Mind the Gap! Developing Skills to Navigate Cultural ... · 1. Discuss why culturally appropriate care matters 2. Explain how culture influences health care/outcomes and how you might

Fireside Chat #411

September 24, 2014 1:00 – 2:00 PM Eastern Time

Mind the Gap! Developing Skills to Navigate Cultural Issues with

Newcomers Children, Youth and Families Attention à la différence!

L’acquisition des habiletés nécessaires pour explorer les problèmes culturels avec des enfants, des adolescents et

des famille néo-canadiens

www.chnet-works.ca

Population Health Improvement Research Network

Canadian Health Human Resources Network University of Ottawa

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Dr Dzung X. Vo Clinical Assistant Professor University of British Columbia

Dr Maureen Mayhew Clinical Associate Professor University of British Columbia

http://www.chnet-works.ca/



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Step #1: Teleconference All Audio by telephone • If your line is ‘bad’ – hang up and call back in • Participant lines muted • Recording announcement

Step #2: The Internet Conference (via ‘ADOBE CONNECT’)

No audio via internet 1. SEE the PowerPoint being shown 2. Post your comments/questions 3. Join the interactive poll

Difficulties? You can still participate! Use the back up PowerPoint – download from www.chnet-works.ca Post your comments via email

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How to post comments/questions during the Fireside Chat

Joining in by telephone +

Adobe Connect Internet Conference

Use the text box!

Joining by

telephone + backup PowerPoint

By email: Respond to the ‘access instructions’ email

[email protected]

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Please introduce yourself!

• Name

• Organization

• Location

• Group in attendance?




© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca

Mind the Gap! Developing Skills to

Navigate Cultural Issues

with Newcomer Children,

Youth & Families

CHNET-WORKS! Webinar

September 24, 2014

Maureen Mayhew,

MD, MPH Clinical Associate Professor

Dzung X. Vo, MD Clinical Assistant Professor

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1. Pediatrician

2. Family physician

3. Other type of physician

4. Nurse practitioner

5. Nurse

6. Other healthcare worker

7. Administrator

8. Policy-maker

9. Other

How would you describe yourself?


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1. Discuss why culturally appropriate care matters

2. Explain how culture influences health

care/outcomes and how you might address this

3. Describe the role of Acculturation and Identity

Development on health

4. Develop culturally appropriate skills in taking a

patient history

Learning Objectives

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Why culturally appropriate

care matters

1

Health Outcomes

Patient Satisfaction

Patient Safety

Culturally Appropriate Care improves

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Dealing with what is… 8


Terminology

Cultural Competence: Skills you can learn that

enable you provide more effective care

Cultural safety: The result of effective learning on

your part - how the patient benefits.

Cultural Humility: Your ongoing commitment to

self-evaluation and longer-term awareness of bias

…….patient-centred care

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Webster’s dictionary

Culture

• the beliefs, customs, arts, etc., of a particular

society, group, place, or time

• a way of thinking, behaving, or working that exists

in a place or organization (such as a business)

How culture influences health

care and health outcomes

2 10

Image source: Slide 6, Introduction to clinical cultural competence. Clinical Cultural Competency Series. Courtesy of the Centre for Innovation & Excellence in Child & Family Centred Care at SickKids Hospital.

Visible & invisible elements of culture 11


Aspects of culture that affect health care

View health/illness

Experience pain

Comply w treatment

Interact w HCW

Stigmatize disease

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12 y.o. Sudanese girl accompanied by parents.


What would you address this visit?

• First visit

• Quiet & withdrawn;

• Interprets for her parents

with PTSD

• They trust no one else

• Clinic interpreter from

persecutor group

• Mother begins with

complaints of body pain,

poor sleep, constant

worry.

• Dad suffers in silence; no

job

• Family lives in a 1

bedroom, basement suite

that is poorly maintained.

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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca © 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca

What would you address this visit?

1. Address use of a child as interpreter

2. Assess mother’s ability to care for the child

3. Assess adaptation issues in the child

4. Assess housing

5. Assess father’s PTSD

6. 1, 2 & 3

7. 2, 4, 5

8. All

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Migration = change


What immigrants face

Happiness &

Fascination

Disappointment,

confusion,

frustration….

Gradual

adjustment or

recovery

Acceptance &

adjustment

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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca © 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca

What immigrants adapt to

Housing

Racism Child

protection & discipline

Sense of security

Social norms

School

Climate

Gender roles

Loss Employment

Language

Loss of status

Disparity/ Poverty

Food

Recreation

Clothing

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What is LEARN?

Tool to enable provision of cultural competent care:

Listen with sympathy and understanding

Explain your perceptions of a problem

Acknowledge and discuss differences & similarities

Recommend treatment

Negotiate agreement

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• Listen with sympathy and understanding

– Patient perception of health condition

– Patient agenda

– Pre/post/migration & stress/trauma

– Adaptation/acculturation process

– Family conflict?

– Bias or discrimination?

– Risky behaviours e.g. sex, substance?

– Basic needs met?

– Usual age appropriate practices

LEARN (cont’d) 18


• Explain your perceptions of a problem

– Biases & values: Know your own well - KEY

– Respect & validate:

• Strengths - personal and cultural

• Resilience - survived adverse experiences

• Ability to adapt to a new culture

LEARN (cont’d) 19


• Acknowledge

• Discuss differences/similarities

– Let the patient teach you

– Know when to stand firm

• Recommend treatment

– Consider traditional, alternative therapy

• Negotiate agreement

– Ensure both agendas met

LEARN (cont’d) 20

Know your own biases

Work Environment

Social (ethnic,

religious, peers)

Family

Education

Individual Recognize that the

health care system

has a culture all its

own. This culture is

familiar to you, but

foreign to patients.

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People often come from private

health systems.

For many, the Canadian health

system makes no sense.

What can make a difference? 22

Case – difficult element; exploration

Example

http://www.kidsnewtocanada.ca/documents/CKNC_cklst(interpreter)_web_FINAL.pdf

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• Identify

• Support system

• Language skills

• Health literacy

• Stage of adaptation to Canada

• Spoken or visual health messages versus printed?

Tips

Remember: they may have survived events that you can

only begin to imagine……

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Moving beyond racial/ethnic

group membership

Acculturation and Ethnic Identity

Development

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• 1.5 - Generation Immigrant

• Working Class Family

• Admitted for severe malnutrition

secondary to Anorexia Nervosa

Case: 14-year-old Chinese Canadian 26


• Conflicts at home

• “I hate Chinese food”

• “I wish I wasn’t Chinese!”

• Mother: “I don’t know how to raise a

Canadian child!”



How would you approach family & cultural

issues?

a. Recommend parenting classes

b. Say to Mom, “Your daughter is in Canada

now, she’s not Chinese anymore”

c. Say to teen, “You’re lucky to have a Mom

who cooks great Chinese food!”

d. Explore acculturation and ethnic identity

development



• Racial/Ethnic Categories =

Homogeneous Groups?

• Every youth is unique individual

• Patient – centered care

• BUT: Culture, race, ethnicity plays

powerful role in health and behavior!

Beyond Simple Racial/Ethnic

Categories

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• Identity Development: Key task of

adolescence (Erikson)

• How does one relate to their own

race/ethnicity?

• Commitment and sense of

belonging to a group

Racial/Ethnic Identity Development

Phinney JS. Psychol Bull 1990;108(3):499-514

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1. Unexamined: “I’m not Chinese, I’m

just an individual.”

2. Identity Search: “Who am I?”

3. Achieved Identity: “Being Chinese

is an important part of who I am.”

• Development is fluid, dynamic, non-

linear

Phinney: Ethnic Identity Development

Phinney JS. Psychol Bull 1990;108(3):499-514

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• Racial/Ethnic Identity linked to self-

esteem

• Limited research on identity and health

• Stronger REI associated with:

•Improved mental health

•Decreased substance use

•Decreased risk of violence

Ethnic Identity and Health

Vo D, Park J. Am J. Men’s Health. 2008; 2(2):192

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• Linear: “Less” to “More” acculturated

• Assumes that involvement w/ dominant

culture and culture of origin are mutually

exclusive

• Assumes “assimilation”

• Proxies: Immigration status, language,

social preferences

Acculturation: Unidimensional Models 33


Acculturation: Multidimensional Model

Source: Berry, JW. “Immigration, acculturation, and adaptation.” Applied Psychology 1997;46(1):10. With permission.

http://www.kidsnewtocanada.ca/culture/adaptation

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• Assimilation: An original culture is rejected and

a person only participates in the new culture.

• Integration: An original culture is retained while

accepting the new culture.

• Separation/segregation: The original culture is

retained and the new culture rejected.

• Marginalization: Both the original culture and

the new culture are rejected

Acculturation Strategies 35


• Adults: Lower levels of stress,

higher levels of functioning

• Youth:

• Fewer risk behaviors

• More positive attitudes towards

health care workers

• Better psychological and functional

outcomes

Integrated Acculturation Style

http://www.kidsnewtocanada.ca/culture/adaptation

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• Youth adapt more quickly than their

parents

• Acculturation Gap associated with:

• Family Conflicts

• Youth Violence

• Mental Health Consequences

Acculturation Gap

http://www.kidsnewtocanada.ca: Adolescent Health chapters (in press)

37


• Diversity of identity and

acculturation styles

• Identity and acculturation is fluid,

dynamic

• Effects on health and behavior

Acculturation and Identity:

Lessons for Clinicians 38


How would you describe her acculturation?

a. Assimilation: An original culture is rejected and a

person only participates in the new culture.

b.Integration: An original culture is retained while

accepting the new culture.

c.Separation/segregation: The original culture is retained

and the new culture rejected.

d.Marginalization: Both the original culture and the new

culture are rejected

How would you explore and counsel around acculturation

and identity issues?

Back to the Case: 14-year-old Female 39


Having a culturally appropriate approach

to this task is more important than

developing a “checklist”!

Taking a Culturally Appropriate History

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• What is your country of origin? What group(s)

do you identify with? What language(s) do you

prefer?

• Why and when did you come to Canada? What

were some of the challenges and difficulties?

• What has helped you and your family to adjust

and cope with challenges?

Assess Immigration History,

Stress, Trauma

http://www.kidsnewtocanada.ca/culture/competence

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• Do parents and children in your family speak the

same primary language?

• How do you get along with your parents? What

do you argue about?

• Do you feel more comfortable being with people

of your family’s background, or mainstream

Canadian society? Or Both? Or Neither?

Assess Identity Development &

Acculturation


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• What do you think has caused this

problem? What do you call it? How do

you understand it?

• What do you fear most about this

problem?

• Are there any healing practices or

medicines that are traditional for your

family that you think might help?

Explore Sociocultural Dimensions of

Health & Health Beliefs


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• Again, avoid assumptions

• Meet with all teens alone & confidentially

• Adolescent psychosocial assessment

(e.g., HEEADSS / SSHADESS)

Screen All Teens Equally

http://www.kidsnewtocanada.ca: Adolescent Health chapters (in press)

44


• Teens vary in attitudes towards

interpreters

• Acculturation, language proficiency,

family roles

• Teens may intentionally mistranslate

Teens: Working with Interpreters

Vo DX, et al. Pediatrics 2007;120(6):e1481-93.

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1. Immigrants are diverse and their cultures are

evolving

2. Culturally competent care makes a difference

3. Be mindful of your own cultural biases and

values when providing care and negotiating

treatment options

4. Be alert to identity and acculturation issues

Take-Home Points

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www.kidsnewtocanada.ca

• “Online textbook”

• Evidence-informed, peer-reviewed

• Free!

More Resources

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“Taking a History” One-Page Guide

http://www.kidsnewtocanada.ca/culture/competence 52


• Medical Assessment

Checklists

• Adolescent Health

• Webinar series

• Ongoing project of CPS

CKNC: Still to Come

53


THANK YOU!

www.kidsnewtocanada.ca


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Documents

Mind the Gap! Developing Skills to Navigate Cultural ... · 1. Discuss why culturally appropriate care matters 2. Explain how culture influences health care/outcomes and how you might