issues are also independent of more specific arguments of mandatory vaccination of healthcare workers as a condition of employment. As important as these issues are, they do not consider the complex politics of ongoing settler colonialism and First Nations community relations. In this paper, we also set aside the very real problems of disinformation, hesitancy, scientific and health illiteracy, and other concerns that drive vaccine hesitancy and refusal. These affect all communities, including First Nations communities. We, instead describe the dominant arguments in favour of mandatory vaccination and critique them in terms of the disputed legitimacy of Settler-Colonial decision-making as it impacts First Nations communities. We contend cultural responsiveness and safety-not state compulsion-must remain the first principles of any engagement-including vaccination-with First Nations Peoples, families, and communities.

A Contextual Behavioral Framework for Enhancing Cultural Responsiveness in Behavioral Service Delivery for Latino Families

In recent years, the field of behavior analysis has shifted its attention to issues of diversity, social justice, and cultural responsiveness. With various cultural groups in the United States, behavior analytic practitioners increasingly find themselves serving clients of diverse cultural backgrounds. One of the populations that continue to face underrepresentation is Latinos. In the current article, a cultural understanding of the Latino culture is provided to support cultural responsiveness in behavioral service delivery. This article explores the Latino identity of individuals receiving behavioral services, systemic barriers faced by Latinos, the use of acceptance and commitment training for Latino families and clients, and Latino cultural values and their role in behavioral service delivery. Most important, a shift in perspective to account for the barriers perceived by practitioners within the context of Latino cultural values is offered through a contextual behavioral framework, the literature, and the authors' personal and professional experiences as Latino behavior analysts. Recommendations in the areas of assessment, treatment design, service delivery, and collaboration when working with Latinos are also discussed.

Breaking through social determinants of health: Results from a feasibility study of Imani Breakthrough, a community developed substance use intervention for Black and Latinx people

Racial and ethnic disparities in substance use intervention design, implementation, and dissemination have been recognized for years, yet few intervention programs have been designed and conducted by and for people who use substances. Imani Breakthrough is a two-phase 22-week intervention developed by the community, run by facilitators with lived experience and church members, that is implemented in Black and Latinx church settings. This community-based participatory research (CBPR) approach is a concept developed in response to a call for action from the State of Connecticut Department of Mental Health and Addiction Services (DMHAS) with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) to address rising rates of death due to opioid overdose, and other negative consequences of substance misuse. After nine months of didactic community meetings, the final design involved twelve weeks of education in a group setting related to the recovery process, including the impact of trauma and racism on substance use, and a focus on citizenship and community participation and the 8 dimensions of wellness, followed by ten weeks of mutual support, with intensive wraparound support and life coaching focused on the social determinants of health (SDOH). We found the Imani intervention was feasible and acceptable, with 42 % of participants retained at 12 weeks. In addition, in a subset of participants with complete data, we found a significant increase in both citizenship scores and dimensions of wellness from baseline to week 12, with the greatest improvements in the occupational, intellectual, financial, and personal responsibility dimensions. As drug overdose rates among Black and Latinx people who use substances continue to increase, it is imperative that we address the inequities in the SDOH that contribute to this disparity gap so that we can develop interventions tailored to the specific needs of Black and Latinx people who use drugs. The Imani Breakthrough intervention shows promise as a community-driven approach that can address these disparities and promote health equity.

Intersectional epistemic tensions associated with building knowledge with LGBTQ+ older adults of color

In gerontological research, lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ+) older adults of color are a hard-to-reach and underrepresented population. In this paper, we reflected upon the process of designing and implementing a Participatory Action Research (PAR) study by and for LGBTQ+ older adults of color committed to intersectionality. Data generted from fieldnotes and focus groups with five older Black lesbians were analyzed to uncover epistemic tensions associated with building intersectional knowledge for social justice. Study findings addressed the fraught nature of scientific knowledge production influenced by inequitable power structures and historically extractive research practices. Specifically, how cultural, political, and intergenerational tensions as well as the COVID-19 pandemic influenced the research process and were instrumental in learning about culturally responsive research. Putting PAR in dialogue with intersectionality opened an expansive paradigm that addressed the limitations of gerontological research. We end with implications for culturally responsive research with marginalized populations in aging studies, such as older LGBTQ+ adults of color.

Teaching at the Convergence of Pandemics and Historically Excluded Patient Populations: The Challenges, and Importance, of Culturally Responsive Communication

Issue: Historically excluded patient populations-particularly racial, ethnic, and sexually and gender minoritized people-experience gross inequities in health, worsened by the HIV and COVID-19 pandemics. Culturally responsive communication (CRC) is a vital tool health professionals can use to address these inequities. Yet, CRC can be challenging to teach, particularly during pandemics. The authors argue that pandemics magnify the powerful intersecting oppressions of heterosexism, racism, transphobia, nationalism, and sexism, essentially targeting Othered bodies for dying, a phenomenon known as necropolitics. Evidence: Five aspects of pandemics make teaching CRC more difficult and, because of the magnification of necropolitics, more critical. First, pandemics heighten teachers' and learners' personal frailties, engendering worries about their own and their families' health and increasing cognitive load. This can make it difficult for them to embrace the discomfort required of CRC, particularly when an increased patient load is squeezing instructional time. Second, guidelines for HIV and COVID-19 testing, prevention, and treatment are ever-changing, often faster than the pace of curriculum development and instructor professional development. Third, for instructors who may already be stretched thin, it is challenging to prepare learners for the variability in how their future practice contexts may address HIV and COVID-19 and, further, how to take a social justice approach to assess and resist the distinct equity issues of each of these contexts. Fourth, pandemics cause uncertain access to patient information about testing, disease status, and vaccination or pre-exposure prophylaxis. This worsens already disparate outcomes for minoritized patients and adds to the complexity of CRC curricula. Finally, virtual care is more prevalent in pandemics and teaching CRC in online contexts can be difficult. Implications: To address these challenges, we adopt the Dimensionality and R4P Health Equity Framework as a tool for evaluating academic programs for CRC so that it remains robust amidst pandemics. This tool addresses the varied social positions and identities (i.e., "dimensions") that present different opportunities for health. We offer specific evaluation questions programs can ask and approaches they can take to (a) redress past harms through removing existing racist, heteronormative and transphobic structures and repairing the damage they have done; (b) plan for a more equitable future by restructuring via policy and organizational change and providing programs that address intersectional disadvantage; and (c) critically evaluate the present by remediating current damage immediately until restructuring efforts are fully functional. As Martin Luther King, Jr. stated, "Of all the forms of inequality, injustice in healthcare is the most shocking and inhuman because it often results in physical death." It is our imperative to teach CRC with intentionality; otherwise we will support necropolitics as we continue to condone disproportionate morbidity and mortality for racialized and queer bodies.

Integrating Diversity, Equity, and Inclusion Readings within Coursework: Suggestions for Instructors Teaching Behavior Analysis

Behavior analysis graduate programs must train their students to be culturally responsive so that they are prepared to effectively serve a diverse clientele. One important strategy for helping students gain a culturally responsive repertoire is embedding diversity, equity, and inclusion materials into behavior analysis graduate course sequences. However, little guidance exists for selecting content related to diversity, equity, and inclusion within behavior analysis to include in behavior analytic coursework. This article provides suggested readings for diversity, equity, and inclusion within behavior analysis that can be embedded into typical course structures in behavior analysis graduate programs. Each course requirement in the Association for Behavior Analysis International's Verified Course Sequence is given specific recommendations.

Using Behavioral Skills Training to Teach Functional Assessment Interviewing, Cultural Responsiveness, and Empathic and Compassionate Care to Students of Applied Behavior Analysis

Within the field of applied behavior analysis, there is a recognized need for increased training for practitioners on cultural responsiveness, as well as to improve behavior analysts' demonstration of compassion and empathy towards the families with whom they work. The present study used behavioral skills training via telehealth to teach three skillsets-functional assessment interviewing, empathic and compassionate care, and cultural responsiveness. Participants were seven graduate students who had no previous coursework in behavioral assessment and whose caseload mainly included clients who did not share the participant's cultural, ethnic, or religious backgrounds. The results showed that behavioral skills training was effective in improving performance across all three skillsets. In addition, high levels of responding maintained following the completion of the training for the majority of the participants. Several levels of social validity measures support the utility and impact of this training. The findings have implications for training practitioners on these vital skills.

Formative process evaluation of a guideline-driven process for improving the cultural responsiveness of alcohol and drug treatment services

Background

To improve Australian Aboriginal and Torres Strait Islander people’s access to, and experience of, healthcare services, including Alcohol and other Drug (AoD) treatment services, principles and frameworks have been developed to optimise cultural responsiveness. Implementing those principles in practice, however, can be difficult to achieve. This study has five aims: i) to describe a five-step process developed to operationalise improvements in culturally responsive practice in AoD services; ii) to evaluate the fidelity of implementation for this five-step process; iii) to identify barriers and enablers to implementation; iv) to assess the feasibility and acceptability of this approach; and v) to describe iterative adaptation of implementation processes based on participant feedback.

Methods

Participating services were 15 non-Aboriginal AoD services in New South Wales, Australia. Implementation records were used to assess the implementation fidelity of the project. Structured interviews with chief executive officers or senior management were conducted, and interview data were thematically analysed to identify project acceptability, and the key enablers of, and barriers to, project implementation. Quantitative descriptive analyses were performed on the post-implementation workshop survey data, and responses to the free text questions were thematically analysed.

Results

A high level of implementation fidelity was achieved. Key enablers to improving culturally responsive practice were the timing of the introduction of the five-step process, the active interest of staff across a range of seniority and the availability of resources and staff time to identify and implement activities. Key barriers included addressing the unique needs of a range of treatment sub-groups, difficulty adapting activities to different service delivery models, limited time to implement change in this evaluation (three months) and the varied skill level across staff. The project was rated as being highly acceptable and relevant to service CEOs/managers and direct service staff, with planned changes perceived to be achievable and important. Based on CEO/management feedback after the project was implemented at the initial services, several improvements to processes were made.

Conclusion

The operationalisation of the five-step process developed to improve cultural responsiveness was feasible and acceptable and may be readily applicable to improving the cultural responsiveness of a wide variety of health and human services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06367-7.

Culturally Responsive Trauma-Informed Services: A Multilevel Perspective from Practitioners Serving Latinx Children and Families

Using a multilevel ecological framework, we take a qualitative approach to examining important cultural considerations that support successful implementation of trauma-informed services within the Latinx community. We conducted key informant interviews with community practitioners recruited primarily in the Phoenix, AZ metro area. Themes that emerged from interviews captured societal, community, and individual barriers to effective implementation of a culturally responsive trauma-informed approach. Specifically, multilevel barriers included socioeconomic circumstances, normalization of trauma exposure, and the transgenerational impact of trauma. Practitioners also reported approaching their work using relationship-focused and family-centered frameworks as facilitators to service engagement. We highlight the critical need for a culturally responsive trauma-informed approach that stresses the importance of context, recognizes transgenerational vulnerabilities, and promotes equity and the utilization of cultural humility in order to lessen the multilayered disparities in service accessibility experienced by minoritized communities.

Cross-university dialogues to support multicultural school consultation training

There is a growing need for school psychologists to build multicultural knowledge, skills, values, and dispositions to serve increasingly diverse student, teacher, and caregiver populations in schools. The purpose of this study was to investigate the process and outcomes of a cross-university dialogue (CUD) activity for 88 school psychologist trainees enrolled in consultation courses, across three school psychology training programs, over three years. The CUD involved partnering with a peer or peers from another training program, individually and then collaboratively completing a case study activity, and writing a guided reflection exercise. It was intended to support trainees' development of multicultural school consultation (MSC) competency and their application of a MSC framework. Constructivist grounded theory methodology and methods, including several features to enhance trustworthiness, guided the investigation. Four themes emerged from the data: (a) trainees established increased self-awareness and professional identity, (b) trainees made sense of multiple perspectives during CUD interactions, (c) trainees learned from their partners and considered future relevance of MSC, and (d) trainees' learning reflected cross-cutting ecological perspectives, influencing the CUD interaction and learning process at multiple levels. A grounded theory based on the data is described, and implications are drawn for the training and development of MSC competence.

Fostering cultural responsiveness in physiotherapy: curricula survey of Australian and Aotearoa New Zealand physiotherapy programs

BACKGROUND

Developing cultural responsiveness among physiotherapists is considered essential to promote quality and equity in healthcare provision for our culturally diverse populations. The aim of this study was to evaluate how entry-level physiotherapy programs in Australia and Aotearoa New Zealand (NZ) design curricula to foster the development of cultural responsiveness in physiotherapy students. Further, the challenges of integrating educational content and approaches, and the perceptions of the effectiveness of these curricula were also explored.

METHODS

A cross-sectional telephone survey with closed and open-ended questions, was conducted with 18 participants representing 24 entry-level physiotherapy programs (82% of all programs) in Australia and NZ between May and September 2017. Data were analysed descriptively in the form of frequencies, percentages or ratios as appropriate. Open-ended responses were thematically analysed.

RESULTS

Results suggest variability in the structure, and teaching and assessment methods used across all programs. The majority of programs appeared to rely on didactic teaching methods, along with knowledge based and implicit assessment methods. The main challenges reported were that cultural responsiveness was thought to be perceived by academic staff as unimportant and that the curriculum was perceived to be 'overcrowded'. Participants also felt there was room for improvement despite perceiving the curriculum to be effective at fostering cultural responsiveness.

CONCLUSION

Results provide insight into the educational content and approaches integrated in entry-level physiotherapy curricula in Australia and NZ, and suggest opportunities for further research and development to foster cultural responsiveness among physiotherapy students.

Examining teachers' classroom management profiles: Incorporating a focus on culturally responsive practice

Effective classroom management practices have been associated with students' behavioral and academic outcomes, but some questions have been raised regarding the degree to which current classroom management strategies are responsive to the backgrounds of students of color in US public schools. Additionally, frameworks for culturally responsive classroom management have emerged, but little attention has been given to systematically measuring and examining these practices, particularly in conjunction with more traditional domains of classroom management. The current study used a person-centered approach with data from 103 middle-school teachers to explore how classroom management practices, including cultural responsiveness, co-occur in teacher practice, and how profiles of practices are associated with teacher and classroom characteristics and student behaviors. The latent profile analysis revealed three ordered profiles of classroom management practices (i.e., high, medium, low), suggesting that cultural responsiveness may operate as an extension of other classroom management strategies. Results also demonstrated that White students were more likely to be in classrooms with high levels of classroom management, and that students in classrooms with low levels of classroom management were more likely to demonstrate elevated levels of negative behaviors. The results suggest that a subset of teachers is in need of comprehensive professional development on a range of classroom management techniques, while all teachers could improve their practices reflecting meaningful participation and cultural responsiveness.

What constitutes globalised evidence? Cultural tensions and critical reflections of the evidence-based movement in New Zealand

The evidence-based movement (EBM) is grounded in a well-intentioned desire to ensure resources are invested in high quality initiatives that generate the intended impact. Nevertheless, recent critiques contest the appropriateness of translating an approach rooted in a medical model to socially complex initiatives. Globalised notions of evidence can also be damaging for programs operating in small, culturally diverse countries with limited resources. Given these polemic views, our aim was to examine local perceptions of the EBM in New Zealand, a small, vibrant, bicultural society with a mix of homegrown and imported programs. Using a snowball sampling approach, 79 professionals working in the education and social sectors completed an anonymous online survey that contained a series of closed and open-ended questions. The results show that although participants positively endorsed a variety of quality evidence markers, traditionally positivist methodological leanings received lower and more varied endorsements compared to more inclusive and pluralistic approaches. Many also expressed concern that the EBM emphasises a narrow and colonised view of evidence that does not align with Māori and Pacific worldviews, and undermines innovation. We discuss the implications as an avenue for advancing intervention and social programming research in an increasingly multicultural and globalised world.

Predictors of self-perceived cultural responsiveness in entry-level physiotherapy students in Australia and Aotearoa New Zealand

BACKGROUND

Ensuring physiotherapy students are well prepared to work safely and effectively in culturally diverse societies upon graduation is vital. Therefore, determining whether physiotherapy programs are effectively developing the cultural responsiveness of students is essential. This study aimed to evaluate the level of self-perceived cultural responsiveness of entry level physiotherapy students during their training, and explore the factors that might be associated with these levels.

METHODS

A cross sectional study of physiotherapy students from nine universities across Australia and Aotearoa New Zealand was conducted using an online self-administered questionnaire containing three parts: The Cultural Competence Assessment tool, Altemeyer's Dogmatism scale, and the Marlowe-Crowne social desirability scale- short form. Demographic data relating to university, program, and level of study were also collected. Data was analysed using one-way ANOVA, t-tests and multiple regression analysis.

RESULTS

A total of 817 (19% response rate) students participated in this study. Overall, students had a moderate level of self-perceived cultural responsiveness (Mean (SD) = 5.15 (0.67)). Fewer number of weeks of clinical placement attended, lower levels of dogmatism, and greater social desirability were related to greater self-perceived cultural responsiveness. Additionally, fourth year undergraduate students perceived themselves to be less culturally responsive than first and second year students (p < 0.05).

CONCLUSIONS

These results provide educators with knowledge about the level of self-perceived cultural responsiveness in physiotherapy students, and the factors that may need to be assessed and addressed to support the development of culturally responsive practice.

Implementing non-invasive prenatal testing into publicly funded antenatal screening services for Down syndrome and other conditions in Aotearoa New Zealand

Background

Non-invasive prenatal testing (NIPT) is a relatively new screen for congenital conditions – specifically, common fetal aneuploidies including Down Syndrome. The test is based on isolating freely circulating fragments of fetal-placental DNA that is present in the mother’s blood. NIPT has a superior clinical performance compared to current screening, and has been available privately in Aotearoa New Zealand for the last 4 years.

Main issue

The proposed implementation of NIPT as a publicly funded service may widen the inequity in access to optional antenatal screening that already exists in this country.

Conclusion

This paper discusses precautions that can be taken at the health system, organisation, and personnel levels to ensure that access to NIPT is equitable, that services are culturally responsive, and women’s informed choice is promoted and protected. The adoption of NIPT into publicly funded services is an example of how genetic screening is becoming mainstreamed into health services; as such our approach may also have relevance around the introduction of other genetic and genomic screening initiatives.