Jenna Hall

2/5/15
Northland Community and Technical College
Occupational Therapy Assistant Program
Final Critically Appraised Topics Assignment
Focused Question:
How can Occupational Therapy improve the quality of life in underserved areas, specifically
rural reservation communities?
Clinical Scenario:
There are roughly 4.12 million American Indian & Alaska Native (AI/AN) individuals in the
United States today, making up approximately 1.5% of the total U.S. population. According to
the National Congress of American Indians (NCAI, 2003):
There are 562 federally recognized Indian Nations (variously called tribes, nations,
bands, pueblos, communities, rancherias and native villages) in the United States.
Approximately 229 of these ethnically, culturally, and linguistically diverse nations are
located in Alaska; the rest are located in 33 other states.
The aforementioned findings exclude tribes in Canada, which is important to note, since some of
the findings in this article were gathered from aboriginal individuals living both off and on
reserves throughout Canada.
While 1.5% of the U.S. population may not seem significant when looking at the bigger picture
and the need for occupational therapy as a whole across the U.S., it is important to note how the
individuals within this population are dispersed across the map. According to the 2010 Census,
53.8% of the nations American Indian/Alaskan Native population resides in rural and small
town areas (HAC, 2012). At just over half of the AI/AN population living in rural and small
town communities, many of these individuals likely reside on or near a reservation. Reservations
are allotments of land that AI/ANs were either forced onto by the federal government or moved
onto freely. In Canada the term reservation, is often replaced by the word reserve, both words
are interchangeable, but there are differences in the governing and treaties of each. Both are
areas of land reserved for a tribe to inhabit. In the U.S. there are three types of reserved federal
lands, they are, military, public, and Indian. A federal Indian reservation is an area of land where
the federal government holds title to the land in trust on behalf of the tribe. Not all federally
recognized tribes have a reservation, nor are all tribes federally recognized (BIA, n.d.).
A federally recognized tribe is an American Indian or Alaska Native tribal entity that is
recognized as having a government-to-government relationship with the United States,
with the responsibilities, powers, limitations, and obligations attached to that designation,
and is eligible for funding and services from the Bureau of Indian Affairs (BIA, n.d.)
Reservations range in size from 16 million-acres to a 1.32 acre parcel of land and are spread
throughout the U.S. Many minorities are clustered geographically in regions closely tied to

historical social and economic dynamics. For many rural minorities, especially those living in
communities with a large minority populations, social and economic conditions continue to lag
far behind those of their white counterparts and urban populations overall (HAC, 2012, p. 2).
Tribal governments, like state governments, receive some federal funding for services, the
funding of concern for this article being money set aside from the federal government to provide
basic health care for all Indian people through IHS. This agreement being part of a treaty
between federal government and tribal governments (NCAI, n.d.).
Occupational Therapy Practitioners have a presence in Indian country, but there is a need for
more therapists, specifically American Indian therapists. According to a report from the United
States Government Accountability Office (GAO) Indian Health Service, (IHS, 2005):
Occupational therapists are needed with experience or interest in some of the following
areas of practice: orthopedics, neuro-rehabilitation, hand therapy, orthotic fabrication,
burn trauma and pediatrics. These constitute many of the services O.T.s provide,
complementing the healthcare challenges in many of the remote and underserved areas of
the country where Indian Health Hospitals are located.
As identified by the GAO, there are three distinct factors associated with the availability of
services offered through IHS. Those factors are, but are not limited to, the facilitys structure,
location, and funding from sources other than IHS. Lack of space or money to create a space for
additional care, especially specialty services, such as Occupational Therapy (OT); fall under the
issue of availability in the facilitys structure. Location of hospitals, health centers, and health
stations, are often rural areas, which means there is a shortage of hospital housing for providers
on the reservation and in the surrounding communities. Some of these isolated locations also
lack educational and recreation opportunities for providers and their families. Funding being one
of, if not the biggest challenge, occupational therapy practitioners wanting to serve in rural
reservation communities come across. Funding for IHS hospitals come from reimbursements
from private and federal health insurance programs, as well as occasional financial involvement
by some tribes in which the facility is serving.
The Network of Native American Practitioners (NNAP) acknowledges the need for skilled
American Indian/Alaskan Natives in communities with population of native peoples to be
served. According to the mission of NNAP on the American Occupational Therapy Association
(AOTA) website (2014):
Increase resources for occupational therapists currently working with, or interested in
working with, Native Americans. The NNAP promotes the recruitment and retention of
Native Americans into the field of occupational therapy and the development of materials
to educate the profession and the AOTA membership about Native American issues.
Understanding how best to serve these communities through therapy, resources, and education
within the profession of occupational therapy is the focus of this assignment.
Summary of Key Findings:

Level II:

Quality of Life in American Indian and White Women With and Without
Rheumatoid Arthritis, Poole, J. L., Chiappisi, H., Cordova, J. S., and Sibbitt, W. (2007)
This article involved a cross-sectional study of 64 women divided up into four groups:
17 American Indian women with rheumatoid arthritis, and 17 without, as well as 15 White
women with rheumatoid arthritis and 15 without. Individuals with rheumatoid arthritis had been
diagnosed for at least a year and did not have any comorbidity. Quality of life in individuals who
have a chronic illness or disease such as rheumatoid arthritis are often studied because of their
involvement or lack thereof in occupations, as well as their overall wellbeing. Some of the
highest prevalence rates, earliest onset age, and severity of rheumatoid arthritis are in the
American Indian populations vs. the white population (as cited in Poole, et al., 2007). This study
sought out if disease or ethnicity had an impact on quality of life between white and American
Indian women with and without rheumatoid arthritis. As a whole, there were few significant
differences between ethnicity and rheumatoid arthritis, however; there were differences that
should be noted. For instance, American Indian women with rheumatoid arthritis had lowerextremity Keital Functional Test (KFT) scores (less motion) as well as slower dexterity than
white women with rheumatoid arthritis. American Indians with rheumatoid arthritis also showed
the lowest community integration.
Level IV:
Brain injury from a First Nations' perspective: Teachings from elders and traditional
healers, Keightley, M. L., Bellavance, A. M., Cameron, D. A., Katt, M. V., Minore, J. B.,
Colantonio, A., et al. (2011)
This study looked at the rehabilitation needs of First Nations peoples, specifically the
lack of knowledge about general rehabilitation services offered and how preconceived cultural
ideas affect the perceptions of many in the community about such services. A focus group of
tribal healers and elders were assembled and participated in a questionnaire and discussion about
western approaches to the healing of patients with brain injuries in the rehabilitation setting.
Acquired brain injury (ABI) is the leading cause of death in young people in North America,
and it increases the risk of suicide or the probability of receiving a diagnosis for a psychiatric
disorder independent of pre-injury suicidal or risk factors (as cited in Keightley et al., 2011, p.
238). The focus group found four arising themes amongst themselves, these were;
pervasiveness of spirituality, fixing illness or injury versus living with wellness, working
together in treating brain injury, and financial support needed for traditional healing (237).
Within those four arising themes, it was apparent that tribal healers and elders lack a detailed
medical knowledge of brain injuries and what goes into the rehabilitation they undergo. There
was consensus among them that they would like to learn more and think it would be beneficial
for families to also become better educated in what these brain injuries mean with regards to
their families. The tribal healers and elders often work with individuals who express a need to
explore within their spirituality and are key components to the psychosocial aspect of
occupational therapy. This study originally sought out to find the relationship between how

traditional healers and OT can come together to provide cultural appropriate care for First
Nations individuals. The sought out brainstorming/partnership building between traditional
healers and OT was not formed due to a lack of knowledge and understanding the tribal healers
and elders have with regards to Western medicine. It is noted to also be likely they have a lack
of knowledge of what OT is and what occupational therapy practitioners can do for their people.
Tribal healers and elders in this study had some perceptions coming into the discussion about
Western medicine and left the discussion eager and willing to find a bridge between Western and
traditional medicine, with a further push to involve OT. There remain concerns about financial
funding and billing if this relationship were to evolve, but that is groundwork for further studies
in trying to figure out how this partnership can take place.
Level V:

Building Inclusive Community: A Challenge for Occupational Therapy, Grady, A.

(1995)
This case report was written based off of a 1994 Eleanor Clarke Slagle lecture and is an
in depth look at community, what it is, what it means, dynamics, etc. It also provides an
overview of what building an inclusive community would mean, what would need to be done,
and challenges likely to be faced. Occupational therapy practitioners are challenged to gain
increased understanding of the unique culture and community of each person and family with
whom they work; create opportunities for these persons to develop their capabilities in
community settings of their choice (300). Only when one understands the meaning of
community and the nature of that community can one look at inclusion within the community.
Despite relocation and eradication efforts, American Indians have a strong sense of community,
understanding those ties of similarities and differences are the foundation necessary for building
the inclusive community. There is a richness that characterizes a community constructed with
appreciation for both differences and similarities among its members (301). In summary, OTs
have their work cut out for them in building inclusive communities. Despite all the groundwork,
there is a richness to be had from the diversity in population. Some of the challenges include
understanding each unique community as an outsider to the community. Promoting the
interactive model for practice, while also trying to adapt to a growing need of more diverse
populations served by OT.

Contextual Issues for Strategic Planning and Evaluation of Systems of Care for
American Indian and Alaskan Native Communities: An Introduction to Circles of Care,
Freeman, B., Iron Cloud-Two Dogs, E., Novins, D., & LeMaster, P. (2004)
This report provides a detailed overview of the relations between American
Indian/Alaskan Natives (AI/AN) and government or government ran programs and initiatives.
The balance between sovereignty and the trust relationships is at the heart of the uniqueness of
the relationship between tribes and the federal government (12). In those relations are years of
mistrust, broken treaties, and documented homicides between government and AI/individuals.
Children and adolescents with serious emotional disturbances (SEDS) in AI/AN communities is

part of the recognition that organizations providing services to AI/AN children and adolescents
and their families face a unique set of cultural, epidemiological, fiscal, jurisdictional, and
operational challenges in developing such systems (10). There were four targeted topics the
authors sought to develop the Circles of Care (CoC) initiative around, for select AI/AN
communities. The CoC initiative was funded by grants and distributed among nine AI/AN
communities, chosen as a fair representation of urban, rural, and reservation communities. In an
attempt to develop culturally appropriate systems of care, taking a look first at the history of why
there is such a high prevalence of mental health issues in Indian communities was necessary to
develop programs that would hold permanence in these communities long after the initial goals
have been met. The first targeted goal was supporting the development of systems of care
designed specifically for children and adolescents with SEDS in AI/AN communities. The
second goal being to position tribes and communities in a manner, so they can address the mental
health issues of their children and adolescents in the future. The third goal was taking action on
the lack of availability of mental health services to AI/AN communities, as well as the issue of
inadequate training of the clinicians that do serve in the area. The final goal was to assist tribal
communities, groups, and villages in creating policies and programs for communities to utilize in
improving systems. Improving the quality of life in rural reservation communities starts within
the community.

Reflections on Building Community: A Different Perspective on Academic-Community

Partnerships Using the Integration Matrix, Jensen, PhD, PT, G. M., & Royeen, PhD,
OTR, C. B. (2001)
This report is about the growing population of multilingual, multiracial, and multicultural
individuals and finding the best method and information to share with practitioners and scholars
providing care in these populations. Documented methods for analyzing, evaluating, and
monitoring the process within federally funded grant projects are limited (168). With that said,
this article is a look at a proposed method, the Integration Matrix of Konrad, which included
discussion and analysis of 12 dimensions covered within the matrix. Stability of leadership,
grant management, cultural sensitivity, financial systems and statutory basis, and community
involvement were all topics touched on briefly supporting the 12 dimensions. The abilities to
bring together more expertise, resources, and contacts, reach more people than a single
institution, and improve quality of both education and health care services are products of these
partnerships (174). Communication between all partners with the matrix will lead to successful
project implementation and evaluation.

Qualitative:
An Occupational Therapy Life Skills Curriculum Model for a Native American Tribe: A
Health Promotion Program Based on Ethnographic Field Research, Demars, P. A. (1992)
This article aimed to utilize sociocultural systems theory, anthropology, and
developmental cognitive behavioral learning theories, combined with ongoing clinical
experience in psychosocial occupational therapy practice and consultancy principles (727). The

purpose being to create a consultancy project of life skills and prevocational programs for Native
American children from elementary school through high school, as well as post-secondary
adulthood. With an alarming dropout rate in Canadian educational systems, the were granted
funding to develop programs to turn these numbers around. A Canadian educational consultant
was called upon to tie cultural relevance and program philosophy. Educators and tribal members
shared their desire to have an program in place tailored to the needs of their people. Using
theory base, program philosophy, and an on-site needs survey, adult education and community
programs were set in place. Focusing on cultural differences, the plan had school operating yearround with longer daytime hours than a traditional school would, but with frequent, long
seasonal vacation breaks. With the breaks being schedule during seasonal times, students can
participate in family and community life such as community activities and setting trap lines for
salmon fishing. Input of the project was collected through surveys, psychosocial clinical
interviewing, and sharing of stories through sit down meetings. The project demonstrated how it
is possible for OT to combine the wishes of the people to keep cultural heritage and adopt as
many of their beliefs as possible into a nontraditional community health based health promotion
program.

"Circle of Caring": A First Nations Worldview of Child Rearing, Gerlach, A. (2008)

This article is a qualitative look at families of the Lil Wat Nation of British Columbia,
Canada who have a family members with a developmental disability. Three of the informants
had a family member with Down syndrome, one had a family member with a mental handicap,
and one had a member with Williams syndrome. The author sought out to research the First
Nations view and understanding in hopes to reduce the risk of the perpetual oppressed, pitiful
Indian mindset. Interviews were conducted for data collection, results reveal that an extensive,
interdependent family network is a highly valued social construct in which grandparents
frequently play an important role in child rearing (24). The results reinforce the need for
occupational therapy theory and practice to reflect and respect the multiple realities of family
life, child rearing, and health so that intervention is inclusive, meaningful, and effective for all
families (24). To not reinforce this and work together with the Lil Wat Nation would only
perpetuate the, oppressed Indian mindset the author set out to reduce.

Health Equity, Aboriginal Peoples and Occupational Therapy, Jull, J. E., & Giles, A. R.
(2012)
The article explains briefly what relations are like between the aboriginal people and their
government in Canada, but specifically pinpoints the relationship between the people and the
healthcare they receive. The authors acknowledge the poor relations and offer a solution to a
longstanding issue. They mention change happening at a smaller level, such as occupational
therapy and working upwards from there. Canadian health professions, including occupational
therapy, have the potential to create positive change at a systems level through the critical
exploration of underlying professional assumptions (70). Occupational therapy seemed a
worthy place to start changing some of those assumptions and begin building relations because
of what OT stands for.

Occupational therapy practitioners use their knowledge of the transactional relationship

among the person, his or her engagement in valuable occupations, and the context to
design occupation-based intervention plans that facilitate change or growth in client
factors (body functions, body structures, values, beliefs, and spirituality) and skills
(motor, process, and social interaction) needed for successful participation (American
Occupational Therapy Association Framework, S1).
The very basis of OT and the framework fosters the relationship the aboriginal people of Canada
might benefit from in terms of providing culturally appropriate care that works with their beliefs,
not against them. The basis of the article was that to move forward with trusted relationships
between health care professionals and their aboriginal partners, OT will need to work towards
educating and familiarizing themselves with the people and work towards fair and inclusive
practices, policies, and resource allocation (70).
Bottom Line for Occupational Therapy Practice:
To improve the quality of life in underserved areas, specifically rural reservation
communities, Occupational Therapy Practitioners must form strong partnerships with
AI/AN/First Nations/Aboriginal peoples and strive to define and implement practices that
promote culturally safe care (Jull and Giles, 2012, p. 74). By forming a strong partnership within
such a native community and engaging with the individuals, Demars was able to identify a need
for preserving the past, Native Americans way of life, while incorporating values, beliefs,
cultural heritage, and integrity, into a present day teaching model (Demars, 1992, p. 735-736).
As Keightley stated, an understanding of traditional perspectives is necessary to provide
culturally safe and responsive occupational therapy services (Keightley et al., 2011, p. 237).
Occupational therapy practitioners are challenged to gain increased understanding of the unique
culture and community of each person and family with whom they work; create opportunities for
these persons to develop their capabilities in community settings of their choice (Grady, 1995,
p. 300). This information should in no way pressure Occupational Therapy Practitioners to have
all the answers or think for a second that they will ever know all the makings of tribal
communities because that is unrealistic even for their tribal members to fully understand.
Communities are fluid, forever changing, but the community ties on rural reservations are also
tight knit. There is change, but there is a solid foundation that remains. It is important to keep in
mind that you are not going into a community to save them, they have survived without many of
the healthcare luxuries of larger hospitals and non-native communities. Instead the Occupational
Therapy Practitioner should enter into an opportunity to work in these underserved areas as a
chance at a partnership with a group of people in need of competent Occupational Therapy
Practitioners and their services.
American Indian populations are reported to have less health insurance, limited access to
health care, especially to specialists such as rheumatologists, lower education levels, and lower
median incomes, and are reported to be in poorer health than the general populations of the
United States (as cited in Poole, et al., 2007, p. 281). Lack of availability, accessibility, and
acceptability of mental health services for AI/AN children and adolescents and their families is

a real issue affecting Indian country (Freeman et al., 2001 p. 8). The ratio of mental health
providers to AI/AN children was a dismal 1 to 25,000 (Freeman et al., 2001 p. 8) Thats 1
competent mental health provider to 25, 000 tribal members. Although that information pertains
to a specific tribe, it is comparable throughout the tribes. As identified by the GAO, there are
three distinct factors associated with the availability of services offered through IHS. Those
factors are, but are not limited to, the facilitys structure, location, and funding from sources
other than IHS. The abilities to bring together more expertise, resources, and contacts, reach
more people than a single institution, and improve quality of both education and health care
services are products of these partnerships (Jensen and Royeen, 2000 p. 174). Occupational
Therapy Practitioners can provide tools and education for individuals to have success within
their own community, so programs can sustain changing of grants, workers, etc. Through a
symbiotic relationship, the OT practitioners can work closely with the residents within these
rural reservation communities to create programs, evidence based practice, and quality of care,
thus quality of life for Native people. The results reinforce the need for occupational therapy
theory and practice to reflect and respect the multiple realities of family life, child rearing, and
health so that intervention is inclusive, meaningful, and effective for all families (Gerlach, 2008
p. 24). Promotion and education within the community about Occupational Therapy and services
offered by Occupational Therapy Practitioners is necessary for the community to form the
symbiotic relationship with therapists and best serve rural reservation communities.
Review Process:
Inclusion Criteria:
Native American population.
Male and females at any age.
Peer-reviewed articles dated from 1990-2014.
Occupational Therapy in Indian Country.
Occupational Therapy on reservations.
American Indian/Alaskan Native Occupational Therapists.
Occupational Therapy.
Occupational Therapists.
Peer-reviewed.
Exclusion Criteria:
Peer-reviewed articles published prior to 1990.
Non-native individuals, unless mentioned with native population of individuals.
Healthcare fields other than occupational therapy.
Healthcare profession other than occupational therapy.
Traditional occupational therapy care.
Search Strategy:

Categories
Patient/Client Population
Intervention
Comparison
Outcome

Key Search Terms

Native Americans
Occupational Therapy
Not included in search
Improved Quality of Life

Databases and Sites Searched:

Databases: All of EBSCOhost databases, The American Journal of Occupational Therapy,
Google Scholar, Canadian Journal of Occupational Therapy, Journal of Allied Health, and
PubMed. All EBSCOhost databases, PubMed, The American Journal of Occupational Therapy,
and The Canadian Journal of Occupational Therapy.
Sites:
An Introduction to Indian Nations in the United States. (n.d.). Retrieved February 4, 2015, from
http://www.ncai.org/about-tribes/indians_101.pdf
Frequently Asked Questions. (n.d.). Retrieved February 4, 2015, from http://www.bia/gov/FAQs/
Health Care Services Are Not Always Available to Native Americans. (2005, August). Retrieved
December 1, 2014, from http://www.gao.gov/assets/250/247558.pdf
Indian Health Service The Federal Health Program for American Indians and Alaska Natives.
(n.d.). Retrieved December 10, 2014, from
http://www.ihs.gov/PhysicalRehab/index.cfm?module=dsp_prs_services
Multicultural Networking Groups. (n.d.). Retrieved December 10, 2014, from
https://www.aota.org/Practice/Manage/Multicultural/Groups.aspx
Race and Ethnicity in Rural America. (2012, April 1). Retrieved February 4, 2015, from
http://www.ruralhome.org/storage/research_notes/rrn-race-and-ethnicity-web.pdf
Quality Control/Peer Review Process: Question was formed and written prior to any research
of secondary sources. Peer-reviewed articles were searched and located using NCTC library
databases, UND School of Medicine databases, and the American Journal of Occupational
Therapy (AJOT) website (navigated from www.aota.org). Articles dated previous to the year
2009 were not used in this research. Once articles were found they were reviewed for relevant
information regarding the focus question. A total of eight peer-reviewed articles, the

Occupational Therapy Practice Framework: Domain and Process 3rd Ed., and three websites
were utilized to answer the focus question. After this document was completed, it was peerreviewed by a colleague who also attends Occupational Therapy Assistant (OTA) classes at
Northland Community and Technical College through email correspondence. Articles dated
previous to the year 1990 were not used in this research. A total of 8 peer reviewed articles have
been reviewed thus far.
Results of Search:
Summary of Study Designs of Articles Selected for Appraisal:
Level of Evidence Study Design/Methodology of Selected
Number of Articles Selected
Articles
Level I
Systematic reviews, meta-analysis,
0
randomized controlled trials
Level II
Two groups, nonrandomized studies (e.g.,
1
cohort, case-control)
Level III
One group, nonrandomized (e.g., before
0
and after, pretest, and posttest)
Level IV
Descriptive studies that include analysis
1
of outcomes (single subject design, case
series)
Level V
Case reports and expert opinion, which
3
include narrative literature reviews and
consensus statements
Qualitative
3
Limitations of the Studies Appraised:
Level II:

Quality of Life in American Indian and White Women With and Without
Rheumatoid Arthritis, Poole, J. L., Chiappisi, H., Cordova, J. S., and Sibbitt, W. (2007)
Limitations of this study include the small sample size, geographic location of sample
chosen, and timing of testing. It is believed that with a larger sample of individuals spread across
several communities, there would be a better representation of the overall population of women
with rheumatoid arthritis. It was also noted that individuals who have rheumatoid arthritis go
into remissions, so testing more than once might better represent characteristics of actual disease.
Level IV:

Brain injury from a First Nations' perspective: Teachings from elders and
traditional healers, Keightley, M. L., Bellavance, A. M., Cameron, D. A., Katt, M. V.,
Minore, J. B., Colantonio, A., et al. (2011)
Limitations of this study included the fact that there was only one focus group, although
that one focus group had a fair representation of the communities of the study. Also, although

the focus group was based on a participatory approach, discussion questions were decided on by
the two Western facilitators of the focus group. When participants started interpreting discussion
questions in way not originally intended by the facilitators, rather than stop or reframe the
question, they allowed the participants to adapt the questions and mold the discussion how they
wanted. Increase sample size, having multiple focus groups, and keeping discussing questions
structured, but open ended will allow for better representation of the sample and community as a
whole and encourage participants to explore the questions further.
Level V:
Building Inclusive Community: A Challenge for Occupational Therapy, Grady, A.
(1995)
The only limitation really of this article is that there was no study done. There is
extensive information about framework, models, and foundational information, which is great
and informative, setting the stage for further research and studies to be conducted using what the
author has given in terms of expertise of the area of communities.

Contextual Issues for Strategic Planning and Evaluation of Systems of Care for
American Indian and Alaskan Native Communities: An Introduction to Circles of
Care, Freeman, B., Iron Cloud-Two Dogs, E., Novins, D., & LeMaster, P. (2004)
Limitations of this study included the size of the nine tribal grantees for the Circles of
Care (CoC) project. Despite the small number of tribe participating in the project, they were a
fair spread of urban, rural, and reservation representatives. The study itself had evaluation
components between the AI/communities and the non-native individuals; this is believed to have
possibly caused tension between the evaluation and project staff. The CoC project also did not
encompass a national evaluation plan, so participants often became frustrated with specific
strategic planning models.

Reflections on Building Community: A Different Perspective on Academic-Community

Partnerships Using the Integration Matrix, Jensen, PhD, PT, G. M., & Royeen, PhD,
OTR, C. B. (2001)
Limitations of this report include three assumptions that came up during the study. They
were community is central, interdependence and co-effect, and multidimensional and linear.
These assumptions suggest a linear way of thinking and need for reconceptualization of the
Integration Matrix, when in reality nonlinear and fluid is more consistent with the with chaos
theory.
Qualitative:
An Occupational Therapy Life Skills Curriculum Model for a Native American Tribe:
A Health Promotion Program Based on Ethnographic Field Research, Demars, P. A.
(1992)
Limitations of this study included the number of participants to finish the introductory
college classes. Shortly after development of the program, the Indian Affairs branch passed that
after the age of 25 years you can no longer participate in high school courses. As a result, the

fifty-five adult individuals who started the programs dropped to fifteen adults who could
participate. Of those fifteen, only fourteen individuals tested out, and twelve of those passed
with a B average.

"Circle of Caring": A First Nations Worldview of Child Rearing, Gerlach, A. (2008)

Limitations of this study were that it included purposeful sampling, where the author had
pre-existing relationships with the informants who she had gained a trust with over the years and
knew would answer questions, two of the five informants were colleagues, therefore having
certain level of education and employment status, which may have influenced the outcome of the
study. The sample was also small, only 5 informants, all of which came from the same
community and tribe, the Lilwat Nation.

Health Equity, Aboriginal Peoples and Occupational Therapy, Jull, J. E., & Giles, A. R.
(2012)
The only limitation of this study was that there wasnt much of a study aside from
researched information. The information provided was great information and necessary as
groundwork to move forward with data collection and evaluation for future articles and studies.
Articles Selected for Appraisal:
Demars, P. A. (1992). An Occupational Therapy Life Skills Curriculum Model for a Native
American Tribe: A Health Promotion Program Based on Ethnographic Field Research.
American Journal of Occupational Therapy, 46(8), 727-736.
Freeman, B., Iron Cloud-Two Dogs, E., Novins, D., & LeMaster, P. (2004). Contextual Issues for
Strategic Planning and Evaluation of Systems of Care for American Indian and Alaska
Native Communities: An Introduction to Circles of Care. American Indian and Alaska
Native Mental Health Research, 11(2), 1-29.
Gerlach, A. (2008). "Circle of Caring": A First Nations Worldview of Child Rearing. Canadian
Journal of Occupational Therapy, 75(1), 18-25.
Grady, P. A. (1995). Blinding Inclusive Community: A Challenge for Occupational Therapy.
American Occupational Therapy Association, 49 (4), 300-310.
Jensen, PhD, PT, G. M., & Royeen, PhD, OTR, C. B. (2001). Reflections on Building

Community: A Different Perspective on Academic-Community Partnerships Using the

Integration Matrix. Journal of Allied Health, 30(3), 168-175.
Jull, J. E., & Giles, A. R. (2012). Health equity, Aboriginal peoples and occupational therapy.
Canadian Journal of Occupational Therapy, 79(2), 70-76.
Keightley, M. L., Bellavance, A. M., Cameron, D. A., Katt, M. V., Minore, J. B., Colantonio, A.,
et al. (2011). Brain injury from a First Nations' perspective: Teachings from elders and
traditional healers. Canadian Journal of Occupational Therapy, 78(4), 237-245.
Poole, J. L., Chiappisi, H., Cordova, J. S., & Sibbitt, W. (2007). Quality of Life in American
Indian and White Women With and Without Rheumatoid Arthritis. American Journal of
Occupational Therapy, 61(3), 280-289.
Other Resources Found
An Introduction to Indian Nations in the United States. (n.d.). Retrieved February 4, 2015, from
http://www.ncai.org/about-tribes/indians_101.pdf
Ferucci, E., Templin, D., & Lanier, A. (n.d.). Rheumatoid arthritis in American Indians and
Alaska Natives: A review of the literature. Seminars in Arthritis and Rheumatism, 662667.
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