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.
Cultural competence lecture
Dr Beatriz CardonaUWS Office of EngagementUniversity of Western Sydney
What we need to consider◦ Demographics (refugees and low socio economicmigrants in western sydney)◦ Disparities in Health Status◦ Health Practices and Beliefs◦ Barriers to Health Care
◦ Culture informs our identity◦ Culture affects the roles played within a family, ethnicgroup and community◦ Culture defines family relationships, family structure,attitudes, beliefs, practices and styles ofcommunication◦ It also impact on our health practices and choices: forexample: use of complementary medicine, attitudestowards vaccinations, dress and food preferences,attitudes toward women, etc◦ However Culture is not he only or the most importantdeterminant of health: think of the 3 factors:demographics, environment and culture
It reflects the ability to acquire and use knowledgeof health care related beliefs, attitudes, practicesand communication patterns of clients and theirfamilies to improve services, strengthen programs,increase community participation and close thegaps in health status among diverse populationgroups.
Cultural competency is not static – you don’treally become but constantly becoming Fluid Culture as constantly being negotiated Multiple cultural identities No single formula but emphasis on processes andskills we use to negotiate interactions Cultures in negotiation _ cultural self-awareness
Cultural Competence is a set of values,behaviors, attitudes and practices within asystem, organization, or among individuals thatenables them to work effectively across cultures. cultural competence focuses on the capacity ofthe health worker to improve health status byintegrating culture into the clinical context. the point of cultural competence is to maximisegains from a health intervention where theparties are from different cultures
Multicultural policy in NSW is administered by the Community RelationsCommission (CRC) for a multicultural NSW and is based on 4 principles ofmulticulturalism.Principles of Multiculturalism require that each publicauthority respect and accommodate the culture,language and religion of all individuals.Cultural diversity is defined as : people from a range ofcultural, ethnic, linguistic and religious background7
• “The healthy migrant effect”: Initial migrant healthadvantage often deteriorates over time as diet andexercise patterns change• Limited research into immigrant health in Australiainvisibility can undermine equity in healthcare provision• Immigrants face additional language and/or culturalbarriers not experienced by Australian-born patients• Poor engagement of older migrants to health systemundermines self-management of chronic conditions:effective communication is crucial to effective care
• 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)
• inadequate vaccinations, nutritional deficiencies(vitamin D and iron) and dental disease • infectious diseases (gastrointestinalinfections,schistosomiasis, and latenttuberculosis) • musculoskeletal, social and psychological problems e.g. PTSD, anxiety, depression
“I do not understand the health care system inAustralia. I have to rely on family and friends …” “It is difficult to find a service that provides aninterpreter …” “Because of my religion, I prefer to see afemale doctor … especially for reproductive issues”(Omeri et al, 2006)
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”◦ Make it Better◦ Control Over Nature◦ Do Something◦ Intervene Now◦ Strong Measures◦ Plan Ahead – Recent isBest◦ Standardize – TreatEveryone the Same “Others”◦ Accept With Grace◦ Balance/Harmony withNature◦ Wait and See◦ Cautious Deliberation◦ Gentle Approach◦ Take Life As It Comes –“Time Honored”◦ Individualize – RecognizeDifferences
The Cultural Competence Continuum◦ Where Am I Now?◦ Where Could I Be?
Cultural Competence Definitions◦ Cultural Destructiveness: forced assimilation,subjugation, rights and privileges for dominant groupsonly◦ Cultural Incapacity: racism, maintain stereotypes, unfairhiring practices◦ Cultural Blindness: differences ignored, “treat everyonethe same”, only meet needs of dominant groups
Cultural Competence DefinitionsCultural Pre-competence: explore cultural issues, arecommitted, assess needs of organization andindividualsCultural Competence: recognize individual and culturaldifferences, seek advice from diverse groups, hireculturally unbiased staffCultural proficiency: implement changes to improveservices based upon cultural needs, do research andteach
Acquiring Cultural Competence◦ Starts with Awareness◦ Grows with Knowledge◦ Enhanced with Specific Skills◦ Polished through Cross-Cultural Encounters
Culturally sensitive approach to asking inquiringabout 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 itwork?◦ How severe is it? How long do you think you will haveit?(continued next page)
Culturally sensitive approach to askingabout a health problem◦ What do you fear most about your illness?◦ What are the chief problems your sickness has causedyou?◦ Anyone else with the same problem?◦ What have you done so far to treat your illness: Whattreatments do you think you should receive? Whatimportant results do you hope to receive from thetreatment?◦ Who else can help you?
Listen to the patient’s perception of the problemExplain your perception of the problemAcknowledge and discuss differences/similaritiesRecommend treatmentNegotiate treatment
Pre interview sessionPre interview session Brief the interpreter about the session Obtain cultural background information from the interpreter Establish mode of interpretingDuring the interviewDuring the interview Introduce everyone and establish roles Establish ground rules – speaking THROUGH the interpreter TO theclient 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 sentencesPost interview sessionPost interview session De-brief the interpreter28
Use simple, plain English Avoid jargon Don’t use slang or verbal jokes Speak slowly, but do not shout or raise yourvoice 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 time29
Australian Bureau of Statistics, Census data 2006 ECC NSW, COPS NSW & DADHC (2006) CulturalCompetency & Case Management Training Package Multicultural skills for health staff, Cultural diversity trainingunit, 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, FairfieldHospital Sockalingum adapted from Hayes, Cultural CompetenceContinuum, 1993 and Terry Cross Cultural CompetencyContinuum30