1

LEARNING GUIDE

INTRODUCTION

Aim: To familiarise yourselves with the Papadopoulos, Tilki and Taylor model of cultural

competence The Papadopoulos, Tilki and Taylor (PTT) Model

for Developing Cultural Competence

Transcultural or intercultural study in health and social care is the study and research of cultural diversities and similarities of people in the way they define, understand and deal with the health/illness and welfare needs. It is also the study of the societal and organisational structures, which either aid or hinder people’s health and welfare.

Papadopoulos, Tilki and Taylor Model for Developing Cultural Competence

.

CULTURAL AWARENESS

Self awareness Ethnocentricity Cultural identity

Ethnohistory Stereotyping

КУЛТУРНА КОМПЕТЕНТНОСТ

Умения за оценяване Диагностични умения Клинични умения Промяна и справяне с предразсъдъците, дискриминацията и различията

CULTURAL KNOWLEDGE

Health beliefs and behaviours Anthropological, socio-political,

psychological and biological understanding

Similarities and differences Health inequalities

CULTURAL SENSITIVITY Empathy, Trust

Interpersonal/Communication/Skills Acceptance

Appropriateness Respect

Barriers to Cultural Sensitivity

LEONARDO PARTNERSHIP PROJECT IENE

Intercultural Education of Nurses and medical staff in Europe

2

As can be seen above the model consists of four stages:

The first stage in the model is cultural awareness which begins with an examination of our personal value base and beliefs. The natures of construction of cultural identity as well as its influence on people’s health beliefs and practices are viewed as necessary planks of a learning platform.

Cultural knowledge (the second stage) can be gained in a number of ways. Meaningful contact with people from different ethnic groups can enhance knowledge around their health beliefs and behaviours as well as raise understanding around the problems they face. Through sociological study we should learn about power, such as professional power and control, or make links between personal position and structural inequalities. Anthropological knowledge will help us understand the traditions and self care practices of different cultural groups thus enabling us to consider similarities and differences.

An important element in achieving cultural sensitivity (the third stage), is how professionals view people in their care. Dalrymple and Burke (1995) have stated that unless clients are considered as true partners, culturally sensitive care is not being achieved; to do otherwise only means that professionals are using their power in an oppressive way. Equal partnerships involve trust, acceptance and respect as well as facilitation and negotiation.

The achievement of the fourth stage (cultural competence) requires the synthesis and application of previously gained awareness, knowledge and sensitivity. Further focus is given to practical skills such as assessment of needs, clinical diagnosis and other caring skills. A most important component of this stage of development is the ability to recognise and challenge racism and other forms of discrimination and oppressive practice. It is argued that this model combines both the multi-culturalist and the anti-racist perspectives and facilitates the development of a broader understanding around inequalities, human and citizenship rights, whilst promoting the development of skills needed to bring about change at the patient/client level.

The underpinning values of the model which was recently further refined and articulated (Papadopoulos I, Lees S, unpublished work, 2003) are based on Human Rights, socio-political systems, intercultural relations, human ethics, and human caring. Specifically these are: The individual All individuals have inherent worth within themselves as well as sharing the fundamental human values of love, freedom, justice, growth, life, health and security. Culture All human beings are cultural beings. Culture is the shared way of life of a group of people that includes beliefs, values, ideas, language, communication, norms and visibly expressed forms such as customs, art, music, clothing and etiquette. Culture influences individuals’ lifestyles, personal identity and their relationship with others both within and outside their culture. Cultures are dynamic and ever changing as individuals are influenced by, and influence their culture, by different degrees.

3

Structure Societies, institutions and family are structures of power which can be enabling or disabling to an individual. Health and illness Health refers to a state of well-being that is culturally defined, valued and practised and which reflects the ability of individuals (or groups) to perform their daily role activities in culturally expressed, beneficial and patterned lifeways (Leininger 1991). Illness refers to an unwanted condition that is culturally defined and culturally responded to. Caring Caring is an activity that responds to the uniqueness of individuals in a culturally sensitive and compassionate way through the use of therapeutic communication.

Nursing Nursing is a learned activity aiming at providing care to individuals in a culturally competent way. Cultural competence Cultural competence is a process one goes through in order to continuously develop and refine one's capacity to provide effective healthcare, taking into consideration people’s cultural beliefs, behaviours and needs.

In order to be culturally competent practitioners, educators and researchers we need to develop both culture-specific and culture-generic competences. Culture-specific competence refers to the knowledge and skills that relate to a particular ethnic group and that would enable us to understand the values and cultural prescriptions operating within a particular culture. Culture-generic competence is defined as the acquisition of knowledge and skills that are applicable across ethnic groups (Gerrish & Papadopoulos 2000).

Conclusion

The Papadopoulos, Tilki and Taylor (1998) model aims to help us deliver culturally competent care that ultimately ensures high quality care for all.

The Transcultural Skills Development Model published by Papadopoulos, Tilki and Taylor (1998) is situated within health and social care, is applicable across the world and has its strengths in the transparency of what is being asked of the multiculturist. The model conceptualises cultural awareness, knowledge and sensitivity and, through the synthesis of these, cultural competence is achieved

However, culture is not wholly definable, it is relative to those who live it and those who observe it and it is open to rapid changes as the world becomes more interactive. The literature tells us that education alone does not ensure culturally competent practitioners (Papadopoulos et al, 1998; Leininger, 2002) and self-awareness and reflection is essential to gaining cultural insight. There is evidence that care is still being given generically and without regard for culturally specific needs (Coffman, 2004; Cioffi, 2005).

4

References

Cioffi J. (2005). ‘Nurses’ experience of caring for culturally diverse patients in an acute care setting’. Contemporary Nurse. September, 20, 1, 78-86.

Coffman MJ. (2004). ‘Cultural caring in nursing practice: A meta-synthesis of qualitative research’. Journal of Cultural Diversity. 11, 3, 100-109.

Gerrish K and Papadopoulos I (1999): Transcultural competence: the challenge for nurse education. British Journal of Nursing, Vol 8 No 21, pp1453-1457. Dalrymple J and Burke B (1995): Anti-oppressive practice. Social care and the law. Open University Press. Buckingham. Leininger M M (1991): Culture care diversity and universality. A theory of nursing. NLN, New York.

Leininger M (2002). in Leininger M & McFarland MR. (2002). Transcultural Nursing. (Third edition). USA: McGraw-Hill. p71-98.

Papadopoulos I, Tilki M and Taylor G (1998): Transcultural Care: A guide for Health Care Professionals. Quay Books. Wilts. (ISBN 1-85642-051 5) Papadopoulos I (Ed): (2006): Transcultural Health and Social Care: Development of Culturally Competent Practitioners. Churchill Livingstone Elsevier. Edinburgh. Read more on: http://www.mdx.ac.uk/www/rctsh/model/

http://www.health.tvu.ac.uk/maryseacole/melting/transcultural/index.asp

5

1. CULTURAL AWARENESS

Aims of Theme

To reflect on and analyse the importance of one’s own culture and that of others.

1.1 Culture and cultural identity

According to French Academy’s Dictionary culture today “designates the entire range of intellectual aspects, moral issues, material and symbolic system of values and finally the lifestyles which are characterizing a civilization.”

In Social Sciences culture, as a term has a very wide range of meanings opening itself to an almost unlimited field. It was Edward Barret Tylor the one who imposed in his “Primitive Culture” (1871) the conception of “Everything is culture”. Alfred L. Kroeber and Clyde Kluckhohn (1952) are offering in their book no less than 163 definitions to the term of Culture. Tylor takes culture to be synonymous with civilization, and therefore gives to that word what he calls a wide ethnographic sense. For him, culture is ‘that complex whole’ produced by people’s historical experience, of which he gives several examples: knowledge, belief, art, morals, law, and custom. However this enumeration is not a final list as Tylor’s definition of culture also includes any other capabilities and habits acquired by man as a member of society.

If we take all of the aspects of culture like: knowledge, beliefs, art, morals, laws etc. And we put them in a context like country, ethnicity we find the cultural identity by extracting the uniqueness or specificity from each of them. Culture is a universal phenomenon but it has individual forms of manifestations across regions, countries, populations or ethnic groups. All these individual manifestations take a form in a cultural identity. The concept of identity refers to an image with which one associates and projects oneself. The most essential feature of identity is its multiple nature. One can have a single identity, but it would always be made up of several layers. Both individual and groups can have identities and like cultures, identities are constantly changing. The term “cultural identity” refers to the shared subjective perception of the group’s history and heritage. When a nation or a continent has a cultural identity it does not mean that it is uniform. The cultural identity is integrated by some factors which make it at least in some ways united. These factors are often external, for example, war, an outside threat or climate (Kiriakos, 2002). The negative impact of the loss of cultural identity of Irish immigrants in England has been explored (Kelleher and Hillier, 1996). Death rates amongst first and second-generation Irish people in England were found to be higher than amongst the host population. It was hypothesised that many Irish people living in England cannot attach themselves to their host culture, the country that subjugated them, but nor can they collectively promote their

6

Irish culture as it is seen as the home of the Irish Republican Army, and not a legitimate ethnic group. So loss of cultural identity, coupled with the low socio-economic status many migrants find themselves in, can contribute to higher death rates. Read more on: http://www.tamu.edu/classes/cosc/choudhury/culture.html http://en.wikipedia.org/wiki/Cultural_identity References

Kelleher D & Hillier S. (1996). ‘The Health of the Irish in England’. In Kelleher & Hillier. Researching Cultural Differences in Health. London: Routledge, p.103-123.

Kiriakos, C. (2002) Europe-Culture and Identity. The programme of International Careers (Progi) Website Address: www.mv.helsinki.fi

1.2 The challenges of living in culturally diverse societies

Although multicultural societies are becoming the norm, this does not mean that all individuals within them enjoy equal and fair treatment, and have their human rights respected and protected. Many migrants continue to view themselves as guests in their adopted country even though they may have lived there many more years than they did in their own country of birth. With increasing population movements within the European Union many people find themselves being labelled as ‘outsiders’ and are seen by some xenophobic members of the ethnic majority as ‘problems’ even though they are all European Union citizens.

Despite European legislation and international agreements migrants and asylum seekers from any part of the world are often accused of (for example):

- Benefiting from national systems they had not contributed in; - Taking the jobs of local people; - Bringing crime to the host country;

Newcomers to a country face hostility but must try to tackle the challenges they face in order to integrate within their adopted country. These challenges include:

- Learning the language of the host country; - Familiarizing themselves with the new social systems e.g education, health, welfare

support, etc; - Developing social networks; - Learning about the values of their adopted country; - Learning about the law of the host country; etc.

7

Read more on:

The Council of Europe: http://www.coe.int/

The RCN’s Transcultural Healthcare Practice: an educational resource for nurses and health care practitioners: http://www.rcn.org.uk/development/learning/transcultural_health/politics Reference

Papadopoulos I (2002): Meeting Health Care Needs in Culturally Diverse Societies. In Daly J et al (Eds): Contexts of Nursing: an Introduction. ISBN 1-4051-0095-8, Chapter 16, pp 196-208, Blackwell Science. Oxford.

1.3 Nursing / Healthcare models promoting transcultural health and cultural competence

Transcultural Nursing was established by Madeleine Leininger in the early 1960s. The focus of transcultural nursing is to provide culturally competent care to all patients/clients. As mentioned in the introductory section Papadopoulos and her colleagues defined this area as the study and research of cultural diversities and similarities in health and illness as well as their underpinning societal and organisational structures, in order to understand current practice and to contribute to its future development in a culturally responsive way. Transcultural nursing (and all other healthcare) requires a commitment for the promotion of anti-oppressive, anti-discriminatory practices. Transcultural health and nursing emphasises the importance of empowering clients to participate in health care decisions, therefore it is imperative that health care professionals must recognise how society constructs and perpetuates power and disadvantage. No other nursing philosophy and framework places so much emphasis in such an explicit way towards the promotion of equality and the value of individuals, as this does (Papadopoulos & Alleyne 1995, Papadopoulos et al 1998, Papadopoulos & Lees 2002). Numerous models for transcultural nursing and health have been developed following Leininger’s pioneering work. In addition to the Papadopoulos, Tilki and Taylor (1998) model which underpins the learning materials on this website, others include that of Purnell’s model (Purnell and Paulanka 1998), Campinha-Bacote’s model (1998), and Giger & Davidhizar (1999). Read more on: http://currentnursing.com/nursing_theory/transcultural_nursing.htm

There are a number of academic models of cultural competence. To explore further, please go to the Mary Seacole MELTING project website: http://www.health.tvu.ac.uk/maryseacole/melting/transcultural/index.asp

8

The RCN’s Transcultural Healthcare Practice: an educational resource for nurses and health care practitioners: http://www.rcn.org.uk/development/learning/transcultural_health/transcultural References Campinha-Bacote J 1998 The process of cultural competence in the delivery of healthcare services. A culturally competent model of care. 3rd ed. Transcultural C.A.R.E. Associates, Cincinnati Giger J, Davidhizar R 1999 Transcultural Nursing. Assessment and intervention. 2nd edn. Mosby, St. Louis Leininger M M 1995 Transcultural Nursing. Concepts, theories, research and practices. 2nd edn. McGraw-Hill, New York Papadopoulos I, Alleyne J 1995 The need for nursing and midwifery programmes of education to address the health care needs of minority ethnic groups. Nurse Education Today, 15:140-144 Papadopoulos I, Tilki M, Taylor G 1998 Transcultural care. A guide for health care professionals. Quay Books, Dinton

Papadopoulos I, Lees S 2002 Developing Culturally Competent Researchers. Journal of Advanced Nursing, 37(3):258-264 Purnell L D, Paulanka B J 1998 Transcultural health care. A culturally competent approach. F A Davies, Philadelphia

1.4 Ethnocetrism and stereotyping

Ethnocentric attitude takes one’s own culture as superior and evaluates the other’s culture as being right or wrong, major or minor depending on how similar or different it is to his own culture. Ethnocentrism operates with concepts like: “chosen people”, “blessed nation”, “true faith”, “savages” or “infidels” etc. Theodore Caplow (1971) demonstrated that the number of persons which overestimate the group they belong to is generally eight times higher than the number of persons which underestimate their own group. Ethnocentrism is universal and can be met in all groups or societies.

Although ethnocentrism is universal it can also have negative effects: such as not being able to empathize with other groups or persons, not being able to see the other’s point of

9

view. These negative effects can be overcome through intensifying communication and interactions between different groups.

Communication and continuous interaction can also invalidate the stereotypes which a group has toward another group. Stereotypes are strong beliefs about the psychological characteristics and/or behaviours of another social group (ethnic, religious, age etc). These strong beliefs are “preconceived” in the sense of not being based on the direct observation, often arbitrary and having a simplified scheme of judgment.

In the recent social science usage the stereotypes are mostly referring to negative attitudes toward different ethnics and/or races. Discrimination is the first and most important effect of negative stereotypes. Read more on: http://www.sociologyguide.com/basic-concepts/Ethnocentrism.php http://en.wikipedia.org/wiki/Stereotype If you have some time to spare why not check the article on ethnocentrism which you can find at http://tinyurl.com/yetg7y Reference Caplow T 1971 Elementary Sociology, Prentice-Hall, New York.

10

2. CULTURAL KNOWLEDGE

Aim of Theme

Critically review the literature in relation to the social, psychological and cultural determinants of health and health behaviours, with a particular focus on inequalities in health and welfare among minority ethnic groups and refugees.

2.1 Migration: reasons, processes, challenges

A key text on migration is that written by Castles and Miller (2009), who claim that: “.. movements take many forms: people migrate as manual workers, highly qualified specialists, entrepreneurs, refugees or as family members of previous migrants. Class plays an important role: destination countries compete to attract the highly skilled through privileged rules on entry and residence, while manual workers and refugees often experience exclusion and discrimination” (p4).

Castles and Miller (2009) further claim that international movements of people are currently growing in volume in all major regions of the world, with more and more countries being affected by migratory movements. The consequences of increased migration include growing ethnic and cultural diversity in countries of immigration and a tendency towards more stringent regulation of migration in receiving countries. Push-pull theories of migration argue that people are ‘pushed’ to leave their home countries in search of a better life in, usually, in a more developed country; they are ‘pulled’ by the attraction of factors like work, better pay and living conditions. Migration often occurs when there are existing links between sending and receiving countries, for example, a history of colonization, trade, or cultural ties (Castles and Miller, 2009). Networks of family and friends are also important when making decisions concerning migration – they are also important in terms of settling in a host country. Castles and Miller (2009) argue that gradual acceptance of cultural diversity in host countries may lead to the development of ethnic communities, whereas rejection of cultural diversity may lead to the formation of ethnic minorities. Refugees and asylum seekers face particular challenges as they have been forced to leave their home countries; their migration is not voluntary. Beiser (1991) concludes that migration is a risk factor for developing mental health problems but mental ill-health is not inevitable. Despite traumatic experiences and difficulties related to resettling in a strange culture, most refugees are resilient and both adapt and contribute to their new society (Beiser, 1991). Refugees and asylum seekers are able to surmount many obstacles and overcome much adversity when fleeing their home countries and arriving in countries of asylum and it would be inappropriate to view them as helpless survivors (Karmi, 1998). Ager (1999) urges an appreciation of the considerable resources that refugees and asylum seekers demonstrate in responding to the challenges of forced migration. Read more on patterns of international migration the following web-sites are useful: International Organisation of Migration: www.iom.int European Council on Refugees and Exiles: www.ecre.org

11

United Nations High Commissioner for Refugees: www.unhcr.org In the United Kingdom, information on migration can be obtained from: UK Border Agency: www.ind.homeoffice.gov.uk Immigration and Nationality Directorate: www.homeoffice.gov.uk REFERENCES Ager, A. (1999) Perspectives on the refugee experience. IN A. Ager (Ed.) Refugees. Perspectives on the experience of forced migration. London: Cassell Beiser, M. (1991) The mental health of refugees in resettlement countries. IN H. Adelman (Ed.) Refugee Policy: Canada and the United States. Toronto: York Lanes Press Castles, S. and Miller, M. J. (2009) The age of migration. International population movements in the modern world. (Fourth Edition. Revised and Updated). Basingstoke: Palgrave Macmillan Karmi, G. (1998) Refugees. IN S. Rawaf and V. Bahl (Eds.) Assessing health needs of people from minority ethnic groups. London: Royal College of Physicians in London

2.2 Culture-generic and culture-specific health beliefs and behaviours

While health, illness and disease are influenced by biological factors, they can also be influenced by social, economic and cultural characteristics of the society in which people live (Helman, 2000; Clarke, 2001). Culture provides a framework within which individuals view and make sense of the world and a set of guidelines which inform ideas, beliefs, values and behaviours (Helman, 2000). Culture is transmitted from one generation to the next, but it is not fixed and involves a process of adaptation and change, rendering generalisations unhelpful if not damaging (Helman, 2000). For example, the formation of fixed ideas about the health beliefs of any particular ethnic group might not be useful if false assumptions are made. As a consequence of acculturation, long-held cultural beliefs may give way to those of the host society. Lay definitions of health, illness and disease are thus embedded in wider socio-cultural contexts and as such are influenced by prevailing social norms and values (Clarke, 2001; Blaxter, 2004). As such, people in different social classes and members of different cultures may hold differing views concerning the nature of health and illness. Many lay beliefs about health and illness adopt a holistic approach and consequently may be at odds with professional notions of health, illness and disease, which have tended to adhere to the bio-medical model often associated with western medicine. It is impossible for healthcare professionals working in very diverse societies to know about all the cultural groups that they will meet. However, it is possible to develop culture-generic competences which entail a deep understanding of how cultural identity and health beliefs influence health, and also how organisational or societal structures can either promote or hinder culturally competent healthcare (Papadopoulos (2003). It is also possible to utilise

12

culture-generic competences in order to develop culture-specific competences, as healthcare professionals acquire knowledge of particular communities.

Read more on:

http://www.mdx.ac.uk/www/rctsh/model/ REFERENCES Blaxter, M. (2004) Health. Cambridge: Polity Press Clarke, A. (2001) The Sociology of Healthcare. Harlow: Pearson Educational Ltd. Helman, C. G. (2000) Culture, health and illness (4th Ed.). Oxford: Butterworth Heinemann

2.3 Health inequalities

Health inequalities, in relation to social class, exist in all western European countries, though the causes of death differ between countries (Mackenbach, Bakker, Kunst et al, 2002; Menke, Streich, Rössler et al, 2003). Kunst et al (1998) found higher mortality in manual classes than non-manual classes in 11 Western European countries and while the causes of mortality differ among the countries, the lower mortality rates of people in higher occupational classes is independent of the specific diseases and risk factors involved. Moreover, Brunner and Marmot (1999) have drawn attention to research that demonstrates the absence of a clear distinction between ‘privileged’ and ‘underprivileged’ people in terms of health status and the presence of a gradient with increasing morbidity and mortality with declining socio-economic status. It is known that rates of ill-health and mortality among minority ethnic groups differ from those of majority populations, and differences exist between the ethnic groups. Diseases of minority ethnic populations do not differ fundamentally from those faced by majority populations. Cardio-vascular disease is a leading cause of death in both developed and developing countries, with marked variations between populations. One early and important study in Britain (Balarajan and Soni Raleigh, 1993) identified the biggest difference in health and illness in relation to coronary heart disease; mortality from coronary heart disease (CHD) being higher among people born in the Indian sub-continent than among the white population and also than other minority ethnic groups. However, later studies (Balarajan, 1996; Bhopal et al, 1999) were able to demonstrate that grouping disparate ethnic groups under one heading can be misleading. When people born in the Indian sub-continent were identified in separate groupings it was found that mortality from CHD was highest among Bangladeshis, followed by Pakistanis, and then Indians. There is a tendency for Indians to enjoy a better socio-economic profile than Pakistanis and Bangladeshis, leading Balarajan to suggest social class as a mediating factor among the determinants of CHD.

13

Following migration to Europe and North America after the second world war, there has been an assumption that immigrants are always at a health disadvantage, and are importers of disease (Marks and Warboys, 1997). The picture in relation to the effects of migration on health lacks clarity. Mortality rates of migrants are often compared to those in their countries of origin, or to those of the host society. Evidence suggests that following migration, migrants’ mortality rates either stay the same, increase or decrease, in relation to mortality rates in their home countries (McKay, Macintyre and Ellaway, 2003). Mortality rates may also be influenced by the selective nature of migration; whether people with good or poor health migrate. Migrants may be ‘positively’ selected for health, for example, when healthy and ambitious people move to another country in order to improve their job prospects, or ‘negatively’ selected when, for example, poor countries or communities are unable to adequately support members with poor physical or mental health (Smaje, 1996). Mortality rates can also be affected by conditions in the countries of origin, conditions in the host country, access to health services, individual behaviours and whether migration is voluntary or involuntary. A similar mixed picture exists concerning mental health; migration does not necessarily cause mental illness, but migrants may find the experience of migration stressful and will benefit from social support from both the already established migrant community and from the host community (Beiser, 1991; Baker, Arseneault and Gallant, 1994; McKay et al, 2003). Migration from one culture to another, for whatever reason, may result in cultural bereavement, especially for involuntary migrants such as refugees and asylum seekers. Cultural bereavement is defined as:

“Grieving for the loss of all the familiar cultural reference points that defined who they were and how they were to live their lives.” (Helman, 2000, p214)

The evidence relating to migrants’ health thus suggests that there are many factors involved and any individual’s health will be affected by his/her particular situation though involuntary migration, experienced by refugees and asylum seekers, is known to be more stressful than voluntary migration (Harrell-Bond, 2000). Migrants’ health will, no doubt, also vary depending on the stage at which it is measured or investigated. Menke et al (2003) conclude that across Europe, compared to citizens, the conditions of life are unsatisfactory for most migrants and these are not conducive to good health. Most migrants in Europe experience low-paid work, which is further characterised by unfavourable working conditions, together with poor housing. These factors generally place migrants in low socio-economic positions. Read more: A key document concerning general health inequalities is: Commission on Social Determinants of Health (2008) Closing the gap in a generation. Health equity through action on the social determinants of health. Geneva: WHO www.who.int/publications/ See also: www.iom.int Search for Migration and Health

14

REFERENCES Baker, C., Arseneault, A. M. and Gallant, G. (1994) Resettlement without the support of an ethnocultural community. Journal of Advanced Nursing, 20, pp1064-1072 Balarajan, R. and Soni Raleigh, V. (1993) Ethnicity and health. A guide for the NHS. London: Department of Health Balarajan, R. (1996) Ethnicity and variations in mortality from coronary heart disease. Health Trends, 28(2), pp45-51 Bhopal, R., Unwin, N., White, M., Yallop, J., Walker, L., Alberti, K. G. M. M., Harland, J., Patel, S., Ahmad, N., Turner, C., Watson, B., Kaur, D., Kulkarni, A., Laker, M. and Tavridou, A. (1999) Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study. British Medical Journal, 319, pp215-220 Brunner, E. and Marmot, M. (1999) Social organization, stress, and health. IN M. Marmot and R. G. Wilkinson (Eds.) Social determinants of health. Oxford: Oxford University Press Harrell-Bond, B. (2000) Foreword. IN F. L. Ahearn, Jr. (Ed.) Psychosocial wellness of refugees. Issues in qualitative and quantitative research. Studies in Forced Migration Vol. 7. Oxford: Berghahn Books

Kunst, A. E., Groenhof, F., Mackenbach, J. P. and the EU Working Group on Socioeconomic Inequalities in Health (1998) Occupational class and cause specific mortality in middle aged men in 11 European countries: comparison of population based studies. British Medical Journal, 316, pp1636-1642 Mackenbach, J. P., Bakker, M. J., Kunst, A. E. and Diderichsen, F. (2002) Socioeconomic inequalities in health in Europe: An overview. IN J. Mackenbach and M. Bakker (Eds.) Reducing inequalities in health. A European perspective. London: Routledge Marks, L. and Warboys, M. (1997) Introduction. IN L. Marks and M. Warboys (Eds.) Migrants, minorities and health. Historical and contemporary studies. London: Routledge McKay, L., Macintyre, S. and Ellaway, A. (2003) Migration and health: A review of the international literature. Glasgow: Medical Research Council Social and Public Health Sciences Unit Menke, R., Streigh, W., Rössler and Brand, H. (2003) Report on socio-economic differences in health indicators in Europe. Health inequalities in Europe and the situation of disadvantaged groups. Bielefeld: Institute for Public Health NRW Smaje, C. (1996) The ethnic patterning of health: New directions for theory and research. Sociology of Health and Illness, 18(2), pp139-171

15

2.4 National and European Legislation related to immigration, human rights, discrimination and service provision

These represent a dynamic and rapidly changing field. Moves have been made towards European harmonisation of immigration and asylum policy. Read more on: EU Immigration Policy: www.ec.europa.eu/justice_home/fsj/immigration/fsj_immigration_intro_en.htm UK Immigration Policy: www.homeoffice.gov.uk European Convention on Human Rights: http://en.wikipedia.org/wiki/European_Convention_on_Human_Rights UK Human Rights Act: www.opsi.gov.uk/acts/acts/1998/ukpga_19980042_en_1 Equality and Human Rights Commission: www.equalityhumanrights.com For migrants’ rights to health care: www.dh.gov.uk

16

3. CULTURAL SENSITIVITY

Aim of Theme

To enhance knowledge and understanding related to the challenges of establishing essential therapeutic relationships with all clients leading to the provision of culturally sensitive care.

3.1 Essential elements of transcultural communication.

3.2 Barriers to transcultural communication.

Some migrants who need to use health services often feel helpless, uncertain and stressed in losing control due to their limited English language skills, their limited understanding of the host culture, and the sub-culture of the health system. Culturally incompetent communication is also stressful to the health/social care practitioner who must endeavour to overcome some of the common barriers to effective communication as this is the foundation of therapeutic relationships. Common communication barriers include: Language difficulties Interpretation needs/problems Lack of accessible information in community languages Non-verbal communication Culturally incompetent communication Common non-verbal communication that can become barriers to effective transcultural communication are: Expressions of physical and emotional pain Expressions of anxiety Use of silence Use of gestures Personal space Eye contact Tone of voice Responding to bad news Culturally incompetent communication could result in giving the wrong information to a patient, or in some case not giving any information both of which could have devastating results. Misunderstandings can also happen which can result in people being offended, becoming stressed, suffering unnecessarily and failing to establish the necessary relationship between patient/family- health professional.

17

Read more on: Ethnicity on line http://www.ethnicityonline.net/cross_cultural_communication.htm The RCN’s Transcultural Healthcare Practice: an educational resource for nurses and health care practitioners http://www.rcn.org.uk/development/learning/transcultural_health/communication

3.3 Empowering clients

There are explicit and implicit similarities between various different definitions of empowerment and more specific empowering clients. They can be formalised into seven core components of empowerment: self-efficacy – one’s belief that a situation may be changed or influenced; participation and collaboration – a collaborative relationship between help-seeker and

help giver sense of control – change is attributed to the actions of the person concerned meeting personal needs – the needs and aspirations of the person are addressed in

ways which make them more capable and more competent understanding the environment- the person is able to make a critical analysis of the

services, structures and sources of (both formal and informal) support in their environment

personal action- there are opportunities to express empowerment in different ways access to resources – resources might include friends and relatives, community groups

and organisations, service supports and self –help groups. It is important to empower clients for a variety of reasons: It enables to recognize their strengths and abilities and perform on their own. It enables them to solve problems in the future on their own and successfully. There are a variety of strategies to empower clients. Some examples are: Challenge stereotypes. See your clients as people rather than labels -- of diagnosis,

gender, class, race, physical or intellectual ability or sexual preference. While challenging stereotypes, do not overlook that your client might be a member of an

oppressed group. Let them know that you are open to talking about any issues they may have relating to their perception of how they are viewed by society.

Set up an egalitarian rather than hierarchical relationship. Treat your clients as collaborators. Brainstorm together.

Listen to their viewpoint on etiology. Ask for and listen to their "solutions." (If not a complete solution, the germ of a solution

may be present.) Rather than solving their problems, teach them how to do so. Discuss the rationale for your decisions and interventions. Do they agree? Obtain their

informed consent on strategies to change. Recognize the role of context on their behavior and help them see it -- rather than

blaming them inappropriately for their problems. Listen to their view on the world and learn from them. Etc… Read more on:

18

1. J.M Slattery, department of psychology, Clarion University – Pennsylvania - USA http://psy1.clarion.edu/jms/empower.html

2. Client-centred empowering partnering in nursing, D. Brown, C Mc William, C. Ward-Griffin, Journal of Advanced Nursing, (V 53-2), 2006 http://www.ingentaconnect.com/content/bsc/jan/2006/00000053/00000002/art00003

3. http://www.library.nhs.uk/SpecialistLibrarySearch/SearchResults.aspx?searchText=empowerment&tabID=289&pgIndex=0&

4. The community power pack, Department of communities & local government, 2008 http://www.communities.gov.uk/documents/communities/pdf/896459.pdf

5. Empowering communities to influence local decision making: a systematic review of the evidence, June 2009 http://www.communities.gov.uk/documents/localgovernment/pdf/1241955

3.4 Universalism, relativism and human dignity

Health professionals will, due to their profession, increasingly encounter references to human rights. A clear link between the profession and human rights is unquestionable. To understand the significance of human rights, an understanding of the underlying concepts is needed. Universalism and relativism are the two most important concepts in terms of understanding the application of human rights to policies and practices. Analyzing and criticising these concepts will be crucial to develop the cultural knowledge and sensitivity about human rights

Links: 1. Reichert E: Human rights: an examination of universalism and cultural relativism.

Journal of Comparative social welfare, 22(1), p. 23-36 http://socialwork.siuc.edu/resourcecenter/RJCS_A_152282.pdf

2. Sjnezana Bilic: Cultural relativism, universalism and women’s rights http://www.unisanet.unisa.edu.au/staff/homepage.asp?Name=snjezana.bilic#ResearchPublications

3. http://ccn.aacnjournals.org/cgi/content/full/24/4/30

4. http://www.professionalnursing.org/article/PIIS8755722305001468/fulltext

5. http://bepolitical.blogspot.com/2008/12/pitting-universalism-against-cultural.html

19

4. CULTURAL COMPETENCE

Aim of Theme

To synthesise the knowledge and understanding gained from the previous themes of awareness, knowledge and sensitivity and to consider how these can best be applied during the assessment of clients and the provision of care within an antiracist, anti-discriminatory and oppressive environment.

4.1 Changing and addressing racism, discrimination and inequalities

Cultural competence is the ability to provide effective care for clients who come from different cultures. A most important component of the cultural competence is “the ability to recognize and challenge racism and other forms of discrimination and oppressive practice” (Papadopoulos 2006)

The racism and racial discrimination is complex and worrying. There are different forms of racism : anti-Semitism, Anti-Black racism, anti-Gypsyism etc.

Public opinion continued to be openly hostile towards Roma and Travellers in many European countries. Migrants, refugees and asylum seekers are particularly subject to the negative climate of opinion.

The nurses are required to have expertise in dealing with racism, xenophobia, anti-Semitism. The issues relating to racism, discrimination, inequality and socio-political aspects should be considered in the nurses education.

Bibliography

Balcazar, Fabricio E.- Yolanda Suarez-Balcazar, Tina Taylor-Ritzler, Cultural competence: Development of a conceptual framework, 2009

Hussein, Rassool G.- Dual diagnosis nursing, 2006

Leininger, Madeleine _transcultural nursing. Concepts, theories,research and tractices, 2002

Papadopoulos, Irena - Transcultural health and social care: development of culturally competent practitioners,2006

Srivastava, Rani - The healthcare professional's guide to clinical cultural competence

Wrench, John - Diversity Management, Discrimination and Ethnic Minorities in

Europe, Norrköping 2002

20

Websites

Council of Europe- European Commission Against Racism and Intolerance:

www.coe.int/ecri

4.2 Culturally competent health care practice with children and their families

The increasing diversity of society is especially evident among our youth. Diversity in culture and beliefs is not restricted to language, but also in culture, belief, knowledge, racial/ethnic, socioeconomic status, etc… The challenge is how to create a healthcare system in which all children and their families receive care that is safe, effective, efficient, timely and family centered, regardless of background or cultural differences. Cultural competence includes being able to recognize and respond to health-related beliefs and cultural values, disease incidence and prevalence, and treatment efficacy. Examples of culturally competent care: providing an environment in which the mother / child from diverse cultural backgrounds feel comfortable discussing their cultural health beliefs and practices in the context of negotiating treatment options. There are many special health care organizations who has the aim to cultural competency in children's and family healthcare. The NICHQ for example designed a ‘cultural competency chance model’, to help improve the quality of care provided to children and their families from diverse backgrounds. Almost all organizations are convinced that health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. The diversity of an organization’s staff is a necessary, but not sufficient condition for providing culturally competent health care services .Staff education and training are also crucial. All organisations ( for.ex: National Centre for cultural competence; National Initiative for Children’s healthcare Quality, Cultural competency resources, etc…) provide education programs to increase the capacity of health care providers for mother and child care

Some strategies are:

Effective health promotion is designed, delivered, and evaluated in partnership with communities to address culturally based health beliefs, practices, credible sources of information, and organizational policy supporting cultural and linguistic competence not only helps practitioners to deliver higher quality care, but can actually impact patient outcomes including use of emergency services, adherence to treatment and satisfaction with care.

Best practices in service delivery to families of children who are disabled or at risk for disabilities have moved toward a much more family focused or family centered approach

21

Family and self-management support focuses on the need for the healthcare system to support and enable the ability of children and families to manage their own care. This includes emphasizing the family’s role in managing their child’s well-being and illness and providing support to the child so s/he is able to manage his/her care in a developmentally appropriate way.

Read more to understand the different ways to succeed in providing culturally competent health care practice with children and their family.

1. National Initiative for Children’s healthcare Quality, Cultural competency resources http://www.nichq.org/cultural_competency_resources.html

mproving Cultural Competency in Children’s Health Care 2. Improving cultural competence in children’s health care: Expanding Perspectives, 2005

http://www.nichq.org/pdf/NICHQ_CulturalCompetencyFINAL.pdf

3. National Center for Cultural Competence, Georgetown University Center for Child and human development. http://www11.georgetown.edu/research/gucchd/nccc/

4. National Standards for Culturally and Linguistically Appropriate Services in Health Care,

2001 http://www.omhrc.gov/assets/pdf/checked/finalreport.pdf

5. Developing cross-cultural competence: A guide for working with young children and their families. Lynch E. ea. ( 1992 – 2009 )

6. Rationale for Cultural and Linguistic Competence in Maternal and Child Health Bureau–Funded: Training Programs http://www11.georgetown.edu/research/gucchd/nccc/documents/Final%20NCCC_RationaleTrainingPrograms-1.pdf

7. National Sudden and Unexpected Infant/Child Death & Pregnancy Loss Project at the National Center for Cultural Competence Infusing Cultural and Linguistic Competence into Health Promotion Training – Video http://www11.georgetown.edu/research/gucchd/nccc/projects/sids/dvd/view_online/index.html

4.3 Culturally competent health care of adults

22

4.4 Culturally competent health care for people with mental health problems

• The cultural appropriateness of mental health services may be the most important factor in the accessibility of services by people from different ethnic and cultural groups. • Developing culturally sensitive practices can help reduce barriers to effective treatment utilization. • Rapport building is a critical component of competency development. • Knowing whom the client perceives as a “natural helper” and whom he/she views as traditional helpers (such as elders, the church) can facilitate the development of trust and enhance the individual’s investment and continued participation in treatment. • Shifts in ethnic diversity are not just about numbers, but also the impact of cultural differences. New approaches are needed in service delivery to address cultural differences among consumers.

Modified from:

Cultural Competency. A Practical Guide For Mental Health Service Providers. By Delia Saldaña, Ph.D. Hogg Foundation for Mental Health

Read more on:

http://www.rcn.org.uk/development/learning/transcultural_health/transcultural/mentalhealth

http://www.hogg.utexas.edu/PDF/Saldana.pdf