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OCCUPATIONAL
THERAPY ASSESSMENTS
IN MONGOLIA
Fredi den Hartog
500707456
Roos Knibbeler
500712718
Gabriela Koster
500702447
Loïs de Visser
500720334
BACHELOR THESIS
25-05-2018, Ulaanbataar
Words: 8,986
Coach Netherlands:
Hetty Tonneijck
Supervisor Mongolia: Dr. Erdenetsetseg Myagmar
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Content
Abstract ... 4 Foreword ... 5 Introduction ... 6 Methodology ... 8 Research Methods ... 8Community Development approach ... 8
Participatory Action Research ... 8
Literature reviews ... 8
Sub-questions ... 9
Plan of Action ... 10
Phase 1: Assessment Selection Process ... 10
Phase 2: Initial evaluation of applicability ... 12
Phase 3: Evaluation of applicability with clients ... 12
Results ... 13
Sub-questions one, two, three & five ... 13
Phase 1: Assessment selection process ... 13
Sub-questions four & six ... 16
Phase 2: Initial evaluation of applicability ... 16
Phase 3: Evaluation of Applicability with clients ... 19
Discussion... 22
Conclusion ... 24
References ... 25
Appendix ... 29
Appendix 1: Extended research method ... 29
Appendix 2: Extended sub-question three & five ... 30
Appendix 3: Compiled list of assessments ... 31
Appendix 4: COPM-MNG ... 32
Appendix 5: ACIS-MNG ... 36
Appendix 6: PEDI-MNG ... 37
Appendix 7: SP-MNG... 39
Appendix 8: Class plan 1 - 4 ... 49
Appendix 9: Posters ... 62
Appendix 10: Concept of the Pediatric Evaluation of Disability Inventory (PEDI) ... 63
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Appendix 12: Initial evaluation ... 80 Appendix 13: Class plan 5 ... 85 Glossary ... 90
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Abstract
Aim: Occupational Therapy (OT) is a new profession in Mongolia. In order to help develop OT in Mongolia, research was conducted on the applicability of OT assessments, with the following main question: ‘What is the applicability of Occupational Therapy assessments within the Mongolian way of Occupational Therapy?’. This research focuses on discovering which aspects are important to include or exclude from an OT assessment, if an OT assessment measures what it is intended to measure and whether it can be used in practice in Mongolia.
Methods: With the use of Participatory Action Research (PAR) and the Community Development (CD) approach, the community has a central role. To evaluate the applicability of OT assessments in Mongolia, this research was split into three phases. Phase 1 was the selection process of OT
assessments where the teachers selected assessments to have introduced to the Mongolian
students. Phase 2 was the initial evaluation, where the Mongolian students and teachers could get a first impression of the assessments. The assessments were introduced and evaluated in the form of a class. Phase 3 was evaluation of the applicability with clients, where students continued practicing the assessments and the assessments were again evaluated in order to draw a conclusion.
Results: The following assessments were chosen by the teachers to introduce to the Mongolian students: the Canadian Occupational Performance Measure (COPM), the Assessment of
Communication and Interaction Skills (ACIS), the Sensory Profile (SP) and the Pediatric Evaluation of Disability Inventory (PEDI). These assessments were translated to Mongolian and evaluated by the Mongolian students and teachers. In phase 2, they mentioned adjustments, important aspects and unimportant aspects for the assessments. In phase 3, they mentioned that they would use the assessments in practice, and perhaps, after gaining more experience, make further adjustments. Translation is something that will have to be improved over time. They stated that the COPM-MNG, ACIS-MNG, PEDI-MNG and SP-MNG measure what they are intended to measure.
Conclusion: This research focused specifically on the applicability of OT assessments. It can be concluded with fair certainty that the COPM-MNG, ACIS-MNG, PEDI-MNG and SP-MNG are applicable in Mongolia. The next step is to use the OT assessments in practice, thereby gaining experience with the assessment while maintaining a critical view. In this way, OT will continue to develop in Mongolia.
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Foreword
With great pride we present our Bachelor Thesis for Occupational Therapy at the Amsterdam University of Applied Sciences (AUAS). ‘Occupational Therapy Assessments in Mongolia’ has been written based on the research we conducted in Mongolia, in collaboration with the Mongolian National University of Medical Sciences (MNUMS). With this research, we aim to aid in the development of Occupational Therapy in Mongolia, specifically regarding the use of Occupational Therapy assessments. It has been our privilege to be a part of these developments of Occupational Therapy in Mongolia.
We are grateful for the guidance and support of Dr. Erdenetsetseg Myagmar and Dr. Bulganchimeg Sanjmyatav during our research. We want to emphasize how thankful we are for making time for our research. Without their help, we could never have conducted this research.
Furthermore, we would like to thank the Mongolian second and third year Occupational Therapy students at MNUMS for being involved in our research. Their knowledge about the culture, daily life, values and beliefs in Mongolia were essential.
We are also thankful to Eric Tigchelaar, a professor at AUAS, for providing us with valuable information regarding the development of Occupational Therapy assessments.
Last but not least, we are grateful to our coach at AUAS, Hetty Tonneijck, for guiding us through the, sometimes turbulent, process of planning, carrying out and writing our research. Her insights and feedback were of great value to our research.
We hope you will read this Bachelor Thesis with as much joy as we had while conducting it.
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Introduction
Occupational Therapy (OT) is a new profession in Mongolia. Presently, there are no local
Occupational Therapists working in Mongolia. Since 2014, the education for OT has been established as a part of the Mongolian National University of Medical Sciences (MNUMS). The Mongolian OT education is supported by the Zurich University of Applied Sciences (ZHAW) and with the University of Japan, Gunma University.
At the MNUMS, all the first year Mongolian OT students start with one standardized medical year. In the second year the students choose a specialization; this is where the students start with specific lessons about OT. In June 2018 the first Mongolian OT students will graduate. The supervisor of the OT education at MNUMS is Dr. Erdenetsetseg Myagmar (Erca). She is a Mongolian medical doctor who helped establish the OT education in Mongolia. Together with Dr. Bulganchimeg Sanjmyatav (Bulga), they are teaching the Mongolian students1. Erca gained her OT knowledge from books and is
currently doing the European Master of Science in Occupational Therapy. She has some work
experience as an Occupational Therapist in Mongolia. Bulga is a rehabilitation doctor who studied OT in Japan for eleven months through theory and observation. She has no work experience as an Occupational Therapist. This means that there is a lack of experience regarding OT in practice in Mongolia. Furthermore, the OT education has been developed with foreign support and with
material from foreign programs. Within OT, context plays a vital role, due to the fact that OT practice is infused with values, beliefs, and social norms of each society (Yau, 2007). This means that foreign materials may not fit within the Mongolian society. Therefore, it is of importance to research if all aspects of the OT education in Mongolia are relevant and fitting within the culture, language, way of living, or if certain aspects are lacking.
To be able to work as an Occupational Therapist, so also in Mongolia, you need to be able to determine the occupational needs of a client. In order to find the occupational needs, an Occupational Therapist has to be able to observe, interview and organize information (Logister-Proost & Steensels, 2012). To do this, you can use models and assessments.
In 2017, three Dutch OT students from the Amsterdam University of Applied Sciences (AUAS) went to Ulaanbaatar, Mongolia to conduct research about ‘The Mongolian Way of Occupational Therapy’ with the following research question: ‘How can the Occupational Therapy education in Mongolia develop to fit the needs of Mongolian citizens?’ One of their findings was that the OT education can be developed on how to gather and process information to discover the client’s occupational needs. According to the previous research, the models Person Environment Occupation (PEO), Model Of Human Occupation (MOHO), Kawa and the Ten Dimensions are suitable in the Mongolian context to find the occupational needs of a client (Asao, Kremer & Van Staa, 2017).
Currently, the PEO, MOHO and Kawa are incorporated into the OT curriculum. However, because of the lack of practical experience in Mongolia, the teachers realized that there is a need for knowledge regarding OT assessments. The assessments that they are familiar with are mainly functional
assessments, and are not necessarily intended for OT. OT assessments can be used to gather valuable information about the occupational performance of the client so the Occupational Therapist can choose an appropriate and goal-oriented intervention. For these reasons, the use of OT assessments within the Mongolian practice has to be researched. It is of importance that the aspects of an OT assessment are relevant within Mongolia. In order to determine this, it is of interest that Mongolian students and teachers have a critical view on OT assessments and awareness of the possible cultural differences in OT assessments.
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From the beginning of February until the end of June 2018, four Dutch OT students, Fredi den Hartog, Roos Knibbeler, Gabriela Koster and Loïs de Visser, will conduct follow-up research on ‘The Mongolian Way of Occupational Therapy’. This research is about the use of OT assessments in Mongolia with the following main question: ‘What is the applicability of Occupational Therapy assessments within the Mongolian way of Occupational Therapy?’. With this research the OT education will be supported.
‘Applicability’ in this research entails the focus on discovering which aspects are important to include or exclude from an OT assessment and if the OT assessments measure what they are intended to measure. This research could be described as a starting point in developing OT assessments that are applicable in Mongolia. In the future, developing will involve adapting them and conducting research to determine their validity.
For this Bachelor Thesis, the Dutch students will collaborate with the Mongolian community. To fit the needs of the Mongolian education, the focus of this research is on two client groups: mental health (MH) clients and children with developmental disorders (CDD).
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Methodology
Research Methods
Community Development approach
In this research, the collaboration with the Mongolian community is essential. The community plays a central role, as they are the ones who need to benefit from this research. The community has the knowledge about culture, norms, values and the way of life of the Mongolian people, as well as the Mongolian way of OT. For these reasons, the choice was made to use the Community Development (CD) approach (see appendix 1 for more information).
To visualize the CD framework, Zinkstok, Engelen and Schiller (2016) use a tent as metaphor. A ger2,
as shown in image 1, will be used as metaphor in this research. The nomadic people of Mongolia build up and break down their ger to move to a new location, according to their needs. This allows them to be flexible. The possibility of moving a
ger quickly represents the flexibility the Dutch students wish to have using the CD approach. Furthermore, the structure of the ger has the poles placed in the most effective way to provide a solid structure. The poles represent the Dutch students and the Mongolian community involved. The combination of the different poles, which result in a strong frame, represent a good collaboration which will lead to a result that all parties involved are satisfied with: a successfully put up ger.
Participatory Action Research
Participatory Action Research (PAR) is the second method that is used for this research. Using PAR, the community will take on the role of researchers by exploring the challenges affecting the development of OT in Mongolia, recognizing the available resources, producing knowledge and taking action to improve the situation. The Dutch students will use the PAR process and methods. The PAR process follows a continuous and emergent cycle of action, reflection, modification and further action (Cockburn & Trentham, 2002) (see appendix 1 for more information).
Literature reviews
A literature review (LR) can be used to search and evaluate the literature that is already available regarding a specific topic (Royal Literary Fund, n.d.). LRs will be conducted as a method to answer the research question. Using this method, the readily available literature related to the main question will be integrated into the research.
2 In Mongolia, 40% of the population lives in a traditional tent named a ‘ger’, also known as a yurt (Ayan Travel,
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Sub-questions
To answer the main question, sub-questions were formulated:
1. What are the cultural challenges of using an Occupational Therapy assessment in Mongolia? Through LR, an indication of possible challenges of the Mongolian culture regarding assessments will be researched. The information will give insight into which cultural aspects are important regarding assessments.
2. What Occupational Therapy assessments are suitable for a Buddhist society?
A LR will show which assessments are suitable for a Buddhist society. These assessments are used in this research because, presently, the most practiced religion in Mongolia is Buddhism (Kaminski, Kohn & McCrohan, 2014).
3. What are the occupational challenges of people with mental health problems in Mongolia? A LR will provide insight into the needs of MH clients in Mongolia, and thus the possible aspects of assessments that are important. This information can aid in determining the assessments that are suitable for MH clients in Mongolia.
4. Which Occupational Therapy assessments are suitable for mental health clients in Mongolia? This answer will show which assessments can be used for MH clients in Mongolia. This sub-question will be answered, in part using the results of sub-questions two and three, and by conducting research using the CD approach and PAR methods with the community.
5. What are the occupational challenges of children with developmental disorders in Mongolia? A LR will provide insight into the needs of CDD in Mongolia, and thus the possible aspects of assessments that are important. This information can aid in determining the assessments that are suitable for CDD in Mongolia.
6. Which Occupational Therapy assessments are suitable for children with developmental disorders in Mongolia?
This answer will show which assessments can be used for children with developmental disorders in Mongolia, in part using the results of sub-question five, and by conducting research using the CD approach and PAR methods with the community.
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Plan of Action
The main question regards the applicability of assessments in Mongolia. The fit between Mongolia and assessments will be assessed with the expertise of the community. The community includes the clients, the students and the teachers at MNUMS. Second and third year OT students and two teachers of the OT course at MNUMS are involved in this research. At the start of the period in which data will be gathered from the students, the aim of the research will be explained to ensure that the students are informed about the research they are involved in. The community also includes the MH clients and CDD. Though the Dutch students may not have direct contact with them, the clients play a role by cooperating with the students that want to practice the assessments. For the two different client groups, MH and CDD, a similar plan of action is used and is explained below. The plan of action is split into three phases, which are: the assessment selection process, initial evaluation of applicability and evaluation of applicability with clients. This choice was made to enhance the structure of the method.
Phase 1 is created to represent the process of the selection of assessments, which will lead into phase 2, to where the students conduct an initial evaluation of the assessment. The initial evaluation entails that the students will have a critical view on the assessments’ contents. Phase 3 is the section where the students will do the second evaluation of the assessments, after they have practiced with clients. With the results of the second evaluation, the Dutch students hope to discover whether the aim and contents of particular assessments are fitting for Mongolia and whether the assessments gather the information that they are intended to gather.
Phase 1: Assessment Selection Process
In the first meeting with Erca and Bulga it became clear that they prefer to have as many
assessments as possible introduced to the students. However, because there is such a large number of assessments and it is unrealistic to introduce them all, a selection process will be conducted to prioritize assessments. Most of the assessments that the students have learned are focused on a biomedical frame of reference. However, to achieve two-body practice, assessments that focus on the interpretative frame of reference will be introduced. Also, the teachers indicated that they would prefer for the assessments to be specifically aimed at occupation and participation. Furthermore, the findings of Asao et al. (2017) indicated that the PEO, Kawa, MOHO and Ten Dimensions are OT models fit within the Mongolian culture. Erca and Bulga mentioned that their preference is for assessments linked with PEO, Kawa and MOHO, but did not mention the Ten Dimensions. Therefore, assessments linked to PEO, Kawa and MOHO are to be included, but the Ten Dimensions excluded, when searching for appropriate assessments to introduce to the students. During the time of this research, the OT curriculum at MNUMS will focus on MH clients and CDD. Therefore, the choice was made, together with the teachers, to introduce assessments that are suitable for those two client groups.
Sub-question one will provided insight and background information regarding OT assessments in Mongolia and the answer will aid in selecting appropriate assessments. A structured selection process will be used to retrieve assessments for the two different client groups, as illustrated in figure 1 and 2. Firstly, relevant assessments for the two separate client groups, and assessments fitting with the above named models, are included. For the MH client group, results from sub-question three are used to retrieve assessments. For CDD, research is done into assessments that are appropriate. Assessments are selected if they are occupation and participation based, which fits with an interpretative frame of reference. Results from sub-questions three and five are used to formulate inclusion aspects. These are aspects that would be important to include within
assessments in Mongolia. For the inclusion aspects for MH, the sub-question used is: ‘What are the occupational challenges of people with mental health problems in Mongolia?’. For the inclusion aspects of CDD, the sub-question used is: ‘What are the occupational challenges of children with
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mental health disorders in Mongolia?’. Assessments are selected based on the inclusion aspects that result from answering the two sub-questions. Assessments are put into different categories, based on their aim, and are then selected based on the Dutch students’ insights and experiences, research concerning the assessments and, once again, the inclusion aspects resulting from the previously mentioned sub-questions. The reason for this is to achieve a manageable number and a variety of assessments to present to Erca and Bulga for the final selection. The teachers select assessments to have introduced to the students.
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Phase 2: Initial evaluation of applicability
After the selection process, which results in a number of assessments, the assessments will be introduced and evaluated with the students and teachers. The introduction of the assessments will be in the context of a class. Though the word ‘class’ may suggest that there is a teacher/student role division, this approach will not be used. The structure of the classes will be in line with the CD approach, which includes equality. The students and teachers, and the Dutch students will sit together around a table. This promotes dialogue between the students and the Dutch students. It is not the intention for the Dutch students to be the only ones who give information; they will use questions and dialogue. Also, due to the language barrier, the Dutch students will use visual aids as much as possible.
The students will be sufficiently introduced to the assessment, meaning that they have the knowledge considering the aim and the structure of the assessment, and have practiced with the assessment. The students will then be asked to write their views of the assessment on a sheet of paper in groups of three or four students. This evaluation will be the initial evaluation of the assessments, as it is based on the first impression of the students.
For the initial evaluation of the assessment, the following four questions will be used: (1) What do you think is important and is included in the assessment? (2) What is not important at all but is included in the assessment? (3) What is very important but was not included in the assessment? (4) Would you use this assessment with a client. Yes/no and why?
With the four evaluation questions, the critical view on the assessments will be stimulated. The students will be more aware of the aspects of the assessment that may or may not be fitting in Mongolia during practice with clients.
Using the data gathered from the initial evaluation, the Dutch students will gain an impression of what possible adjustments the students would make regarding the assessment.
Phase 3: Evaluation of applicability with clients
In this phase, the students will start to practice the assessments with clients, using the knowledge they gained about the assessments in phase 2.
The Dutch students will use an open dialogue with the students to do the second evaluation. This will be done with the four evaluation questions from phase 2. However, in this phase, a fifth question will be added regarding the aim of the assessment because at that point the students will have gained more knowledge about the assessment. In order for the students to better answer the fifth question, the aim of the assessment will be repeated, and then then following question will be asked: (5) In your opinion, does this assessment gather the information you intended to gather?
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Results
Sub-questions one, two, three & five
Phase 1: Assessment selection process
The choice was made to include the assessments originating from the models MOHO, PEO and Kawa. The MOHO has four assessments for children and seven assessments for adults (University of Illinois Board of Trustees, 2018). The PEO has no existing assessments (Ramafikeng, 2009). The Kawa is a model, but can also be used as an assessment (Teoh & Iwama, 2015). However, due to the fact that the previous students already introduced the Kawa and the way to use it as an assessment, the Kawa as an assessment was excluded in the selection process.
Sub-question one provided insight and background information regarding OT assessments in Mongolia. As described by Asao et al. (2017), the Mongolian culture can be categorized as a ‘collectivist society’, with characteristics like ‘dependency’ and ‘family-centered’ being two important aspects. Family is an aspect that should be taken into account when looking at an assessment, and dependency is a possible factor that could influence the overall process of the OT. The family of a client is an important aspect because collectivist societies have a strong sense of unity and decisions are often made by families (Scheidegger, Torrance-Foggin, 2015). Dependency, which will lead to the passiveness of a client, can be explained by different social norms. The first one being that the family will take care of a person if they become dependent (Tamaru, McColl, & Yamasaki, 2007; Al Busaidy & Borthwick, 2011; Yang, Shek, Tsunaka, & Lim, 2006; Scheidegger & Torrance-Foggin, 2015; Lim, Honey, Du Toit, Chen, & Mackenzie, 2016). Another one that being taken care of by others is a sign of being loved and respected, which prevents a client from becoming independent. Another aspect that should be taken into account is the traditions
influencing the treatment process. Traditions could include different clothes, furniture or alternative medicine. All these important points will be kept in consideration when selecting and researching assessments.
Internet research and sub-question two were used to compile the first list of assessments (University of Illinois Board of Trustees, 2018, Hemphill-Pearson, 2008; CanChild, 2018; Therapo, 2018; Bekkers, Gieles, Kropman, & Tigchelaar, 2016; Center for Innovative OT Solutions, 2016; Meetinstrumenten in de zorg, n.d.).Included within the assessment selection process for MH clients, are the results of sub-question two. The results showed that the OT-Quest is the only suitable OT assessment, and that The FICA and the HOPE are suitable non-OT assessments that measure the spirituality of the client (Borneman, Ferrell, & Puchalski, 2010; Gray, 2015; Hemphill, 2015). Furthermore, two alternative strategies were used to select the assessments, which are: assessments obtained through the knowledge that the Dutch students gained through experience and the inclusion of the COPM. Erca indicated that she had already translated the COPM into Mongolian, but she did not fully understand the COPM yet. For these reasons, she wanted the COPM to be included. In order to avoid duplicates, all the assessments that were mentioned more than once in the compiled list were deleted. An assessment was included if it was occupation or participation based. An assessment was excluded if not enough information could be found for the Dutch students to understand it accurately with the resources available. For example, one assessment for children was named in a resource, but with further research, no other information regarding the contents was
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found. After that, inclusion aspects were formulated based on the results of sub-questions three and five and used to select assessments.
Sub-question three aimed to determine the occupational challenges for people with MH problems in Mongolia. The inclusion aspects that recurred in the reviewed studies were accessibility to MH care, social support, finances and alcoholism (Altangerel et al., 2014; Burnette, & Myagmarjav, 2013; Carlson, Witte, Pala, Tsai, Wainberg, & Aira, 2017; Dietrich, Beck, Bujantugs, Kenzine, Matschinger, & Angermeyer, 2004; Hung, Kempen, & De Vries, 2010; Kohrt, Hruschka, Kohrt, Panebianco, &
Tsagaankhuu, 2004; Kikuzawa, 2006). For more information see appendix 2.
Sub-question five aimed to determine the occupational challenges of CDD in Mongolia. Important aspects are the way disabilities are perceived, stigma and discrimination of children with disabilities and their parents, difficulties with receiving an accurate diagnosis, or any diagnosis at all, the use of both traditional treatments and ‘western’ treatments, limited support services, and schools being hesitant to accept CDD. (Chi, 2014; Ha, Whittaker, Whittaker and Rodger, 2014; Huang, Jia, & Wheeler, 2012; Lim, Downs, Li, Bao, & Leonard, 2013; Wang & Michaels, 2009). For more information see appendix 2.
The assessments were placed in different categories based on their aim. The categories for assessments for MH were the following: psychiatric problems, social aspects, spirituality, work, environment, occupation and participation based and life story. The categories for assessments for CDD were the following: school, environment, social aspects, occupation, and participation. The assessments were selected based on their aim, using the Dutch students’ insights and experiences, research of the assessments and the inclusion aspects.
The selection process is illustrated in figure 3 and 4. This selection process resulted in a list of selected assessment for MH and CDD (appendix 3). These assessments were presented to Erca and Bulga, so they could select two assessments that they regarded as the most relevant for the client group. Only two assessments per client group were selected due to the time available. For clients with MH problems, the teachers chose the Canadian Occupational Performance Measure (COPM) and the Assessment of Communication and Interaction Skills (ACIS). For CDD, the teachers chose the Sensory Profile (SP) and the Pediatric Evaluation of Disability Inventory (PEDI). For explanations of the assessments, see table 1.
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Sub-questions four & six
Phase 2: Initial evaluation of applicability
Due to the fact that the official assessments were translated, the Dutch students chose not to refer to them by their official names in this thesis. Seeing as the assessments will be concept versions of officially validated assessments, they will be referred to as follows: COPM-MNG, ACIS-MNG, PEDI-MNG and SPMNG (the assessments can be found in appendix 4 -7).
In order for the students to have a better understanding about the use of assessments, the teachers confirmed that it would be valuable to have a class with a short introduction to OT theory related to assessments. For that reason, the Dutch students used the first class for a dialogue about the link between OT models and assessments, the aim of assessments and OT as two-body practice.
The selected assessments were introduced and evaluated, the class plans can be found in appendix 8. The Dutch students shared their knowledge about the selected assessments from experience and theoretical education, when there was a need. Due to the language barrier and to improve the communication, the Dutch students used posters (appendix 9) and videos3 to support verbal
explanations. When the assessments were introduced, role-play was used to gain better understanding about the assessment.
The Dutch students had access to the ACIS manual, but for legal reasons were not able to share this manual with the students and teachers. This resulted in difficulties in understanding and translating the assessment accurately. Unfortunately, the Dutch students were not able get access to the complete SP and PEDI. Even so, the Dutch students used the information they could gather to introduce the assessment as thoroughly as possible. For the SP, a concept of the Child Questionnaire was made based on available resources (The Acr Alliance, n.d.; Pearson Clinical, 2014). See appendix 10 and 11 for the English concept for the PEDI-MNG and the SP-MGN. For those reasons, the Dutch students decided not to make a video for the SP and PEDI. Since the complete PEDI, and thus a complete PEDI-MNG, was not available, the choice was made not to practice it using role-play. The students evaluated the assessments, using the four evaluation questions, in groups of three to four students, writing their answers on a sheet of paper. The answers were translated to English. In order to prevent misinterpretation by the Dutch students, the translation was checked at a later moment.
3There were two instruction videos created for the support of verbal explanation in the class of the COPM and the ACIS.
The video shows a role-play, where one person takes the role of an Occupational Therapist and one person takes the role of a client. The main process of how the COPM and the ACIS are administered are shown.
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The initial evaluation of the COPM-MNG, ACIS-MNG and PEDI-MNG were done by the students in five different groups, and the SP-MNG was done in four different groups. One teacher answered the questions individually afterwards. See appendix 12 for translated gathered data.
After the evaluation of each assessment, the teacher and students concluded the following, with the number of groups that mentioned a particular point shown in brackets.
Canadian Occupational Performance Measure - Mongolia (COPM-MNG)
The different categories, self-care, productivity and leisure, are important(2). The COPM-MNG identifies the challenges of the client, “the most valuable 5 occupations” and it “assesses their
satisfaction in order to improve it”(1). The following items are important: activities, interests,
hobbies and the environment of the client(1). The COPM-MNG reveals the problems and feelings of the client, like stress and frustration(1), how efficiently the client lives, and helps to remind the client of the activities that he or she used to do(1). The teacher mentioned that there are many important items included in the COPM-MNG, the most important being “the level of satisfaction”.
It is unfortunate that occupations are limited to five and the COPM-MNG should include “the quality
of performance”(1). There are no unimportant things included(4). The teacher thought the
explanation of the COPM-MNG form should be more brief and understandable.
Pictures could be used about self-care or leisure activities when a client cannot read, talk or understand written text well enough. Then the client can select and arrange the pictures based on importance(1). The items ‘social environment’ and ‘attitude’ should be included. These items would give information about the client’s social behaviour towards their social environment, and the social behaviour of the social environment towards the client(1). The ‘income capacity’ is an important item that should be included. For example, people with MH disorders become dependent, because they have problems with productive work(1). The family context should be included(3). The COPM-MNG should meet the needs of the significant ones of the client(1). According to the teacher, the COPM-MNG is not suitable for someone who has problems in cognitive function, including lack of self-awareness and self-judgement.
All would use the COPM-MNG with a client and said it is easy to use, collects information and can find a problem in the occupational performance(5). It is easy to understand for the client(1). It is not suitable for all clients; the client should be able to self-reflect and express their opinion about themselves(1). For example, it is not suitable to use with a client with a severe mental disorder, who cannot make judgements about themselves. A strength is that the assessment is flexible, due to it being a semi-structured interview and it can be used in different settings(1). The teacher mentioned that “we need to check the translation, validity, and reliability of the Mongolian version of COPM. We
need more practice to be confident using it”.
The Dutch students thought there was a mistake in how the students understood the COPM-MNG in regards to including “quality of performance”, as it is already included in the assessment. Also, though the teacher said the explanation on the form should be shorter, the students later mentioned it was useful and should remain the same.
Assessment of Communication and interaction Skills - Mongolia (ACIS-MNG)
It is important that the ACIS-MNG not only uses the weaknesses, but also the strengths of a client. This is helpful, because the strengths of the client could be used in the interventions(4). ‘Physicality’ is also an important item(1).
They would exclude the item ‘gestures’, ‘’Mongolian people don’t use many gestures, so it’s not
necessary’’. They interpreted this item as the movement people make when they talk(2). There are
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sensitive”. The cultural sensitivity of some items is also indicated by the students with their example
of the item ‘gestures’.
Within the item ‘information exchange’, “talks actively and uses appropriate vocabulary” should be added. By this they mean the use of correct words and pronouncing them clearly(1). Also ‘body language’ should be added(1). The overall aspect environment was missing, for the environment can influence the communication and interaction skills of a client and therefore should be taken into account(1). No item should be added for now(1). However, if they would practice with clients, they think they would come up with items that should be added.
They all would use the assessment(5), since it is “easy to use, effective, client-centered and
applicable for almost every client”(1). They would not use the ACIS-MNG with clients who experience
speaking limitations(1). The teacher indicated that it is difficult for the Occupational Therapist to both be the person interacting with the client and the observer. Also, the manual should be studied thoroughly and the draft translation should be improved. Aside from that, research needs to be done on the validity and the reliability of the ACIS-MNG and the practitioners need more time to practice to be more confident in using the ACIS-MNG.
The Dutch students noticed that there was misunderstanding regarding items in the ACIS-MNG due to mistakes in translation. Results regarding specific items were therefore regarded as less valid information.
Pediatric Evaluation of Disability Inventory - Mongolia (PEDI-MNG)
Self-care(3), social function and mobility(1) are important items. A strength of the PEDI-MNG is that every item is assessed in detail(1). The teacher described that the lay-out of the PEDI-MNG is important; ‘’it is designed to be answered by parent or someone who knows the child very well’’. She also described that the PEDI-MNG includes various functional skills.
‘Cycling’(1) and ‘transfer to a car’(1) are unimportant items that should be excluded. The reason why the latter item was evaluated as unimportant is because the parents will carry out the transfer to a car for their child; ‘’parents or caregivers put the child in the car, so it is not important because the
child does not do the transfer to a car’’. The ‘Rehabilitation equipment’ (R) and ‘Extensive
modification’ (E) of the modification scale are two of the four rating points. However they should rather be one point, due to the fact that they are similar(1). There are no items that are included that they would evaluate as unimportant(3). It was not possible for the teacher to answer the question concerning which aspects of the PEDI-MNG are not important but are included, since the teacher does not have access to the full list of items.
‘To get on a horse’ and ‘to put on a deel4’, which includes ‘buttoning it’ and ‘wear a belt’ are items
that should be included(1). The rest and the sleep of a child should also be included, “For example,
can the child go to bed independently, does he/she need assistance from the caregiver? How long a child sleeps? Etc.”(1). An overall aspect missing in the PEDI-MNG, is the environmental aspect(1). The
teacher indicated that she cannot answer the question about which aspects are important but are not included in the PEDI-MNG; ‘’I need to see the whole list and try out using it on real client. Then I
can tell if there is anything missing’’. She also indicated that the PEDI-MNG is too time-consuming
due to the fact that it uses various functional skills.
They would use this assessment with clients(5). However, it should be “suitable for Mongolian
children”(3). The teacher indicated that the PEDI-MNG should be bought and officially translated;
“then the Mongolian version of the assessment will be validated so that medical and health
practitioners can use to evaluate the functional skills of a child in detail”.
4 A deel is a traditional piece of clothing that is a loose, calf-length tunic made of one piece of material
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During the check of the gathered data, the Dutch students realised that the students thought the PEDI-MNG was only for very young children, and therefore may have said the item ‘transfer to a car’ should be excluded. Perhaps it is a necessary item for older children. Regarding the modification scale, the students may not have understood the difference correctly.
Sensory Profile - Mongolia (SP-MNG)
An important strength of the SP-MNG is that ‘’it shows all forms of sensory processing of a child and
not only one form and that it is measured in different items as auditory, visual, touch, movement, body position and oral sensory processing’’(3). The SP-MNG assesses sensory processing and
personal characteristics of a child at the same time(1) and the 86 items are detailed and precise(1). The teacher mentioned that ‘conduct’ and ‘social emotional processing’ are important sections. All things in the SP-MNG are important(3). Some items were not clear and for that reason they think that these items are not important to include(1). For example, the item ‘Jumps from one thing to another so that it interferes with activities.’ A teacher clarified that it could be a mistake in the translation, so they misinterpreted this item. According to the teacher, there are no unimportant things included.
Something that is missing is a comment section where the caregiver can give more information about the child(1). An important item to add is characteristics for a seeker in the auditory sensory processing section(1). According to the teacher, some signs of proprioceptive and vestibular input are missing and should be included.
They will use the assessment in practice(2). Some would make adjustments based on cultural features of Mongolia(2). An example provided by the students was that, in the countryside of Mongolia, people live in a different environment than people in the capital city, Ulaanbaatar. This leads to other sensory stimuli for children. Living in a ger, there is only one room, so the child cannot retreat to another room when there is too much noise. In conclusion, the countryside is a different environment, so as a consequence the SP-MNG may need to be different. The teacher would use the SP-MNG in practice.
According to the Dutch students, the result about adding characteristics for a seeker in the auditory section regards the structure of the assessment and does not add or take away from the usefulness of the assessment.
Phase 3: Evaluation of Applicability with clients
In phase 3 the students gathered more in-depth knowledge about the four assessments. They did this by studying and practicing the assessments in class, at a MH hospital and at three kindergartens. Not everyone had the opportunity to work with a client, so some worked with cases in class. Table 3 shows how many of the Mongolian student practiced with the assessments. They looked into the ACIS-MNG, since they received the manual for the ACIS from a different source.
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In total, twelve students were involved during the evaluation of the COPM-MNG and ACIS-MNG. The PEDI-MNG and SP-MNG involved thirteen students, as one student joined later. Two teachers were included in the dialogue.
To gain insight into whether the students and teachers will use the assessment or not, a multiple-choice question was added: (A) I would use the assessment in Mongolia as it is, (B) I would use the
assessment in Mongolia but with adjustments within the assessment, (C) I would not use the assessment in Mongolia. This question was added because, during evaluations, the Dutch students
realized it was sometimes difficult to get a definite, clear answer, so using a multiple-choice question could help. Furthermore, the multiple-choice question could stimulate further dialogue. It was decided in dialogue with the students and teachers that modifications in translation of the
assessment are not included as an adjustment. Therefore, if they decided only the translation had to be modified in order to use it in Mongolia, they would choose answer (A). Translation is a process and will be improved over time. For the class plan, see appendix 13.
Canadian Occupational Performance Measure - Mongolia (COPM-MNG)
Multiple answers were given for the fifth question. One student described that the COPM-MNG gathered the information the student intended to gather because the client explained what their daily activities and occupational challenges were from the morning to the night. Another student did not gather the intended information because the student suspected the client misunderstood the question concerning self-care. For that reason, no occupational challenges arose. Another student indicated that the COPM-MNG is very well organised and gatherers the intended information. As shown in chart 1, ten of the twelve students and both teachers would use the COPM-MNG as it is now. Two students would use the COPM-MNG but make an adjustment. One student mentioned that the scoring system of performance and satisfaction should be changed from 1-10 to a system with words like ‘very well’, ‘average’ and ‘not at all’, due to an experience where the client had difficulties understanding the scoring system as a result of intellectual problems. However, one student commented that, if the aim the COPM-MNG is explained very well, the scoring does not need to be changed. Furthermore, one student mentioned that extra writing space on the COPM-MNG form would be useful. Lastly, one student mentioned that a part should be included about where the environment of the occupation takes place, because an activity might be performed differently in another environmental context.
Assessment of Communication and interaction Skills - Mongolia (ACIS-MNG)
Some items were not clear when the ACIS-MNG was first introduced. As they got access to the manual, the items became clearer. All the students said that the ACIS-MNG assesses the information that they intended to.
When asked about the fit of the ACIS-MNG in Mongolia, they answered “Mongolian people talk
wrongly but understand rightly; people talk grammatically wrong, but when a person listens to it, they will understand it”. In the ACIS-MNG, when a person does not speak in full sentences, the
students said they would score four, meaning the client is competent, but one of the teachers would score two meaning the client has a deficit. It depends on your own background how you score the ACIS-MNG. Another example is that there are some new words that the young people use. One teacher would not understand if a client used these words, so she would score one. The students said that in a situation like that, they will put on their OT glasses; “we should be occupational
therapist, from OT perspective, not from a linguist’s perspective”.
All students except one would use the ACIS-MNG in practice as it is (chart 1). This student mentioned that there should be a “conclusion part to add numbers, to explain which area the client should
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Pediatric Evaluation of Disability Inventory - Mongolia (PEDI-MNG)
The students and teachers indicated that the general items of the PEDI-MNG are fitting with the culture. However, each item in the PEDI-MNG has several sub-items and there is a possibility that these sub-items do not fit within the Mongolian culture. In order to determine this, they will need the full manual and have to evaluate the sub-items.
The students were unable to conduct the PEDI-MNG properly and concluded that it was not possible to gain the information they wanted to assess. However, the students and teachers assume that they would be able to gain all the information they would want to assess if they would be able to conduct the PEDI-MNG properly.
None of the students or teachers would adjust the PEDI-MNG, as shown in chart 1. However, they assume that if they were provided with the full manual, they would be able to evaluate the sub-items and discover aspects that do not fit within Mongolia.
Sensory Profile - Mongolia (SP-MNG)
One student discovered a significant difference between scores from a child with autism and a child without a disorder, the autistic child having more difficulty with sensory stimuli.
Generally, the students thought the assessment is suitable for Mongolia because it was translated well. However, a few students were not sure about the fit of the assessment in Mongolia as they did not have much experience with it yet.
With the knowledge and experience that the students have up to this point, they think the SP-MNG is effective in gathering the information they want to gather from the client.
As shown in chart 1, all thirteen students and both teachers said they would use the SP-MNG in Mongolia without any further adjustments. They did add that they might make adjustments after gaining more experience with it in practice.
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Discussion
Data gathered during phase 2 and 3 were compared to answers for sub-questions one, three and five. The answers indicated that family is important in Mongolia. The students indicated that the COPM misses the aspect concerning family. Sub-question one indicates that traditions may influence the treatment process, which includes different clothes. ‘Putting on a deel’, a traditional piece of clothing, is an item that the students would include in the PEDI. This sub-question also indicates the dependency of a client being influenced by the family; in collectivist societies, it is important that the family takes care of a person because it is a sign of being loved and respected. One of the items that the students would exclude from the PEDI is ‘the transfer to a car’ because parents carry the child. The result of sub-question three indicated that a lot of people with MH problems have become unemployed as a result of the transition in Mongolia, from socialism to capitalism. The evaluation of the COPM with the students indicated that ‘income capacity’ should be taken into account.
For this research, the choice was made to use PAR and the CD approach, which led to methods being constantly adapted for improvement and meeting the needs of the community. For example, after the classes there was time for the students to give feedback on the class, which was then used to improve the following class. The students mentioned that they appreciated how their feedback had been used. PAR turned out to be a very useful method. Using PAR helped stimulate the students and teachers to look critically at assessments. Students were creative and took initiative to practice assessments with clients in whatever way possible. For example, they observed a child and filled in the SP-MNG, as opposed to doing an interview with the parent, which was not possible. This way they still gained more experience with the SP-MNG. The CD approach was fitting to use; it was important to continually verify that the research was being carried out with and for the community. The knowledge of the community about culture, norms, values and the way of life of the Mongolian people was fundamental. Using the metaphor of the ger, the use of the CD approach is depicted beautifully: the expertise of the students and teachers about Mongolia, the knowledge of the Dutch students about OT and assessments, and the clients that cooperated with students to practice the assessments, all worked together, forming a strong frame for the ger.
When evaluating this research, aspects of the community should be considered. The sixteen students involved all have the opportunity to study, are mainly female and within the same age-range. Furthermore, the only two OT teachers at MNUMS were included, both of whom are female and have had the opportunity to study. There may be differences in what is considered important to include in an assessment. The inclusion of only one male student may have led to particular items that are more important for males in Mongolia, to be left out. Additionally, the students that were involved are second and third year OT students, yet these students have not had specific OT classes for the whole duration of their education at MNUMS. The outcome of this research is mainly based on students’ opinions and knowledge about OT, a factor that should be taken into account. Not all students were able to practice the assessments with clients and perhaps there are still aspects of the assessments that are unclear or misunderstood. This was taken into consideration and extra time was planned for students’ questions about the assessments. Furthermore, not all sixteen students and two teachers were included in all the evaluation moments; sometimes the group was complete, and sometimes the group was much smaller.
Another factor that should be taken into account is the language barrier. The students do not speak English. Everything was translated by Erca and Bulga, including the classes, the videos and the answers to the evaluation questions. This may have led to more opportunities for misinterpretation to occur, possibly influencing the gathered data. For this reason, the Dutch students chose to check the translated data with the students to make sure the interpretation was as accurate as possible. Also, the assessments that were introduced had all been translated from English into Mongolian. As the Dutch students do not understand Mongolian, they could not know for certain if the assessment
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was similar enough to the English version to be able to discuss and evaluate it appropriately, and draw valid conclusions.
Due to circumstances, phase 1 for MH clients was carried out in a short amount of time. This may have resulted in minor inaccuracies in the process that was followed. For the selection of
assessments for CDD, a similar process to that for MH clients was used. However, there were a few minor differences, causing discontinuity in the selection process. Despite these minor points, the final selection of assessments was made by the teachers, which was fitting with the CD approach. In phase 2, concerning the four evaluation questions, it was noticeable that the students would look at each other’s sheets of paper for their answers. This could have led to multiple groups giving similar answers. Multiple similar answers can therefore not be regarded as more significant answers. The four evaluation questions were asked at the end of the class and the Dutch students noticed that the attention levels were low and the students, understandably, seemed less motivated to answer the evaluation questions. A few times, the students had not written anything as answer to an evaluation question. This could be due to a lack of time as class finished or the students not understanding the question properly. The PEDI-MNG was introduced, but the students did not practice with it during class, making it more difficult for them to answer the evaluation questions. Furthermore, the check for interpretation of the answers took place after some students had already practiced the assessments more. This may affect the way they reacted when asked about the
answers they had given before.
The plan for phase 3, that turned out differently, was to gather more data after the students had practiced the assessments with clients. However, due to circumstances, it was not possible for all students to practice with clients, and not all assessments could be carried out properly with the client. It was positive to see that the students made an effort to practice the assessments nonetheless.
A very important point regarding the use of these assessments in Mongolia is that the assessments have been translated, and perhaps adjustments will be made based on the results of this research. In this way, the assessments will be more fitting for Mongolia, but the assessments will not be the official versions of the assessments. Therefore, the official names of the assessments cannot be used for the translated and adjusted versions. Furthermore, no research has been carried out in Mongolia with the translated and adjusted assessments to determine their validity. In the future, it would be valuable to continue the research of assessments with Occupational Therapists working in Mongolia.
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Conclusion
The main question was: ‘What is the applicability of Occupational Therapy assessments within the Mongolian way of Occupational Therapy?’. Answers to the sub-questions formed the foundation for answering the main question. Based on this research, it can be concluded with fair certainty that the COPM-MNG, ACIS-MNG, PEDI-MNG and SP-MNG are applicable in Mongolia. Furthermore, there are general conclusions that can be drawn about assessments in Mongolia.
The majority of the teachers and students think the COPM-MMG, ACIS-MNG, PEDI-MNG and SP-MNG gather the information they are intended to gather, and they would use the assessments in practice in their current states, without making adjustments apart from the translation. However, the results of phase 2 provide valuable insight into adjustments that could be considered. Perhaps after the Mongolian community has gained more experience with the assessments, these
adjustments could be useful for improving the applicability of the assessments in Mongolia. For the COPM-MNG, it could be considered if concluding with only the five most important occupations is too limited. Furthermore, adjusting the 10-point scale to a rating scale with words, adding more writing space and a section where the environment of the occupation takes place could be considered. In addition, it would be useful to have access to pictures of activities about self-care or leisure for clients who experience problems in communication. Also the following items may be included: social environment and attitude, income capacity and family-context.
Regarding the ACIS-MNG specifically, it was found that accurate translation of the assessment and studying the manual are important. Regarding content, two adjustments could be considered: adding the environment and adding more writing space for a conclusion about the client.
For the PEDI-MNG, possible adjustments are the exclusion of the items ‘cycling’ and ‘transfer to a car’, and adding ‘environment’, ‘sleep’, ‘rest’, ‘self-expression’, ‘to get on a horse’ and ‘to put on a deel’. Furthermore, it was noted by the students and teachers that access to the complete
assessment and the manual is important.
Concerning the SP-MNG, some signs of proprioceptive and vestibular input and a comment section where the caregiver can give more information about the child
can be included.
Furthermore, it was indicated that adjustments might be made after gaining more experience.The students and teachers have developed a critical view when looking at an assessment, and have become aware of the importance of cultural influences and access to a manual of an assessment in order to fully understand it.
This research focused specifically on the applicability of assessments. The next step is to use the assessments in practice, thereby gaining experience with the assessment while maintaining a critical view. In this way, OT will continue to develop in Mongolia.
Follow-up research could expand upon the research of assessments, either by continuing with the PEDI-MNG and SP-MNG or introducing other assessments more in-depth. Perhaps the applicability of assessments for clients living in apartments, ger-district and countryside can be compared. Other options are to research OT practice, since the first students have graduated, or research OT
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Appendix
Appendix 1: Extended research method
CD ApproachThe aim of the CD approach is to bring about social inclusion and participation in the community. This approach represents equality, participation, empowerment, collaboration reflection and dialogue. In this research the Dutch students have the role of facilitators. They have knowledge about OT in The Netherlands and can use the knowledge they have when there is a need from the community. By using the CD approach, the vision of the Dutch students is to listen to the needs of the community, that the roles within the research are equal and that each individual is free to share their perspective and knowledge (Zinkstok, Engelen & Schiller, 2016).
PAR
PAR is in many ways similar to the CD approach. Both are based on the same ideas and experiences: when people are given the opportunity to take ownership of their challenges and are given
responsibility for the process, they are more willing to learn or develop activities that help to bring about the desired change. The main difference between the CD and PAR is the way in which the used approach and obtained results are reported and distributed. The PAR is aimed at research and the spreading of knowledge that has been obtained about effective solution strategies to meet needs, while that is not necessarily the aim of the CD approach (Zinkstok et al., 2016).
PAR is based on reflection, data collection, and action that aims to improve health and reduce health inequities, through involving the people, who in turn take actions to improve their own health (Baum, MacDougall & Smith, 2006).
