Cultural adaptation of a preventive program for ultra-Orthodox preschool boys

Journal of Occupational Therapy, Schools, & Early Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

Cultural adaptation of a preventive program for ultra-Orthodox preschool boys Yafit Gilboa OT, PhD To cite this article: Yafit Gilboa OT, PhD (2016) Cultural adaptation of a preventive program for ultra-Orthodox preschool boys, Journal of Occupational Therapy, Schools, & Early Intervention, 9:3, 258-268, DOI: 10.1080/19411243.2016.1207214 To link to this article: http://dx.doi.org/10.1080/19411243.2016.1207214

Published online: 16 Aug 2016.

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Date: 16 August 2016, At: 23:25

JOURNAL OF OCCUPATIONAL THERAPY, SCHOOLS, & EARLY INTERVENTION 2016, VOL. 9, NO. 3, 258–268 http://dx.doi.org/10.1080/19411243.2016.1207214

Cultural adaptation of a preventive program for ultra-Orthodox preschool boys Yafit Gilboa, OT, PhDa,b a

School of Occupational Therapy, Faculty of Medicine, Hadassah and The Hebrew University of Jerusalem, Jerusalem, Israel; bAchiya—Learn That You Can, Bnei-Brak, Israel ABSTRACT

ARTICLE HISTORY

Cultural factors significantly influence the effectiveness of pediatric screening that enables the prevention of developmental disturbances. The formulation of intervention programs must match the needs of the child, his or her family, and educators. Recognizing the importance of creating an intervention program accessible to the culture of the child and the child’s mentors, this article describes a multidisciplinary early screening and preventive intervention program for preschool boys within the ultra-Orthodox sector. The adaptation strategy for intervention in the ultra-Orthodox community included both surface changes and deep restructuring of content and delivery. Lessons learned were applied to pilot testing resulting in a feasible model.

Received 5 April 2016 Accepted 26 June 2016 KEYWORDS

Culturally accessible; preventive intervention; modification of delivery; cultural isolation; adaptation strategy

Pediatric screening and early preventive interventions Interventions initiated with young children with a high risk of neurodevelopmental problems are usually preventive programs (Spittle, Orton, Anderson, Boyd, & Doyle, 2012). The effectiveness of early preventive interventions in many areas is evidence based (Weber & Jenni, 2012). Many research studies indicate the connection between early intervention and the prevention of future educational problems among primary school–aged children. Significant impact was documented in cognitive skills (Nordhov et al., 2010; Spittle et al., 2012), language skills (Peacock, Konrad, Watson, Nickel, & Muhajarine, 2013), motor skills, (Zask et al., 2012) and academic and social outcomes (Walker, Holland, Halliday, & Badawi, 2012). There is evidence that intervention in the earliest years of life provides the greatest social benefits to the individual, the family, and the wider community (Walker et al., 2012). Studies of early intervention programs show that the earlier a child is exposed to a developmental environment that matches his or her educational needs, the better the child’s chances of significant improvement and the reduction of future difficulties (Clark, Polichino, & Jackson, 2004). In the past 2 decades, evidence has shown that preschool programs are associated with a wide range of positive outcomes that enhance well-being and promote economic benefits to society (Reynolds., Temple, White, Ou, & Robertson, 2011). The positive outcomes emerge in many areas, such as in graduating high school, attending college, maintaining health insurance coverage and employment, and in lowering the rate of felony arrests (Reynolds et al., CONTACT Yafit Gilboa yafi[email protected] School of Occupational Therapy, Faculty of Medicine, Hadassah and the Hebrew University of Jerusalem, Mt. Scopus, P.O. Box 24026, Jerusalem, Israel 91240. © 2016 Taylor & Francis

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2007). Moreover, knowledge of the long-term effects has strengthened confidence in the economic feasibility of these programs (Reynolds et al., 2011). Many of the early intervention programs are based on ecological theories and models that assume that different environmental factors (e.g., cultural, economic, or familial) influence children’s development and performance (Golos, Sarid, Weill, & Weintraub, 2013). Therefore, early intervention programs are often implemented in the children’s natural environment, such as in their homes or educational framework (Clark et al., 2004; Golos et al., 2013).

The intervention model Ma’agan (“anchorage” in Hebrew) is an early childhood intervention program funded by the Israeli government. Ma’agan is a multidisciplinary developmental program whose goal is to prevent aggravation of disabilities and enable the child’s integration into the elementary school framework. The program’s specific aims are (1) teaching and guiding the educational preschool staff in issues relevant to normal and abnormal child development; (2) accompanying the educational staff in developing sensitivity to the unique needs of different children; (3) screening for children with developmental difficulties and referral through their parents to appropriate intervention and follow-up on their progress; (4) guiding and providing consultation for the educational preschool staff in order to promote an adaptation of the curriculum to different children based on their unique needs and developmental stages; (5) guiding the teacher in communication with parents of children with special needs; (6) supporting parents in relation to the unique needs of their child; and (7) promoting cooperation with the services provided in the community (Ministry of Education, 2013). The main principles governing the program are as follows: (1) Program operation takes place in a normal educational setting while emphasizing the teachers as the leaders of the process; (2) the program team must include professional staff; (3) the intervention continues throughout the school year; (4(the intervention is ecological and takes into account all the factors surrounding the child: the educational system, the parents, and the community resources (Ministry of Education, 2013). In general, the goal of any preventive intervention is to develop a broad reach and maximum inclusion. Challenging questions emerge, however, when the aspiration for inclusiveness meets the reality of cultural heterogeneity. The ultimate success of preventive intervention lies in its ability to engage and influence the growing presence of subcultural groups (Barrera, Castro, & Steiker, 2011). This concept is known as “cultural accessibility.” Every intervention program must adapt itself to the specific cultural context in which it functions. Programs must be relevant to the cultural context of the educators, the children, and the families who are their target audience; this is the only way such programs will be accepted and internalized in the daily life of the target community (Colby et al., 2013). This challenge to prevention science highlights the need to develop culturally informed and responsive programs that deliver the best practice while also addressing the practical concerns of a local community (Castro, Barrera, & Martinez, 2004).

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Defining the cultural group: The isolated ultra-Orthodox community in the wider context Jews may be culturally identified on a spectrum of religiosity: secular, traditional, religious, and ultra-Orthodox (Greenberg & Witztum, 2013). Ultra-Orthodox Jews are defined by their commitment to preserving and observing an entire life-enfolding system of immutable values, norms, laws, and institutions representing an essential integrating force in the identity of Jewish individuals, families, and communities (Weiss, Shor, & Hadas-Lidor, 2013). The ultra-Orthodox Jews are distinct from other Jews in their dress, their decision to live in monocultural enclaves, and the overriding importance they place on keeping the edicts and obligations of the Torah (the Jewish Bible) and the Halacha (the oral Jewish law) (Gilboa & Rosenblum, 2012; Negev & Garb, 2014). These laws influence all aspects of dayto-day living, such as diet, dress, family life, and education (Gilboa & Rosenblum, 2012; Golos, Sarid, Weill, Yochman, & Weintraub, 2011). The ultra-Orthodox Jews also emphasize strict rules of modesty and separation by gender (Marcus, Josman, & Zlotnik, 2015). They set clear boundaries between themselves and general society in order to maintain their special character and prevent “foreign” influences (Gilboa & Rosenblum, 2012). Ultra-Orthodox communities exist worldwide. Numerically they are approximately 10% of the more than 13 million Jews in the world today, and their numbers are increasing due to their high birth rate and low rate of assimilation. The 700,000 ultraOrthodox Jews in Israel comprise approximately 9% of the population. In the United States, ultra-Orthodox Jews are mainly concentrated in New York and New Jersey; in Israel, many live in Bnei-Brak and Jerusalem (Gurevich & Cohen-Castro, 2004). Cities constructed for the ultra-Orthodox community are characterized by the Israeli Central Bureau of Statistics as being of low socioeconomic status (Gurevich & Cohen-Castro, 2004). It should also be noted that the ultra-Orthodox community does not adhere to one central authority regarding philosophy, expectations, or practice; slight differences exist according to their subcultures and sects (Rosenbaum, De Paauw, Aloni, & Heruti, 2013). In order to preserve their distinct way of life, the ultra-Orthodox community’s educational system is usually partially or fully independent from the state, with little or no supervision and support from the Israeli Ministry of Education (Erhard & Erhard-Weiss, 2007; Negev & Garb, 2014). The boys’ and girls’ educational systems are separate and use different curriculums from the age of 3 (Erhard & Erhard-Weiss, 2007; Golos et al., 2011). The educational curriculum for the boys’ preschool classes focuses on reading ability as a basic skill necessary for religious studies (Negev & Garb, 2014) with relatively few opportunities and little equipment for play or other physical activities that enhance sensory-motor development (Golos et al., 2011). Indeed, a study that examined the prevalence of children at risk and/or with developmental delay in the ultra-Orthodox community found a higher percentage of children who were at risk or delayed in gross motor and motor-cognitive skills compared with the percentage reported in the literature (Golos et al., 2011). In addition, the ultra-Orthodox boys’ preschools do not require their male teachers to have official certification in education (Negev & Garb, 2014). Therefore, the majority of their kindergarten teachers lack formal training. This is reflected in, among other things, a lack of tools and a lack of awareness of the importance of play (Somech & Elizur, 2012) and movement at an early age and an inability to identify slight developmental challenges (Wolfson & Stoler, 2007).

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Cultural adaptation of the Ma’agan program to the ultra-Orthodox preschool setting “Cultural adaptation” refers to program modifications that are culturally sensitive and tailored to a cultural group’s traditional worldviews (Kumpfer, Alvarado, Smith, & Bellamy, 2002). The challenge of the successful cultural adaptation of an intervention program is to maintain essential elements while adapting the program’s delivery methods and materials to the target population (McNaughton, Cowell, & Fogg, 2014). This article uses examples from a screening and preventive intervention program designed for the ultra-Orthodox preschools in the city of Beni-Brak to illustrate the adaptation process employed to make these services more culturally accessible. The primary aim of the cultural adaptation was to generate a culturally equivalent version of the nationwide Ma’agan model. The adaptation was driven by identification of those factors in the isolated ultra-Orthodox community lifestyle that influence the therapeutic framework. These identifications guided the process of making the content and language accessible. The current program has been adapted by a professional multidisciplinary staff that includes occupational and speech therapists. The municipality is funding 75% of the program’s cost; the remainder is being funded by a philanthropic foundation. The adaptation strategies were based on principles of community partnership and included both surface and deep structural adaptation (Resnicow, Baranowski, Ahluwalia, & Braithwaite, 1999). Surface structural strategies included health-education materials translated to the targeted community’s literacy level and language, posters and flyers with culturally appropriate photos, interventionists who culturally resembled (matched) the population of interest, and selection of venues associated with the culture of the group (Resnicow et al., 1999). The secular professional staff also tried to preserve the religious character of the setting; for example, all developmental therapists agreed to work in this community, which differed culturally from their own, and agreed to conform while at work to the community’s religious dictates in dress and behavior. The staff complied with the laws of separation between men and women and the community’s exacting dress code (skirts and long sleeves for women and skullcaps for men). Staff members were employed according to gender (male therapists for the boys’ classes) and appropriate language (Yiddish). All screening and intervention sessions were carried out according to the behavioral codes suited to each environment. An effort was made to choose appropriate games, equipment, and illustrations that would be approved by the community’s spiritual authorities (i.e., without pictures of girls, women, or foods forbidden by “kosher” laws). Materials had to be specifically designed for the ultra-Orthodox sector and, conceivably, for the genders. Non–ultra-Orthodox materials are considered as representing an irrelevant and illegitimate “foreign” and “modern” sense (Negev & Garb, 2014). Cultural adaptations must also extend beyond surface structure (Resnicow, Soler, Braithwait, Ahluwalia, & Butler, 2000). Deep structural strategies require knowledge of the cultural values, social norms, history, opinions, and challenges experienced by the population. These strategies necessitate firsthand knowledge, and understanding and communication with community members, to incorporate their priorities, problems, and preferred methods of participation (Resnicow et al., 1999).

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Phase 1: Establish cooperation with the community leadership Since collaboration between the professional service director and local rabbis is a key for implementation of services in an ultra-Orthodox town (Somech & Elizur, 2012), extensive preparation work was done with various highly acclaimed rabbinical leaders from different sectors in the ultra-Orthodox community to ensure that the project would be accepted. Many questions were asked about the necessity of the program and about the relationship between motor skills at the age of preschool and readiness for religious studies, especially for reading. Those questions were a consequence of the community’s unique approach to education, which typically views motor and physical activity as a low priority. In addition, because of the wish to maintain cultural isolation and the fear of stigma that might result from the inclusion of professional developmental staff in the school, a few of the rabbinical leaders and school principals refused to join the program. Eventually, however, the process was endorsed and blessed by most of the leading spiritual authorities in the community. The community rabbis were consulted by the school principals on a regular basis throughout the intervention program. Different approaches of the school principals regarding the level of parents’ involvement in the program were presented and accepted. Ultra-Orthodox advisors were employed to serve as a bridge between the secular professionals and the service recipients.

Phase 2: Modifying the program Two basic forms of adaptation were involved in modifying the program: content and delivery. In the adaptation of Ma’agan, modification of the content was based on the school principal’s request. This included special additions. Because of the male teachers’ lack of formal training in education and the low socioeconomic status of most of the population, two main parts were added to the ultra-Orthodox program. The first was a series of teacher and principal workshops focused on describing child development milestones and supplying basic tools for developmental enrichment of the preschool environment and activities. Six workshops of 3 hours each were conducted by a male occupational and speech therapist on different aspects of child motor and language development. The second was the inclusion of an ultra-Orthodox male educational counselor who visited each preschool once a week. The third was a series of parent workshops, with fathers and mothers meeting separately (Somech & Elizur, 2012) with male and female occupational and speech therapists, respectively. These workshops presented information about early childhood development, red flags signaling difficulties, appropriate parenting responses, and more play skills to promote attitude change (i.e., that playtime contributes to child development) (Somech & Elizur, 2012). The numbers of children, educators, and parents participating in the Ma’agan Program to the ultra-Orthodox preschool programs is presented in Table 1. “Modification of the delivery” refers to presenting the same program content but with changes in how it is communicated and implemented (Castro et al., 2004). Modification in this case was made in the delivery person(s). Male ultra-Orthodox teachers with basic formal training in child development (parallel to an occupational and speech-language therapist assistant) delivered the screening and enrichment program rather than certified occupational and speech-language therapists (which in Israel are mainly women).

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Table 1. The numbers of children, educators, and parents participating in the Ma’agan Program in the ultra-Orthodox preschool programs in 2014– 2015 in Bnei-Brak. The services of the program Screening Taken part in workshops Principals’ forums Parent workshops

The number of participants 602 boys 25 preschool teachers 8 preschool principals 304 parents

Table 2. A year plan for the Ma’agan Program in the ultra-Orthodox preschool setting and the adaptation needed. The stages of the program Screening

Adaptation needed Developmental assistants conducted screenings using specific adapted tools. Then the developmental assistants discussed the results of the screening with the teachers. Reporting the screening results to the Teacher along with the preschool principals and/or the developmental parents assistants reported the screening results to the parents. Children with suspected developmental delays were referred for further evaluation to the health clinics. Enrichment groups intervention to promote Developmental assistants performed group sessions with identified motor and language skills children and with the entire class, enabling the preschool teachers to learn onsite. Teacher workshops Teacher attended six workshops of 3 hours each during the year. Principals’ forums The school principals attended four meetings of the principals’ forums throughout the year. Educational counselor Educational counselor met weekly with a child and his parents together with the preschool teachers. Workshops for parents Series of parent workshops was offered, with fathers and mothers meeting separately.

Occupational and speech therapists were hired to train the developmental assistant. This modification required switching the type of occupational therapy intervention from a direct to an indirect service delivery model (AOTA, 2014). Detailed description of the program’s stages and the adaptation needed is summarized in Table 2. In conclusion, the cultural adaptation implemented for the ultra-Orthodox community did not alter any of the core components of the original Ma’agan program. The adaptations centered primarily on cultural changes to curriculums and intervention materials and on revisions in recruitment and intervention delivery procedures.

Phase 3: Pilot testing Thirteen ultra-Orthodox preschool male teachers were enrolled in the pilot program at the end of the year. Twelve participants delivered the rated questionnaires anonymously. On a Likert scale of 1 to 6, the teachers reported favorable results (high score indicates better score) (see Table 3). The self-questionnaires include 10 questions that aimed to assess the ability of the teachers to perform different aspects of the program’s goals. Two qualitative questions were added to provide the cultural adaptation team with feedback about the teachers’ satisfaction with the intervention. The first question was to define which of the skills that the program taught were most helpful. One teacher

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Table 3. Survey of male teachers (N = 12) in ultra-Orthodox preschools that participated in Ma’agan (2014–2015). Statement 1. I conduct observations of children’s function in the classroom. 2. I conduct observations of children’s function during recess and in the playground. 3. I can identify children with motor development difficulties in my classroom. 4. I can identify children with speech difficulties in my classroom. 5. I can identify children with emotional difficulties in my classroom. 6. I enrich children’s development in the classroom with the tools suggested by the Ma’agan staff. 7. I prepare a personal program for each child according to his needs. 8. The Ma’agan program has impacted my work with all children in the kindergarten. 9. The Ma’agan program has improved my ability to report to parents about their child’s difficulty. 10. The Ma’agan program has improved my communication with parents. Total average

Mean 5.83 4.41 5 4.75 4.08 4.6 3.45 5.08 4.5 4.18 4.59

responded, “Now I am able to better recognize a child with a problem and especially to understand the origin of his problem.” Another young teacher wrote: “Now I better understand how to play in the playground or with building games, as well as how to read a story and talk with the kids in a way that will promote their development.” Some teachers found the course to be very helpful. One teacher specifically described the courses as “very interesting and helpful; now I feel that I can talk with parents with more confidence.” The teachers were also asked to mention subjects that they would want presented in order to continue their learning. One teacher expressed frustration that “sometimes I recognize that a specific child has a problem, but I don’t always know to whom I should refer the family for help.” Some teachers mentioned the lack of developmental equipment and facilities at their school.

Discussion Phase 4 of the cultural adaptation process is full evaluation (Lewin et al., 2015). Despite not having completed this final phase as of yet, the adaptation process undertaken to date has yielded some important lessons concerning cultural accessibility. Specifically, and in line with previous cultural adaptation (Lewin et al., 2015), three broad areas that required meaningful adaptation were identified: (1) recruitment, (2) engagement, (3) the contextual relevance of the program content.

Recruitment Cultural competence in early intervention programs necessarily depends on the actions of the recruited staff. It is important to not only culturally adapt clinical models but to also ensure that they are delivered in a culturally sensitive manner (Davey, Kissil, Lynch, Harmon, & Hodgson, 2012). Professionals accustomed to working in secular settings not only reside outside the community but are also “outsiders” in terms of access to community relationships. Therapeutically, this can be both an asset and a limitation (Mares & Robinson, 2012). The complementary role of community coleaders is crucial in ensuring program accessibility, but it requires the outsiders to be flexible in their approach to group work with parents and children, yet without

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abandoning their professional stance or compromising the program structure and content (Mares & Robinson, 2012). Engagement The ultimate success of preventive interventions relies on their ability to engage and influence the growing presence of subcultural groups (Barrera et al., 2011). In order to successfully engage and retain ultra-Orthodox teachers and families as willing participants in intervention, we learned that it is important to train ultra-Orthodox males as therapist assistants, as they can build trust with both the school-age children and their male teachers by demonstrating cultural sensitivity and providing a gender-separated environment. Developing such trust-based collaborations with spiritual and community leaders may be the first step in understanding better ways to offer more culturally sensitive childdevelopment support. Matching of therapist’s and participants’ religiosity is one way to be culturally sensitive and to retain participants. Clinicians leading this type of intervention also need to be personable, be accessible to the participants, and be able to maintain a safe environment so that the participants feel comfortable. The long-term goal of engagement is to empower members of the community to recognize their own potential through meaningful occupations (Simo-Algado, Mehta, Kronenberg, Cockburn, & Kirsh, 2002). Therefore, the intervention staff’s ability to innovate and highlight the strengths of the community is a valuable tool of intervention in a disadvantaged social and cultural environment where there are few economic resources (Simo-Algado et al., 2002). The contextual relevance of program content Cultural competence in early intervention programs likewise depends on the “cultural logic” of the intervention—that is, its suitability to the patterns of interaction and relationships within a specific community (Robinson, 2011). Clinical research focusing on the best ways to integrate cultural sensitivity training into child-development practice settings can help to improve the well-being of ultra-Orthodox Jews and similar minority groups. As our case demonstrated, modification of content may also be necessary if a user group needs or wants certain supporting elements not offered by the original program model. This content may be incorporated throughout the curriculum or manual, or it may be designed as a complete supplemental module (Castro et al., 2004). To summarize, this article describes a new cultural adaptation of preventive intervention for use in an underserved and traditionally hard-to-reach population. Although its effectiveness in influencing child development outcomes has not yet been clinically determined, the improved accessibility has been successfully implemented in a pilot program and the adaptation was rated by participants as an acceptable and feasible intervention tool in this subcultural group.

Conclusion Culturally sensitive care is viewed as a core concept of client-centered occupational therapy (Hammell, 2013; Heien, Kelto, & Szczech Moser, 2012; Lindsay, Tetrault,

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Desmaris, King, & Pierart, 2014). Cultural adaptation is a dynamic process and requires continual reevaluation (Lewin et al., 2015). The ongoing evaluation of staff recruitment and training, as well as the chosen methods of engagement with the target population should take all culturally relevant factors into account to ensure that the intervention program is culturally accessible while maintaining therapeutic fidelity and efficacy. For ultra-Orthodox patients, religion is a primary source for self-determination and expression (Stolovy, Levy, Doron, & Melamed, 2013). Ultra-Orthodox Jews may be less educated concerning health care and illness prevention than members of the wider population due to sociocultural isolation, and clinicians may find it a challenge to implement successful health-education programs. Cultural competency begins by building effective working relationships among coworkers to successfully function in different cultural contexts (Knight & Hawkins, 2011). Liaison with religious authorities and community-based educational organizations may provide valuable access (ColemanBrueckheimer & Dein, 2011). Culturally sensitive professional staff who show respect for the ultra-Orthodox community enable their patients to feel respected as people beyond their status as patients. Furthermore, culturally sensitive treatment allows patients to feel respected and acknowledged through their sociocultural affiliation. Therefore, the patient’s social status and self-esteem remain protected (Stolovy et al., 2013). This project that began in 2005 confirmed the feasibility of a culturally adapted screening and preventive intervention program for the isolated ultra-Orthodox children and related community (parents and teachers). Now the adapted intervention takes place in 10 different ultra-Orthodox municipalities, representing the enormous potential for nationwide early childhood intervention programs and models that may be applied to other insular communities in Israel and across the world.

Acknowledgments The author would like to thank the staff of “Achiya—Learn That You Can,” for their valuable participation, especially, Founder and General Manager Mr. Yitzchak Levin, project manager Mr. Tzali Perlstein, and speech therapists Mrs. Shila Paskaro and Mrs. Noa Gubi. The author would also like to thank linguistic editors Mrs. Hanna Weiss and Mr. Andrew Goldstein.

Funding The program was funded by the Bernard van Leer Foundation and the municipality of Bnei-Brak.

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