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

Why are you here today?

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.

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

Miniature Earth Miniature Earth

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.

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

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.

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”.

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.

Immigration and the Immigrant Experience

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

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

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)

Immigrant Experience

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

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

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)

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?

Social Determinants of Health

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

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.

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)

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)

Culture

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)

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

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

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”.

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

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

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.

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

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

Cultural Competence

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) (

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

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)

Culturally Competent Practice

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)

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

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

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)

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.

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

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)

Cultural Assessment

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)

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?  

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.”

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.

Questions?

THANK YOU!!

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 http://www.ccrweb.ca/documents/claimsfacts07.htm Citizenship and Immigration Canada (2009). Refugee claims in Canada- Who can apply. http://www.cic.gc.ca/english/refugees/inside/apply-who.asp 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) 1573-1593. Free Country Media Production (n. d). Medicine Box: Healthcare and the New American. Retrieved May 18, 2010 from http://video.google.com/videoplay?docid=-5106027191893998854#

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References Nova Scotia Department of Health. (2002). A cultural competency guide for healthcare professionals in Nova Scotia. Retrieved November 12, 2010 from http://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guide_for_Primary_Health_Care_Professionals.pdf 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), 264-298. 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), 495-498. 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), 731-732. Raphael, D. (2006). Social determinants of health: Present status, unanswered questions and future directions. International Journal of Health Services. 36(4) 651-677.

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