Cultural Diversity and Health Care

Overview Cultural diversity and cultural sensitivity relate to the competencies of: Professionalism Interpersonal and Communication Skills Oral health education Adapted from: www.apds.org

This presentation is intended to address the following Dental Hygiene Competencies…

The DH as a professional must: A9. Respect diversity in others to support culturally sensitive and safe services.

The DH as a Communicator and Collaborator must: B2. Demonstrate active listening and empathy to support client services. B3. Select communication approaches based on clients’ characteristics, needs, and linguistic and health literacy level. B9. Work with clients, family members, substitute decision makers and stakeholders to assess, diagnose, plan, implement and evaluate services for clients. B4. Consider the views of clients about their values, health and decision-making.

The DH as an Oral health educator must: G4. Elicit information about the clients’ oral health knowledge, beliefs, attitudes and skills as part of the educational process.

OBJECTIVES: At the completion of this seminar the student will be able to: 1. Evaluate the importance of the role culture plays in determining how different people perceive and shape their world. 2. Identify cultural influences on one’s own beliefs and values. 3. Identify cultural strengths and barriers that influence utilization of health care services. 4. Identify strategies for delivery of culture-specific care based on the evaluation of cultural assessment data.

1.‘Are you culturally competent?’ quiz

Issues of Cultural Sensitivity Include: • Spirituality and religious issues • Communication and interpersonal relationship styles including word choice, voice tone and volume, eye contact, and proper titles • End‐of‐life situations • Delivering bad news • Clothing, hair styles, and body adornment www.apds.org

• Gender issues and consideration of appropriate male/female interaction • Age, respect, and seniority • Discipline, correction, and training methods • Informal and social interactions • Individualism and equality

What is Culture? Set of values, beliefs, attitudes, languages, symbols, rituals, behaviors, customs,communication styles and thinking patterns Learned and shared by a group of people Dynamic and changing Guides decisions and actions of a group through time.

Culture is… • created through individuals’ interactions with the world, resulting in ways of naming and understanding reality. • Symbolic, often identified through symbols such as language, dress, music and behaviors. • Learned and passed on through generations, changing in response to a generation or individual’s experiences and environment.

Some important concepts…

Ethnicity Classification of people based on national origin or culture Examples: African Canadian, Asian Canadian, European Canadian, Hispanic Canadian, Middle Eastern/Arabic Canadian, Native Canadian

What do you see?

…so…tell me: What is a Canadian-Canadian???

Race Classification of people based on physical or biological characteristics Involves multiple cultures and ethnic groups

Principles and Assumptions As individuals we often consciously or unconsciously make 2 key assumptions: Everyone who looks or sounds the same IS the same 2. Everyone who looks or sounds like us IS like us

We need to pay attention to how we think or feel about other people and how these beliefs will influence our actions towards them. It is important to be aware of our biases, which are part of our own cultural backgrounds, so that we can reduce the barriers that keep us from understanding each other.

! • Similar appearances (e.g., Chinese, Japanese, and Korean) do not mean cultural similarity • Sharing a language (e.g., English‐speaking East Asia Indians, British, Nigerians, Americans) does not mean cultural similarity • Sharing a nationality (e.g., Ontarians, Albertans, Newfoundlanders) does not mean cultural similarity • Sharing a religion does not mean cultural similarity www.apds.org

Cultural Diversity Differences based on cultural, ethnic, and racial factors “Melting Pot” or “Salad Bowl” approach Must be considered when providing health care Healthcare providers must recognize and appreciate the characteristics of all patients

Cultural Diversity We All Have It! Obvious Manifestations: Religion Ethnicity (Race) National Origin (language) Gender Social class

Cultural Diversity Less Obvious Manifestations: Age Education Educational Status Mobility (including handicaps)

http://www.youtube.com/watch?v=nU5MtVM_zFs

How does socioeconomic status create barriers within society? What are the oral health implications of social class in Canada?

Areas of Cultural Diversity Family organization Language Personal space Touching Eye contact Gestures Health care beliefs Spirituality Religion

Aspects of Culture Related to Health Care • Ethnicity • Country of Origin • Religious Belief System • Other Beliefs and Customs • Social Status • Gender and Sexual Orientation • Location—Rural vs. Urban • Economic Status • Education Level • Language Proficiency and Reading Comprehension www.apds.org

Expressions of Culture in Health Care Health Belief Systems Define and categorize health and illness Offer explanatory models for illness Based upon theories of the relationship between cause and the nature of illness and treatments

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

“Ours” “Others” 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

2.FAMILY PRACTICES AND ATTITUDES (THEN AND NOW) activity

Varies Based on Cultural Background Definition of Health Varies Based on Cultural Background

World Health Organization A state of complete physical, mental, and social well-being, not merely the absence of disease

South African Harmony with nature Harmony of mind, body, and spirit

Asian Physical and spiritual harmony with nature Balance of yin and yang

European Personal responsibility with diet, rest, exercise, and prevention

Hispanic Good luck Reward from God Balance between hot and cold forces

Middle Eastern/Arabic Spiritual Causes Cleanliness

Illness Abnormal functioning of a body’s system or systems Causes vary based on cultural/ethnic background

What about the Healthcare Providers’ Culture?

Beliefs “Standardized definitions of health and illness” “The omnipotence of technology”

Practices “The maintenance of health and the prevention of disease through such mechanisms as the avoidance of stress and the use of immunizations” “Annual physical examinations and diagnostic procedures such as Pap smears”

Habits “Charting” “The constant use of jargon” “ Use of a systematic approach and problem-solving methodology”

Likes “Promptness” “Neatness and organization” “Compliance”

Customs “Professional deference and adherence to the ‘pecking order’ found in autocratic and bureaucratic systems”

Rituals “The physical examination” “The surgical procedure” “Limiting visitors and visiting hours”

Cultural Beliefs Concerning Epidemiology and Pain Medical culture is in direct opposition sometimes Bacteria/viruses/carcinogens/pollutants versus “soul loss”/”spirit possession”/voodoo/witchcraft Free, open expression of feelings versus never revealing true feelings

Examples of Cultural Clashes “Mr. Smith in room 222 is the ideal patient. He never has a single complaint.” Are you sure he has no complaints or is it his cultural influence not to be a bother?

“Mrs. Cohen in room 223 is a real complainer “Mrs. Cohen in room 223 is a real complainer. She is constantly asking for pain medication and putting on her light.” Is she really in pain or is it her cultural programming concerning dealing with pain?

“Mr. Chen in room 225 says nothing. I often wonder what he is feeling What is really happening with Mr. Chen?

Healthcare Providers Must change to accommodate other cultural beliefs and behaviors towards health and illness

Like all people, individuals from culturally diverse populations have differing skills, knowledge, and values. It is important to understand people as individuals within the context of cultural competence.

Cultural Competence Begins with Respect Avoids profiling and stereotypes by attaining data through respectful questioning and dialogue Practices effective communication techniques and monitors patient comprehension through dialogue www.apds.org

Cultural competence is important because It reduces disparities in health services and increases detection of culture-specific diseases It addresses inequitable access to primary health care It impacts health status of culturally diverse communities It responds to Canada’s changing demographics – an increasingly diverse population.

Cultural competence is a process with emphasis on adapting one’s attitudes, behaviors, knowledge and skills. We need to avoid the trend to stereotype.

Cultural Competence – Definition A set of congruent behaviors, practices, attitudes and policies that come together in a system or agency or among professionals, enabling effective work to be done in cross-cultural situations.

The Cultural Competence Continuum Where Am I Now? Where Could I Be?

The Cultural Competence Continuum Positive Cultural Proficiency Cultural Competence Cultural Precompetence Cultural Blindness Negative Cultural Incapacity Cultural Destructiveness

Cultural Competence Stages 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

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

Where are you in this continuum?

SELF-ASSESSMENT CHECKLIST activity

Exploring Differences Generally, people with invisible differences have a greater ability to blend in with the dominant culture than people with visible differences. Visible differences can be seen or heard and are often noticed upon initial encounters. Invisible differences cannot be seen or heard and may never be detected. Both visible and invisible differences can have an impact on health.

Equitable Access Access is the ability or right to approach, enter, exit, communicate with, or make use of health services. Equitable access recognizes that things like geographic location, communication styles, language of service; signage, physical design and service-delivery style influence a person’s access to health services and strives to address these issues. For instance, language barriers to access in health promotion, prevention and screening result in inequitable access leading to the use of more expensive services as health deteriorates.

When we treat people EQUALLY we ignore differences. When we treat people EQUITABLY we recognize and respect differences.

There are different types of racism, some conscious and some unconscious. All types of racism can impact a person’s ability to obtain health services, thereby impacting health status.

Acquiring Cultural Competence Starts with Awareness Grows with Knowledge Enhanced with Specific Skills Polished through Cross-Cultural Encounters

1) The Explanatory Model Arthur Kleinman, Ph.D. 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?

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?

2) The LEARN Model Berlin and Fowkes Listen to the patient’s perception of the problem Explain your perception of the problem Acknowledge and discuss differences/similarities Recommend treatment Negotiate treatment

-Read literature from other cultures 3) LIAASE: A General Cultural Competence Tool From Ontario Healthy Communities coalition Learn -Read literature from other cultures -Identify your own biases and stereotypes

Inquire Ask questions to clarify and understand information Dig deeper to find reasons for behaviors or attitudes Frame inquires as searches for answers, show a willingness to learn Do not judge or interpret actions or speech, verify that what you understand is correct Speak clearly; avoid slang, colloquial expressions and large, complex words

Avoid Polarization Solicit other options or points of view Ask what perspective a person from a different background would have

Avoid Arguing and Defending Curb the impulse to defend your point of view or opinion Agree to disagree on differences in values

Show Empathy Listen not just to the words, but to the feelings behind the words Acknowledge and validate powerful emotions when expressed

EIGHT STEPS TO CULTURAL COMPETENCE FOR PRIMARY HEALTH CARE PROFESSIONALS Examine your values, behaviors, beliefs and assumptions. 2. Recognize racism and the institutions or behaviors that breed racism. 3. Engage in activities that help you to reframe your thinking, allowing you to hear and understand other world views and perspectives. 4. Familiarize yourself with core cultural elements of the communities you serve, including: physical and biological variations, concepts of time, space and physical contact, styles and patters of communication, physical and social expectations, social structures and gender roles.

5. Engage clients and patients to share how their reality is similar to, or different from, what you have learned about their core cultural elements. Unique experiences and histories will result in differences in behaviors, values and needs. 6. Learn how different cultures define, name and understand disease and treatment. Engage your clients to share with you how they define, name and understand their ailments. 7. Develop a relationship of trust with clients and co-workers by interacting with openness, understanding, and a willingness to hear different perceptions. 8. Create a welcoming environment that reflects the diverse communities you serve.

Remember that medicine {and dentistry} are a "language" that may require translation even for native‐English speakers. www.apds.org

ACTIVITY 4: CULTURAL NEGOTIATIONS SCENARIOS

Patient Illiteracy Not everybody understand dental or medical vocabulary! • A big percentage of the population have a limited English proficiency . www.apds.org

Communication When possible, a translator is a better option than family members. Why? Remember that communication has not always occurred when someone nods and smiles. A good technique is asking the patients to repeat what they’ve heard. Adapted from: www.apds.org

Learn and use a few phrases of greeting and introduction in the patient’s native language. This conveys respect and demonstrates your willingness to learn about their culture. Tell the patient that the interpreter will translate everything that is said, so they must stop after every few sentences.

Repeat important information more than once. When speaking or listening, watch the patient, not the interpreter. Add your gestures, etc. while the interpreter is translating your message. Reinforce verbal interaction with visual aids and materials written in the client’s language. Repeat important information more than once. (continued on next page)

Always give the reason or purpose for a treatment or prescription. Make sure the patient understands by having them explain it themselves. Ask the interpreter to repeat exactly what was said. Personal information may be closely guarded and difficult to obtain. Patient often request or bring a specific interpreter to the clinic.

It is because we are different that each of us is special.

References Putsch III RW. Cross-cultural communication: The special case of interpreters in health care. JAMA 1985;254(23):3344-48 Sockalingum adapted from Hayes, Cultural Competence Continuum, 1993 and Terry Cross Cultural Competency Continuum. Cultural Competence and dental hygiene care delivery: integrating cultural care into the dental hygiene process of care. P.Fitch, Journal of Dental Hygiene Winter 2004

CDHO Guideline for Incorporating Culture Sensitivity into Dental Hygiene Care http://hr.healthcare.ucla.edu/Download/Cultural%20Diversity%20and%20Health%20Care.ppt http://www.cte.unt.edu/health/curriculum/Cultural_Diversity_in_HealthCare.ppt http://www.apds.org/ARCS%202008/Cultural%20Diversity%20and%20Sensitivity%20Surg%20Curriculum%20-%20M.%20Tarpley.pdf A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia. Primary Health Care Section, Nova Scotia Department of Health