Part B: Cross-Cultural Communication and Practical Applications

1. 1 Cultural Competence for Healthcare Professionals Part B: Cross-Cultural Communication and Practical Applications

2. Workshops Session A • Introduces health disparities, the immigrant experience, social determinants of health (SDOH), and clinical cultural competence. Session B • Develops knowledge and skills on collaborative communication, cross-cultural communication, and clinical cultural competence as it pertains to parenting, mental health and pain management. Session C • Develops knowledge and skills on clinical cultural competence in the use of complementary and alternative therapies, bereavement and grief. Participants will have an opportunity to practice with Standardized Patients

3. Learning Objectives 3 Upon completion of Workshop B participants will be able to: • Apply collaborative conversation techniques in a clinical scenario • Describe strategies and resources to facilitate cross-cultural communication • Recognize cultural differences in parenting practices, mental health perspectives, and the expression of pain • Describe strategies for providing culturally competent care to children experiencing pain and mental health problems

4. Caveat 4 “The encounter with persons, one by one, rather than categories and generalities, is still the best way to cross lines of strangeness” (Bateson, 2000)

5. Cross-Cultural Communication

6. Assigning Meaning 6

7. Joy Luck Club 7 Joy Luck Club, (1993)

8. Discussion • What did you notice about the ways in which the individuals in the film were communicating? • How did culture influence their interactions?

9. Context of Communication 9 High Context Low Context • Communication is less explicit; most of the message is in the physical context or internalized in the person • More emphasis on what is left unspoken; more likely to “read into” the interactions • i.e. Asian and Latin American cultures • Most of the information is made verbally explicit • Information is often repeated to ensure understanding (if it is relevant and important it must be stated, if it is not stated it is not relevant) • i.e. North American culture (Hall, 1976)

10. Context of Communication 10 High Context Low Context • More responsibility on the listener – to hear, to interpret and then to act • More need for silence; longer pauses (to reflect, understand the context and process the message) • The responsibility for communication lies with the speaker; it is better to over communicate and clarify, than to leave things unsaid • Silence and pauses often misunderstood as signs of agreement or a lack of interest (Hall, 1976)

11. Collaborative Conversation:A Communication Tool

12. Collaborative Conversations 12 (Greene & Ablon, 2006)

13. Things to Consider 13 • Power Dynamics • Experience and Expertise • Communication Styles

14. Case Study

15. Health Literacy 15

16. What is Health Literacy? 16 • Health literacy involves the ability to obtain, process and understand basic health information (Ratzan & Parker, 2000) • Canadians with the lowest literacy scores are two and a half times as likely to see themselves as being in fair or poor health (Rootman & Gordon-El-Bihbety, 2008)

17. Health Literacy 17 We should not assume people understand words or their meaning. Health literacy is more than: • giving a family a pamphlet in their own language (English or otherwise) • providing interpretation in the language of their choice

18. Interpreter Services and Language Line

19. Costs of Not Providing Interpretation in Healthcare 19 A literature review described inequitable care with regard to three specific factors: • Inappropriate tests and procedures • Increased adverse events • Lack of or inappropriate hospital utilization (Access Alliance, 2009)

20. Things to Consider… 20 Availability of interpreters • Interpreters are sometimes unavailable • Strategies are always needed to support effective communication, even when interpreters are unavailable (ex. Language Line) Trained versus untrained interpreters • Trained interpreters were 70% less likely to make medical translation errors than untrained interpreters (Gany et al., 2010)

21. How to Assess a Family’s Need for an Interpreter 21 • Ask the family what language they speak at home • Observe what language the family speaks among themselves • Explore with the family when having an interpreter may be helpful

22. How to Assess a Family’s Need for an Interpreter 22 • Pay attention to non-verbal cues • Ask the family to tell you their understanding of what was discussed • Continue to assess the need for an interpreter on an ongoing basis

23. Things to Consider… 23 Barriers to the use of Interpreter Services: • Some families may be concerned about confidentiality if they are from a small ethnic community where they may be known to the interpreter • Families may decline interpreter services out of fear of being viewed as different or difficult (Chalmers & Rocco-Buckton, 2008)

24. Working Effectively with Medical Interpreters 24 • Introduce yourself, the interpreter, and the parent and/or patient • Briefly provide background information to the interpreter (purpose of the meeting) • Address the patient/family, not the interpreter • Ensure closure and debrief with the interpreter • Document the conversation

25. Interpreter Services: SickKids Policy 25 • Must be related to direct patient care • The request must be made by a healthcare professional • 24-48 hours notice must be provided (during business hours)

26. 26 Working Effectively with Medical Interpreters

27. Language Line:SickKids Policy 27 • Recommendations for use of Language Line: • Urgent or same day requests • Ideally, use a phone with a speaker or 3-way calling • Provides services in languages unavailable through Interpreter Services • Requires the department cost centre code • Available 24/7

28. Cultural Differences in Parenting

29. Cross-Cultural Parenting 29 They openly laughed at me for speaking of “teaching” children to walk. A child walks of its accord, they said. I would be saying next that trees had to be instructed in how to bear fruit. (Hogbin, 1943)

30. Have you been surprised by a cultural difference in parenting? 30 “Parental behaviours outside of one’s own cultural framework can seem strange or even dangerous” (Greenfield & Suzuki, 1998)

31. How Culture Affects Parenting 31 • Sleep • Feeding • Discipline • Parenting style • Routines • Media • Play • Talking to children • Attachment • Education • Conflicts • Safety • Family type • Adolescence • Roles • Advice seeking

32. Parenting Differences Across Cultures 32 Gusii mothers of Kenya hold their 9-10 month old infants and engage in soothing physical contact more than middle class mothers from Boston, but also look and talk to them less (Richman, Millar & Solomon, 1988)

33. Historical Perspective 33 • Parent-child relationships among racialized groups are often portrayed as deficient (Keller, Volker & Yovsi, 2005)

34. Individualism and Collectivism in Parenting

35. Individualism Collectivism 35 Definitions • Focus on the “I” • Goal of autonomy • Values • Personal choice • Emphasize • Goals focus on the individual preferences, rights and pleasure • Universalistic approach • Same values are applied to all • Focus on the “We” • Promote relatedness and interdependence • Values • Connection to the family • Respect and obedience • Emphasize • Goals focus on the group • Pluralistic approach • Different values and standards are applied to members of “in group” and “out group” (Tamis-LeMonda, Way & Hughes, 2008, Srivastiva, 2007)

36. Communication 36 Individualism Collectivism (Srivastiva, 2007) • Communicate about the physical world, such as using objects, and other topics that prepare children for school • Emphasize outward expressions using words or gestures – e.g. pointing to an object while saying the name to teach infants new words • Use communication to develop children’s social knowledge, such as how objects relate to one another • Use more non-verbal and subtle expression – such as learning games through observation or using touch, gaze, posture, and facial expressions to express meaning

37. Family Structure and Roles 37 Individualism Collectivism (Srivastiva, 2007) • The core family unit is usually the authority when it comes to decisions, parenting and child rearing • The extended family unit plays a key role in child rearing • The family system is the highest authority

38. Sleep 38 Individualism Collectivism • Often believe that separate sleeping arrangements help children develop independence and maintain parental privacy • Regularly co-sleep (as many as 2/3 of the world’s cultures) • Self-soothing less important • Help child-parent bond

39. Discipline 39 Individualism Collectivism • Value providing structured discipline while being available, involved, warm and sensitive • Encourage thinking about their behaviour and learning about limits • May use strategies such as shaming • Encourage respect for elders and authority figures • May use other relatives or networks for discipline (Srivastiva, 2007)

40. 40 Immigrant Parenting Experience Other considerations: • Transitioning • Idea of transitioning from child to adult services is based on Western values • The concept of encouraging a child to gain autonomy and make decisions independently may not be appropriate in some cultures • Primary caregiver roles (Chalmers & Rocco-Buckton, 2008)

41. 41 Immigrant Parenting Experience PARENTING VIDEO

42. Foreign Visitor Activity

43. Foreign Visitor Activity 43 • What is the issue? • Is the criticism true? Fair? • What underlies it? What is the logic behind it? • How could you explain or defend it?

44. Parenting: Key Considerations 44 • Recognize how culture and the new immigrant experience impacts parenting • Recognize cross-cultural implications for the teaching that we do around parenting • Be aware of the strengths of individualistic and collectivistic approaches to parenting • Understand that personal parenting styles may not effectively cross cultures in the context of growth and development

45. 45 When teaching about parenting it is important to remember that optimal child development can follow many paths.

46. Mental Health Supporting Immigrant and Refugee Families and their Mental Health Needs

47. Culture and Mental Health Culture affects how people: Label and communicate distress Explain causes of mental health problems Perceive mental health providers Respond to treatment Culture influences who people seek help from and how they access treatment 47

48. New Immigrant Experience and Mental Health 48 • Balancing/navigating two or more cultures • Intergenerational tension • Social determinants of health • Language barriers

49. Immigration and Mental Health 49 Even though it is a stressful process, immigration itself doesn’t jeopardize mental health. Rather, it is the circumstances that surround the migration including stressful pre and post-migration experiences that determine the risk of developing a mental health problem. (Hyman, 2001)

50. Immigrant Youth, Identity, and Mental Health Immigrant children may experience cultural conflict as they attempt to identify with new cultures Biculturalism: “the ability of a person to function effectively in more than one culture and also to switch roles back and forth as the situation changes” (Jambunathan, Burts, & Pierce, 2000) 50