This document discusses diversity, equity, and cultural competence in healthcare. It notes that Toronto is one of the most multicultural cities in the world, with half the population born outside Canada. Providing culturally competent care that addresses health disparities experienced by marginalized groups is important. Barriers immigrants face include lack of language access and healthcare system familiarity. Understanding different cultural contexts and not making assumptions can help improve cross-cultural communication and service excellence.

1. Renascent Valuing Diversity and Understanding Health Equity Name: Waheeda Rahman, MA, BA (Hons.) Title: Director, Diversity, Equity and Stakeholder Outreach Date: Feb. 25, 2011

2. Question What do you think makes you unique?

3. Our Global Community is The Diversity of Our Population Diversity are all the ways we are different. It can include, but is not limited to, economic status, gender, immigration status, age, sexual orientation, religion, ability, mental health, education, ethnicity, culture and even different professions etc.

4. Why should we care about diversity? Mandated by Government Legislations: Canadian Charter of Rights and Freedoms Ontario Human Rights Code Accessibility for Ontarians with Disabilities Act (AODA) The Excellent Care for All Act, 2010 Employment Equity

5. Why is a ‘diversity lens’ important for every organization? It is an organization’s ability to capitalize in three areas: Staff Clients Community

6. Our Diverse Staff Diversity is about harnessing the potential of all staff by maintaining plurality of perspectives and life experiences which can only boost excellence, creativity, innovation, service delivery and also provides increase access to networks. Creating an inclusive, welcoming and barrier-free work environment. What are the tools and resources required across disciplines in serving a diverse population? Example: Recruitment of diverse staff who are encouraged to utilize ‘all of themselves’ including their cultural/linguistic experiences

7. Our Diverse Clients Diversity is about truly providing client-centered care that is welcoming, inclusive and barrier-free to a diverse population by recognizing, respecting and embracing their unique needs. Examples : Ensuring available interpretation services. What are the cultural barriers?

8. Our Diverse Clients Marginalized populations have poorer health outcomes People living in poverty experience poorer health in almost all health areas including mental health, substance abuse or addiction Recent immigrants from non-European countries are twice as likely as Canadian-born residents to report deterioration in their health over an eight-year period. Health disparities prevalent in new immigrant population, regardless of language, culture, race, health, disease beliefs etc..

9. Our Diverse Community Diversity is about building partnerships with Toronto community partners in better serving and advocating for our global community. Examples: Community outreach/partnerships with community agencies/settlement organizations Ensuring that staff are able to make community referrals through community displays

10. Who is this global community? Toronto is recognized as one of the most multicultural cities in the world; Toronto is the # 1 destination for new immigrants to Canada followed by Vancouver and Montreal; Between 2001 and 2006, Canada received 1,109,980 international immigrants.

11. Who is this global community? Half of Toronto's population (1,237,720) was born outside of Canada, up from 48 per cent in 1996. In 2006, half of all immigrants to the City of Toronto have lived in Canada for less than 15 years. 47 per cent of Toronto's population (1,162,635 people) reported themselves as being part of a visible minority, up from 42.8 per cent (1,051,125) in 2001.

12. Visible Minority "Visible minority" is defined by Statistics Canada as "persons, other than Aboriginal peoples, who are non-Caucasian in race or non-white in colour" The top five visible minority groups in Toronto were: South Asian at 298,372 or 12.0 per cent of our population; Chinese at 283,075 or 11.4 per cent; Black at 208,555 or 8.4 per cent; Filipino at 102,555 or 4.1 per cent; Latin American at 64,860 or 2.6 per cent.

13. Ethnic Origin Regardless of where people were born, or when they came to Canada, everyone reports on their ethnic background or heritage. Respondents are permitted to report more than one ethnic origin if appropriate and this is happening more frequently. Toronto's rich multi-cultural diversity is expressed by the more than 200 distinct ethnic origins residents identified in their response to the 2006 Census. In 2006, twenty-eight percent of all ethnic origin responses in Toronto were European; 19 per cent identified themselves with the British Isles (including England, Scotland, and Ireland); 16 per cent as East or Southeast Asian; and 10 per cent as South Asian in origin.

14. Language Over 140 languages and dialects are spoken in Toronto In 2006, forty-seven percent of the population had a mother tongue in a language other than English or French. Since 1996, the number of persons with Tamil as a home language has surpassed those who speak Italian while Spanish as a home language has overtaken Portuguese. The top 5 mother tongue languages in 2006 were: Chinese (420,000); Italian (195,000); Punjabi (138,000); Tagalog/Pilipino (114,000); Portuguese (113,000).

15. Aboriginal Peoples Aboriginal Identity refers to those persons who reported identifying with at least one Aboriginal group (North American Indian, Métis or Inuit), or those who reported being a Treaty Indian or a Registered Indian as defined by the Indian Act of Canada, or those who reported they were members of an Indian band or First Nation. Census counts for aboriginal identity include persons living in private households only. Individuals who lived in collective residences, institutions or were homeless at the time of the enumeration are not reflected. The results of the 2006 Census may be undercounting actual population numbers. Approximately 70,000 Aboriginal people living in the City of Toronto.

16. Aboriginal Peoples The number of urban aboriginal persons reported by the Census has historically been sharply lower than estimates from agencies serving this community. In 2006, Aboriginal agencies estimated that there were From 2001-2006, the aboriginal population in the GTA went from 23.950 to 31,910, an increase of 33.2 per cent. The GTA aboriginal population includes higher proportions of children (22.1 per cent vs 18.7 per cent) and youth (16 per cent vs 13.4 per cent). The proportion of seniors, meanwhile, is significantly lower (4.6 per cent vs 11.4 per cent). Among aboriginals in the City, 67.1 per cent were North American Indians, 26.8 per cent Métis, and 1.4 per cent Inuit.

17. Accessibility About 1.85 million people in Ontario have a disability. That's one in seven people. Over the next 20 years as people grow older, the number will rise to one in five Ontarians. People with disabilities travel, shop and do business just like everyone else.

18. Sexual Orientation 21.2% — The proportion of all same-sex couples who resided in Toronto in 2006 3% — The percentage of all male same-sex couples who had children aged 24 and under living in the home in 2006. 16% —The percentage of all female same-sex couples who had children aged 24 and under living in the home in 2006.

19. Religion By 2031, the number of people having a non-Christian religion in Canada would almost double from 8% of the population in 2006 to 14% in 2031. Within the population having a non-Christian religion, about one-half would be a Muslim by 2031, up from 35% in 2006. There were also substantial increases in the number of Buddhists, Hindus and Sikhs, whose ranks also doubled.

20. Mental Health and Addiction 1 in 5 Canadians will experience a mental illness in their lifetime. The remaining 4 will have a friend, family member or colleague who will (Centre for Addiction and Mental Health). About 20% of people with a mental disorder have a co-occurring substance use problem (CAMH). Almost one half (49%) of those who feel they have suffered from depression or anxiety have never gone to see a doctor about this problem (Canadian Mental Health Association). $34 billion is the cost of mental illness and addictions to the Ontario economy (CAMH). According to the World Health Organization, depression will be the single biggest medical burden on health by 2020 (CAMH).

21. Miniature Earth If we could turn the population of the earth into a small community of 100 people keeping the same proportions we have today, it would be something like this. Miniature Earth

22. Immigrants

23. 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 in Canada with better health scores and five years later have lower health scores than average Canadians Why?

24. Walkabout Activity Walk around and review the posted data and statement clusters. After 15 minutes you’ll be asked to explain the cluster that is of most interest to you.

25. Definitions Social Inequities in Health: Disparities judged to be unfair, unjust and avoidable that systemically burden certain populations. 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”.

26. Immigrant Experience

27. Importance of Health Equity and Diversity 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.

28. 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

29. Immigrant Experience – Resettlement Challenges Underemployment/unemployment Low socioeconomic status Lack of family/social support Lack of familiarity with the healthcare system Mental health (Post-traumatic stress disorder, depression) Inconsistent public policy between levels of government

30. 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 Health Literacy

31. 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: Clinical appropriateness, need and patient preferences How the healthcare system functions Discrimination: Biases and prejudice, stereotyping, and uncertainty (Institute of Medicine, 2002)

32. Immigration What is Canada’s immigration policy? Why do families immigrate here? What is culture shock? What do staff need to consider to provide service excellence to new immigrant clients?

33. Immigration Immigrant : Someone who moves to another country Refugee : An individual who flees their homeland due to fears of persecution based on race, religion, nationality, membership in a particular social group, or political opinion or activity (CIC, 2009) Permanent resident is an immigrant or refugee who has been granted the right to live permanently in Canada Refugee claimant is a person who has made a claim for protection as a refugee. (Canadian Council for Refugees, 2004) Non-status immigrants are individuals who have made their home in Canada but lack formal immigration status

34. Health Equity Terminology Equal means the same; to ignore differences Equitable aims to produce the same opportunity for positive outcomes Disparities refers to the differences in outcomes Equitable Access refers to the ability or right to approach, enter, exit, communicate with or make use of health services

35. 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.

36. Culture

37. What does culture mean to you? 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)

38. 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”.

39. Iceberg Above Ice Festivals Clothing Music Food Literature Language Rituals 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

40. 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; Long & Nelson, 1999; Ogbu, 1994)

41. Stereotypes/Assumptions of the ‘Other’ Scene from the Movie Crash

42. What is Cross-Cultural Understanding? 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)

43. Actions that Support Cultural Understanding Examine own values, beliefs & assumptions Recognize conditions that exclude people such as stereotypes, prejudice, discrimination and racism Reframe thinking to better understand other world views Become familiar with core cultural elements of diverse communities

44. Actions that Support Diversity and Equity Develop a relationship of trust by interacting with openness, understanding and a willingness to hear different perceptions Create a welcoming environment that reflects and respects the diverse communities that you work with and that you serve (A Cultural Competence Guide for Primary Health Care Professionals in Nova Scotia)

45. Service Excellence

46. Service Excellence Icebreaker Define what service excellence in your job means. Identify challenges you experience providing service excellence at work. Describe something you believe would help you deliver service excellence

47. Success Factors for Service Excellence A commitment to embrace and improve quality of care, involving: Asking patients and families what they want Listening to patients and families Providing excellent service in light of patients and families requirements. A commitment to organizational flexibility and change (Brathwaite, 1993)

48. Linking Service Excellence and Cultural Competence Cultural competence and service excellence involve: Willingness to learn what patients/families need and want, and to modify how you provide services to meet those needs Sensitivity to differences and embracing the pluralism of ideas Accepting and respecting patient/family differences Respectful communication with patient /family Willingness to adapt one’s communication style to meet the needs of others and utilizing the patients preferred and most effective means of communication

49. Linking Service Excellence and Cultural Competence A commitment to flexibility in the provision of care and services Recognizing healthcare access barriers, and helping patients/families overcome them Commitment to achieving health equity Demonstrating awareness, respect and sensitivity in eliciting sensitive information from clients and families Accurate identification and documentation of population and clients language preferences, level of proficiency and literacy Continuously engaging in reflective practice by reflecting before action and after

50. Mini Cases – What would you do? You are having lunch with colleagues. A discussion of issues on the unit begins and someone mentions the new employee, who is an immigrant. Three people begin talking about how hard it is to understand her and a discriminatory comment is made. You have just finished coordinating a return visit for a patient and family who was having difficulty understanding your instructions due to a language barrier. After they leave, a colleague makes a discriminatory comment regarding the family.

51. Cross-Cultural Communication

52. Assigning Meaning What it means to me What it might mean to another Not making eye contact Saying “YES” Spending time on small talk Arriving late for an appt/class/work Needing to consult family

53. Joy Luck Club

54. Context of Communication Asian and Latin American cultures Is less explicit, most of the message is in the physical context or internalized in the person More emphasis on what is left unspoken, more likely to “read into” the interactions North American culture Most of the information is made explicit in language used Information is often repeated for emphasis to ensure understanding (if it is relevant and important it must be stated, if it is not stated it is not relevant) Low Context High Context

55. Context of Communication More responsibility on the listener – to hear, to interpret and then to act More need for silence; longer pauses (to reflect, understand the context and process the message) The responsibility for communication lies with the speaker; it is better to over communicate and be clear then to leave things unsaid Silence and pauses often misunderstood as signs of agreement or lack of interest (Hall, 1976) High Context Low Context

56. Collaborative Conversations 3 Steps: Empathy – Attempt to understand the other person’s perspective Define the Concern – Express your concern Invitation – To generate solutions that address both concerns 2 Key Ingredients: Two concerns on the table Win/win solutions (Greene, 2006)

57. Collaborative Conversations 3 2 Key phrases Empathy - Understanding Two concerns I’ve noticed . . . Help me understand . . Tell me more . . Can you explain that a bit more? What else are you thinking? Define the Problem What I’m thinking . . . I’m concerned that . . . I’ve been considering . . Invitation to generate solutions Win/win solutions Would you be open to . . .. Could we consider . . . . What can we do about this? Let’s consider . . . What about . . . I wonder if there is a way . . . .

58. Things to Consider How can having a collaborative conversation with someone contribute to Service Excellence? Other points to consider: Power Dynamics Experience and Expertise Communication Styles

59. Health Literacy

60. Health Literacy Health literacy is “the ability to access, understand and act on information for health” (Canadian Public Health Association) It “involves the ability to obtain, process and understand basic health information” (Ratzan and Parker, 2000) Canadians with the lowest literacy scores are two and a half times as likely to see themselves as being in fair or poor health (Rootman & Gordon-El-Bihbety, 2008).

61. Health Literacy It involves appropriate use of translated materials and resources such as interpreter services It is not enough to give the family a pamphlet in their own language

62. How to Assess a Family’s Need for an Interpreter Pay attention to non-verbal cues Ask the family to repeat back to you their understanding of what you’ve just told them

63. Cross-Cultural Communication Strategies Assume differences Listen to stories Share your intent, your purpose, your thinking Ask for clarification Be sincere and respectful Acknowledge your own ethnocentrism Take risks and be prepared to apologize

64. Conclusion Understanding of diversity and equity is an integral component of service excellence as it acts to: Create organizational flexibility and improves organizational climate. Create an attitude toward improving information and understanding. Improve the quality of care.

65. Questions?

66. THANK YOU!!