The role of culture and gender in the provision of care for immigrants

Sylvia Reitmanova, MD, MSc, PhD

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Outline

• Part 1: Theoretical underpinnings

• Part 2: Culture, gender and immigrants’ health needs

• Part 3: Institutional and personal support

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Cross-cultural care:

Theoretical underpinnings

Part 1

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The lack of culturally-responsive care

Misunderstanding and miscommunication

Patient general dissatisfaction

Poor adherence to therapy and care

Poor health outcomes

Health and care disparities

Rationale for the provision of culturally safe services

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Negative consequences

• stress-induced hormonal and immune responses make women more vulnerable to pre-term labour, low birth weight, and perinatal mortality and morbidity including gestational diabetes and post-partum depression

(Patrick & Bryan, 2005; Van Eijsden, M. et al. 2006)

• destructive to women’s decisions to utilize services in the future

(Carlton, T. et al., 2005)

• healthy immigrant effect

(Beiser, 2005)

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• Association of Faculties of Medicine of Canada:

the Social Accountability Initiative to address and advocate the changing needs of the communities

• Liaison Committee on Medical Education:

“… demonstrate an understanding of the manner in which people of diverse cultures and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments.”

“… to recognize and appropriately address gender and cultural biases in themselves and others, and in the process of health care delivery.”

Socially responsible healthcare

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Intersection of culture and health

• Conceptions of health and disease

• Treatment approaches and responses

• Expectations from health professionals

• Social determinants of health

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Which term to use?: Two models of cross-cultural care

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Cultural competence model

culture = fixed patterns of learned beliefs, values, practices, ways of interacting and communicating shared among groups and passed between generations

• all patients in one cultural group present the same health beliefs and behaviours

• eliciting patients’ health beliefs, concepts of time, space and physical contact, communication styles, the role of family and gender, social expectations, and decision-making preferences

• a list of “do’s and don’ts”

• tolerance, inclusion, and appreciation

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Cultural safety model

culture = flexible system of values and world views that people live

by and recreate continuously depending on larger social, economic and political circumstances

• the role of the social determinants of health in health outcomes, choices and behaviours (variations in socioeconomic status, employment, and housing patterns, the effects of war, torture, and abuse, racism)

• intersectionality of culture, ethnicity, skin colour, gender, class, ability, age or sexual orientation in production of health

• exploration of personal biases, fears, emotional reflexes, and psychological defences

• advocacy

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Cross-cultural care:

Immigrants’ needs

Part 2

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Barriers to mental healthcare

• Lack of information about mental illness and services

• Long wait times

• Financial constraints

• Linguistic concerns

• Cultural barriers

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Culture and mental health

spirituality, moral values, family ties, & non-materialistic life

internal strength, support, and understanding of the purpose of life

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Cultural barriers

Cultural differences and understanding

They [Canadian-born doctors] would never understand what I was going to say. I know that. There are a lot of things that I say to Canadian friends or neighbours and they just don’t know what I am talking about.

Maybe understanding can be attained between the patient and the mental health provider, but after the understanding, there is treatment and help itself. I am not sure if there is a single recipe for everyone from different cultures.

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Cultural validity of diagnostic methods

Psychological testing:• Having fits, Blue spells, Raw deal• Do you believe that the man should be the head of the family?

Cultural barriers

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Cultural barriers

Treatment approaches

• Psychological therapy (meditation, imagining, problem solving) • Social therapy (family involvement, social re-integration)• Physiological therapy (massage, acupuncture) • Supernatural therapy (prayers, rituals - traditional folk healers or

religious authorities)• Herbal remedies

• Drug therapySome patients (e.g. Hispanics and Nigerians) have low levels of Cytochrome P450 isoenzymes involved in the oxidation of many drugs resulting in poor metabolism of drugs

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Culturally appropriateness of activities promoting mental well-being

Dance or drink: these are things we are offered to do and they will criticize us why we are not doing these things.

• Lack of gender-based sports, leisure and

social programs

Cultural barriers

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Cultural insensitivity

I am not expecting from my family doctor to ask me to go and pray. One should admit it there is a difference [between cultures]. I do not expect him to ask me to recite my Holy Book. But I remember when I got cured from my condition and I said that “I want to thank God and you,” he asked me “Why do you put God in this one?” I told him that we always thank God for everything. It is a simple thing you do. But he did not understand why I [first] thank God and then to him. He expected maybe to thank only to him.

Cultural barriers

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Barriers to maternal healthcare

• Lack of information about maternity and services

• Lack of emotional and practical support

• Linguistic concerns

• Cultural barriers

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Lack of women-only prenatal classes

Lack of room privacy

Lack of dietary accommodation

Lack of specific services (male circumcision)

Lack of female health professionals and staff

I want to say that there should be more female doctors here. And they should be flexible to come for a delivery when any woman needs. It’s the most important moment to have a female doctor during the delivery… if she is not there as if I did nothing [to protect my modesty].

Cultural barriers

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Cultural stereotypes, prejudice and insensitivity

She [a nurse] asked me, “And do you have cars in your country? Do you have electricity?” I think she thought we ride on camels, so I told her about my country

You see their faces, you feel it that they think you are stupid and you don’t know anything about this world.

I asked nurses if they can knock before they enter so I can get dressed. I also put a sign on the door but they didn’t respect it. This man came and saw me [unveiled]. I was very upset and crying. One nurse came and she said, “Oh, why you are crying? You are beautiful! You don’t need to cover yourself.”

Cultural barriers

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Cross-cultural care:

Institutional and personal support

Part 3

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Institutional support for cultural safety

• Policy and practice

• Service planning

• Hiring and retention of staff

• Professional development of staff

• Physical environment

• Health education materials

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• Diversity, gender, and social determinants of health

• Health beliefs and practices

• Personal self-reflection and advocacy

• Social interaction and communication

• Professional development activities

Personal support for cultural safety

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Nurturing cultural competence: Salem Hospital, Oregon

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