Cultural Adaptation: Cultural Adaptation: The Ambiguity The Ambiguity

Toward This Notion Toward This Notion in Healthcare in Healthcare

MargueriteMarguerite CognetCognet, Ph.D Sociology, Ph.D Sociology

SpyridoulaSpyridoula XenocostasXenocostas, M.Sc. , M.Sc. AnthropologyAnthropology

METISS Research Team, Research and METISS Research Team, Research and Training Center Training Center

CSSS Côte-des-Neiges, Metro, Parc CSSS Côte-des-Neiges, Metro, Parc ExtensionExtension

University Affiliated Center University Affiliated Center

• What are we talking about?What are we talking about?• Who must adapt to whom and to what?Who must adapt to whom and to what?

"Cultural Adaptation of "Cultural Adaptation of ServicesServices" or “Culturally " or “Culturally

Sensitive Care”Sensitive Care”  An Ambiguous ConceptAn Ambiguous Concept

• Up to what point must the healthcare system Up to what point must the healthcare system provide culturally adapted services?provide culturally adapted services?

• What are the limits for practitioners in their What are the limits for practitioners in their ability to be culturally sensitive?ability to be culturally sensitive?

The Clinical Encounter in an The Clinical Encounter in an Intercultural Context : First Intercultural Context : First

StudiesStudies• The clinical encounter between patients The clinical encounter between patients

and doctors within a cultural context of and doctors within a cultural context of difference. difference. (Guibert, et al., 1997-1999)(Guibert, et al., 1997-1999)– Semi-structured interviews: 25 doctors (private Semi-structured interviews: 25 doctors (private

and public practice; 12 men and 13 women;. 15 and public practice; 12 men and 13 women;. 15 Canadian born; 10 immigrants).Canadian born; 10 immigrants).

• Homecare workers: training, ethnicity and Homecare workers: training, ethnicity and institutional trajectory institutional trajectory  (Meintel et al., (Meintel et al., 1999-2002)1999-2002)– Semi-structured interviews: 40 homecare Semi-structured interviews: 40 homecare

workers (private agencies and public services; workers (private agencies and public services; 28 women and 12 men; 23 immigrants and 17 28 women and 12 men; 23 immigrants and 17 Canadian born).Canadian born).

Culture in the Clinical Culture in the Clinical Encounter Encounter

Initial FindingsInitial Findings

Positive FormA source

• Enrichment

• Openness toward the world

• Learning new models

• Mediation tool in the construction of a successful relationship

A resource to be exploited

Negative FormA source of problems

• Inability to take care of themselves or their children

• Misunderstanding of the healthcare system

• Resistance toward norms and values of Canadian society

• Instrument of domination

An obstacle to be eliminated

2 Opposite yet Coexistent Views of 2 Opposite yet Coexistent Views of CultureCulture

Inter / Intra Group Inter / Intra Group DifferencesDifferences

DoctorsDoctors Homecare Homecare workersworkers

"Patient" must adapt to

health system

Health system must adapt to

"client"

Clear sense of professional

identity, role and mission

Conceptions of health/illness and

treatment grounded in a solid

value system

Weak professional identity

Weak professional models of

reference and practice

Immigrants / Non Immigrants / Non ImmigrantsImmigrants

The Practice of Nurses : The Practice of Nurses : Between Professional and Between Professional and

Cultural Models (Cognet et Cultural Models (Cognet et al, 2002-2005)al, 2002-2005)

• Three sectors of practice in Montreal Three sectors of practice in Montreal (Quebec):(Quebec):– Public sector (CLSC : 6 local, primary health and Public sector (CLSC : 6 local, primary health and

social services centers)social services centers)– Private for profit sector (18 agencies)Private for profit sector (18 agencies)– Non profit private sector (2 associations)Non profit private sector (2 associations)

• Questionnaire (n=260)Questionnaire (n=260)

• Semi-structured interviews (n=45)Semi-structured interviews (n=45)– Agencies, CLSC, Associations; Women, Men; Agencies, CLSC, Associations; Women, Men;

Immigrants, Non immigrants; Education training Immigrants, Non immigrants; Education training ( bachelor, college)( bachelor, college)

Adaptation : A continuum Adaptation : A continuum of representationsof representations

The The immigrant immigrant

must must adapt, be adapt, be educated, educated, “normalis“normalis

ed” ed” 

InterventiIntervention on

practice, practice, values, values, system system must must adaptadapt

““One must really understand the perceptions people have of One must really understand the perceptions people have of different illnesses. According to their origin, religion, they different illnesses. According to their origin, religion, they perceive illness differently and treatment differently too. We perceive illness differently and treatment differently too. We have to take this into account, and sometimes we have to have to take this into account, and sometimes we have to adapt a lot …”adapt a lot …”

““it was necessary (to show her), how to organise herself, how it was necessary (to show her), how to organise herself, how to manage a budget (ugh) how to take care of a newborn, to manage a budget (ugh) how to take care of a newborn, because of the way she was taking care of the baby, let’s just because of the way she was taking care of the baby, let’s just say that it wasn’t normal, it was necessary that she adapt to say that it wasn’t normal, it was necessary that she adapt to our way of doing things... Her behaviour was not normal. our way of doing things... Her behaviour was not normal. She was open to learning, open to trying new things, but she She was open to learning, open to trying new things, but she needed help. ”needed help. ”

The Canadian Health The Canadian Health System System

Superiority Superiority of the of the

Western Western Medical Medical ModelModel

Relativism Relativism of the of the

Western Western Medical Medical ModelModel

““They have a panoply of knowledge. (…) They first They have a panoply of knowledge. (…) They first treat themselves according to how they know and treat themselves according to how they know and when this doesn’t work, they come to the clinic. And when this doesn’t work, they come to the clinic. And often both things happen at the same time. They often both things happen at the same time. They ask for antibiotics and at the same time they use ask for antibiotics and at the same time they use their herbal medicine. I feel this is wonderful. I their herbal medicine. I feel this is wonderful. I agree with that : It’s functional!”agree with that : It’s functional!”

«I will adapt, I will try to find another solution, as «I will adapt, I will try to find another solution, as long as it respects the norms of healthcare and the long as it respects the norms of healthcare and the rules of healthcare in order to assure the quality of rules of healthcare in order to assure the quality of care. This is not a question of tolerance. It is a care. This is not a question of tolerance. It is a question of being a professional and respecting... question of being a professional and respecting... We see things like that, false beliefs, and we must We see things like that, false beliefs, and we must work hard since – no – I will not adapt to something work hard since – no – I will not adapt to something like that.»like that.»

Portraits of ImmigrantsPortraits of ImmigrantsRecipient of Recipient of goods and goods and services\services\AbuserAbuser

Carrier of Carrier of knowledge knowledge

and and resourcesresources

«One must never act as an expert and act as if they «One must never act as an expert and act as if they know nothing… it is not true, these people have a know nothing… it is not true, these people have a life behind them, they have experiences that may be life behind them, they have experiences that may be different, but they also know a lot of things and we different, but they also know a lot of things and we can also learn from others... »can also learn from others... »

« These people arrive here, over there they don’t « These people arrive here, over there they don’t have anything, okay, you don’t work, you don’t eat, have anything, okay, you don’t work, you don’t eat, it’s the way things work over there. But they come it’s the way things work over there. But they come here, we offer all kinds of services. These people are here, we offer all kinds of services. These people are really well taken care of here. They have here what really well taken care of here. They have here what they never had at home. »they never had at home. »

Superiority of the Superiority of the western health modelwestern health model

Relativism of the Relativism of the western health modelwestern health modelR

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Conclusion Conclusion

Individual Individual biographical biographical and personal and personal dimensionsdimensions

Political context Political context of interethnic of interethnic relations in relations in

societysociety

Varying models of cultural Varying models of cultural adaptation in healthcare adaptation in healthcare

and servicesand services