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1. Cultural Competence for
Healthcare Professionals
Part A:
Introduction to Clinical
Cultural Competence
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2. Why are you here today?
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3. 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.
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4. 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
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5. Miniature Earth
Miniature Earth
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6. The Health of New Immigrants
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.
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7. 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.
Walkabout Activity
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8. 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.
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9. 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”.
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10. 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.
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11. Immigration and
the Immigrant
Experience
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12. Immigration
 What do you know about Canada’s immigration policy?
 Why do families immigrate here?
 What is culture shock?
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13. Cultural Competence:
What are you doing about it?
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13

14. Overview of Eligibility
for Health Benefits
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15. Immigrant Experience
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16. 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
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17. 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
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18. 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:
1.Clinical appropriateness, need and patient preferences
2.How the healthcare system functions
3.Discrimination: Biases and prejudice, stereotyping, and
uncertainty (Institute of Medicine, 2002)
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19. 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:
1. What do you think is occurring in this situation?
2. How do you think this situation may have been understood by the new employee?
3. How might this differ from your experience of this situation?
4. How might you elicit information from the staff about their views of this situation?
5. Identify two actions that would demonstrate a respect and valuing of the staff’s culture and expectations.
6. What strategies might enhance the cultural competency of the interactions in this and similar situations?
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20. Social Determinants
of Health
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21. 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
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22. 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
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Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd ed.).
Toronto: Canadian Scholars' Press Incorporated.

23. 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)
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24. 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)
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25. Culture
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26. What is Culture?
 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)
What does culture mean to you?
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27. 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)
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28. Organizational and Professional
Culture
What is the culture of SickKids?
Values
 Innovation
 Excellence
 Collaboration
 Integrity
What is the culture of your profession?
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29. 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”.
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30. •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
Festivals Clothing Music Food Literature Language Rituals
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Iceberg Concept of Culture

31. Visible and Non-Visible
Aspects of Culture
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32. 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.
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33. 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.
What are the visible and non-visible
aspects of culture?
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34. 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
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35. Cultural Competence
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36. Definitions of Cultural
Competence
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)
(
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37. Cultural Competence
“We would not accept substandard
competence in other areas of clinical
medicine, and cultural competence should
not be an exception.”
Dr. Joseph Betancourt,
2006
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37

38. 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)
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39. Culturally
Competent
Practice
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40. Reducing Health Disparities
Through Culturally Competent Care
(Brach & Fraser, 2002)
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41. Actions and Strategies that
Support Cultural Competence
1. Examine own values, beliefs and assumptions
2. Recognize conditions that exclude people such as stereotypes,
prejudice, discrimination and racism
3. Reframe thinking to better understand other world views
4. Become familiar with core cultural elements of diverse communities
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42. Actions that Support
Cultural Competence
5. Engage patients and families to share similarities and differences from what
you have learned about their core cultural elements
6. Learn from and engage clients to share how they define, name and understand
disease and treatment
7. Develop a relationship of trust by interacting with openness, understanding and
a willingness to hear different perceptions
8. 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)
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43. Cultural Competence Continuum
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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)

44. What would you
do in these cases?
1. 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.
2. 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.
3. 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.
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45. Clinical Cultural Competence and
Family-Centred Care
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46. 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
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
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
(Adapted from Saha, Beach, & Cooper, 2008)
Cultural Competence and
Family-Centred Care
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47. Cultural Assessment
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48. Cultural Assessment Tool
Potential topics to explore:
(Andrews & Boyle, 2003)
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
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49. 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:
1.What do you think is occurring in this situation?
2.How do you think this situation may have been understood by this family?
3.How might you elicit information from family members about their view of this situation?
4.Identify two actions that would demonstrate a respect and valuing of the child/family’s culture and expectations.
5.What strategies might enhance the cultural competency of the care being provided in this and similar situations?
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50. 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.”
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51.  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
Take Away Activity
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52. Questions?
52

53. THANK YOU!!
53

54. 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,
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• Dunn, J.R. and Dyck, I., (2000). Social determinants of health in Canada’s immigrant population:
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55. References
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http://www.miniature-earth.com/me_english.htm
55

56. References
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healthcare professionals in Nova Scotia. Retrieved November 12, 2010 from
http://www.healthteamnovascotia.ca/cultural_competence/Cultural_Competence_guid
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• Paez, K., Allen, J., Beach, M. C., Carson, K., and Cooper, L. A. (2009). Physician
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• Pollick, H. F., Rice, A. J., Echenberg, D. (1987). Dental health in recent immigrant in
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• Raphael, D. (2006). Social determinants of health: Present status, unanswered
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56

57. References
• Raphael, D. (Ed.). (2008). Social Determinants of Health: Canadian Perspectives (2nd
Ed.).
Toronto: Canadian Scholars’ Incorporated36(4): 651-677
• Saha, S., Beach, M. C., and Cooper, L. A. (2008). Patient centeredness, cultural
competence and healthcare quality. Journal of National Medical Association, 100(11),
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• Sanmartin, C. and Ross, N. (2006). Experiencing difficulties in accessing first contact
health service in Canada. Healthcare Policy, 1(2), 103-119.
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m
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