Marika Podda Connor Migrant Health Unit

1. Marika Podda Connor Migrant Health Unit Migration: Culture & Diversity in Health Care

2. Outline of presentation Defining culture Migration in Europe Cultural issues and related concepts Cultural Competence Racism and discrimination in Health Care

3. Aim of presentation Gain AWARENESS of our culture and how these might influence the patient-provider relationship Understand how cultural belief systems affect health-seeking behaviors, outcomes, and quality of care and satisfaction

4. British National Consensus - Ethnic Origin • A. White [ ] British [ ] Irish [ ] Scottish [ ] Welsh [ ] Any other White background (specify): ______________________ • B. Mixed [ ] White and Black Caribbean [ ] White and Black African [ ] White and Asian [ ] • Any other Mixed background (specify): ________________________________________ • C. Asian or Asian British [ ] Indian [ ] Pakistani [ ] Bangladeshi [ ] • Any other Asian background (specify): ________________________________________ • D. Black or Black British [ ] Caribbean [ ] African [ ] Any other Black background (specify): _______________________ • E. Chinese [ ] • F. Other ethnic background [ ] Not known [ ] Information refused [ ]

5. Irish people in London: a predominantly ‘WHITE’ community Skin colour can be a marker of health and social disadvantage – even white skin The Irish in Britain experienced pressure to assimilate, and the prevalence of negative stereotypes of dirtiness, stupidity, aggression and drunkenness Being fair skinned and speaking English made it easier for those who felt the pressure to keep quiet; others changed their accents in order to 'pass' as English

6. Relevant key points to health care Awareness of sociocultural factors on patients’ health beliefs, values and behaviors Knowledgeof specific cultural issues including social and historical factors shaping health behaviors, disease epidemiology, ethno-pharmacology and complementary health practices Communication Skillssuch as eliciting patients’ health beliefs, participatory decision-making, and working with medical interpreters.

7. Migrants residing in Malta (Grech, 2009)

8. Hangar Open Centre

9. Tent Village Halfar

10. Self-awareness of prejudices & biases What is impeding a positive, effective clinical encounter? What is making me feel uncomfortable? Is it lack of Knowledge? Skills?

11. Culture A shared system of values, beliefs and learned patterns of behaviour, and not simply defined by ethnicity Low, 1984 Learned and shared by people Dynamic: neither fixed nor static Existence of similarities and differences

12. Components of culture Values– Morals, standards & principles Beliefs– viewpoint, way of life Norms- rules and expectations which society uses to guide the behavior of members Rituals/Traditions- Christmas midnight mass, quccija Ceremonies- birth, weddings, funerals

13. Comparisons of Cultural Aspects

14. Terms related to culture Assimilation Acculturation Ethnocentricity Culture shock Stereotyping Xenophobia

15. The Iceberg concept of culture Dress Language Customs Looks Food Bodylanguage Concept of time Personal space Religion Concept of self Patterns of handling emotions Social Roles Concept of health & Illness Family Attitudes towards elderly

16. Fundamental responsibilities of Health Professionals Students at the Faculty of Medicine and Surgery should: Respect patients regardless of their lifestyle, culture, beliefs, race, colour, gender, sexuality, disability, age, social or economic status University of Malta Medical School and Malta Medical Student Association (2007) Nurses should: not discriminate amongst patients/clients on grounds of age, nationality, race, sex, gender orientation, religious beliefs, personal attributes, nature or origin of their health problem or any other factor Maltese Code of Ethics for Nurses & Midwives (1997)

17. Geneva Convention: "A person who owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it.." United Nations (1951) Who is the refugee?

18. Why Do People Migrate? Pull Factors: Climate, job opportunities, studying, etc VoluntaryMigration PushFactors: Food shortage, war, floods, etc Involuntary Migration

19. Types of Migrants Documented migrants (single or families) * Asylum seekers * Humanitarian protection * Refugee Status * Failed asylum seekers (undocumented migrants) * Unaccompanied minors Study programmes Labour migrants – (new trend –Filipinos domestic workers) Family re-unifications * 1st Generation 2nd Generation * Trafficked migrants * Irregular migrants

20. Trafficking Traffickersuse violence, coercion and deception to take people away from their homes and families, and force them to work against their will

21. Challenges for newcomers Lack of proper orientation to living in host country Lack of employment opportunity Lack of time to socialize Language problems Family violence and breakdown Difficulties in education system Problems accessing health system Loneliness and not fitting in

22. FGM (Female Genital Mutilation)– its importance for women (marriage secures their identity, status, and respect as an adult) Difficulties in schools– skin colour (labeling), language problems Mental health issues– evil spirits/evil eye/PTSD Physical problems– injuries, communicable diseases, under-nutrition, psychosomatic symptoms, immunization status Rape (sexual violence & torture) - stigma Maternity issues– strictly a woman’s role Decisions by elderly - Collective approach vis-à-vis individualistic approach in decision making and treatment options Health and social issues of migrants

23. Cultural Differences in…… Appointment making and keeping Health literacy Body language Meaning of illness/disease Timeframes Attitudes to treatment-unaware of lifestyle changes Expectations of treatment

24. Unfamiliarclinical issues Redness of skin – inflammation may go unnoticed Cyanosis – not easily detected Yellowish sclera – can’t all be suffering from Jaundice!! Skin rashes – difficult to diagnose Vitamin D deficiency – not well absorbed by dark skin

25. Factors affecting health care delivery Longer clinical encounters Cultural and Language differences in the concept of illness and disease Accessibility (when, how & where to seek help) Public Health Issues - DOT Preventing misdiagnosis/miscommunication Attitude Clinical staff/front desk personnel Racism – conscious/unconscious

26. Cultural considerations in health care Health beliefs & practices

27. Examples of cultural behaviours Avoiding eye contact– as a sign of respect (may be mistaken for disinterest) May take long to express themselves (may be mistaken for making up a story) and result in a time consuming consultation. Asking many questions to higher authority in certain cultures is considered impolite Responding/nodding‘yes’ to everything is considered to be polite

28. Culture & related concepts Time Space Language

29. Space – recognizing one’s own territory In western countries, space determines the nature and degree of interpersonal space and involvement with others Leininger & Mc Farland (2002)

30. Time Western Countries (Monochromic) – time is limited; appointments scheduled in slots Some cultures regulate their concept of time by sun, day-night activities: e.g. eating, working and sleeping Therefore, we need to be oriented to culture time to reduce anger, frustration and non compliance

32. The inability to speak English does not mean the client is not intelligent !!! Language Family interpreters Issues of confidentiality in sensitive issues May interpret things the way they see it Blurring of parent’s/child roles Professional interpreters Translating / Interpreting Managing a conversation between the client, health professional and interpreter Issues of confidentiality Clarification of non-verbal gestures

33. Beliefs, Values, asylum seeking experience, possible trauma, torture and violence, his/her own interpretation of disease, illness and health + Language problems and looking for coping strategies to adapt to the new culture: housing, employment, education, etc Successful outcome depends on eliciting, probing, trust collaboration with Cultural Mediator Efficacy depends on confidentiality, impartiality,credibily & collaboration with Health Provider Patient Health Provider Cultural Mediator Beliefs and values, sheltered from war conflict, torture and violence, expert in the health field and how the health system functions + Unfamiliar with cultural issues of migrants Beliefs, Values, own asylum seeking experience, possible trauma, torture and violence, his/her own interpretation of disease, illness and health. + Educated, bilingual, knowledge of both cultures and trained OYO Project - The Triadic Model of Communication in Health Care (Podda Connor, 2010)

34. It is the ability to negotiate care with people of different backgrounds, taking into consideration their beliefs, values and behaviours to encourage a positive clinical encounter. Cultural Competence Cultural Competence is NOT a recipe book! Cultural competence IS an ongoing process Cultural Blindness: differences ignored, “treat everyone the same”, only meet needs of dominant groups

35. Clinical encounters LISTEN to your patient from his or her cultural perspective. EXPLAIN your concerns and reasons for asking for personal information, e.g. lifestyle and family issues. ACKNOWLEDGEyour patient’s concern. RECOMMENDa course of action. NEGOTIATEa plan with your patient/client that takes into consideration his or her cultural norms and personal lifestyle. Berlin E, Fowkes, W. A. (1983)Teaching Framework for Cross-Cultural Health Care. Western Journal of Medicine;139:934-938

36. The Media Worrying Indeed! 31% increase in immigrant arrival More Illegal immigrants Tikber il-Pjaga

37. Tackling racism & Discrimination Individuals who experience discrimination are: Less likely to seek care More likely to present at a late stage of disease More likely not to comply with treatment regimes • Identify vulnerable individuals • Advocate against discrimination. • Educate the public

38. PROBLEM OR OPPORTUNITY ? TOLERANCE OR CO-EXISTENCE ?

39. Books & Movies

40. Put empathy at the heart of practice Thank you! Contact details: marika.poddaconnor@gov.mt Marika Podda Connor MSc European Nursing (Lond), BSc(Hons) Nursing Studies, Dip. Soc. Stud, RN.