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
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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
For assistance: [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
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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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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?
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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
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Health Outcomes
Patient Satisfaction
Patient Safety
Culturally Appropriate Care improves
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Dealing with what is… 8
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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
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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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
Aspects of culture that affect health care
View health/illness
Experience pain
Comply w treatment
Interact w HCW
Stigmatize disease
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
12 y.o. Sudanese girl accompanied by parents.
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
Migration = change
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
What immigrants face
Happiness &
Fascination
Disappointment,
confusion,
frustration….
Gradual
adjustment or
recovery
Acceptance &
adjustment
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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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
Moving beyond racial/ethnic
group membership
Acculturation and Ethnic Identity
Development
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 1.5 - Generation Immigrant
• Working Class Family
• Admitted for severe malnutrition
secondary to Anorexia Nervosa
Case: 14-year-old Chinese Canadian 26
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• Conflicts at home
• “I hate Chinese food”
• “I wish I wasn’t Chinese!”
• Mother: “I don’t know how to raise a
Canadian child!”
Case: 14-year-old Chinese Canadian 27
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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
Case: 14-year-old Chinese Canadian 28
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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)
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• Diversity of identity and
acculturation styles
• Identity and acculturation is fluid,
dynamic
• Effects on health and behavior
Acculturation and Identity:
Lessons for Clinicians 38
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
Having a culturally appropriate approach
to this task is more important than
developing a “checklist”!
Taking a Culturally Appropriate History
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
http://www.kidsnewtocanada.ca/culture/competence
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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
http://www.kidsnewtocanada.ca/culture/competence
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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)
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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• 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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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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© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
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
© 2014 Canadian Paediatric Society I www.kidsnewtocanada.ca
• Medical Assessment
Checklists
• Adolescent Health
• Webinar series
• Ongoing project of CPS
CKNC: Still to Come
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THANK YOU!
www.kidsnewtocanada.ca
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