Critical Cultural Perspectives and Health Care Critical Cultural Perspectives and Health Care

Involving Aboriginal Peoples Involving Aboriginal Peoples

Annette J. Browne, PhD, RN

Associate Professor

New Investigator, Canadian Institutes of Health Research

Michael Smith Foundation for Health Research Scholar

School of Nursing, University of British Columbia

Vancouver, Canada

ObjectivesObjectives

Examine commonly-held assumptions about “culture” in health care; Examine commonly-held assumptions about “culture” in health care;

Explore how conventional thinking about culture has the potential to Explore how conventional thinking about culture has the potential to

become problematic in health care become problematic in health care

a. Distinguish cultural sensitivity from cultural safetya. Distinguish cultural sensitivity from cultural safety

Examine the relevance of “critical cultural approaches” Examine the relevance of “critical cultural approaches”

in relation to health care involving Aboriginal peoples.in relation to health care involving Aboriginal peoples.

Culture is a Very Complex Concept!

Anthropologist Margaret Lock (1993):

“culture is “one of the two or three most complicated

words in the English language”.

Our ideas about culture are so strongly influenced by

recent historical events, today’s political climate, and

expanding patterns of globalization.

Conventional Notions of Culture in Health Care

Beliefs, values, behaviors, customs, and lifestylesBeliefs, values, behaviors, customs, and lifestyles

Fixed sets of characteristics that belong to particular Fixed sets of characteristics that belong to particular groups groups

Often presented as “lists” of cultural traits

Tends to be based on fairly Tends to be based on fairly narrow narrow definitions of culturedefinitions of culture

Founded on values of multculturalism, cultural defined in terms of: Founded on values of multculturalism, cultural defined in terms of:

Examples from Research: Health Care Providers’ Understandings about Culture

Health care providers’ ideas: Health care providers’ ideas:

““I find with Native people, just the way I find with Native people, just the way their culturetheir culture is, I think is, I think

you get a lot more social things that you need to deal with.” you get a lot more social things that you need to deal with.”

““It is in It is in their culturetheir culture to have a lot of violence, stabbing, alcohol to have a lot of violence, stabbing, alcohol

abuse… more than what you see in otherabuse… more than what you see in other cultures cultures.”.”

Culturalism: An Important Concept to Grasp

Is a process of equating culture with social problems or health Is a process of equating culture with social problems or health issuesissues

Is closely linked to ideas about “difference”, Othering, stigma, Is closely linked to ideas about “difference”, Othering, stigma, discrimination and racism discrimination and racism

Additional Examples from Research: Perceptions about Culture

Health care providers: Health care providers:

“She [the woman] didn’t take care of any of her own responsibilities.

She didn’t look after her own child. Now, I know that is a cultural

thing.”

“Quite often in this culture, they drink a lot”

Culturalism………….diverts our attention

Problematic because:

Our attention is diverted Our attention is diverted awayaway from the wider social, historical and from the wider social, historical and economic contexts that shape peoples’ liveseconomic contexts that shape peoples’ lives

Enables us to overlook the “burden of history”Enables us to overlook the “burden of history”

“Othering”…. ….also an important concept

Is the process of defining one’s self in relation to a differentiated Other, Is the process of defining one’s self in relation to a differentiated Other,

thus dividing the world into an “us” and “them”. thus dividing the world into an “us” and “them”.

People who are considered “different” are constructed as being even People who are considered “different” are constructed as being even more different [from “us”] than they really are more different [from “us”] than they really are

(Varcoe + McCormick, 2007) (Varcoe + McCormick, 2007)

Cultural Safety: Cultural Safety: An Alternate to Cultural SensitivityAn Alternate to Cultural Sensitivity

Developed in New Zealand by nurse leaders, in

collaboration with Maori people, to address Māori

health concerns related to:

Persistent health disparities

Power imbalances in the delivery of health care

Inequities in access to health care

Discriminatory attitudes and practices embedded

in health care

Cultural Safety

Moves beyond cultural sensitivity

Toward shifting the attitudes and practices in nursing and health care Toward shifting the attitudes and practices in nursing and health care that contribute to inequitiesthat contribute to inequities

20% of New Zealand’s Nursing Registration Exam 20% of New Zealand’s Nursing Registration Exam

is on Cultural Safetyis on Cultural Safety

Cultural Safety: Cultural Safety: Founded on a Founded on a CriticalCritical Cultural Perspectives Cultural Perspectives

Critical Critical Definition of CultureDefinition of Culture::

Culture is understood to be Culture is understood to be located within a located within a

constantly shifting network of meanings enmeshed constantly shifting network of meanings enmeshed

within historical, social, economic and political within historical, social, economic and political

relationships and processes. relationships and processes.

Cannot be reduced to a set of characteristics Cannot be reduced to a set of characteristics

Is not a politically neutral concept Is not a politically neutral concept

Has an explicit social justice agendaHas an explicit social justice agenda

Founded on a Founded on a critical critical and and politicized politicized understandingunderstanding of cultureof culture

Cultural Safety versus “Cultural Risk” Cultural Safety versus “Cultural Risk”

Cultural Risk: Cultural Risk:

Situations that arise when people Situations that arise when people

from a particular group believe they from a particular group believe they

are “are “demeaned, diminished or demeaned, diminished or

disempowereddisempowered by the actions by the actions and and

the delivery systems of people from the delivery systems of people from

another cultureanother culture” ”

(Wood and Schwass, 1993)(Wood and Schwass, 1993)

Cultural Safety: Cultural Safety:

Requires us to Requires us to shift our gazeshift our gaze onto onto

the the culture of health careculture of health care, , and how and how

practices, policies practices, policies andand research research

approaches can themselves approaches can themselves

perpetuate marginalizing conditions perpetuate marginalizing conditions

and inequities and inequities (Browne, Smye & Varcoe, 2005)(Browne, Smye & Varcoe, 2005)

Case Example: Case Example:

HIV Rates Among Aboriginal Women in CanadaHIV Rates Among Aboriginal Women in Canada

Cultural safety asks:

What social, economic and historical conditions led to this degree of

vulnerability?

How do assumptions about Aboriginal women shape their ability to

access care?

How do policies impact women’s capacity to access resources for

health?

What is it about the culture of health care that creates marginalizing

conditions for Aboriginal women affected by HIV/AIDS?

Aboriginal women represent 45.1% of all positive HIV test reports among Aboriginal

people compared to 19.5% for non-Aboriginal women (McKay-McNabb,2006).

Colonizing Messages in (Current) Neo-Colonial TimesColonizing Messages in (Current) Neo-Colonial Times

Excerpt from Canadian Newspaper (2002): Excerpt from Canadian Newspaper (2002):

““It’s called a culture of entitlement and a whole lot of Canada’s It’s called a culture of entitlement and a whole lot of Canada’s

aboriginals have it real bad. Those who suffer from this energy aboriginals have it real bad. Those who suffer from this energy

sapping affliction almost always grow lethargic and passive. People sapping affliction almost always grow lethargic and passive. People

around them come to resent them, a situation that fosters an around them come to resent them, a situation that fosters an

unhealthy society…Even the label ‘First Nations’ speaks of unhealthy society…Even the label ‘First Nations’ speaks of

entitlement, as though all others are second in line…The truth is, entitlement, as though all others are second in line…The truth is,

however, impolitic it may be to say it, pandering to Native Indians has however, impolitic it may be to say it, pandering to Native Indians has

become a virtual industry in this county.” become a virtual industry in this county.”

Impact on PatientsImpact on Patients

Without necessarily intending it as such:

Social problems become reframed as “cultural” issues

“Cultural differences” are presented as factual information

Pragmatic Applications: Pragmatic Applications: Applying Cultural Safety as a Conceptual Framework in Health Applying Cultural Safety as a Conceptual Framework in Health

Care Care

Raises ethical and moral concerns:

What is our responsibility in disrupting inequities that sustain the

status quo?

How might we be reinforcing “norms” of practice that may be

alienating to indigenous people (and others)?

How can we challenge and counter assumptions about “cultural

Others”?

How can we work to raise critical consciousness in our own local practice areas?

How do current policies cause people to feel “demeaned, diminished, or disrespected” as

they seek health care?

““If all are like me, then all are my relations” If all are like me, then all are my relations”

(Little Bear, 2000, p. 68)(Little Bear, 2000, p. 68)