Post on 09-Feb-2022
Dr Cheryll Adams, Independent Advisor, Health Visiting and Community Public Health
United Kingdom
Aim
To discuss how, by having an understanding of cultural issues (cultural competence), you can communicate more effectively as a health visitor/public health nurse across cultural and language barriers
Objectives
To consider how to always see a situation from your client/patient’s cultural and societal perspective
To encourage delegates to take on any necessary actions to become more culturally competent in their work
To inspire you to test new approaches in your work to improve your outcomes with those clients who are of a different culture, and do not have a shared language.
What is Culture?
Shared, inherited view of the world by a group of people Any cultural group shares an unconscious set of assumptions
with other members of that group Culture defines how people construct their identity Your cultural background influences how you think, how you
behave, how you bring up your children and your views of illness Some people have a culture of origin and also a culture of
adoption from where they move to In most societies there are regional as well as national cultures,
also a culture of social class
Culture offers:
Systems
Values
Method of communication
Rituals
Sense of belonging
Cultural identity Bacon and eggs, and fish and chips are common
quick meals, marks of my cultural identity (S) It is accepted for new mothers to go back to
work (V) Putting your thumb up means you like
something (C) We bath our very young children before putting
them to bed (R) The dominant religion is Christianity amongst
older people (SoB)
Ethnicity Defines your identity but not your cultural heritage,
genetic in origin
The effects of ethnicity on health outcomes is not reflective of cultural issues alone
Important to separate out ethnicity and culture with respect to health improvement
Health outcomes are linked to education, social economic issues and employment as well as to ethnic, cultural and personal features such as gender and sexuality
Must acknowledge any organisational and professional response to diversity
Task
Tell the person sitting next door to you 3 unique characteristics of your culture of origin or adoption.
Subcultures:
Football or Rugby supporters
Cricket supporters
Those living in the north or south of a country
Urban v rural
Those who like opera, rock music
Vegetarians
Those who like gardening, sailing, collecting stamps, cars
New subculture: Solar panel culture!
How much of an issue is it?
In 2002 UN estimated 175 million people living outside the country of their birth or citizenship
In London in 2000 a study found only 2/3 of children had English as a first language
307 different languages spoken in London
Culture and language influence health behaviours
Cultural beliefs and childbirth Western - Births in hospital and increasingly normal for father to be
present.
Colostrum considered very important.
Woman may find herself at home alone within a few days
Non industrialised world- Births at home with only women present.
Colostrum discarded as not ‘real milk’
New mother conforms to ritualised postpartum period of up to 40 days when she may not be able to leave the home and other women look after her
Cultural challenges for non English mothers in the UK
‘It is hard to comply with the 40 day rule in England but my family don’t understand’
Urdu speaking muslim mother
‘The doctors receptionist didn’t understand that I couldn’t bring my baby to the surgery because of the 40 day rule’
Bengali speaking Indian mother
‘In Hong Kong mothers eat special soup when they are breastfeeding but it is considered too strong for the milk in the UK’
Chinese mother
‘Often mothers say their heart is hurting when they are depressed’
Arabic mother
What is cultural competence?
Ability to communicate across cultural divides to deliver the needs of any community.
To be able to manage the challenge of any language barrier and understand any problems you are working with, in the way that the community expresses them
To understand that cultures are not homogenous, variations within cultural groups may be larger than those between them
Understanding that differences between cultures can be related to many things apart from cultural beliefs
E.G. opportunity or education
TASK
What one thing could you do to make your practice more culturally competent?
Research into culturally issues in nursing advises:
Importance of consulting users when developing services
Similarities of experience of different ethnic groups
Importance of culturally specific aspects of people’s lives
Being culturally sensitive is about treating people with dignity and respect
Need to develop bi-cultural approaches in response to multi-culturalism
Reasons women from SE Asia don’t enter nursing
Culley, JRN, 13.2, 2011
Communication?
‘The act of imparting information’ (Oxford English Dictionary)
‘Exchange of understanding’
‘Transmitting information from one person to another’
‘Who says what to whom, in what channel, with what effect’
Issues to consider Information about services should be available in a range
of languages and formats
Employing staff from minority ethnic communities at all levels of an organisation increases cultural competence within it
Families may need to be involved in the communication process
Effective communication requires action at the institutional as well as individual level
Why does good communication across cultures matter?
In UK, (also Nordic countries?) if you have mental illness e.g. postnatal depression and come from an ethnic minority group:
More likely to be detained under the mental health act
If admitted to hospital more likely to stay longer
More likely to have medication than psychological services
When present to primary care your problem less likely to be recognised
How do we communicate? Verbal – tone, speed, emphasis
Non verbal (TASK) Facial expression – fear, happiness, sadness, anger, interest,
disgust
Eye contact – hostility or interest
Posture
How we behave
How we dress – personality, age, job
Persuasive – used to change attitudes
Breastfeeding needs Bangladeshi women in England
Breastfeeding needs and experience of Bangladeshi women largely the same as those of English mothers
Services did not consider women’s individual needs and expectations
Practitioner stereotypes and assumptions get in the way of delivering appropriate help and support, based on an understandings of cultural groups as fixed and homogenous ie ethnicity, not culturally sensitive
Wanted convenient sessions specifically for women from similar ethno-religious backgrounds where they were understood
McFaddyn, JRN, in press
Conclusion from breastfeeding research
Focussing on making mainstream services sensitive to the needs of all women is likely to improve breastfeeding support for women from diverse ethnic backgrounds, although there are important cultural differences to consider.
Approaches to antenatal breastfeeding education for women from diverse backgrounds should consider accessibility of venue, women’s embarrassment and household duties.
Successful communication?
Ability to assess non –verbal cues to determine appropriate style of communication
Underpinned by mutual respect
Absence of factors such as time pressure, distraction
Presence of appropriate physical environment e.g. home rather than busy clinic, willingness to communicate
Common language
The importance of listening to clients
W9: Like today you people [researchers] have come and are asking me, well like this if other people who come and advise me more about how to breastfeed or what the benefits are I am willing to learn. Yes I would like to know new ideas that have come out. (Translated)
McFaddyn, JRN, in press
Communication
Patient satisfaction
Adherence
Health Outcomes
Linking communication to health outcomes
Betancourt et al, Public Health Reports, 2003
Communication challenges when assessing non English speaking mothers for postnatal
depression (PND)
Language barrier
Understanding cultural norms
Understanding mothers concept of ‘health’ or ‘illness’
Finding suitable communication channels
Effective use of interpreters and link workers
Arranging suitable access
Understanding the conflicts individuals face between their ethnic culture and the community where they live
Understanding the professionals own prejudices
Mother driven communication tools
Challenge of getting women with PND to tell someone
PND Conference
Mother told her story
Suggested poster
‘For 9 out of 10 mothers having a baby is bliss, for 1 out of 10 it is HELL!’ – flames
Poster development
Assessing for postnatal depression in mothers who have
English as a second language
Sheffield, Yorkshire, England Multicultural society
Ethnic minority population 9%, some illiteracy
Health visitors assessing for postnatal depression using the Edinburgh Postnatal Depression Scale supported by interpreters or link workers
Concern unsatisfactory as depression expressed in unfamiliar ways by many of these groups of women
Word ‘depression’ non existent in many cultures
Postnatal depression 14%, in minority ethnic groups?
Risk factors for Punjabi speaking mother living in England
Being a new bride and recent migrant
Living in an unfamiliar environment
Experiencing unfamiliar antenatal care, possibly partly delivered by men
Poor housing, unemployment
Having difficulties adjusting to the husbands family
Lack of choice of birth management
Lack of information and poor communication due to language barrier
Lack of access to interpreters in hospital
Too close for comfort: – a local story
A Punjabi questionnaire?
We tested a Punjabi questionnaire among 100 postnatal women in Sheffield and Bradford. The women themselves identified the need for an alternative to a questionnaire.
Difficulties in understanding words due to different dialects
Too structured, wanted to tell own story
Depended on skills of link workers
Not suitable for other ethnic groups – many in Sheffield
No alternatives
Project To develop:
a culturally appropriate alternative to a questionnaire to assess for the presence of postnatal depression.
a visual tool which could be use to communicate with non-western women who may have speak no English and may be illiterate
a tool to improve communication between professionals and this group of mothers
a visual way of triggering discussion of symptoms of PND so that it is recognised early
Resources for Promoting and Discussing Mental and Social Health With Mothers From Urdu, Bengali, Arabic, Somali &
Chinese Communities
Conceptual stage Planning stage Development of culturally appropriate illustrations Agreeing the picture interpretation and translations
with users Piloting and evaluation Production of final booklets Dissemination
37
Developing the Picture Booklets
Client involvement at every
stage – individually and in groups
Drafting & piloting
Interpretation & translation
Local pilot
National pilot
Redesign, printing and distribution
38
Client comments
‘Yes that used to be me you know’
‘Yes I don’t know why I used to feel like that I just sat on the bed and cried, sometimes I would cry in the bathroom where no one could see me’
The title page
Eye catching culture -
specific cover page
‘How are you feeling?’ -
The ice breaker!
Explain the purpose of the
contact/familiarise
Inside pages - simple engaging
Highlight social interactions
Depressed mood/irritability
Practical help and emotional support
Feelings about self/life
Somatization – physical symptoms.
Page 5 – Antenatal and postnatal
Pregnant or just had a baby?
Acknowledge the obstetric status of the woman and ask how she is feeling?
Ensure mutual understanding of the purpose of the contact.
Page 6 – Social activities
Explore each relevant illustration
May talk about diminished interest in activities she previously enjoyed
Page 7- Depressed mood
Sad
Miserable
Been crying
May be associated with irritability
Page 8 – Sleep disturbance
Three illustrations to aid the discussion around sleep pattern
Page 9 - Social interactions
With partner
With friends
With relatives
Having people around
Page 10 – Coping? Family dynamic?
How are you coping?
Weak, fed-up
Family set up and who helps
who
Happy, feels OK, unhappy
Page 11- Help and support
Children
Partner
Other family members
In-laws
Friends
Home/abroad
Page 12 - Support network
Your support system
Children
Siblings
Partner
Friends
Your family
His family
Health workers
Page 13 – Feeling down/low?
Are you feeling low, down,
even with help, support and
a loving environment?
(A dreadful sense
of isolation)
Page 14 – The urge to
Scream – pull your hair
out
Run away from it all
Hide away
Just feel low/down
Page 15 – You and your life
Facial expressions
(Oxford Happiness
Inventory)
Self worth
Self harm
Suicidal thoughts
Page 16 – Food & appetite
Appetite disturbance
Page 17 – Physical symptoms
Somatization
Aches, pains, fatigue
Clusters - head, chest,
abdomen, back
May manifest from head to toe –
light headed, heavy heart,
pins and needles etc.
Page 19 – Information/advice
Opportunity to provide
information about available
help and support, include
statutory, voluntary, faith and
community organisations.
Inform/involve family
members
Feedback from health visitors ‘It was a useful way of entering into a conversation teasing out
additional information about emotional health’ (used with English speaking mother)
‘There is no other way to assess the mood of Finnish speaking mothers. I used the husband to help interpret and it worked well’.(with Finnish mother)
‘The How are You feeling leaflet cuts out the long talk and gets straight to the point’ (used with English mother)
‘As soon as the mother saw the pictures she smiled. That was to say thank goodness someone knows what I am talking about. ‘(used with Urdu speaking mother)
‘The English version is very useful with mothers who have low literacy’
How are you feeling leaflets
Designed to leave with the mother
Used same pictures
Tested across the UK with mothers from a range of ethnic backgrounds
Marketed for local healthcare organisations to purchase
What did this work teach us in the UK?
The need to be culturally competent, especially in relation to any ethnic minority group
Considerable differences exist within as well as between cultural groups
The need to understand the different somatic symptoms mothers from many ethnic groups use to describe mental illness e.g. back ache, heavy heart
To be very careful referring to mental illness as it carries a social stigma which can lead to rejection in some ethnic groups
The same stressful events occur in every culture but different cultures deal with them in different ways
Lessons continued Any such tools must be developed with the mothers
themselves and tested carefully
The need to translate linguistically as well as culturally
The importance of listening to mothers
How isolated and vulnerable many mothers are who have English as a second language
The need to address the mental health needs of non-Western women from a holistic perspective considering cultural, individual, social and environmental issues
Five essential elements of institutional cultural competence
1. valuing diversity; 2. having the capacity for cultural self-assessment; 3. being conscious of the dynamics inherent when cultures interact; 4. having institutionalized cultural knowledge; and 5. having developed adaptations of service delivery reflecting an understanding of cultural diversity.
Cross, T., Bazron, B., Dennis, K., and Isaacs, M. (1989)
Challenges to delivering cultural competent healthcare
1. Recognizing clinical as well as other differences among people of different ethnic and racial groups
2. Communication
3. Ethics – respect for the belief systems of others
4. Trust - based on ability to form relationship
Meyer CR, 1996
Conclusion
To be truly effective in our work it is essential to not only develop systems for communicating across language barriers, but we must also understand how people draw on aspects of their culture to influence their health decision making.
Key messages
Involving families in designing the services they are going to use
Value in using a range of formats to inform about services
Cultural competency will deliver more effective health outcomes
Acknowledgements
Abi Sobowale – Senior Health Visitor, Sheffield, UK
Unite/Community Practitioners’ and Health Visitors’ Association
Department of Health and other funders
NoSB and Astid Ersvik
Contacts
Dr Cheryll Adams: CheryllMA@gmail.com
To purchase booklets, posters, leaflets:
www.cphvabookshop.com