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Cultural competence lecture
- 1. Dr Beatriz Cardona UWS Office of Engagement University of Western Sydney
- 2. What we need to consider ◦ Demographics (refugees and low socio economic migrants in western sydney) ◦ Disparities in Health Status ◦ Health Practices and Beliefs ◦ Barriers to Health Care
- 3. ◦ Culture informs our identity ◦ Culture affects the roles played within a family, ethnic group and community ◦ Culture defines family relationships, family structure, attitudes, beliefs, practices and styles of communication ◦ It also impact on our health practices and choices: for example: use of complementary medicine, attitudes towards vaccinations, dress and food preferences, attitudes toward women, etc ◦ However Culture is not he only or the most important determinant of health: think of the 3 factors: demographics, environment and culture
- 4. It reflects the ability to acquire and use knowledge of health care related beliefs, attitudes, practices and communication patterns of clients and their families to improve services, strengthen programs, increase community participation and close the gaps in health status among diverse population groups.
- 5. Cultural competency is not static – you don’t really become but constantly becoming Fluid Culture as constantly being negotiated Multiple cultural identities No single formula but emphasis on processes and skills we use to negotiate interactions Cultures in negotiation _ cultural self-awareness
- 6. Cultural Competence is a set of values, behaviors, attitudes and practices within a system, organization, or among individuals that enables them to work effectively across cultures. cultural competence focuses on the capacity of the health worker to improve health status by integrating culture into the clinical context. the point of cultural competence is to maximise gains from a health intervention where the parties are from different cultures
- 7. Multicultural policy in NSW is administered by the Community Relations Commission (CRC) for a multicultural NSW and is based on 4 principles of multiculturalism. Principles of Multiculturalism require that each public authority respect and accommodate the culture, language and religion of all individuals. Cultural diversity is defined as : people from a range of cultural, ethnic, linguistic and religious background 7
- 8. • “The healthy migrant effect”: Initial migrant health advantage often deteriorates over time as diet and exercise patterns change • Limited research into immigrant health in Australia invisibility can undermine equity in healthcare provision • Immigrants face additional language and/or cultural barriers not experienced by Australian-born patients • Poor engagement of older migrants to health system undermines self-management of chronic conditions: effective communication is crucial to effective care
- 9. • Humanitarian immigrants (refugees) are known to have poorer health than other immigrants (Khoo 2010) • Vitamin D deficiency common in newly arrived refugee children- consider rickets (Sheikh et al, 2011) • Afghanis may need written information in Dari and Pashtu, as well as interpreters (Omeri et al, 2006) • Ask Horn of Africa refugees about prior use of qaat (e.g. addictive - illegal in Aust.) (Bruce-Chwatt (2010)
- 10. • inadequate vaccinations, nutritional deficiencies (vitamin D and iron) and dental disease • infectious diseases (gastrointestinal infections,schistosomiasis, and latent tuberculosis) • musculoskeletal, social and psychological problems e.g. PTSD, anxiety, depression
- 11. “I do not understand the health care system in Australia. I have to rely on family and friends …” “It is difficult to find a service that provides an interpreter …” “Because of my religion, I prefer to see a female doctor … especially for reproductive issues” (Omeri et al, 2006)
- 12. Can you give any examples? 12
- 13. Interpreters Bilingual health workers Culturally appropriate food Non denominational quiet rooms Translated health information Cultural competence training Signage 13
- 14. 14
- 15. 15 Understand the importance of culture Recognise the dynamics of cultural differences Build cultural knowledge Adapt services to meet cultural needs
- 16. 16 • Language Differences • Culture • Non verbal communication • Stereotyping • Discrimination • Stress • Organisational constraints • The human factor • Resistance to change
- 18. The Culture of Western Medicine ◦ Meliorism – make it better ◦ Dominance over nature – take control ◦ Activism – do something ◦ Timeliness – sooner than later ◦ Therapeutic aggressiveness – stronger=better ◦ Future orientation – plan, newer=better ◦ Standardization – treat similar the same
- 19. “Ours” ◦ Make it Better ◦ Control Over Nature ◦ Do Something ◦ Intervene Now ◦ Strong Measures ◦ Plan Ahead – Recent is Best ◦ Standardize – Treat Everyone the Same “Others” ◦ Accept With Grace ◦ Balance/Harmony with Nature ◦ Wait and See ◦ Cautious Deliberation ◦ Gentle Approach ◦ Take Life As It Comes – “Time Honored” ◦ Individualize – Recognize Differences
- 20. The Cultural Competence Continuum ◦ Where Am I Now? ◦ Where Could I Be?
- 22. Cultural Competence Definitions ◦ Cultural Destructiveness: forced assimilation, subjugation, rights and privileges for dominant groups only ◦ Cultural Incapacity: racism, maintain stereotypes, unfair hiring practices ◦ Cultural Blindness: differences ignored, “treat everyone the same”, only meet needs of dominant groups
- 23. Cultural Competence Definitions Cultural Pre-competence: explore cultural issues, are committed, assess needs of organization and individuals Cultural Competence: recognize individual and cultural differences, seek advice from diverse groups, hire culturally unbiased staff Cultural proficiency: implement changes to improve services based upon cultural needs, do research and teach
- 24. Acquiring Cultural Competence ◦ Starts with Awareness ◦ Grows with Knowledge ◦ Enhanced with Specific Skills ◦ Polished through Cross-Cultural Encounters
- 25. Culturally sensitive approach to asking inquiring about a health problem ◦ What do you call your problem? ◦ What do you think caused your problem? ◦ Why do you think it started when it did? ◦ What does your sickness do to you? How does it work? ◦ How severe is it? How long do you think you will have it? (continued next page)
- 26. Culturally sensitive approach to asking about a health problem ◦ What do you fear most about your illness? ◦ What are the chief problems your sickness has caused you? ◦ Anyone else with the same problem? ◦ What have you done so far to treat your illness: What treatments do you think you should receive? What important results do you hope to receive from the treatment? ◦ Who else can help you?
- 27. Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment
- 28. Pre interview sessionPre interview session Brief the interpreter about the session Obtain cultural background information from the interpreter Establish mode of interpreting During the interviewDuring the interview Introduce everyone and establish roles Establish ground rules – speaking THROUGH the interpreter TO the client Maintain eye contact with the client, if culturally appropriate Speak slowly and clearly Summarize your discussion periodically throughout the interview With consecutive interpreting, use short sentences Post interview sessionPost interview session De-brief the interpreter 28
- 29. Use simple, plain English Avoid jargon Don’t use slang or verbal jokes Speak slowly, but do not shout or raise your voice Be concise and clear Give instructions in a clear, logical sequence Ensure you have been understood Reinforce what you say Reduce the stress Be aware of your language all the time 29
- 30. Australian Bureau of Statistics, Census data 2006 ECC NSW, COPS NSW & DADHC (2006) Cultural Competency & Case Management Training Package Multicultural skills for health staff, Cultural diversity training unit, University of Sydney, 1998 Cross cultural workshop, Macarthur health service Centre for culture, ethnicity & health www.ceh.org.au Multicultural awareness, Corporate orientation program, SSWAHS Cultural competence, Facility orientation program, Fairfield Hospital Sockalingum adapted from Hayes, Cultural Competence Continuum, 1993 and Terry Cross Cultural Competency Continuum 30
Notas do Editor
- I was the author of 3 major projects looking at cultural competence : East meets West: Exploring cultural diversity in the BM: Some of the main points coming from this report include The importance of adopting approaches to diversity and the health needs of CALD people as complex interactions between communication (how we communicate to each other – gaps in understanding), culture (what system of values and norms is transmitted in the interaction); structures (what is available and how it operates) , socio-economic (levels of disadvantage , ability to access resources) and personal issues (often linked to all of the above: ability to negotiate, sense of emporwerment, sense of entitlement, health literacy levels) The emphasis and recognition of the complexity inherent in any dicsussions of culture and cultural competence allows us to move away from previosu approaches to cultural diversity which emphasized THE OTHER as the problem. Me have move beyond the idea that for instance to increase service utilisation by migrants and refugee communities we need to work with them so they can be BETTER EDUCATED, BETTER COMMUNICATORS, MORE RESPONSIBLE FOR THEIR SELF-CARE, MORE INVOLVED IN SERVICES – from this perspective of them as the target of our efforts to improve service use and health outcomes we have moved to a greater awareness and acknowledgment and apprecaition of cultural diversity including our own cultural values and the manistream values and norms informaing health, social and other institutions in Australia. My presentation today utlises this model of approaching cultural competence in such a way that it involucrates us the service providers as much as them the service users.
- Cultures in negotiation: We have for example Schools culture: Introduction of new technologies changes or forces a negotiation of how things are done at school – we change the school culture Youth culture: Civil society and the internet: it is being argued that social networking is changing youth culture: It centers around different practices, different language and values Seniors culture: We have seen dramatci changes on ageing and cultural values associated with later life: greater expectations of living longer healthier and productive lives than 30 years ago; the way elderly people construct their identities, the baby boomers – these are cultural transformations that are taking place in Australian society and around the world. Often when we think about cultural competence we tend to narrow it to a very limited understanding around skills needed to communicate with a very specific target group: people from culturally and Linguistically diverse backgrounds. We forget we need to be culturally competent to communicate with youth, older people, children, and even to understand ourselves: many of our aspirations, fears and dreams and motivations are culturally informed: the value we place in buying certain things or achieving certain jobs, or religious experiences – it doesnot happen in a vaccium but responds to the cultural mileu we inhabit. Cultures in negotiation also refers to an awareness of what we are bringing to the table when we engage in an interaction with aonther person becoming aware of our own cultural identity facilitates our capacity to: Explore, understand, acknowledge, and value our cultural and social background regarding 'race,' ethnicity, social class, gender, regionality, sexual orientation, exceptionality, age, religion/spirituality, language, and dialect. Increase our awareness and insight into our own learning processes, strengths, weaknesses, successes, failures, biases, values, goals, and emotions. Experience our own cultures in relation to others as they are illuminated during cross-cultural interactions. Understand and respond to areas of conflict and tension when we encounter individuals from unfamiliar cultures or experiences, and learn to be more comfortable with being uncomfortable. Explore and appreciate thought processes that occur across cultures but may also take on different shapes and meanings for different cultural groups and for individual group members. Understand and respect more deeply the cultural values and beliefs of those with whom we come in contact
- In a previous lecture I believe you discuss some of the legislative frameworks in Australia and NSW that account for policies such as Multicultural Policy : I won’t go into that but you are aware that public institutions and services are required by law to implement programs to ensure access and equity for CALD as well as indigenous communities.
- Language differences: not only that person can’t speak the dominant language but also refers to differences in dialects, the effect of jargon & idioms, whether or not the person can read or write in their first language. Culture; Determines our expectations of how things will happen, what is considered polite or rude, what is understood without saying a word. It is not only ethnicity but relates to gender, class, education and environmental factors. Non verbal communication: Gestures, expressions and body language can easily be misinterpreted eg avoid eye contact as a sign of respect Stereotyping: Over generalisation or boxing the communnities together Discrimination: judging someone’s behaviour based on inadequate information Stress: is heightened by the presence of anxiety, pain, illness and other barriers of communication Organisational constraints: Bureaucratic systems usually makes communication difficult for both professionals and clients eg complex forms The human factor: Individuals with distinct personalities which in itself may cause communication difficulties Resistance to change: ability to be flexible, to change styles or practices to gain effective outcome
- Use simple plain English: eg start and finish rather than commence or terminate. No pidgin English Avoid using idioms: eg fed up, start from scratch etc Give instructions in a clear, logical sequence: eg First rinse the bottle then sterilise it rather than don’t sterilise the bottle until you have rinsed it or befor you sterilise the bottle rinse it. Repeat if you’re not understood. Don’t assume anything. Reinforce what you say: use non verbal communication to reinforce what you say, draw diagrams or use pictures Reduce the stress: Create a pleasant, unstressed atmosphere with a non authoritarian, relaxed friendly approach.