Beth Pyatak PhD, OTR/L, CDE
Room: CHP 133
Phone: (323) 442-2615
Beth Pyatak has primary research interests in the intersection of chronic care management, occupational engagement and health and well-being among individuals with chronic illness and/or disability. She is currently the Principal Investigator on a NIH-funded, three-year mentored career development award to pilot-test an innovative intervention targeting underserved minority young adults with poorly-controlled diabetes (NIH #K01DK099202). In 2011 she was awarded a Mentored Career Development Award through the Southern California Clinical and Translational Science Institute (SC CTSI) to develop a lifestyle intervention aimed at improving health and quality of life outcomes among young adults with both type 1 and type 2 diabetes (NIH/NCRR #KL2RR031991). In addition, she is collaborating with faculty at the Keck School of Medicine of USC to implement a transition program aimed at improving health and psychosocial outcomes, and increase medical follow-up, among young adults with type 1 diabetes transitioning from pediatric to adult healthcare settings (Helmsley Foundation 2010PG-T1D011; PI: A. Peters). As a postdoctoral research associate at USC she worked on the Lifestyle Redesign® for Pressure Ulcer Prevention in SCI (LR-PUPS) study (NIH/NCMRR #1R01 HD056267-01; PI F. Clark).
Master of Science (MS) in Clinical, Biomedical and Translational Investigations
University of Southern California
Doctor of Philosophy (PhD) in Occupational Science
University of Southern California
Master of Arts (MA) in Occupational Therapy
University of Southern California
Bachelor of Arts (BA) in Psychology
University of Southern California
Clark, F. A., Jackson, J., & Pyatak, E. A. (2013). Developing an integrated occupational science research program: The USC Well Elderly and Pressure Ulcer Prevention studies. In D. Pierce (Ed.), Occupational science for occupational therapy (pp. 291-310). Thorofare, NJ: Slack, Inc. Full text
Pyatak, E. A., Carandang, K., Vigen, C., Blanchard, J., Sequeira, P. A., Wood, J. R., Spruijt-Metz, D., Whittemore, R., & Peters, A. L. (2017). Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) study: Methodology and baseline characteristics of a randomized controlled trial evaluating an occupation-based diabetes management intervention for young adults. Contemporary Clinical Trials, 54, 8-17. doi:10.1016/j.cct.2016.12.025 Abstract →
OVERVIEW: This paper describes the study protocol used to evaluate the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) intervention and reports on baseline characteristics of recruited participants. REAL Diabetes is an activity-based intervention designed to address the needs of young adults diagnosed with type 1 (T1D) or type 2 diabetes (T2D) from low socioeconomic status or racial/ethnic minority backgrounds. The REAL intervention incorporates tailored delivery of seven content modules addressing various dimensions of health and well-being as they relate to diabetes, delivered by a licensed occupational therapist.
METHODS: In this pilot randomized controlled trial, participants are assigned to the REAL Diabetes intervention or an attention control condition. The study's primary recruitment strategies included in-person recruitment at diabetes clinics, mass mailings to clinic patients, and social media advertising. Data collection includes baseline and 6-month assessments of primary outcomes, secondary outcomes, and hypothesized mediators of intervention effects, as well as ongoing process evaluation assessment to ensure study protocol adherence and intervention fidelity.
RESULTS: At baseline, participants (n=81) were 51% female, 78% Latino, and on average 22.6years old with an average HbA1c of 10.8%. A majority of participants (61.7%) demonstrated clinically significant diabetes distress and 27.2% reported symptoms consistent with major depressive disorder. Compared to participants with T1D, participants with T2D had lower diabetes-related self-efficacy and problem-solving skills. Compared to participants recruited at clinics, participants recruited through other strategies had greater diabetes knowledge but weaker medication adherence.
DISCUSSION: Participants in the REAL study demonstrate clinically significant medical and psychosocial needs.
Pyatak, E. A., Sequeira, P. A., Vigen, C. L., Weigensberg, M. J., Wood, J. R., Montoya, L., Ruelas, V., & Peters, A. L. (2017). Clinical and psychosocial outcomes of a structured transition program among young adults with type 1 diabetes. Journal of Adolescent Health, 60, 212-218. doi:10.1016/j.jadohealth.2016.09.004 Abstract →
PURPOSE: We identified and treated young adults with type 1 diabetes who had been lost to follow-up during their transfer from pediatric to adult care, comparing their clinical, psychosocial, and health care utilization outcomes to participants receiving continuous care (CC) throughout the transition to adult care.
METHODS: Individuals in their last year of pediatric care (CC group, n = 51) and individuals lost to follow-up in the transfer to adult care ("lapsed care" [LC] group, n = 24) were followed prospectively for 12 months. All participants were provided developmentally tailored diabetes education, case management, and clinical care through a structured transition program.
RESULTS: At baseline, LC participants reported lapses in care of 11.6 months. Compared with CC participants, they had higher hemoglobin A1C (A1C; p = .005), depressive symptoms (p = .05), incidence of severe hypoglycemia (p = .005), and emergency department visits (p = .004). At 12-month follow-up, CC and LC participants did not differ on the number of diabetes care visits (p = .23), severe hypoglycemia (no events), or emergency department visits (p = .22). Both groups' A1C improved during the study period (CC: p = .03; LC: p = .02). LC participants' depressive symptoms remained elevated (p = .10), and they reported a decline in life satisfaction (p = .007). There was greater loss to follow-up in the LC group (p = .04).
CONCLUSIONS: Our study suggests that, for young adults with a history of lapses in care, a structured transition program is effective in lowering A1C, reducing severe hypoglycemia and emergency department utilization, and improving uptake of routine diabetes care. Loss to follow-up and psychosocial concerns remain significant challenges in this population.
Carandang, K., Pyatak, E. A., & Vigen, C. P. (2016). Systematic review of educational interventions for rheumatoid arthritis. American Journal of Occupational Therapy, 70, 7006290020p1-7006290020p12. doi:10.5014/ajot.2016.021386 Abstract →
OBJECTIVE: In this study, we systematically reviewed the effectiveness of educational interventions falling within the scope of occupational therapy practice for people with rheumatoid arthritis (RA). These interventions included disease education, joint protection and energy conservation, psychosocial techniques, pain management, and a combination category.
METHOD: Two databases, MEDLINE and CINAHL, and select journals were searched for randomized controlled trials published between January 2002 and June 2015. Qualitative synthesis was used for between-study comparisons.
RESULTS: Twenty-two studies, with approximately 2,600 participants, were included. The interventions were found to have strong evidence for constructs that dealt with increasing coping with pain and fatigue as well as maintaining positive affect. There was limited or no evidence supporting the effectiveness of these interventions on most other measured constructs.
CONCLUSION: Interventions in which a combination of educational techniques is used may complement pharmacological therapies in the care of people with RA. Future research is needed to identify specific mechanisms of change.
Pyatak, E. A., Diaz, J., & Delgado, C. (2015). Engage/Trojan Neighbors: A community service partnership between an academic division and residential community. Work, 52, 503-508. doi:10.3233/WOR-152193 Abstract →
This paper describes the case of an after-school program, focused on providing enrichment opportunities for neighborhood youth, jointly administered through an academic division and residential community within a large urban research university. The program, originally conceived as an activity-based after-school program for middle school youth, expanded in scope in response to both community and student needs. The resident faculty fellow in this community served as a liaison between the academic division and office of residential education, helping maintain continuity and facilitating effective student leadership of the program. In this case, we detail the origins and evolution of the program, including strategies used to resolve challenges that arose over several years of program implementation.
Lu, Y., Pyatak, E. A., Peters, A. L., Wood, J. R., Kipke, M., Cohen, M., & Sequeira, P. A. (2015). Patient perspectives on peer mentoring: Type 1 diabetes management in adolescents and young adults. The Diabetes Educator, 41, 59-68. doi:10.1177/0145721714559133 Abstract →
PURPOSE: The purpose of the study was to identify attitudes and topics relevant to peer mentoring as an adherence-promoting intervention for adolescents and young adults (YAs) with type 1 diabetes (T1D).
METHODS: Self-administered survey data were collected in 2 diabetes clinics from a convenience sample of adolescents as prospective mentees (ages 13-18) and YAs as prospective mentors (ages 19-25) with T1D. Survey topics included demographics, disease history, glycemic control, adherence, depression, barriers to disease management, social support, and interest in peer mentoring. Descriptive statistical analyses, thematic coding, and stepwise multivariate logistic regression were performed.
RESULTS: A majority of the 54 adolescents and 46 YAs expressed interest in a peer mentoring program. Having supportive friends and living in a large household positively predicted adolescent interest in having a peer mentor. Approximately one-third of all participants experienced social barriers to diabetes management. For adolescents, barriers included inflexible schedules, unfamiliar foods, and the embarrassment of checking blood glucose in front of others. Young adults reported barriers in tracking food consumption and remembering to check blood glucose. Various diabetes management skills were in high demand by adolescents, who especially desired to learn about managing T1D on their own and in college. Participants were open to multiple communication modes, including in-person meetings, phone, text messaging, and social media.
CONCLUSIONS: Many adolescents and young adults with T1D are interested in peer mentoring as a way to facilitate learning and sharing essential diabetes management skills and experiences.
Sequeira, P. A., Pyatak, E. A., Weigensberg, M. J., Vigen, C. P., Wood, J. R., Ruelas, V., Montoya, L., Cohen, M., Speer, H., Clark, S., & Peters, A. L. (2015). Let's Empower and Prepare (LEAP): Evaluation of a structured transition program for young adults with type 1 diabetes. Diabetes Care, 38, 1412-1419. doi:10.2337/dc14-2577 Abstract →
OBJECTIVE: To evaluate the efficacy of a structured transition program compared with usual care in improving routine follow-up, clinical, and psychosocial outcomes among young adults with type 1 diabetes.
RESEARCH DESIGN AND METHODS: Eighty-one young adults in their last year of pediatric care were recruited from three clinics. Intervention group (IG) participants (n = 51) received a structured transition program incorporating tailored diabetes education, case management, group education classes, and access to a newly developed young adult diabetes clinic and transition website. Control group (CG) participants (n = 30) received usual care. The primary outcome was the number of routine clinic visits. Secondary outcomes included glycemic control, hypoglycemia, health-care use, and psychosocial well-being. Assessments were conducted at baseline, and 6 and 12 months.
RESULTS: Limitations in CG follow-up prevented direct comparisons of adult care visits; however, at the 12-month follow-up among IG participants discharged from pediatric care (n = 32), 78% had one or more adult visits. Among IG participants, the total number of clinic visits did not differ between those who transitioned and those who remained in pediatric care (3.0 ± 1.24 vs. 3.11 ± 0.94, P = 0.74). IG compared with CG participants had improved glycemic control (-0.40 ± 1.16% vs. 0.42 ± 1.51% [4.4 ± 12.7 mmol/mol vs. 4.6 ± 16.5 mmol/mol], P = 0.01), incidence of severe hypoglycemia (0.0% vs. 16%, P = 0.02), and global well-being (P = 0.02) at 12 months.
CONCLUSIONS: A structured transition program was successful in facilitating transition to adult care without a decrease in clinical follow-up. Compared with usual care, the transition program facilitated improvements in glycemic control, hypoglycemia, and psychosocial well-being.
Pyatak, E. A., Carandang, K., & Davis, S. (2015). Developing a manualized occupational therapy diabetes management intervention: Resilient, Empowered, Active Living With Diabetes. OTJR: Occupation, Participation and Health, 35, 187-194. doi:10.1177/1539449215584310 Abstract →
This article reports on the development of a manualized occupational therapy intervention for diabetes management. An initial theoretical framework and core content areas for a Stage 1 intervention manual were developed based on an in-depth needs assessment and review of existing literature. After evaluation by a panel of experts and completion of a feasibility study, the intervention was revised into a Stage 2 manual in preparation for a randomized study evaluating the intervention's efficacy. In developing the initial manual, we delineated core theoretical principles to allow for flexible application and tailoring of the intervention's content areas. Expert panel feedback and feasibility study results led to changes to the intervention structure and content as we developed the Stage 2 manual. Through describing this process, we illustrate the dynamic evolution of intervention manuals, which undergo revisions due to both theoretical and practical considerations at each stage of the research-to-clinical practice pipeline.
Ghaisas, S., Pyatak, E. A., Blanche, E., Blanchard, J., & Clark, F. (2015). Lifestyle changes and pressure ulcer prevention in adults with spinal cord injury in the Pressure Ulcer Prevention Study Lifestyle Intervention. American Journal of Occupational Therapy, 69, 6901290020p1-6901290020p10. doi:10.5014/ajot.2015.012021 Abstract →
Pressure ulcers (PrUs) are a major burden to patients with spinal cord injury (SCI), affecting their psychological, physical, and social well-being. Lifestyle choices are thought to contribute to the risk of developing PrUs. This article focuses on the interaction between lifestyle choices and the development of PrUs in community settings among participants in the University of Southern California-Rancho Los Amigos National Rehabilitation Center Pressure Ulcer Prevention Study (PUPS II), a randomized controlled trial of a lifestyle intervention for adults with SCI. We conducted a secondary cross-case analysis of treatment notes of 47 PUPS II participants and identified four patterns relating PrU development to lifestyle changes: positive PrU changes (e.g., healing PrUs) with positive lifestyle changes, negative or no PrU changes with positive lifestyle changes, positive PrU changes with minor lifestyle changes, and negative or no PrU changes with no lifestyle changes. We present case studies exemplifying each pattern.
Clark, F., Pyatak, E. A., Carlson, M., Blanche, E. I., Vigen, C., Hay, J., Mallinson, T., Blanchard, J., Unger, J. B., Garber, S. L., Diaz, J., Florindez, L. I., Atkins, M., Rubayi, S., & Azen, S. P. (2014). Implementing trials of complex interventions in community settings: The USC-Rancho Los Amigos Pressure Ulcer Prevention Study (PUPS). Clinical Trials, 11, 218-229. doi:10.1177/1740774514521904 Abstract →
BACKGROUND: Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.
PURPOSE: We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.
METHODS: Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.
RESULTS: PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.
LIMITATIONS: We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.
CONCLUSIONS: Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.
Pyatak, E. A., Sequeira, P. A., Whittemore, R., Vigen, C. P., Peters, A. L., & Weigensberg, M. J. (2014). Challenges contributing to disrupted transition from paediatric to adult diabetes care in young adults with type 1 diabetes. Diabetic Medicine, 31, 1615-1624. doi:10.1111/dme.12485 Abstract →
AIM: To examine challenges contributing to disruptions in care during the transition from paediatric to adult care among young adults with Type 1 diabetes who are primarily in ethnic minority groups and have low socio-economic status.
METHODS: Participants (n = 20) were newly enrolled patients in a transition clinic for young adults with Type 1 diabetes with a history of loss to medical follow-up. Participants completed qualitative semi-structured interviews detailing their transition experiences in addition to demographic, HbA1c and psychosocial measures. Descriptive statistics were completed for quantitative data, and narrative thematic analysis of interviews was used to identify common themes. A mixed-method analysis was used to identify the associations between stressors identified in interviews and clinical and psychosocial variables.
RESULTS: Three categories of challenges contributing to loss to follow-up were identified: psychosocial challenges, health provider and health system challenges and developmental challenges. Participants experienced a high degree of stressful life circumstances which were associated with higher HbA1c (r = 0.60, P = 0.005), longer duration of loss to follow-up (r = 0.51, P = 0.02), greater emergency department utilization (r = 0.45, P = 0.05), and lower life satisfaction (r = -0.62, P = 0.003).
CONCLUSIONS: A confluence of challenges, including stressful life circumstances, healthcare system barriers and the developmental trajectory of young adulthood, contributes to a high risk of loss to follow-up and poor health in this population of young adults with Type 1 diabetes. An integrated approach to transition addressing medical and psychosocial needs may facilitate improved follow-up and health outcomes in clinical settings.
Pyatak, E. A., Florindez, D., Peters, A. L., & Weigensberg, M. J. (2014). “We are all gonna get diabetic these days:” The impact of a living legacy of type 2 diabetes on Hispanic young adults' diabetes care. The Diabetes Educator, 40, 648-658. doi:10.1177/0145721714535994 Abstract →
PURPOSE: The purpose of this study was to investigate how an intergenerational legacy of type 2 diabetes affected the knowledge, attitudes, and treatment strategies of Hispanic young adults with diabetes.
METHODS: Eight Hispanic young adults (ages 18-30 years) participated in a series of in-home longitudinal qualitative interviews, and 11 of their family members completed single in-home interviews, regarding their diabetes management practices. Interview transcripts were analyzed thematically by a team of researchers.
RESULTS: Five themes emerged that characterized the influence of an intergenerational legacy of diabetes on young adults: food and family (how meal preparation and eating are shared within families), doing together (activity participation is contingent on others’ participation), knowledge and expectations (expectations for the future and understandings of diabetes are shaped by family members), miscarried helping (well-intentioned actions have negative consequences), and reciprocal support (children and parents support each other’s diabetes care).
CONCLUSIONS: Hispanic young adults’ knowledge, attitudes, and self-care practices related to diabetes are strongly influenced by the diabetes management practices of family members with diabetes, which often depart from current standards of diabetes care. Care providers should consider family members as a potentially significant influence, either positive or negative, on the diabetes self-care practices of this population.
Pyatak, E. A., Sequeira, P., Peters, A. L., Montoya, L., & Weigensberg, M. J. (2013). Disclosure of psychosocial stressors affecting diabetes care among uninsured young adults with Type 1 diabetes. Diabetic Medicine, 30, 1140-1144. doi:10.1111/dme.12248 Abstract →
AIMS: To determine the disclosure rates of psychosocial issues affecting routine diabetes care.
METHODS: A total of 20 young adults were interviewed regarding the impact of psychosocial stressors on their diabetes care. The interviewer, endocrinologist and case manager reported the prevalence rates of psychosocial stressors. Disclosure rates were compared to determine the prevalence of psychosocial issues and the different patterns of disclosure.
RESULTS: Participants reported a high number of psychosocial stressors, which were associated with poorer glycaemic control (r = 0.60, P = 0.005). Approximately half of all disclosed stressors (50.9%) were identified in routine care; other stressors were identified only through intensive case management and/or in-depth interviews.
CONCLUSIONS: Identifying psychosocial stressors in routine care, and providing referrals to psychological or social services, is a significant unmet need and may improve glycaemic control among certain populations with diabetes. Systematic mechanisms of capturing this information, such as by screening surveys, should be considered.
Pyatak, E. A., Florindez, D., & Weigensberg, M. J. (2013). Adherence decision making in the everyday lives of emerging adults with type 1 diabetes. Patient Preference and Adherence, 7, 709-718. doi:10.2147/PPA.S47577 Abstract →
PURPOSE: The purpose of this study was to explore motivations underlying nonadherent treatment decisions made by young adults with type 1 diabetes.
METHODS: Eight emerging adults each completed a series of semi-structured interviews concerning their approaches to diabetes care, relationships with clinicians, and everyday activities and routines. A narrative thematic analysis was used to develop initial themes and refine them through continued data collection and review of the research literature.
RESULTS: FIVE THEMES WERE IDENTIFIED AS MOTIVATING NONADHERENCE: (1) efforts to mislead health care providers, (2) adherence to alternative standards, (3) treatment fatigue and burnout, (4) social support problems, and (5) emotional and self-efficacy problems.
CONCLUSION: Instances of nonadherence generally involved a combination of the five identified themes. Participants reporting nonadherence also described difficulties communicating with care providers regarding their treatment. Nonjudgmental communication between providers and emerging adults may be particularly important in promoting positive health outcomes in this population.
Pyatak, E. A., Blanche, E. J., Garber, S. L., Diaz, J., Blanchard, J., Florindez, L., & Clark, F. A. (2013). Conducting intervention research among underserved populations: Lessons learned and recommendations for researchers. Archives of Physical Medicine and Rehabilitation, 94, 1190-1198. doi:10.1016/j.apmr.2012.12.009 Abstract →
Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.
I present the findings of a study aimed at developing an in-depth understanding of how engagement in occupation influences young adults’ ability to effectively manage diabetes and, conversely, how their diabetes self-management strategies shape their occupational participation. The qualitative interview-based study of 8 people ages 19–25 with Type 1 diabetes revealed that study participants often experienced tension between diabetes self-management and participation in valued occupations, which required them to make calculated decisions about how to balance these competing priorities in their everyday lives. Seven themes are discussed in detail that characterized the relationship between participating in valued occupations and attending to the complex factors that dictate successful diabetes self-management. This research offers a preliminary framework for occupational therapists to assist young adults with diabetes and other chronic illnesses in reconciling these competing demands.
Approximately 23.6 million people in the United States are living with diabetes, a disease that is a leading cause of disabling conditions including blindness, kidney failure, amputations, heart disease, and stroke. Although these complications of diabetes can be delayed or prevented through intensive diabetes self-management (DSM), maintaining control of the disease can be burdensome and negatively impact quality of life. Occupational therapy has a largely untapped potential to assist individuals who struggle with managing diabetes in the context of everyday life, yet there is little discussion of DSM in the occupational therapy literature. The author conducts a systematic review of the existing occupational therapy literature on diabetes, examines the current state of DSM interventions, and discusses a potential role for occupational therapy using programs such as Lifestyle Redesign®.
Pyatak, E. A., & Muccitelli, L. (2011). Rap music as resistive occupation: Constructions of Black American identity and culture for performers and their audiences. Journal of Occupational Science, 18, 48-61. doi:10.1080/14427591.2011.554154 Abstract →
Rap music and hip-hop culture represents a contested space within contemporary culture in the United States, often stigmatized by members of the dominant culture as an offshoot of inner city gang and drug culture. However, this dismissal fails to consider the complex historical, social, and political factors that have contributed to the development and evolution of this form of cultural expression. This article argues that rap music constitutes a resistive occupation, employed by marginalized Black American youth to communicate thoughts and concerns that are often discounted by the dominant culture, and in doing so makes a significant contribution to Black American identities and culture. To support that perspective, the authors critically analyze the conceptualization of ‘culture’ in occupational science, reinterpreting the term through a postcolonial lens that considers the influence of power, domination, and resistance in the production of culture.