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Participants: The population from which the sample will be drawn consists of approximately 100 occupational therapists in Shreveport- Bossier City, Louisiana. Since 90% of occupational therapists are female (AOTA, 2009), the sample will be limited to females in order to improve sample representation of the target population. The sample will be limited to females who self-identify as white since the intervention is aimed at improving racial attitudes towards African Americans. Two groups of nine occupational therapists will be recruited through advertisements posted at local clinics and through personal contacts. Sample size has been determined by the space available in the LSUHSC SAHP computer lab.

Sample selection criteria

  1. Licensed to practice occupational therapy in the state of Louisiana

  2. At least average computer experience and keyboard skills

  3. Female, self-identified as White race

  4. Self-report of desire to gain improved cultural competence

Table 8 Description of the Instructional Module

Objective

Instructional Strategies

Assessment Measure

1. a. Therapists will demonstrate an increased awareness of personal cultural heritage

1.b. Therapists will compare their own cultural background with that of minorities in the United States.

Multi-media presentation on educational, environmental, and socioeconomic differences between white and minority neighborhoods

Therapists will be given a note card with open ended questions aimed at stimulating reflection on cultural advantages and heritages. Therapists will write responses and share verbally during a group discussion.

2. Therapists will articulate an understanding of healthcare disparities in Louisiana and possible causes.

DVD: Bridging the Great Divide (Kaiser Permamente, 2008)

PBS video: Unnatural Causes: Kim Anderson's Story (California Newsreel, 2008)

Therapists will participate in small group discussion

3. Therapists will demonstrate ability to verbally advocate for, and interact with, African American clients.

Power Point presentation on racism (see appendix)

Presentation of problem-based learning scenario

Role play with group members in response to scenario.


Measurement instruments

The Racial Argument Scale (RAS) contains 13 paragraphs describing evidence to support a position on a current social issue related to African Americans (Saucier & Miller, 2003). Six of the paragraphs argue for pro-Black conclusions and seven of the paragraphs support negative conclusions. A concise statement of the conclusion follows each paragraph. Subjects are asked to rate on a Likert scale how well they think the paragraph of evidence supports the corresponding conclusion. Subjects are not asked how much they may agree with the arguments, but how well the argument supports the conclusion. Ratings for each item range from 1 (not at all) to 5 (very much). The final score on the RAS is considered interval data since it is a composite of all the item ratings. RAS scores range from 13 to 65, with higher scores indicating more racist views. Factor analysis yielded a Cronbach’s alpha of 0.74. Comparison of initial test scores and test scores two weeks later yielded a correlation of 0.81, (p<.001) indicating good test-retest reliability. The RAS did not correlate significantly (r=-.03, p>.05) with a test of social desirability, suggesting that the RAS may uncover hidden bias. Convergent validity for the RAS is evidenced by its correlation with three other tests of racism, coefficients ranging between 0.42 and 0.57.

The Racial Attitude Implicit Association Test (RAIAT) is a timed test that takes 10 to 15 minutes to complete (Implicit Association Test, Inc.; 2002-2008). Psychometric properties of the test describe the validity and reliability of the association between categories regardless of the type of association being studied. Coefficients describe the reliability and validity of the method of testing, rather than the test itself. Internal consistency of testing implicit associations is reported with a Cronbach’s alpha of 0.78. (Lane, Banaji, Nosek, & Greenwald, 2007). Test-retest reliability ranges from 0.32 (after two weeks) to 0.65 (within 24 hours). Evidence for the convergent validity of the RAIAT lies in its strong correlation with measures of ethnocentrism. The RAIAT is able to discriminate between groups with explicit preferences. The correlation between implicit and explicit preferences varies according to the strength of the implicit preferences; the stronger the preference the higher the correlation. The RAIAT can predict a variety of behaviors such as physiological response, social action, and social judgments.

Therapists will complete a survey following the intervention consisting of open-ended reflection questions. In addition, four questions will be embedded in the environment. Answers to these questions will be recorded on a separate form placed in the participants’ workshop notebook (see Appendix G).

Protocol

  1. Prior to actual implementation of the experiment, the primary investigator will gain IRB approval from both Nova University and Louisiana State University Health Science Center. The investigator will also obtain approval for provision of continuing education credit from the Louisiana Board of Medical Examiners. Participants will be awarded .6 continuing education units at the conclusion of the instruction.

  2. The interventions will take place in the Allied Health Building at LSUHSC, Shreveport, Louisiana. The groups will meet face-to-face in the computer lab and each participant will sign an informed consent.

  3. Each participant will be assigned a computer with Internet connection and Second Life software. Each participant will devise a unique code name which will serve as an identifier for all outcome measures. Each therapist will write her code name on a note card that will be turned into the PI, who will then check for duplicates. In the unlikely case of duplicates, the process will be repeated. No record will be made linking the participant’s identity to the corresponding code name, in order to preserve confidentiality and avoid investigator bias. Next, therapists will write an email address on a note card which will be collected by the PI. The list of email addresses will be kept separate from all other study materials. The email will be used to remind therapists to take a post test of the RAS one week later. A week interval between the pre and post-test of the RAS will limit the threat to validity due to re-testing. This threat is not as problematic with the RAIAT since results are less under the test taker’s control and the test is randomized for each administration; therefore, the RAIAT may be taken again immediately following the intervention.

  4. Participants will complete an anonymous demographics form.

  5. Nine avatars will be created for therapist in Second Life prior to the training in order to reduce the learning curve for the interface. Each Therapist will be given a notebook with written instructions on navigation controls, multimedia controls, and other information needed to participate in Second Life. Paper and pens will be provided for participants to record thoughts about the experience as the training progresses.

  6. The primary investigator will give an orientation to the workshop.

  7. All nine therapists will be directed to the online version of the Race Attitude Implicit Association Test and told to complete the implicit portion. The investigator will manually record the results on the RAIAT Scoring Sheet (see Appendix H) and instruct therapists to complete the RAS which will be formatted as a Google Docs Survey. The results of each test will collected in a table by the Google software, with the code name for each therapist as the only identifier.

  8. After the completion of both tests, the investigator will provide instructions on the Second Life environment and participants will practice avatar movements and navigation skills.

  9. The Second Life environment will have three stations for each of the major content areas: cultural beliefs and attitudes, health disparity knowledge, and practice skills. Each station will be designed to provide scaffolding necessary for the therapists to complete the exercises independently. The investigator will be available in person and as an avatar in Second Life to provide assistance as needed. Group members will be able to instant message and chat with anyone in the class. The group will spend approximately one hour to an hour and a half in each station, viewing multimedia, interacting with each other, and completing assignments.

  10. After completing one of the three modules, participants will be asked to answer an open ended reflection question in writing. Answers will be collected by the investigator to be analyzed with other qualitative data collected during the exit survey (Appendix G).

  11. Once all groups have completed all three stations, all members will participate in a processing session either face-to-face or within Second Life.

  12. Following the group discussion, participants will retake the IAT, in addition to completing the survey of their subjective experience of the training.

  13. All participants will be awarded with continuing education certificates at the conclusion of the workshop.

  14. The PI will send a group blind carbon copy email seven days later to remind therapists to take the RAS online. The participant code name will be the only identifier on the second RAS. If not all of the post-intervention Racial Argument Scales are completed, the investigator will send a second reminder.

Data Analysis

Qualitative Data

Qualitative data in the form of an exit survey will be collected on each participant’s subjective experience of the instructional module. The data will be examined for themes and coded accordingly by the primary investigator and triangulated with analysis from two other experts. The results of this process will be used to answer the three research questions: 1) Can a culturally immersive virtual world experience promote cultural competency changes in attitudes, behaviors, and interactive reasoning in Louisiana occupational therapists? 2) What instructional strategies are effective in training Louisiana occupational therapists in cultural competence in a virtual world environment? 3) What type of scaffolding is necessary in an online virtual environment designed to teach Louisiana occupational therapists cultural competency? 4) What is the phenomenological experience of occupational therapists participating in cultural competency training in Second Life?

Quantitative Data

The first hypothesis, “Louisiana occupational therapists participating in cultural competency training in Second Life will have statistically significant lower post test compared to pre-test scores on the Racial Argument Scale” will be tested by analyzing the differences between pre and post test scores of the RAS with a dependent t test since the RAS returns a composite score that is considered to be interval data. The second hypothesis, “Louisiana occupational therapists participating in cultural competency training in Second Life will have statistically significant improvement in post test compared to pre-test scores on the Racial Attitude Implicit Association Test” will be tested by analyzing the difference in pre- and post test scores on the RAIAT with a chi square. A chi square test is appropriate since the RAIAT yields ordinal data.

Resources

The interventions will take place in the Louisiana State University Health Science Center School of Allied Health Professions computer lab. The lab contains twelve Dell computers, with Intel® Core™ 2 Duo processors, loaded with the Second Life client. Bandwidth allocation is typically under 300 kbps, and often under 100 kbps. All computers have 256MB ATI Radeon® X1300 Pro graphics card or better. USB headsets with microphones and earphones will be used for audio and voice.

Summary

The ADDIE model as applied by Wang and Hsu (2008) will be used as an overall framework for this study. The first three stages of the model will direct the development phase of the study in which the virtual environment will be constructed, and the last two stages will guide the experimental phase of the study. The prototype instructional module developed in Second Life will undergo an iterative design process, which will include a survey of occupational therapists, a usability test with occupational therapy students, an expert review of the instructional plan, and a heuristic evaluation. The instructional intervention will take place using two samples of occupational therapists in the LSUHSC computer lab. Therapists will be led through three cultural competency learning modules in Second Life. Qualitative data collected will include answers to reflection questions embedded in the environment and responses to an exit survey. Quantitative measures will include the RAS and the RAIAT given as a pre-tests and post-tests.


Appendix A

Louisiana Occupational Therapist Survey



  1. Gender:  Male  Female




  1. Age:




  1. Which of the following categories best describes you?
    (Select as many as apply)



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