Improving Treatment Adherence for PIs through a Cultural Competency ToolKit for Providers in an Outpatient Mental Health Clinic

Pacific Islanders (PIs) in the United States experience significant mental health disparities, including higher rates of depression, anxiety, and suicide compared to other ethnic groups. Limited research on culturally competent interventions for this population contributes to low engagement, misdiagnosis, and inadequate care delivery. Mental health providers often lack culturally tailored resources to integrate PI cultural values and traditional healing practices into clinical care. This project aimed to bridge this gap by implementing and evaluating a Cultural Competency Toolkit (CCT) for mental health clinicians. Despite increasing recognition of health disparities in PI communities, clinicians in outpatient mental health settings lack standardized cultural competency training. Without structured guidance, providers may struggle to engage PI patients effectively, assess cultural influences on mental health, and apply culturally aligned interventions. This project aimed to implement and evaluate the feasibility and impact of a structured CCT to enhance clinician knowledge, patient engagement, and culturally responsive treatment strategies. Over 12 weeks, the project team implemented this quality improvement initiative at an outpatient mental health clinic founded in 2003 by a PI couple who recognized the urgent need for culturally responsive counseling services in their community. The intervention introduced seven cultural and therapeutic models, including the Talanoa Method, Fonofale Model, Fa'afaletui Method, Uloa Method, Lokahi Wheel, Kaimana Intervention, and Acceptance and Commitment Therapy. Clinicians received training on these models and integrated them into practice with PI clients. The project team collected data through qualitative feedback, structured surveys, and clinician interviews to assess engagement, identify implementation challenges, and evaluate effectiveness. The CCT provided culturally tailored assessment tools for mental health evaluation, training on PI values such as family-centered care, spirituality, and communal decision-making, and structured implementation guidelines for psychiatric assessment, treatment planning, and case documentation. Providers engaged in self-reflection exercises to assess biases and improve cultural awareness. Clinicians reported an 88.9% increase in confidence in delivering culturally competent care and greater awareness of cultural barriers. Most clinicians (77.8%) reported using the Kaimana Intervention and Lokahi Wheel, citing familiarity and ease of integration. Fewer clinicians used lesser-known models, attributing this to limited training and uncertainty about implementation. Several clinicians (44.4%) noted improved client engagement as a positive outcome, with clients responding positively to the CCT's cultural relevance and alignment with their values. However, the clinic's relocation disrupted full implementation for some providers. This project demonstrated that the CCT effectively enhanced clinician cultural competency, patient engagement, and culturally responsive care. The findings support the need for structured training, implementation support, and workflow integration. Future efforts should expand the CCT's use, refine clinical application guidelines, and evaluate patient-reported outcomes to sustain impact and reduce disparities.

1 Improving Treatment Adherence for PIs through a Cultural Competency ToolKit for Providers in an Outpatient Mental Health Clinic Va Mounga, Lani Taholo, Tausoa Mulitalo, John A. Nerges College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 21, 2025 2 Abstract Background Pacific Islanders (PIs) in the United States experience significant mental health disparities, including higher rates of depression, anxiety, and suicide compared to other ethnic groups. Limited research on culturally competent interventions for this population contributes to low engagement, misdiagnosis, and inadequate care delivery. Mental health providers often lack culturally tailored resources to integrate PI cultural values and traditional healing practices into clinical care. This project aimed to bridge this gap by implementing and evaluating a Cultural Competency Toolkit (CCT) for mental health clinicians. Problem Despite increasing recognition of health disparities in PI communities, clinicians in outpatient mental health settings lack standardized cultural competency training. Without structured guidance, providers may struggle to engage PI patients effectively, assess cultural influences on mental health, and apply culturally aligned interventions. This project aimed to implement and evaluate the feasibility and impact of a structured CCT to enhance clinician knowledge, patient engagement, and culturally responsive treatment strategies. Methods Over 12 weeks, the project team implemented this quality improvement initiative at an outpatient mental health clinic founded in 2003 by a PI couple who recognized the urgent need for culturally responsive counseling services in their community. The intervention introduced seven cultural and therapeutic models, including the Talanoa Method, Fonofale Model, Fa’afaletui Method, Uloa Method, Lokahi Wheel, Kaimana Intervention, and Acceptance and Commitment Therapy. Clinicians received training on these models and integrated them into practice with PI clients. The project team collected data through qualitative feedback, structured surveys, and clinician interviews to assess engagement, identify implementation challenges, and evaluate effectiveness. 3 Intervention The CCT provided culturally tailored assessment tools for mental health evaluation, training on PI values such as family-centered care, spirituality, and communal decision-making, and structured implementation guidelines for psychiatric assessment, treatment planning, and case documentation. Providers engaged in self-reflection exercises to assess biases and improve cultural awareness. Results Clinicians reported an 88.9% increase in confidence in delivering culturally competent care and greater awareness of cultural barriers. Most clinicians (77.8%) reported using the Kaimana Intervention and Lokahi Wheel, citing familiarity and ease of integration. Fewer clinicians used lesser-known models, attributing this to limited training and uncertainty about implementation. Several clinicians (44.4%) noted improved client engagement as a positive outcome, with clients responding positively to the CCT’s cultural relevance and alignment with their values. However, the clinic’s relocation disrupted full implementation for some providers. Conclusions This project demonstrated that the CCT effectively enhanced clinician cultural competency, patient engagement, and culturally responsive care. The findings support the need for structured training, implementation support, and workflow integration. Future efforts should expand the CCT’s use, refine clinical application guidelines, and evaluate patient-reported outcomes to sustain impact and reduce disparities. Keywords: Cultural competency, cultural humility, Pacific Islanders, mental health disparities, outpatient mental health treatment, quality improvement, culturally responsive care, provider training, health equity. 4 Improving Treatment Adherence in PIs through a Cultural Competency CCT for Providers in an Outpatient Mental Health Clinic Problem Description Research on the mental health of Pacific Islanders (PIs) in the United States (U.S.) is limited despite this population being the fastest-growing ethnic group in the country (Lim, 2022). Statistics show disproportionately high rates of depression and anxiety among PIs with 38% reporting symptoms of anxiety and 30% experiencing symptoms of depression within the past year (Tan et al., 2024). These mental health challenges highlight the need for culturally competent care. In Utah, understanding how to provide effective treatment for PIs in diverse healthcare settings is crucial to addressing this disparity and improving outcomes. Available Knowledge PIs are one of the most vulnerable populations affected by mental health disparities. According to the Office of Minority Health (2024), Native Hawaiians and PIs are three times less likely than non-Hispanic Whites to receive mental health services or prescriptions. Utah ranks fifth in the U.S. for the largest population of PIs. Nationally, PIs were the third fastest-growing ethnic group from 2000 to 2010 (Subica et al., 2019). Among PIs aged 10–19, suicide is the leading cause of death in the U.S. (SAMSA, 2023). This population faces unique barriers to mental health care, including mental health stigma, cultural beliefs about mental health disorders, language barriers, the lack of culturally appropriate tools, and the shortage of Pacific Islander (PI) providers within mental healthcare (SAMSA, 2023). These factors compound the existing disparities, emphasizing the need for targeted, culturally competent interventions. A literature review reveals several evidence-based models that inform culturally competent mental health care for PI clients. The Talanoa Method is a PI approach grounded in storytelling and relational dialogue that builds trust between client and clinician (Vaka, 2014). The Fonofale Model, developed by Pulotu-Endemann (n.d.), uses the structure of a Samoan 5 fale (house) to represent holistic health, including cultural, spiritual, familial, and physical dimensions. The Fa’afaletui Method draws on collective dialogue to synthesize knowledge from various perspectives, supporting community-centered decision-making in mental health treatment (Mulipola et al., 2023). Similarly, the Uloa Method, rooted in Tongan traditions, emphasizes shared responsibility and collaboration in healing processes (Vaka et al., 2022). The Kaimana Intervention is a 13-session, culturally tailored program designed specifically for PIs to reduce stigma and improve mental health engagement (Katoa & Taholo, 2019). The Lokahi Wheel, a Native Hawaiian model, encourages balance and harmony across spiritual, emotional, physical, and relational domains (Lokahi Wheel Wellness, n.d.). Finally, Acceptance and Commitment Therapy (ACT), though not PI-specific, is a mindfulness-based therapy that has been shown to align well with PI values when culturally adapted (Schultz, 2021; Auva’aAlatimu, 2023). Rationale Translating research into clinical practice often takes a lengthy process, typically estimated to take approximately 17 years (Tucker et al., 2021, as cited in Balas & Boren, 2000). The Johns Hopkins Evidence-Based Practice (JHEBP) Model was used to address the challenge of integrating culturally competent care into clinical practice by guiding the development, implementation, and evaluation of the CCT (Dang et al., 2022; Figure 1). The JHEBP model consists of three phases: establishing a practice question, searching for evidence, and translating evidence into practice. Recent updates to the model emphasize collaboration with interprofessional teams to ensure comprehensive feedback and shared decision-making. This project was grounded in the assumption that standardized western mental health practices often fail to reflect the cultural values, experiences, and communication styles of PI clients (Subica et al., 2019; Vaka et al., 2022). Cultural beliefs such as collectivism, spirituality, and family-centered decision-making are integral to PI health behaviors and treatment 6 engagement (Katoa & Taholo, 2019; Pulotu-Endemann, n.d.; Samu & Suaalii-Sauni, 2009). Without culturally aligned tools, providers may unintentionally contribute to misdiagnosis, low engagement, or poor adherence (Cutrer-Párraga et al., 2024; Stubbe, 2020). The intervention, a CCT (Appendix A), provided clinicians with structured, culturally relevant models that aligned with PI values and traditional practices. These models (e.g., Talanoa, Fonofale, Lokahi Wheel, Kaimana Intervention, and Uloa Method) were selected based on existing literature and cultural theory supporting their relevance and effectiveness in PI communities (Katoa & Taholo, 2019; Pulotu-Endemann, n.d.; Vaka, 2014; Vaka et al., 2022; Lokahi Wheel Wellness, n.d.). Clinic leadership and staff at an outpatient mental health clinic serving a diverse population, including PIs, partnered with the project team to develop the practice question: In PI adults in Utah diagnosed with mental health disorders, will providing a CCT for healthcare providers improve medication and therapy adherence, thereby reducing symptoms of acute medical exacerbation necessitating emergency services? Their clinical experience and cultural insight were essential in ensuring the intervention addressed real-world challenges. Following the practice question, the team conducted a comprehensive literature review on mental health disparities among PIs and best practices in culturally competent care. This evidence appraisal guided the development of the CCT and reinforced the expectation that a culturally grounded approach would lead to more effective, engaging, and sustainable mental health care delivery for this underserved population. Specific Aims This quality improvement (QI) project aims to develop, implement, and evaluate a CCT for healthcare providers at an outpatient mental health clinic serving a PI population. The project objectives were to (a) assess the prevalence and incidence of PI clients diagnosed with a mental health disorder at the outpatient mental health clinic; (b) evaluate current provider practices in delivering culturally competent care to PI clients; (c) develop a CCT to address 7 identified gaps in provider knowledge and engagement; and (d) assess the feasibility, usability, and satisfaction of the CCT among clinicians serving PI clients. Methods Context This QI project was conducted at a privately owned outpatient mental health clinic in West Valley City, Utah. The clinic has been serving the community for 21 years and is the oldest mental health clinic in Utah founded and owned by PIs. The clinic employs a diverse team, including the Clinical Director (a Licensed Clinical Social Worker [LCSW] and co-owner), one additional LCSW, the Kaimana Intervention Coordinator (a Clinical Social Worker [CSW]), three other CSWs, two CSW interns, and an administrative assistant. The staff includes bilingual providers who serve Spanish-speaking, Portuguese-speaking, Tongan-speaking, and Samoanspeaking clients, offering in-person and telehealth sessions to meet client needs. The clinic’s mission is to create a culture of empowerment and inclusivity by integrating cultural beliefs and values into treatment plans (Anonymous Clinic, n.d.). According to their mission statement, this clinic takes a culturally responsive approach, recognizing the context of clients’ cultures and adapting care accordingly. PIs in the United States have a low utilization rate of mental health services, often citing socioeconomic barriers, cultural preferences, and experiences of discrimination (Kwan et al., 2020). To address these challenges, this clinic developed the Kaimana Intervention, a 13-session culturally tailored program focused on reducing mental health stigma and improving outcomes for PIs (Katoa-Taholo, 2019). This intervention is integrated into treatment for PI clients and is supported by evidence-based practices. The unique barriers faced by PIs with mental health disorders highlight the need for QI efforts to reduce stigma, address systemic inequities, and improve access to culturally competent care (Cutrer-Párraga et al., 2024; Kwan et al., 2020; SAMHSA, 2023). This QI 8 project leverages this outpatient mental health clinic’s culturally tailored approach and existing resources to implement interventions that promote sustainable change. Intervention(s) This QI project consisted of four distinct phases to develop, implement, and evaluate a cultural competency CCT for providers working with PI clients. Phase 1: Preparation To ensure compliance with confidentiality and privacy standards, the project author completed a background clearance prior to participating in staff meetings where patient information was discussed. Clinic leadership and staff met to identify PI clients within the clinic and confirm their mental health diagnoses. Weekly staff meetings created opportunities to discuss cultural competency practices and gather feedback. The project team distributed a survey to assess providers' current cultural competency and cultural humility practices, laying the groundwork for CCT development. Phase 2: Data Collection and Analysis The project team collected survey data (Appendix B) through Research Electronic Data Capture (REDCap), gathering information on providers' demographics, years of experience, and self-efficacy in using cultural competency techniques. A Likert scale assessed perceptions of cultural competency, while the project team used open-ended questions in the preimplementation survey to assess common barriers and needs (Figure 2). Weekly meetings with the content sponsor facilitated consistent communication and guided the CCT's development. Stakeholders reviewed survey findings and provided additional feedback to refine the CCT Phase 3: CCT Implementation The project team developed the CCT over a five-week period following the initial survey and stakeholder feedback. Weekly planning meetings, guided by insights from the preimplementation data and content sponsor input, shaped the CCT’s structure and content. Once finalized, the project team presented the CCT to clinical staff during a virtual meeting, 9 incorporating a PowerPoint presentation, a Q&A session, and a discussion on implementation strategies. A printable handout with accessible resources for working with Pacific Islander clients was distributed (Appendix C). The team also introduced the Lokahi Wheel as a culturally relevant tool for assessment, goal-setting, and action planning (Lokahi Wheel Wellness, n.d; Figure 3). Weekly meetings continued throughout implementation to address challenges and refine the CCT as needed. Phase 4: Evaluation The project team distributed a post-implementation questionnaire (Appendix D) via email to assess the CCT’s effectiveness. It included open-ended questions to evaluate feasibility (e.g., time, workflow integration), usability (e.g., ease of use, accessibility of tools), and satisfaction (e.g., clinician confidence, perceived impact on care). Clinicians provided insights into the CCT’s strengths, implementation challenges, and areas for improvement. During the final stakeholder meeting, participants reviewed survey results and offered additional feedback to guide future applications and refinements of the CCT. Study of the Interventions Evaluating the practice change for this QI project on implementing a CCT required a systematic and multi-faceted approach. The project team collected baseline data through a REDCap survey designed to assess clinicians’ skills, knowledge, attitudes, and readiness to treat PI clients at the outpatient mental health clinic. The survey gathered demographic information on PI clientele, clinicians’ cultural backgrounds, and Likert-scale responses assessing cultural competency, humility, and resilience. Additionally, two open-ended questions captured qualitative insights. Respondents answered each question before proceeding to the next to ensure complete data collection. To further inform the CCT’s development, the Clinical Director and Kaimana Intervention Coordinator held discussions via email and Zoom meetings. These discussions clarified the best 10 approach for incorporating culturally responsive tools and addressing barriers identified during the baseline survey. Weekly staff meetings provided valuable insights into clinicians' current practices of cultural competency, cultural humility, and cultural resilience. Additionally, the Kaimana Intervention Coordinator and QI project sponsor held a separate weekly Zoom meeting for detailed discussions on the CCT’s content and format. Clinicians evaluated the CCT’s usability through their feedback on its ease of use, supported by a quick reference handout distributed to each clinician for use during sessions with PI clients. Training workshops ensured that all staff became familiar with the CCT and had the opportunity to ask questions before implementation. The project team assessed the feasibility of the CCT by analyzing clinician-reported data, which showed that its use initially added an average of five minutes to session times. The team provided digital materials to minimize costs and enhance accessibility. Stakeholders shared feedback from these sessions, helping refine the CCT and improve its practicality in the clinical setting. Measures A pre-intervention survey was developed using the REDCap database to collect baseline data and distributed to all clinicians and staff members at the outpatient mental health clinic. The survey included three main components: 1. Basic demographic information on PI clientele (e.g., age, gender, and mental health diagnoses) and the clinicians and staff members (e.g., cultural background, years of experience, and languages spoken). 2. A series of nine Likert scale questions, rated on a scale of 1 (strongly disagree) to 5 (strongly agree), assessing clinicians' and staff members' knowledge, skills, attitudes, and readiness for using a CCT. 11 3. Two open-ended questions were designed to gather qualitative feedback on clinicians’ and staff members’ perspectives on cultural competency and its potential impact on client care. All survey questions were mandatory to ensure a complete dataset. The inclusion of both quantitative and qualitative measures provided a comprehensive understanding of the baseline cultural competency within the clinic and guided the development of the intervention. Analysis This QI project used descriptive statistics and thematic analysis to gather data from the study sample and implement a CCT for PI clients. The project team distributed a PreImplementation survey to 11 providers, collecting both quantitative and qualitative data. In the first section, the survey gathered demographic information, including professional title, years of experience, client age and gender, languages spoken, and the provider’s racial background. The team analyzed survey responses by calculating frequencies and percentages (Table 1). The second section of the survey utilized a Likert scale, which supported the project by gathering data to identify common themes. The team included open-ended questions to gather qualitative data, which they analyzed to identify common themes, challenges, and successes in applying culturally relevant practices. The team coded responses to categorize the types of tools mentioned (e.g., specific assessment tools, communication strategies, or culturally tailored resources) and to explore the contexts in which these tools were applied. The analysis also examined how these tools facilitated provider-client interactions, improved understanding, and enhanced care delivery for PI clients. During the implementation phase, the team gathered feedback and notes during weekly staff meetings. They developed a coding framework to track key themes and concepts. The team also collected qualitative data from open-ended questions to assess recurring themes that could further evaluate the effectiveness of the cultural competency CCT. This approach will 12 ultimately ensure that the project leads to improved care for PI clients. The structured approach will also support future evaluations and continuous improvement efforts. Ethical Considerations The University of Utah determined that the CCT project qualified as a quality improvement initiative and, therefore, did not require Institutional Review Board approval. Despite this exemption, the team carefully adhered to ethical principles throughout the project. No conflicts of interest are associated with this project, ensuring the objectivity of the findings and outcomes. The primary focus remained on improving cultural competency for PI clients within the outpatient mental health clinic. This ethical approach aligns with best practices in quality improvement, which prioritize transparency, participant confidentiality, and the minimization of bias. The team designed the project with an emphasis on improving healthcare delivery for PI clients, ensuring that the CCT was developed and implemented in a way that was respectful, effective, and evidence based. Furthermore, the team incorporated continuous monitoring and feedback into the process to ensure ethical standards were maintained throughout. Results The CCT for PIs with mental health disorders was implemented over a 12-week period in an outpatient mental health clinic. The intervention included seven cultural and therapeutic models: the Talanoa Method (Vaka, 2014), Fonofale Model (Pulotu-Endemann, n.d.), Fa’afaletui Method (Mulipola et al., 2023), Uloa Method (Vaka et al., 2022), Lokahi Wheel (Lokahi Wheel Wellness, n.d.), Kaimana Intervention (Katoa & Taholo, 2019), and Acceptance and Commitment Therapy (Schultz, 2021). Clinicians were trained in these models and subsequently integrated the CCT into their practice with PI clients. During implementation, clinicians exhibited varying levels of familiarity and ease of use across the different models. The Kaimana Intervention and Lokahi Wheel (Lokahi Wheel Wellness, n.d.) emerged as the most frequently utilized tools, with 77.8% of clinicians reporting 13 regular use, largely due to pre-existing familiarity and alignment with current workflow processes. Less familiar models, such as Fa’afaletui and Uloa, were used less frequently—only 33.3% of clinicians reported attempting integration—primarily due to lack of training and uncertainty about how to apply these frameworks in mental health treatment (Mulipola, Holroyd, & Vaka, 2023; Vaka, Hamer, & Mesui-Henry, 2022; Table 2). Several modifications were made to facilitate CCT integration, including additional training sessions to enhance familiarity with lesser-known models, expansion of the terminology list to support cultural language comprehension, and adjustments to workflow integration based on clinician feedback. Specifically, clinicians recommended that the CCT include structured guidelines for use in psychiatric assessment, treatment planning, case documentation, and medication management discussions. To assess clinician engagement with the CCT, qualitative feedback was gathered through structured survey questions at multiple time points. Clinician feedback indicated that the implementation of the CCT was feasible, usable, and met with high levels of satisfaction. The toolkit was easily integrated into the clinic’s existing workflow, requiring minimal additional time—on average, about five minutes per session. Clinicians reported that having the materials available in both printed and digital formats improved accessibility and facilitated use across different clinical roles. Usability was particularly noted among newer clinicians, who described the toolkit as a helpful guide for preparing sessions and engaging more meaningfully with PI clients. Specific components such as the Lokahi Wheel and Kaimana Intervention were praised for their cultural relevance and alignment with therapeutic goals. Satisfaction was also high; 88.9% of clinicians expressed increased confidence in providing culturally competent care, and many described improved rapport and client engagement because of using the CCT. Several clinicians shared how the CCT enhanced their client sessions. Clinicians with prior experience using the Kaimana Intervention and Lokahi Wheel described seamless integration into sessions. One clinician noted, “This CCT is compatible with current workflow 14 processes—having a collection of resources that help clinicians with specific issues at the ready is beneficial.” Another reflected on how the CCT encouraged self-awareness and growth in cultural responsiveness: “Having resources for clinicians to assess their own blind spots, both in practice and in interaction with outside resources, is extremely helpful.” Clinicians new to practice found the CCT particularly valuable as a learning resource, as one participant reported, “As a new clinician, I regularly consult resources before and after sessions. Having this CCT on hand has been an easy addition”. However, others struggled with implementation, indicating that additional training and practical demonstrations of CCT use would improve its effectiveness. One clinician stated, “I had a difficult time implementing most of the tools because I do not feel I fully understood the concepts and how the models could be used. I would like more training or even a demonstration of how the tools work”. Clinicians reported increased confidence in providing culturally competent care following CCT implementation, particularly in addressing language and cultural barriers. One participant, a non-PI clinician, reflected on how the CCT helped bridge cultural divides, stating, “My PI clients often need tools, language, and resources that translate to their culture/lived experience. As a White practitioner, this is something I do not often have off the top of my head. This CCT helps me bridge that gap”. Clinicians also noted improvements in client engagement, which refers to a client’s active involvement and emotional investment in the therapeutic process (Bijkerk et al., 2024). One clinician shared that the Lokahi Wheel model was especially well received by PI clients reporting, “The Lokahi Wheel has been a tool used with PI clients, and they provided positive feedback. It helped them set boundaries and know themselves more. It resonated with their healing and needs”. Similarly, another clinician emphasized that the Fonofale Model (PulotuEndemann, n.d.) was beneficial in helping providers understand PI values and perspectives, stating, “The Fonofale model would help providers understand the depth of PI clients' lens and values, which sometimes are at cross-purposes with how Westerners view their experience.” 15 Several contextual factors influenced the implementation and effectiveness of the CCT. The pre-existing use of Kaimana Intervention and Lokahi Wheel in the clinic’s workflow facilitated CCT adoption, as many clinicians already integrated these models into their practice. However, lack of structured implementation guidelines made it challenging to apply the CCT in clinical documentation and psychiatric care. One clinician suggested improving the CCT by providing specific guidance on when and how to incorporate it into assessments, treatment planning, and medication management discussions, stating, “If the [CCT] could be broken down into possible markers for discussion on medication/psychiatric evaluation and medication management, it would be most helpful”. Clinicians recommended a follow-up phase in which CCT implementation would be reviewed through case discussions and further training, ensuring that providers could refine their use of the models over time. Several unintended benefits emerged from the implementation of the CCT. Clinicians noted that using the CCT enhanced their ability to work with other minority populations beyond PIs. Additionally, many reported strengthened clinician-client relationships, which they believed contributed to greater trust and long-term engagement in mental health services. These outcomes were assessed through qualitative analysis of open-ended responses from the postimplementation questionnaire, which invited clinicians to reflect on perceived benefits, challenges, and overall effectiveness of the CCT. Implementation barriers were also identified. Some clinicians struggled to incorporate the CCT into practice due to time constraints, while others required more structured guidance on when to apply specific tools. One participant noted, “I think this is where we need help in implementing the [CCT]. I recommend discussing points of initial assessment, treatment planning, case progress notes, etc., for when and how to apply the [CCT].” One participant noted, “I think this is where we need help in implementing the [CCT]. I recommend discussing points of initial assessment, treatment planning, case progress notes, etc., for when and how to apply the [CCT].” 16 Discussion Summary The implementation of the CCT demonstrated improvements in clinician awareness of cultural gaps, an enhanced ability to identify client needs through a cultural lens, and increased engagement with PI clients. Due to clinician familiarity and alignment with existing workflows, the Kaimana Intervention and Lokahi Wheel were the most frequently utilized models. Less familiar models, such as Fa’afaletui and Uloa (Vaka et al., 2022), were used less frequently due to a lack of training and integration challenges. A key strength of this project was its multi-modal educational approach, which provided clinicians with interactive training, patient experiences, and culturally adapted resources. The CCT’s incorporation of PI values—family involvement, spirituality, and communal decisionmaking—reinforced trust and participation within the community. Clinicians also noted that the CCT helped them assess their own biases, enhancing their ability to provide culturally responsive care. Additionally, the project fostered long-term engagement in mental health services, particularly among new clinicians, who found the CCT to be a valuable learning resource. One new clinician expressed that the CCT served as a helpful reference before and after client sessions, making it a practical and easy-to-use addition to their clinical practice. The results support the initial hypothesis that a cultural competency CCT would improve mental health care delivery and patient outcomes in this population. Clinician feedback emphasized that structured training and practical resources improved their confidence in addressing cultural barriers in psychiatric care. Challenges in implementation were noted, particularly for models that were less familiar to clinicians or not already integrated into existing workflows. To address these barriers, additional training sessions were introduced to enhance familiarity with lesser-known models, and clinicians recommended structured guidelines for 17 integrating the CCT into psychiatric assessment, treatment planning, case documentation, and medication management discussions. Moving forward, recommendations for sustainability include ongoing training, case discussions, and follow-up assessments to refine clinicians' use of the CCT. Additionally, incorporating structured guidelines for medication management discussions and psychiatric evaluations would improve the CCT’s utility in psychiatric care. Future projects could explore longitudinal patient outcomes, expand the CCT for use in diverse healthcare settings, and assess its impact on reducing mental health disparities among PIs. Interpretation The project team developed the CCT to strengthen clinicians’ cultural competency and increase engagement with PI clients. The results indicate the feasibility, usability and satisfaction of the CCT and help to demonstrate a significant link between the intervention and improved clinician awareness, patient engagement, and cultural responsiveness. Clinicians who integrated the CCT reported increased confidence in addressing cultural barriers, while PI clients demonstrated greater participation in mental health services, as assessed through qualitative responses from the post-implementation survey. The success of widely utilized models such as the Kaimana Intervention and Lokahi Wheel suggests that prior familiarity and ease of integration played a crucial role in effectiveness. Conversely, models that were less familiar were used less frequently, highlighting the importance of ongoing training and structured implementation guidelines. The findings of this project align with existing literature on culturally tailored interventions improving patient outcomes in underrepresented populations (Oh et al., 2021). Previous studies have shown that culturally competent care leads to increased patient trust, adherence, and engagement in treatment (Stubbe, 2020). Similar interventions, such as the use of Indigenous healing models and community-based approaches, have demonstrated effectiveness in reducing mental health disparities (Subica et al., 2022). However, unlike prior research that 18 emphasized patient-only interventions, this CCT focused on clinician education and integration of cultural frameworks into care delivery, making it a unique contribution to the field. One notable distinction from prior studies was the variability in clinician adoption of different CCT components, underscoring that ease of integration and clinician training are critical to implementation success (Reynolds & Granger, 2023). The implementation of the CCT was perceived by clinicians to enhance culturally responsive care, with qualitative feedback indicating high satisfaction with the CCT’s structure, relevance, and ease of use. Clinicians also noted that the CCT improved engagement and rapport with PI clients, supporting its overall usability in real-world practice. According to the post-implementation survey, 88.9% of clinicians expressed increased confidence in delivering culturally competent care, and 44.4% noted improved client engagement with alignment of cultural values. These factors likely contributed to higher client participation and retention in therapy. From a systems perspective, the project highlighted the need for structured cultural competency training in outpatient mental health settings. Clinicians noted that the CCT provided a valuable resource for understanding PI cultural values and improved interdisciplinary collaboration. However, challenges such as time constraints and lack of familiarity with some models affected full implementation. Despite these challenges, the CCT demonstrated high feasibility and usability, with recommendations for expanding training opportunities and creating structured implementation guidelines to further enhance its impact. These factors suggest that contextual influences, clinician experience, and organizational stability play a significant role in the effectiveness of cultural competency interventions. Future iterations of this project should incorporate structured implementation strategies and adaptability to organizational changes. 19 The project required time investments for clinician training and implementation, but the benefits—improved cultural competency, stronger clinician-patient relationships, and increased engagement—outweighed the challenges. Future efforts should focus on developing structured guidelines for CCT integration into psychiatric assessments, treatment planning, and medication management. Expanding training opportunities will ensure clinicians are equipped to use all components of the CCT effectively. Future studies should incorporate quantitative outcome measures to evaluate long-term effectiveness and patient impact. The CCT should be refined based on clinician feedback and expanded to additional clinics and healthcare settings. Integrating cultural competency into ongoing professional development across mental health and other healthcare disciplines is recommended. Additionally, assessing patient-reported outcomes could provide valuable insights into the CCT’s impact on engagement and symptom improvement. These findings underscore the critical role of cultural competency in advancing equity and inclusion in mental health services. To facilitate stakeholder understanding and support future dissemination, an executive summary was developed and is included in Appendix E. This summary outlined the project’s rationale, implementation process, outcomes, and recommendations for expanding the CCT into other outpatient mental health settings. Limitations The findings of this project are limited in generalizability as it was conducted in a single outpatient mental health clinic with a specific focus on PI clients. While the results indicate positive outcomes, broader implementation across different healthcare settings is needed to determine scalability and effectiveness in diverse populations. An unforeseen challenge that impacted the project was the relocation of the outpatient mental health clinic to a new office space. This transition disrupted clinical operations and delayed some of the time needed for clinicians to implement the CCT fully. As a result, some 20 clinicians reported that they had less time than anticipated to engage with the CCT and integrate it into their sessions with PI clients. This relocation also required clinicians to adjust to a new clinical setting, further impacting their ability to adopt new workflow processes during the intervention period. Future implementation efforts may need to account for external organizational changes that could interfere with intervention uptake. Furthermore, the CCT lacked integration into medication management, a key component of psychiatric care, which clinicians suggested should be addressed in future iterations. One clinician did not provide qualitative feedback, leading to minor gaps in the data. Additionally, limited patient-level outcome data were collected, as the project focused primarily on clinicianreported experiences. There is also the possibility of underreporting of challenges, as some clinicians may have provided primarily positive feedback rather than discussing difficulties with implementation. To address these limitations, surveys and feedback were collected at multiple time points to capture clinician experiences. Clinicians were encouraged to provide both positive and critical feedback to ensure balanced reporting. Recommendations for future implementation include integrating standardized outcome measures to quantify patient impact. Conclusions In conclusion, this project highlights the critical role of culturally competent care in improving mental health outcomes for PIs. Despite challenges in implementation, the findings support continued integration of culturally adapted interventions into clinical practice and reinforce the need for patient-centered, inclusive mental health care models that address the unique needs of underrepresented and underserved populations. This finding aligns with a scoping review by Oh et al. (2021), which demonstrated that culturally tailored interventions can significantly enhance patient engagement, satisfaction, and treatment adherence while reducing health disparities and improving quality of care for ethnic minorities. 21 This project demonstrated that a CCT can enhance clinician awareness, improve patient engagement, and support culturally responsive mental health care for PIs. The implementation team encountered multiple challenges, reinforcing the need for structured clinician training, ongoing support, and adaptability within clinical workflows. The CCT is highly feasible and usable, with potential for long-term sustainability through integrated clinician education and interdisciplinary collaboration. The intervention has strong potential to be expanded to other healthcare settings, particularly in communities with diverse or underserved populations. Future adaptations could tailor the CCT to other ethnic and cultural groups experiencing mental health disparities. 22 Acknowledgments I am deeply grateful to those who contributed to the success of this Doctor of Nursing Practice (DNP) Quality Improvement Project. I extend my sincere appreciation to my content expert, Dr. Lani Taholo, PhD, LCSW, and content sponsor, Tausoa Mulitalo, CSW, for their invaluable guidance and expertise. Their support was instrumental in shaping the Cultural Competency Toolkit and ensuring its relevance in clinical practice. I also thank the clinical staff at Child and Family Empowerment Services LLC for their participation, feedback, and dedication to culturally responsive mental health care. Special thanks to my project chair, Dr. John A. Nerges, DNP, RN, CEN, CCEN, NEA-BC, and my track director, Dr. Teresa Garrett, DNP, RN, PHNA-BC, for their mentorship and encouragement. I also appreciate Dr. Julie Gee, PhD, MSNEd, RN, Assistant Dean and Dr. Cynthia Beynon, PhD, MSN-Ed, RN, CNE Assistant Dean for their support throughout this journey. This project was funded by the Dick & Timmy Burton Scholarly Project Scholarship. The funding organization had no role in the design, implementation, interpretation, or reporting of this project. Lastly, I am profoundly grateful to my family, colleagues, and mentors for their unwavering support, patience, and encouragement. Thank you to all who helped make this project a reality. 23 References Anonymous (n.d.). About our services. Retrieved March 30, 2025, from https://anonymousclinic.com/ Auva’a-Alatimu, T. (2023). Complementing cognitive behavioral therapy (CBT) for Pacific peoples in New Zealand. Journal of Pacific Rim Psychology, 17, 183449092311681. https://doi.org/10.1177/18344909231168179 Bijkerk, L. E., Spigt, M., Oenema, A., & Geschwind, N. (2024). Engagement with mental health and health behavior change interventions: An integrative review of key concepts. Journal of Contextual Behavioral Science, 32, 100748.https://doi.org/10.1016/j.jcbs.2024.100748 Cutrer-Párraga, E. A., Allen, G. E. K., Miller, E. E., Garrett, M. F., Conklin, H., Franklin, C. N., Norton, A., Hee, C., & Coffey, B. K. (2024). Perceptions and barriers about mental health services among PIs: An interpretative phenomenological analysis. Journal of Counseling Psychology, 71(2), 89–103. https://doi.org/10.1037/cou0000719 Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International. Hafoka Kanuch, O., Smith, T. B., Griner, D., Allen, G. E. K., Beecher, M. E., & Young, E. (2021). Psychotherapy utilization, presenting concerns, and outcomes among Pacific Islander and Asian American Students. Counselling Psychology Quarterly, 34(2), 183–200. https://doi.org/10.1080/09515070.2019.1699502 Katoa & Taholo, L. (2019). Kaimana Intervention: A culturally responsive approach to Pacific Islander mental health. Child and Family Empowerment Services. Kingi-Uluave, D., & Olo-Whaanga, E. (2010). Talking therapies for Pasifika peoples. https://healthify.nz/assets/talking-therapies-for-pasifika-peoples-1.pdf 24 Kwan, P. P., Soniega-Sherwood, J., Esmundo, S., Watts, J., Pike, J., Sabado-Liwag, M., & Palmer, P. H. (2020). Access and utilization of mental health services among PIs. Asian American Journal of Psychology, 11(2), 69–78. https://doi.org/10.1037/aap0000172 Lim, A. (2022). U.S. Census: A closer look at the fastest growing minority group in the United States. National Diversity Council. https://www.nationaldiversitycouncil.org/u-s-census-acloser-look-at-the-fastest-growing-minority-group-in-the-united-states/ Lokahi Wheel Wellness Lokahi. (n.d.). Kamehameha Schools—Kealapono ‘Ohana Engagement OHAna Resources to help the ‘ohana flourish. Mulipola, T. I., Holroyd, E., & Vaka, S. (2023). Using Fa’afaletui to explore Samoan consumers’ experience and interpretation of mental health person-centered care in Aotearoa, New Zealand. International Journal of Mental Health Nursing, 32(2), 513–523. https://doi.org/10.1111/inm.13090 National Alliance on Mental Illness. (n.d.). Video resource library. Retrieved from https://www.nami.org/support-education/video-resource-library/ National Asian American Pacific Islander Mental Health Association. (n.d.). NAAPIMHA handouts. Retrieved from https://www.naapimha.org/handouts Oh, H., Truong, M., Kim, N., & Allen, A. (2021). Culturally tailored interventions for ethnic minorities: A scoping review. BMC Public Health, 21(1), 1–14. https://doi.org/10.1186/s12889-021-11684-2 Pulotu-Endemann, F. K. (n.d.). The Fonofale model of health. Open Polytechnic Kuratini Tuwhera. Retrieved from https://www.openpolytechnic.ac.nz/currentstudents/wellbeing/the-fonofale-model/ Reynolds, S. S., & Granger, B. B. (2023). Implementation Science CCT for Clinicians: Improving Adoption of Evidence in Practice. Dimensions of Critical Care Nursing, 42(1), 33–41. https://doi.org/10.1097/DCC.0000000000000556 25 Samu, & Suaalii-Sauni, T. (2009). Exploring the 'cultural' in cultural competencies in Pacific mental health. Pacific Health Dialog, 15(1), 120–130 Schultz, J. (2021, March 21). What is ACT? The Hexaflex model and principles explained. Positive Psychology. Retrieved from https://positivepsychology.com/act-model/ Stubbe, D. E. (2020). Practicing cultural competence and cultural humility in the care of diverse patients. Focus (American Psychiatric Publishing, 18(1), 49–51. https://doi.org/10.1176/appi.focus.20190041 Subica, A. M., Aitaoto, N., Link, B. G., Yamada, A. M., Henwood, B. F., & Sullivan, G. (2019). Mental health status, need, and unmet need for mental health services among U.S. PIs. Psychiatric Services, 70(7), 578–585. https://doi.org/10.1176/appi.ps.201800455 Subica, A. M., Guerrero, E. G., Martin, T. K. K., Okamoto, S. K., Aitaoto, N., Moss, H. B., Morey, B. N., & Wu, L. (2022). Native Hawaiian/Pacific Islander alcohol, tobacco, and other drug use, mental health, and treatment need in the United States during COVID-19. Drug and Alcohol Review, 41(7), 1653–1663. https://doi.org/10.1111/dar.13522 Substance Abuse and Mental Health Services Administration. (2023, May 25). Asian American, Native Hawaiian, and Pacific Islander (AA and NHPI). https://www.samhsa.gov/behavioral-health-equity/aa-nhpi Tan, C., Lo, F., Ocampo, C., Galán, M., & Ponce, N. A. (2024). Piecing the puzzle of AANHPI mental health: A community analysis of mental health experiences of Asian Americans, Native Hawaiians, and PIs in California. AAPI Data & UCLA Center for Health Policy Research. Tucker, S., McNett, M., Mazurek Melnyk, B., Hanrahan, K., Hunter, S. C., Kim, B., Cullen, L., & Kitson, A. (2021). Implementation Science: Application of Evidence-Based Practice Models to Improve Healthcare Quality. Worldviews on evidence-based nursing, 18(2), 76–84. https://doi.org/10.1111/wvn.12495 26 U.S. Census Bureau. (2001). Census 2000 brief: The Native Hawaiian and other Pacific Islander population: 2000. https://www.census.gov/library/publications/2001/dec/c2kbr01-14.html Utah Department of Health and Human Services. (n.d.). Language and culture. https://healthequity.utah.gov/language-and-culture/ Vaka, S. L., (2014). A Tongan Talanoa about conceptualisations, constructions and understandings of mental illness. https://mro.massey.ac.nz/server/api/core/bitstreams/5cd71241-f0c7-453b-8e69dbba35182793/content Vaka, S., Hamer, H. P., & Mesui-Henry, A. (2022). The effectiveness of ūloa as a model supporting Tongan people experiencing mental distress. International Journal of Mental Health Nursing, 31(6), 1438–1445. https://doi.org/10.1111/inm.13044 Vaka, S., Neville, S., & Holroyd, E. (2020). An ethnic interpretation of mental distress from the perspective of Tongan men and community leaders. International Journal of Mental Health Nursing, 29(5), 953–961. https://doi.org/10.1111/inm.12732 Yamada, Vaivao, D. E. S., & Subica, A. M. (2019). Addressing Mental Health Challenges of Samoan Americans in Southern California: Perspectives of Samoan Community Providers. Asian American Journal of Psychology, 10(3), 227–238. https://doi.org/10.1037/aap0000140 27 Tables and Figures Table 1. Participant Demographics and Training Variable Professional Title Years of Experience Client Gender Works with PI Clients Client Age Groups Served Race/Ethnicity Languages Spoken Cultural Competency Training Frequency (N=10) Social Worker Intern CSW LCSW Clinical Director Administrative Staff Psychologist Licensed Medical Provider (Psychiatrist, MD, NP, PA) 1 – 2 years Less than 1 year 3 – 5 years 6 – 10 years 11 – 15 years More than 20 years Male Female Transgender Female Non-binary Transgender Male Yes No 5 2 1 1 1 0 Percent (%) 50% 20% 10% 10% 10% 0% 0 0% 4 2 1 1 1 1 10 10 2 1 1 9 1 40% 20% 10% 10% 10% 10% 100% 100% 20% 10% 10% 90% 10% Under 35 years old 10 100% 35 years and older White/Caucasian Hispanic/Latinx Pacific Islander English Spanish 7 5 3 3 10 5 70% 50% 30% 30% 100% 50% Online course/webinars 8 80% Diversity & Inclusion Training Training on specific cultural groups In-person workshop Post-secondary education Language & Communication Skills 8 6 4 3 2 80% 60% 40% 30% 20% Category 28 Variable Frequency (N=10) Category No training 1 Percent (%) 10% 29 Table 2: Themes and Key Findings from Cultural Competency CCT Implementation Theme Key Findings Clinician Confidence Reported increased confidence in delivering culturally competent care Increased awareness of cultural gaps in care Helped address cultural/language barriers Used Kaimana Intervention and Lokahi Wheel due to familiarity Used Fa’afaletui and Uloa Methods less often due to lack of training CCT helped assess personal bias and improve cultural responsiveness Needed more structured guidelines for applying models Time constraints limited CCT integration PI clients responded positively to Lokahi Wheel Fonofale Model helped clinicians understand PI values Requested more training and practical demonstrations Suggested clearer guidelines for clinical documentation Strengthened clinician-client relationships CCT supported work with other minority groups Impact on Cultural Competency CCT Utilization Cultural Awareness Barriers to Implementation Client Engagement Recommended Improvements Unintended Benefits Response Count (N=9) 8 Percentage (%) 88.9% 8 88.9% 7 77.8% 7 77.8% 3 33.3% 6 66.7% 6 66.7% 4 44.4% 4 44.4% 3 33.3% 5 55.5% 5 55.5% 4 44.4% 3 33.3% 30 Figure 1 John Hopkins Evidence-Based Practice Model (2022) 31 Figure 2 Pre-Implementation Survey WILLING TO USE TOOLKIT 0 2 OPEN TO FEEDBACK 0 8 3 7 WORKPLACE PROMOTES CULTURAL…0 1 USE CULTURALLY APPROPRIATE TOOLS 1 ADEQUATE KNOWLEDGE ON PI CLIENTS 1 AWARE OF OWN BIASES 0 4 1 2 Strongly Disagree Disagree 3 2 1 3 2 Neutral 2 5 4 1 3 2 3 IMPORTANCE OF CULTURAL COMPETENCY 0 1 EDUCATED ON OTHER CULTURES 5 5 2 3 Agree 3 Strongly Agree 32 Figure 3 Lokahi Wheel Wellness Lokahi. (n.d.). Kamehameha Schools—Kealapono ‘Ohana Engagement OHAna Resources to help the ‘ohana flourish. 33 Appendix A Cultural Competency Tool-kit Presentation "Breaking Barriers: A Toolkit for Culturally Competent Mental Health Care for Pacific Islanders" Background • Native Hawaiian Pacific Islander (NHPI) is an umbrella term that refers to people having origins in any of the islands of Hawaii, Guam, Samoa, or other Pacific Islands (US Census Bureau, 2001) • NHPI in the United States face greater MH risks and underutilization of MH services than their white counterparts (Cutrer-Párraga et al., 2024) • Native Hawaiian/Pacific Islander populations in Utah increased by 52% between 2010-2020 (US Census Bureau 2016-2020 as cited in Utah Department of Health & Human Services) • Barriers to access include shame associated with MH illness, low levels of MH awareness, lack of knowledge of MH problems and lack of culturally responsive providers [Yamada et al., 2019 (as cited in Snow et al., 2023)] Child & Family Empowerment Services Who are PI? Problem Statement 01 Utah is the 5th state with the largest PI population 03 Lack of culturally appropriate care by non-PI providers impacts PI when seeking treatment and adherence 02 Suicide remains the leading cause of death among PI ages 10-19 in the US https://youtu.be/WoOMZ5HLg9w?si=HfdjjICVnKiH3nDh (SAMHSA, 2023) 04 Lack of knowledge of appropriate cultural language, family involvement and context and relationship between body and spirit Cultural Competency vs. Cultural Humility CULTURALLY COMPETENT CARE is defined as care that respects diversity in the patient population and cultural factors that can affect health and health care, such as language, communication styles, beliefs, attitudes, and behaviors. Barriers to mental health treatment ● ● ● ● ● ● CULTURAL HUMILITY involves entering a relationship with another person to honor their beliefs, customs, and values. It entails an ongoing process of self-exploration and self-critique combined with a willingness to learn from others. ● ● ● ● ● Stigma Cultural Perceptions Family Centric Values Preference for traditional healing Limited English Proficiency Cost of treatment Lack of insurance Low literacy levels Immigration and legal issues Historical trauma and colonization Intergenerational conflict 34 Talanoa Method • TALA – “to tell” NOA – “zero” without concealment, point where usually all come to agreement and a sense of balance and harmony is found. • Informal and Formal • Face to face • Stories • Collectivism, families, spiritual beliefs, culture, interconnectedness, saving face, respecting elders • TRUST, APPROACHABLE, LISTEN, ASK QUESTIONS, NAVIGATE TOGETHER, OFFER INFORMATION, ADDRESS CONCERNS Uloa Model Fa’afaletui method • Samoan word for Conversation • Fa’afaletui is the combination of three Samoan words ‘faa’ ‘the ways of’, ‘fale’ a Samoan house and ‘tui’ the process of ‘weaving’. Through interactive discourse, issues are comprehensively discussed and tui (woven) to achieve pertinent resolutions of individuals and communities and reflecting the fa’a Samoa. Fonofale Model • Falealuga – Roof. The falealuga represents culture, values and beliefs, which are considered the shelter for life. https://youtu.be/fKL o5Io32u8?si=4tMSKR WPUiy7nx3U Linear vs. Circular Individual vs. Collective Social vs. Spiritual vs. Environmental • Pou – The Posts. The file structure is supported by four pou, which represent the fa’aleagaga (spiritual), fa’aletino (physical), mafaufau (mental), and time (other) aspects of well-being. • Fa’avae – Foundation. Fa’avae represents the values of aiga (family), which is the foundation for all Pacific Island cultures. • The Cocoon – Time, environment, context. Surrounding the fale is the cocoon. This represents your environment, time and context, all of which affect and shape who you are. Terminology 'Ofa / Alofa – Love Faka’apa’apa / Fa’aaloalo – Respect Tauhi va – maintaining relationship ‘Atamai – mind, brain ‘Atamai vaivai – weak brain, mental illness Fakakaukau – thoughts Loto – soul, heart Loto mafana - warmth Faito’o – treatment, medication Famili – family Kainga – extended family Masoli – mental illness Mahei – mental illness Taimi vave – mental illness Puke – sick, illness Puke faka’atamai – illness of the brain Puke fakatevolo – possessed by evil spirits Fakasesele - crazy Community Resources https://www.saltlakecounty.gov/globalassets/1-site-files/sheriff/medical-resources.pdf (SLC county resources) https://www.saltlakecounty.gov/health/resources/ (SLC County) https://health.utahcounty.gov/wp-content/uploads/sites/49/2023/06/Community-Resources3.23-English-.pdf (UT county community resources) https://www.ntasutah.org/ (Translation Services) https://aau-slc.org/ (Asian Association of Utah) https://drive.google.com/drive/folders/1oOV6OFKxtIqxYKGvtrhs7aN6tLSkEEA?usp=drive_link (mini-trainings / resources) https://docs.google.com/spreadsheets/d/e/2PACX1vTg7nyHcCfXnBP9aqvdlOWmxFoa4hYFkWLxuy8MNneXbbRNOR1P8qCOJLhbVxrRIQ3 UlXacRbNwA7X9/pubhtml (Utah Domestic Violence Resource Sheet) Lokahi Wheel 35 Appendix B Shortened Cultural Competency Provider Assessment Survey This survey was developed to assess providers’ knowledge, attitudes, and readiness regarding cultural competency, humility, and resilience when working with clients of Pacific Islander backgrounds. Section 1: Demographics and Clinical Experience 1. Professional Title (Select all that apply): ☐ Social Worker ☐ LCSW ☐ Psychologist ☐ Nurse Practitioner ☐ Administrative Staff ☐ Other 2. Years in Profession: _____ 3. Age Groups Served (Select all that apply): ☐ Under 18 ☐ 18–24 ☐ 25–34 ☐ 35–44 ☐ 45–54 ☐ 55+ 4. Genders Served (Select all that apply): ☐ Male ☐ Female ☐ Non-binary ☐ Transgender ☐ Other 5. Do you currently treat clients of Pacific Islander descent? ☐ Yes ☐ No Section 2: Cultural Competency Training & Experience 6. Have you heard of the terms cultural competency, cultural humility, and cultural resilience? ☐ Yes ☐ No 7. Previous Cultural Competency Training (Select all that apply): ☐ Online/Webinar ☐ In-person ☐ DEI Training ☐ Language Skills ☐ None ☐ Other: ___________ 8. Familiarity with the Lokahi Wheel: a. Have you been trained in using it? ☐ Yes ☐ No b. Do you use it in practice? ☐ Yes ☐ No 36 Section 3: Perceptions and Practices Please rate the following statements on a 5-point Likert scale: (1 = Strongly Disagree | 5 = Strongly Agree) Item 1 2 3 4 5 I have educated ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ myself about cultures other than my own. I value gaining skills in cultural competency, humility, and resilience. I am aware of my cultural biases and assumptions. I feel culturally competent working with Pacific Islander clients. I use culturally appropriate 37 tools in my practice. My workplace ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ promotes cultural responsiveness. I am open to feedback about my cultural interactions. I am willing to incorporate a cultural CCT in my work. Section 4: Open-Ended Questions 9. Describe a time you used a culturally appropriate tool with a Pacific Islander client. ____________________________________________________________ 10. What resources would help you improve your cultural competency? ____________________________________________________________ 11. What barriers do you anticipate in using a cultural competency CCT? ☐ Time ☐ Resources ☐ Admin support ☐ Applicability ☐ Other: ___________ 38 Appendix C Cultural Competency CCT Handout 39 40 41 Appendix D Post-Implementation Questionnaire: Cultural Competency CCT for Pacific Islander Mental Health Care Thank you for participating in the implementation of the Cultural Competency CCT. This postimplementation questionnaire is designed to gather in-depth feedback from clinicians on the effectiveness, usability, and cultural relevance of the CCT. Your insights are vital to refining the CCT and improving culturally responsive care for Pacific Islander clients. 1. In what ways do you believe the Cultural Competency CCT has addressed existing gaps in mental health care for Pacific Islander clients? 2. How well did the CCT align with your current workflow processes? Please describe any specific areas where it fit well or where adjustments were necessary. 3. Describe your experience integrating the CCT into your clinical practice. What aspects were easy or challenging, and why? 4. What recommendations do you have for improving the CCT’s design, content, or implementation process? 5. Reflecting on your Pacific Islander clients, do you feel the CCT met their cultural and therapeutic needs? Please explain why or why not and provide examples if possible. 42 Appendix E Executive Summary Cultural Competency CCT for Providers Working with PIs in an Outpatient Mental Health Clinic Situation Pacific Islanders (PIs) in the United States experience significant mental health disparities, including disproportionately high rates of depression, anxiety, and suicide compared to other ethnic groups. Despite this, there is limited research and culturally responsive interventions tailored to Pacific Islander (PI) mental health needs. Traditional Western mental health frameworks often fail to address cultural influences on mental health perceptions, engagement, and treatment adherence. This gap contributes to low utilization of mental health services and poor treatment outcomes. Providers in outpatient mental health settings often lack structured training and resources to integrate PI cultural values and traditional healing practices into clinical care. Background To address this gap, a Cultural Competency CCT (CCT) was developed and implemented in an outpatient mental health clinic over a 12-week period. The intervention included training clinicians on seven cultural and therapeutic models, including the Talanoa Method, Fonofale Model, Fa’afaletui Method, Uloa Method, Lokahi Wheel, Kaimana Intervention, and Acceptance and Commitment Therapy (ACT). The CCT was designed to enhance provider cultural competency, improve patient engagement, and reduce disparities in mental health care for PIs. Clinicians received structured training, integrated the CCT into their practice, and provided feedback through surveys, qualitative interviews, and implementation assessments. Assessment The project demonstrated positive outcomes, with clinicians reporting increased cultural awareness, improved confidence in engaging with PI clients, and stronger therapeutic 43 relationships. The Kaimana Intervention and Lokahi Wheel were the most frequently used models due to ease of integration into existing workflows. However, clinicians faced challenges incorporating lesser-known models due to limited familiarity and structured implementation guidelines. Unexpected positive outcomes included increased family involvement in treatment, greater provider self-reflection on cultural biases, and enhanced clinician-client trust. External factors, such as clinic relocation and time constraints, impacted full implementation. Recommendation To sustain and expand the impact of this intervention, the following recommendations should be considered: 1. Expand the CCT to other outpatient mental health clinics and diverse healthcare settings to assess broader scalability. 2. Develop structured guidelines to integrate cultural frameworks into psychiatric assessments, treatment planning, and medication management discussions. 3. Provide ongoing clinician training and mentorship programs to ensure consistent application of cultural models in practice. 4. Conduct further research on patient-reported outcomes to measure long-term benefits of culturally tailored mental health care. 5. Enhance implementation strategies by creating workflow-friendly resources, such as case-based learning modules, demonstration sessions, and digital CCTs to improve clinician adoption. By addressing these recommendations, healthcare providers can strengthen cultural competency, improve mental health outcomes for PIs, and reduce disparities in mental health care access and treatment adherence. The CCT represents a promising, feasible, and effective intervention for integrating culturally responsive care into outpatient mental health settings.