1. Cultural Competence for Healthcare Professionals
Part A:
Introduction to Clinical Cultural Competence

2. Why are you here today?

3. Workshops
Session A
Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence.
Session B
Develops knowledge and skills on collaborative communication, cross-cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management.
Session C
Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative medicine, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients.

4. Learning Objectives
Upon completion of Session A participants will be able to:
Recognize the different types of settlement stressors experienced by new immigrant families and their effects on health
Identify how the SDOH affect immigrants and refugees
Understand the meanings of culture and cultural competence
Recognize how personal biases affect the patient/family-healthcare provider relationship
Describe the relationship between clinical cultural competence and family-centred care
Complete a cultural assessment

5. Miniature Earth
Miniature Earth

6. The Health of New Immigrants “The Healthy Immigrant Effect”
How would you describe the health status of new immigrants upon arrival in Canada?
“The Healthy Immigrant Effect”
New immigrants arrive with better health scores than average Canadians. Five years later their health scores are lower than those of the general population.

7. Walkabout Activity
Walk around and review the posted data and statement clusters. After 10 minutes you’ll be asked to stand beside the cluster that most affected you. 7

8. Health Equity Terminology
Equal: to treat the same.
Equitable: the same opportunity for positive outcomes.
Disparities: differences in outcomes.
Equitable Access: ability or right to approach, enter, exit, communicate with or make use of health services.
Social Inequities in Health: disparities judged to be unfair, unjust and avoidable that systemically burden certain populations.

9. Health Equity Terminology
Marginalized: Confined to an outer limit, or edge (the margins), based on identity, association, experience or environment. Racialized Groups: Racial categories produced by dominant groups in ways that entrench social inequalities and marginalization. The term is replacing the former term known as “visible minorities”.

10. The Importance of Cultural Competence at SickKids
Increasing Immigration
Toronto is the destination of choice for 45.7% of all new immigrants to Canada (Stats Canada, 2006)
By 2031, 63% of Toronto’s population will be members of racialized groups (Stats Canada, 2010)
Culturally competent health care is one strategy for addressing and ideally reversing health disparities.

11. Immigration and the Immigrant Experience

12. Immigration What do you know about Canada’s immigration policy?
Why do families immigrate here?
What is culture shock?

13. Cultural Competence: What are you doing about it?13
Cultural Competence: What are you doing about it?

14. Overview of Eligibility for Health Benefits
Immigration Status
Healthcare Coverage
No status in Canada, and no applications in progress
No public health insurance
Refugee Claimant (Refugee application in progress)
Interim Federal Health
Accepted Refugee
OHIP
(3 month waiting period may apply)
Permanent Resident (aka Landed Immigrant)

15. Immigrant Experience

16. Immigrant Experience
What are some challenges you think new immigrants may face during resettlement?
Skills and credential recognition
Racism/discrimination
Language
Access to affordable housing
Access to appropriate community and settlement supports
Inconsistent public policy between levels of government 16

17. Immigrant Experience
Challenges directly related to healthcare include:
Healthcare coverage
Access to and navigation of the healthcare system
Lack of significant knowledge of and sensitivity to diverse healthcare needs 17

18. Sources of Health Disparities
A review of over 100 studies regarding healthcare service quality among diverse racial and ethnic populations found three main areas that caused disparities:
Clinical appropriateness, need and patient preferences
How the healthcare system functions
Discrimination: Biases and prejudice, stereotyping, and uncertainty (Institute of Medicine, 2002)

19. Case Study
A new employee starts on your medical unit. She is an experienced professional with an advanced degree and
credentials obtained internationally. Her first day on the unit, she is oriented by staff on the ward. She comes
to work prepared and asks many questions about protocols and procedures. She speaks freely about
differences in care provided “back home”.
At the end of her first week, you overhear colleagues questioning the new hire’s credentials, and joking
around about the poor quality of education in her country and “ramshackle” hospitals. They have said that
they doubt she will succeed at her employment in Canada, and would prefer not to work with her. You wonder
if you should intervene.
Questions:
What do you think is occurring in this situation?
How do you think this situation may have been understood by the new employee?
How might this differ from your experience of this situation?
How might you elicit information from the staff about their views of this situation?
Identify two actions that would demonstrate a respect and valuing of the staff’s culture and expectations.
What strategies might enhance the cultural competency of the interactions in this and similar situations?

20. Social Determinants of Health

21. Social Determinants of Health
The term ‘social determinants of health’ emerged from researchers’ efforts to examine specific mechanisms underlying the different levels of health and incidence of disease experienced by individuals with differing socio-economic status

22. Social Determinants of Health
Early life
Aboriginal status
Education
Employment & working conditions
Food security
Gender
Health care services
Housing
Social safety net
Income & its distribution
Social exclusion
Unemployment & employment security
Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.).
Toronto: Canadian Scholars' Press Incorporated.

23. Social Determinants of Health
Housing
Asthma incidence is higher among children who live in crowded homes/aging buildings (Gilbert et al., 2003)
Families are often unable to accommodate a child with special needs in an small apartment, particularly when renting (Chalmers & Rosso-Buckton, 2008)

24. Social Determinants of Health
Income and Socioeconomic Status
Immigrant families are under-represented in upper middle class and high income households and are less likely to report very good health (Dunn and Dyck, 2000)
Socioeconomic status is a significant predictor of heart disease, adult onset diabetes and some cancers (Raphael, 2006)

25. Culture

26. What is Culture? What does culture mean to you? Dynamic:
Created through interactions with the world
Shared:
Individuals agree on the way they name and understand reality
Symbolic:
Often identified through symbols such as language, dress,
music and behaviours
Learned:
Passed on through generations, changing in response to experiences and environment
Integrated:
Span all aspects of an individual’s life
(Nova Scotia Department of Health, 2005)

27. Common Assumptions Everyone who looks & sounds the same...IS the same
Being aware of cultural commonalities is useful as a starting point…
BUT
Drawing distinctions can lead to stereotyping
Making conclusions based on cultural patterns can lead to desensitization to differences within a given culture
(Garcia Coll et al., 1995; Greenfield, 1994; Harkness, 1992; Ogbu, 1994) 27

28. Organizational and Professional Culture
What is the culture of SickKids?
Values
Innovation
Excellence
Collaboration
Integrity
What is the culture of your profession?

29. Iceberg Concept of Culture
Like an iceberg, nine-tenths of culture is out of conscious awareness. This “hidden” part of culture has been termed “deep culture”.

30. Iceberg Concept of Culture
Festivals Clothing Music Food Literature Language Rituals
Above Ice
Beliefs Values Unconscious Rules Assumptions Definition of Sin
Patterns of Superior-Subordinate Relations Ethics Leadership
Conceptions of Justice Ordering of Time Nature of Friendship Fairness
Competition vs Co-operation Notions of Family Decision-Making
Space Ways of Handling Emotion Money Group vs Individual

31. Visible and Non-Visible Aspects of Culture
Ask people to identify the visible and non-visible aspects of culture.

32. What are the visible and non-visible aspects of culture?
Christopher I suppose something that would not be perceived immediately would be my having cancer. I don't have it anymore, I've been treated for it, but nonetheless, my experience with it has a large say in who I am. I am a humble person and I don't feel as if I love to share everything with everyone, just like my experience with cancer, though I suppose now I am telling everyone who reads this about my experience….I come off frequently as either being very formal and polite or as being coldhearted. The real me, however, is very emotional and understanding. When I got chemotherapy I saw children not even five years old with more severe cases of cancer or intestinal problems and I felt I knew something was wrong with this, with young, innocent children being sick in the way they were, and I wished I could take their pain and suffering from them. From then on, I look at people with a different outlook, and I see how ignorant many people are from events like that, and it lifts me to a new level of understanding.

33. What are the visible and non-visible aspects of culture?
Omar I know that I shouldn't but sometimes I wonder how other people look at me. What do they see first? My brown-ness, my beard, my cap, my clothes, the color of my eyes, the design of my T-shirt? I think that people see my skin color first. They probably see me as a brown guy. Then, they might see my black beard and my white kufi (prayer cap) and figure out I am Muslim. They see my most earthly qualities first. Brown, that's the very color of the earth, the mud from which God created us. Sometimes I wonder what color my soul is. I hope that it's the color of heaven.
COPYRIGHT

34. Culture and the Paediatric Experience
Things to consider:
Young people may wish to minimize any “differences” as they want to feel connected with their peers
(Chalmers and Rosso-Buckton, 2008):
May attempt to distance themselves from the visible aspects of their culture/heritage
May see their parents’ need for interpretation as a sign of not belonging
May try to regain control by resisting treatment

35. Cultural Competence

36. Definitions of Cultural Competence
A set of congruent behaviours, attitudes and policies that come together to enable a system, organization or professionals to work effectively in cross-cultural situations.
(Terry Cross, 1988)
Culturally Competent Care
“the integration and transformation of knowledge about individuals
and groups of people into specific clinical standards, skills and
approaches that match an individual patient’s culture and increase
the quality and appropriateness of the care provided”.
(Hogg Foundation of Mental Health, 2001) (

37. Cultural Competence 37
“We would not accept substandard competence in other areas of clinical medicine, and cultural competence should not be an exception.” Dr. Joseph Betancourt, 2006

38. Benefits of Cultural Competence
Higher cultural competency scores predicted higher quality of care for children with asthma (Lieu et al., 2004)
A group provided with a culturally competent smoking cessation intervention adapted for African Americans had a significantly higher rate of smoking cessation than the standard group (Orleans et al.,1998)
Physicians self-reporting more culturally competent behaviours had patients who reported higher levels of satisfaction and were more likely to share medical information (Paez et al., 2009)

39. Culturally Competent Practice

40. Reducing Health Disparities Through Culturally Competent Care
Diverse Populations
Cultural Competence Techniques
Clinician/ Patient Behavioural Change
Appropriate Services
Improved Outcomes
Reduction of Health Disparities
(Brach & Fraser, 2002)

41. Actions and Strategies that Support Cultural Competence
Examine own values, beliefs and assumptions
Recognize conditions that exclude people such as stereotypes, prejudice, discrimination and racism
Reframe thinking to better understand other world views
Become familiar with core cultural elements of diverse communities 41

42. Actions that Support Cultural Competence
Engage patients and families to share similarities and differences from what you have learned about their core cultural elements
Learn from and engage clients to share how they define, name and understand disease and treatment
Develop a relationship of trust by interacting with openness, understanding and a willingness to hear different perceptions
Create a welcoming environment that reflects and respects the diverse communities that you work with and that you serve
(Nova Scotia Department of Health, 2005)
Faciliator tip: see previous slide 42

43. Cultural Competence Continuum
Cultural Destructiveness
Cultural Incapacity
Cultural Blindness
Cultural Sensitivity
Cultural Competence
Cultural Proficiency
Cultural competence builds on the concepts of cultural sensitivity and cultural awareness and refers to the ability of healthcare providers to apply knowledge and skill appropriately in interactions with clients (Srivastava, 2007)

44. What would you do in these cases?
You walk into a room to teach a child about a new exercise/diet/medication. You want to share this information with the child’s caregiver so that they are able to help their child to get better; however, the parent does not speak any English.
You are transferring a patient to their MRI appointment and just before entering one of the MRI staff notices an iron bracelet on the patient’s wrist. The MRI cannot be performed with any metallic objects on the patient’s body.
A patient is in need of an urgent procedure. The parents understand the need for the procedure but will not consent until the family’s spiritual healer has met with the child. The healer will not be able to make it to the hospital for another 36 hours.

45. Clinical Cultural Competence and Family-Centred Care
Need to redo photos

46. Cultural Competence and
Family-Centred Care
Family-Centred Care
Recognzing family as
the constant in a child’s
life
Facilitating child/family
and professional
collaboration
Sharing information
Understanding
developmental needs
Recognizing family
strengths and
individuality
Culturally Competent
Family-Centred Care
Exploring and respecting
child and family beliefs,
values, meaning of illness,
preferences and needs
Recognizing and honouring
diversity
Implementing policies and
programs that support
meeting the diverse health
needs of families
Designing accessible
service systems
Culturally
Competent Care
Understanding the
meaning of culture
Knowing about
different cultures
Being aware of disparities
and discrimination that
affect racialized groups
Being aware of own
biases and
assumptions
Family-Centred Care
Recognizing family as
the constant in a child’s
life
Facilitating child/family
and professional
collaboration
Sharing information
Understanding
developmental needs
Recognizing family
strengths and
individuality
(Adapted from Saha, Beach, & Cooper, 2008)

47. Cultural Assessment

48. Cultural Assessment Tool
Potential topics to explore:
Bio-cultural Variations and Cultural Aspects of the Incidence of Disease
Health Related Beliefs and Practice
Communication
Kinship and Social Network
Cultural Affiliation
Nutrition
Cultural Sanctions and Restrictions
Religious Affiliation
Developmental Considerations
Values Orientation
Educational Background
(Andrews & Boyle, 2003)

49. Case Study
A family has recently immigrated to Canada from Lebanon who happen to have a son with physical disabilities. When you meet the family in clinic, all are disheartened about their experience with the health care system and adaptation to Canadian life in general. They were unable to afford housing near the hospital or near resources and services that would be helpful to their son. They have also found some of the costs of their son’s care surprising.
He has trouble navigating the small apartment with his wheelchair. The homecare physiotherapist who has
begun weekly visits was disrespectful, from their point of view. They are skeptical of the quality of care they are receiving. They seem reluctant to book new appointments and accept instructions on how to proceed with their son’s care.
Questions: 
What do you think is occurring in this situation?
How do you think this situation may have been understood by this family?
How might you elicit information from family members about their view of this situation?
Identify two actions that would demonstrate a respect and valuing of the child/family’s culture and expectations.
What strategies might enhance the cultural competency of the care being provided in this and similar situations?

50. Words to remember…
“I am only one, But still I am one. I cannot do everything, But still I can do something; And because I cannot do everything I will not refuse to do something that I can do.”

51. Take Away Activity Option 1:
Reflect on the visible and non-visible aspects of your own culture
Option 2:
Choose a culture other than your own and explore the perception of illness and health beliefs
Option 3:
Using the cultural assessment guide as a tool, ask a family a question that you have previously never asked
Facilitator tip: To be discussed in Session B.

52. Questions?

53. THANK YOU!!

54. References
Anderson, J. M., Blue, C., Holbrook, A., and Ng, M. (1993). On chronic illness: Immigrant women in Canada’s workforce – a feminist perspective. Canadian Journal of Nursing Research, 25(2), 7-22.
Andrews, M. M. and Boyle, J. (1999). Transcultural concepts in nursing care. Philadelphia, United States: Lippincott Williams and Wilkins.
Canadian Council for Refugees (2007). Refugee claimants in Canada: Some facts. Retrieved from
Citizenship and Immigration Canada (2009). Refugee claims in Canada- Who can apply.
Chalmers, S. and Rosso-Buckton, A. (2008). Are you taking to me? Negotiating the Challenge of Cultural Diversity in Children’s Health Care. Centre for Cultural Research, University of West Syndey.
Cross, T. (1988). Service to minority populations: Cultural competence continum. Focal Point, 3, 1-4.
Dunn, J.R. and Dyck, I., (2000). Social determinants of health in Canada’s immigrant population: results from the National Population Health Survey . Social Science and Medicine. 11(1)
Free Country Media Production (n. d). Medicine Box: Healthcare and the New American. Retrieved May 18, 2010 from

55. References
Greenfield, P. (1994). Independence and interdependence as developmental scripts: Implications for theory, research, and practice. In P. Greenfield and R. Cocking (Eds.), Cross-cultural roots of minority child development (pp.1-37). Mahwah, NJ: Lawrence Erlbaum.
Institute of Medicine (2002). Unequal treatment: Confronting racial and ethnic Disparities in health care. Consensus report.
Harkness, S. (1992). Human development in psychological anthropology. In T. Schwartz, G. White, and C. Lutz (Eds.), New directions in psychological anthropology (pp ). New York: Cambridge University Press. Hyman, S. E. (2001). Mood disorders in children and adolescent. Biological Psychiatry, 49(12),
Kodjo, C. (2009). Cultural competence in clinical communication. Pediatrics in Review, 30,
Lien, T., Finkelstein, J., Lozano, P., Chi, F., and Quesenberry, C. (2004). Cultural competency and other predictors of asthma care quality for medicaid insured children. Pediatrics, 114(1),
Meadows, D. (2001). The miniature earth project. Retrieved November 1, 2009 from

56. References
Nova Scotia Department of Health. (2002). A cultural competency guide for healthcare professionals in Nova Scotia. Retrieved November 12, 2010 from
Orleans, C. T., Boyd, N. R., Binglar, R., Sutton, C., Fairclough, D., Heller, D., McClatchey, M., Ward, J. A., Graves, C., Flesisher, L., and Baum, S. A self help intervention for African American smokers: tailoring cancer information service for a special population. Prev. Med. 1998, 27(5), S61-S70.
Ogbu, J. (1994). Racial stratification and education in the United States: Why inequality persists. Teachers College Record, 96(2),
Paez, K., Allen, J., Beach, M. C., Carson, K., and Cooper, L. A. (2009). Physician cultural competence and patient ratings of the patient- physician relationship. Journal of General Internal Medicine, 24(4),
Pollick, H. F., Rice, A. J., Echenberg, D. (1987). Dental health in recent immigrant in the newcomer schools, San Francisco, American Journal of Public Health, 77(6),
Raphael, D. (2006). Social determinants of health: Present status, unanswered questions and future directions. International Journal of Health Services. 36(4)

57. References
Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd Ed.). Toronto: Canadian Scholars’ Incorporated36(4):
Saha, S., Beach, M. C., and Cooper, L. A. (2008). Patient centeredness, cultural competence and healthcare quality. Journal of National Medical Association, 100(11),
Sanmartin, C. and Ross, N. (2006). Experiencing difficulties in accessing first contact health service in Canada. Healthcare Policy, 1(2),
Srivastava, R. H. (2008). The ABC (and DE) of cultural competence in clinical care. Ethnicity and Inequalities in Health and Social Care, 1(1),
Statistics Canada (2006). Community profiles: Toronto. Retrieved May 20, 2010 from
Statistics Canada (2010). Projections of the diversity of Canadian population. Retrived June 1, 2010 from
Times Magazine. (2010). Teens in America: Class pictures. Retrieved May 21, 2010 from