1. How are we to talk about this?
Module 4 – Communicating culturally sensitive issues
How are we to talk about this?
Acknowledge traditional owners.

2. This project was made possible using funding from Health Workforce Australia

3. Outline of today’s session
Overview of Module 4
Sensitive issues
Torture and trauma experiences of refugees
Challenges of end-of-life palliative care
Challenges with minority sexual orientation
Role Play (optional)
Simulation
Provide an overview of the CREST and Module 1 – including aims and learning objectives.
General discussion of cultures, religious beliefs, life experiences and circumstances, and how they influence an individual's identity, relationships and health belief system.
2. Discuss the following sensitive issues and the way they may impact on health and health seeking behaviours. Also discuss the support and resources available, and the role of the health care provider.
The torture and trauma experiences of refugees prior to and after arrival in Australia.
Challenges of end-of-life palliative care in some religions and cultures.
Challenges with minority sexual orientation in some religions and cultures.
3. Rehearse key questions to ask about culturally sensitive issues based on the Kleinman’s model
4. Provide ground rules for the simulation and describe the role of the interviewer and purpose of the interview – to sensitively explore the issues
Describe how this will take place. Eg. ‘fishbowl’ role play, panel interview.
Students will be encouraged to use the Kleinman’s model.
Case studies 2, 6, 7 and 8 will be suitable for use in this module.
Tutor may choose to
do the case studies as simulated learning or as case presentation/discussion;
do one or two case studies.

4. Overview of CREST Four modules:
Module 1 – Introduction to Cultural Diversity
Module 2 – Negotiating between different health beliefs
Module 3 – Effective communication when English Proficiency is low
Module 4 – Communicating culturally sensitive issues

5. Communicating culturally sensitive issues
Today, we will explore some of the culturally sensitive factors that may affect the identity and health of cultural diverse patients, and to understand culturally sensitive health assessment and engagement.

6. Primary Learning Objectives:
Gain an understanding of
the distinct health inequalities experienced by some CALD patients particularly refugees;
how some cultures and religious beliefs strongly shape or even dictate relationships and daily life practices;
specific patient support resources;
using the Kleinman’s explanatory model to facilitate disclosure of sensitive issues and influence decision-making.

7. Let’s have a yarn…
How do cultures, religious beliefs, life experiences and circumstances influence our identity, relationships and health belief system?
General discussion

8. Our cultures, religious beliefs, life experiences and circumstances…
…affect everything we think and do. The way we define ourselves culturally (by ethnicity, religious belief, politics, sexual orientation, disability, age and more) affects our health belief and behaviour.

9. Explanatory Models
“Explanatory models are notions that patients, families and practitioners have about a specific illness episode. These informal descriptions of what an illness is about have enormous clinical significance; to ignore them may be fatal.”
Kleinman, A. Conflicting Explanatory Models in the Care of the Chronically Ill (Cahpter 7). In: The Illness Narratives: Suffering, Healing and the Human Condition Basic Books, New York.
Notes to teachers and tutors:
RECAP – refer to Module 1 powerpoints.

10. Explanatory Models (contd)
“Eliciting the patient’s (explanatory) model gives the physician knowledge of the beliefs the patient holds about his illness, the personal and social meaning he attaches to his disorder, his expectations about what will happen to him and what the doctor will do, and his own therapeutic goals.”
Kleinman A., Eisenberg L., Good B. Culture, illness, and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med 1978;88:251–88.
Notes to teachers and tutors:
RECAP – refer to Module 1 powerpoints.

11. Kleinman’s Explanatory Model
What do you think has caused your problem?
Why do you think it started when it did?
What do you think your sickness does to you? How does it work?
How severe is your sickness? Will it have a short or long course?
What kind of treatment do you think you should receive?
What are the most important results you hope to receive from this treatment?
What are the chief problems your sickness has caused for you?
What do you fear most about your sickness?
Notes to teachers and tutors:
RECAP – refer to Module 1 powerpoints.

12. Cultural differences that could affect communication with a refugee
patterns of communication
views about the causes of illness and the ways they should be managed
views about the relationship between service provider and client
views about the role of Western medicine
individual versus communal approaches to illness and health
views about gender roles

13. Trauma experience by refugees prior to arrival in Australia
threats to their lives
death squads
witnessed mass murder and other cruelties
disappearances of family members and friends
perilous flight or escape
separation from family members
extreme deprivation: poverty, unsanitary conditions, lack of access to health care
persistent and long-term political repression, deprivation of human rights and harassment
removal of shelter, forced displacement from their homes
refugee camp experiences involving prolonged squalor, malnutrition and a lack of personal protection
privation of personal space with consequent disruption to personal and intimate relationships
interrupted or lack of education
Notes for teachers and tutors
Also discuss the ‘trauma’ experience AFTER arrival. Examples include
Cultural shock
Racism
Language barriers
Food/housing/education

14. Resources for practitioners
Caring for Refugee Patients in General Practice: A Desk-top Guide; the Victorian Guide. 4th Edition. Promoting Refugee Health: A guide for doctors, nurses and other health care providers caring for people from refugee backgrounds. 3rd Edition. Available from

15. Support and resources for refugee patients
Victorian Foundation for Survivors of Torture
Department of Health Refugee and Asylum Seeker Health
Victorian Refugee Health network
Amnesty International Australia
Australian Government Department of Immigration and Citizenship
 World Health Organisation: Refugees

16. Culture and religion affect one's perception of palliative care and end-of-life decision-making
“It is important to realise that there is an entire system at play that includes the patient, their family, their physicians, and other healthcare providers. In order to provide the best possible care to patients and families in end-of-life situations, it is important to understand their cultural constructs as well as their individual preferences. It is also important for each caregiver to realize that we each bring our own set of biases to these discussions based on our cultural and religious background and personal experiences.”
Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci. 2011 Jul-Dec; 1(2): 154–156. doi:   /

17. Resources and references
Palliative Care Victoria website
Kleinman A, Eisenberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross- cultural research. Ann Intern Med Feb;88(2):251-8.
Steinberg SM. Cultural and religious aspects of palliative care. Int J Crit Illn Inj Sci. 2011 Jul-Dec; 1(2): 154–156. doi:   /
Javanparast S et al. Barriers to and facilitators of colorectal cancer screening in different population subgroups in Adelaide, South Australia. MJA 2012; 196: 521–523. doi: /mja

18. Challenges of minority sexual orientation in some religions and cultures
patient’s own culture/religion may view being gay as a sin, as morally evil, a source of shame
death penalty exists for homosexual acts in some countries
fear of lack of confidentiality of health provider may prevent disclosure (so documentation issues are important, and involvement of interpreters can be difficult)
multiple identities- needing to express sexuality while maintaining cultural identity
mental health sequelae are common in this setting

19. Resources available Australian GLBTIQ Multicultural Council
Health Care Providers’ Handbook on Muslim Patients
Centre for culture, ethnicity and health. Double Trouble? The health needs of culturally diverse men who have sex with men.
Sue, Derald Wing, Sue, David. Counselling Sexual Minorities (Chapter 23). In: Counselling the Culturally Diverse: Theory and Practice, 2007, 5th ed. John Wiley, Hoboken, New Jersey.

20. General resources
Walker PF & Barnett ED. Immigrant Medicine. Saunders Elsevier 2007.

21. Role Play Exercise (optional)
break into groups of 3 or 4
take turns to play a patient or a health care practitioner – rehearse key questions to ask about culturally sensitive issues based on the Kleinman’s model
role-play for 5 mins for each interview including giving feedback to one another
Notes to teachers and tutors:
This is an optional exercise. You may delete this slide or modify the exercise to suit your need.