Marika Podda Connor Migrant Health Unit 1

Migration: Culture & Diversity in Health Care
Marika Podda Connor
Migrant Health Unit
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Outline of presentation
Defining culture
Migration in Europe
Cultural issues and related concepts
Cultural Competence
Racism and discrimination in Health Care
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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
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British National Consensus - Ethnic
Origin
A. White [ ] British [ ] Irish [ ] Scottish [ ] Welsh
background (specify): ______________________
[ ] Any other White
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
background (specify): _______________________
E. Chinese
[ ]
Any other Black
[ ]
F. Other ethnic background [ ]
Information refused [ ]
Not known
[ ]
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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
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Relevant key points to health
care
Awareness of sociocultural factors on patients’
health beliefs, values and behaviors
Knowledge of specific cultural issues including social
and historical factors shaping health behaviors,
disease epidemiology, ethno-pharmacology and
complementary health practices
Communication Skills such as eliciting patients’
health beliefs, participatory decision-making, and
working with medical interpreters.
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Top 10 non-EU residents
Serbia
1,011
Russia
899
China
795
Libya
697
India
463
Philippines
413
Ukraine
409
Turkey
343
Bosnia
Herzegovina
243
Korea
217
Migrants residing
in Malta
African migrants
Under
5,000
EU Citizens holders 4,282
of a working permit (ETC, 2009)
(Grech, 2009)
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Hangar
Open Centre
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Tent Village Halfar
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Self-awareness of prejudices & biases
What is making
me feel
uncomfortable?
What is impeding
a positive,
effective clinical
encounter?
Is it lack of
Knowledge?
Skills?
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Culture
A shared system of values, beliefs and learned
patterns of behaviour, and not simply defined by
ethnicity
Learned and shared by people
Low, 1984
Dynamic: neither fixed nor static
Existence of similarities and differences
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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
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Comparisons of Cultural Aspects
Aspects of
culture
Western Culture
Other cultures
Relationships:
family and friends
Focus on nuclear
family. Responsibility
on self.
Focus on extended
family. Loyalty and
Responsibility to family.
Age give status
and respect.
Group orientation.
Conformity.
Values and norms
Beliefs and attitudes
Age seen as
handicap
Individual orientation.
Independence.
Preference for direct
confrontation of conflict.
Challenging of authority.
Individuals control their
destiny.
Gender equity.
Preference for
harmony.
Respect for
Authority. Individuals
accept their destiny.
Different roles for
men and women.
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Terms related to culture
Assimilation
Acculturation
Ethnocentricity
Culture shock
Stereotyping
Xenophobia
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The Iceberg concept of culture
Dress
Language
Looks
Food
Concept of time
Religion
Concept of self
Social Roles
Family
Customs
Body language
Personal space
Patterns of handling emotions
Concept of health & Illness
Attitudes towards elderly
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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)
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Geneva Convention:
Who is the refugee?
"A person who owing to a wellfounded 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)
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Why Do People Migrate?
Pull Factors:
Climate, job
opportunities, studying,
etc
Voluntary Migration
Push Factors:
Food shortage, war,
floods, etc
Involuntary Migration
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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
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Trafficking
Traffickers use violence,
coercion and deception to take
people away from their homes
and families, and force them to
work against their will
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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
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Health and social issues of
migrants
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
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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






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Unfamiliar clinical 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
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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
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Cultural considerations
in health care
Health beliefs & practices
Western Cultures
Non-Western Cultures
Seeks health system to prevent and
treat illness
Seeks health system when in acute
stage of illness
Values independence & freedom
Values interdependence with family and
community
Individual needs are valued and
encouraged
Individual interests are subordinate to
family needs
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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
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Culture & related concepts
Time
Space
Language
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Space – recognizing one’s
own territory
In western countries,
space determines the
nature and degree of
interpersonal space
and involvement with
others
Intimate
0 to 18”
Personal
18” to 3’
Social
3’ to 6’
Leininger & Mc Farland (2002)
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Time
Western Countries
(Monochromic) – time is
limited; appointments scheduled
in slots
Some cultures regulate their
concept of time by sun, daynight activities: e.g. eating,
working and sleeping
Therefore, we need to be
oriented to culture time to
reduce anger, frustration and
non compliance
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Language
The inability to speak English does not mean the
client is not intelligent !!!
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
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OYO Project - The Triadic Model of
Communication in Health Care
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
Health
Provider
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
Efficacy depends on
confidentiality,
impartiality,credibil
y & collaboration
with Health
Provider
Patient
Cultural
Mediator
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
(Podda Connor, 2010)
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Cultural Competence
Cultural Competence is NOT a recipe book!
Cultural competence IS an ongoing process
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.
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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.
ACKNOWLEDGE your patient’s concern.
RECOMMEND a course of action.
NEGOTIATE a 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
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The Media
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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
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PROBLEM
OR
OPPORTUNITY ?
TOLERANCE
OR
CO-EXISTENCE ?
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Books & Movies
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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.
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