Mind the Gap! Developing Skills to Navigate Cultural ... · 1. Discuss why culturally appropriate...

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

1

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/



2

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

For assistance: [email protected]




mailto:[email protected]



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]

3

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

4


5

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?


6

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

4

Why culturally appropriate

care matters

1

Health Outcomes

Patient Satisfaction

Patient Safety

Culturally Appropriate Care improves

7

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

9


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

12


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.

13

© 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

14


Migration = change


What immigrants face

Happiness &

Fascination

Disappointment,

confusion,

frustration….

Gradual

adjustment or

recovery

Acceptance &

adjustment

15

© 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

16


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

18


• 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.

21

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

23

• 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……

24


Moving beyond racial/ethnic

group membership

Acculturation and Ethnic Identity

Development

3 25


• 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

29


• 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

30


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

31


• 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

32


• 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

34


• 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

36


• 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

4 40


• 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

41


• 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


42


• 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


43


• 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.

45


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

46


www.kidsnewtocanada.ca

• “Online textbook”

• Evidence-informed, peer-reviewed

• Free!

More Resources

5 47

“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


54

Mind the Gap! Developing Skills to Navigate Cultural ... · 1. Discuss why culturally appropriate...

Documents

Transcript of Mind the Gap! Developing Skills to Navigate Cultural ... · 1. Discuss why culturally appropriate...