Cultural competence for Pacific People

Dr Debbie Ryan

Pacific Perspectives

NZ in the Pacific

• What is the problem?

• What is cultural competence and how is it being applied to address Pacific health?

• Themes from literature on cultural competence

• Insights from Pacific Perspectives projects and thoughts on culturally competent care for Pacific people

Outline

‘A cc system acknowledges and incorporates - at all levels - the importance of culture, assessment of cross-cultural relations, vigilance towards dynamics that results from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs.’

Betancourt et al.2003. p 294

Cultural Competence Definition

‘There is an obligation on all doctors to understand their patients’ backgrounds and contexts, and have appropriate awareness, attitudes, knowledge and skills in relation to different cultures’.

Source: Best Health Outcomes for Pacific Peoples: Practice implications 2010.

Cultural Competence NZ Medical Council

Attitudes

seek patients preferences and follow their lead;

attempt to enter into, and understand, the patient’s world.

Awareness

reflect on potential judgements and prejudices based on skin colour and appearance;

appreciate patients cultural expectations around consultations and personal interaction;

Pronunciation (names, greetings)

NZ Medical Council

KnowledgeAwareness of history, have some knowledge and respect of other cultures.SkillsAbility to ask about the patient’s background and heritage; the ability to involve whānau; the ability to ensure that the patient understands what is being planned; and the ability to seek advice and the capacity to develop the connections through which this can happen.

Barriers to services experienced by ethnic groups:

• Language proficiency

• Cultural differences with heath staff and systems

• Socioeconomic factors

• Environmental hazards (poor housing, risks in workplaces, unsafe neighbourhoods).

Dauvarin et al. 2014. Culturally competent interventions in Type 2 diabetes mellitus management: an equity oriented literature review. Ethnicity and Health. 19 (6) 579-600

What is the problem?

• Some evidence of improved patient health outcomes

• Studies lack methodological rigor. Truong et al 2014

• Assumptions that groups share certain cultural traits, values, attitudes which influence health service engagement

• Culture is not fixed, but involves dynamic, flexible, ongoing processes

• Recognition of cultural diversity and analysis of structural sources of inequality more helpful Kirmayer. 2012

Review of cultural competence literature

Overall the majority of studies focus on changing people rather than the environment (community and policy level. This is in contrast to evidence that multilevel theory is the most effective approach.

Heo et al. 2014

Changing people or systems?

• Complex needs NZ Productivity Commission 2015

• Chronic diseases – ‘burden’ and ‘othering’ Walton & Lazarro-Salazar 2016

• Vulnerability, marginalised, high needs Loh Trevallyn et al 2015

‘Othering’ and ineffective services

CC interventions showed no evidence of reduction of health inequalities. In fact CC programmes may increase stereotypes and prejudice among health professionals. Dauvarin et al.2014.

• NHS service responses to migrants in the 1970s

• Located minorities in their ‘cultural deviance absolved the statutory sector of the need to change

• Separate services were cheaper and high profile

Ahmad and Bradby. 2007. Locating ethnicity and health: exploring concepts and contexts. Sociology of Health and Illness 29 (6).

Special Projects

• Minority groups: defined by ethnicity, cultural, linguistic differences

• Indigenous- NZ Maori/Pacific; USA Native Hawaiian Other Pacific Islander (NHOPI)

• Migrant – Culturally and Linguistically Distinct (CALD), Asian American and Pacific Islander

• New Zealand- Pacific peoples, Pacific islander, BNZ, Pasefika, Pacifica

Definition of Pacific groups

• Lower rapport, shorter consultations –NATMEDCA

• Pacific people value relationships vs transactional, contract /business approaches of practices. Southwick et al 2012.

• Poor understanding of chronic conditions and treatment due to health beliefs. Barnes et al 2004.

Evidence of unmet health service needs for Pacific but not why and how cultural differences lead to problems

‘There is a strong flavour through all of the interviews that families are a blessing and a strength; it is central to how Pacific people describe their situations. It is expressed in the view that if all is well with the family, then all will be well…’

Southwick, Kenealy &Ryan. 2012. Primary Care for Pacific People: A Pacific and Health Systems Approach

Family is central to Pacific health

Family composition in NZ by ethnicity

http://www.superu.govt.nz/sites/default/files/Seminars/Paul%20Spoonley.pdf

The Misi family case study –a Pacific family model of care

Pacific Perspectives 2012. Pacific Health Workforce Service Forecast.

“I have seven children that aren’t [my] biological [children], some are my biological nieces and

nephews. They are my babies because I have had them from birth”

“[child] is my youngest [but he’s not the] youngest in the house…he’s the biggest one in the house.

There are smaller children, they’re not mine, they’re my grandchildren…I’m just caring for this new one because the parents, their lives are not okay. I just grabbed that one for the meantime”

Pacific Perspectives.2015. The healthcare experiences of Pacific families who have children with rheumatic fever

Pacific Families

Evaluation of Pacific navigator service

‘...our biggest concern is the house during the winter. It gets very cold in this house for us...We have holes in the wall that have been there before we moved into the house. I did get in touch with [Housing NZ] regarding this issue and they said they were going to help make it better for us. But we haven’t heard anything from them since’.

‘...in hospital there are so many different faces, people I don’t even know, people I’ve never seen before, they come in and say hello I’m blah blah, you can’t expect me to remember every Tom, Dick and Harry that comes in’.

Complexity

Case studies with 6 service users with long term mental health and disability needs• Relationship with peer support worker over many

years- up to 20• Relapsing, progressive nature of conditions• Extended family support often not seen• Resilience • CSW and PSW provided deep and broad support

eg seeking work, daily schedule, using public transport, cleaning, social outings, visited during Christmas and other times when they were alone

Community and peer support workers

‘… medicine or our potions from different people and places…all over the place. Every time someone says this potion

or medicine will help, we will try it, we do all this in combination with the doctor’s medication and treatment. When the doctor asks are you feeling better? I don’t know

what’s making me feel better so I just say yes’.

‘...if someone tells of a new medicine or treatment we buy the medicine or we try it out, we are always up to try anything. I

don’t always depend on the doctor’s pills to work, I believe they may work for a short while and then stop working’.

Alterntative therapies and health literacy

• Best practice is use of professional translators

• Not common in primary care

• Tovia Laufau case study

Communication and translation

• Outward acceptance of healthcare masked dissatisfaction

• Patients ‘powerless’ in clinical encounter

• Non-attendance and non-concordance were ‘…powerful statements of self-determination…’

Sheridan, Kenealy et al. 2012. Patients engagement in primary care: powerlessness and compounding jeopardy

Powerlessness

‘…They think I don’t care about my baby but the truth is I can see they don’t talk to me properly, but with my Mum they talk more serious than

they are with me, give her more information and I know this will help my baby more. So I let them

think I don’t care so my baby gets help…’

Pacific Perspectives. 2013. Maternity Care Experiences of Teen, Young, Maori, Pacific and Vulnerable Mothers at Counties Manukau Health

Vulnerability

‘…It’s kind of like when you go in there, you just feel that stigma. I think that’s me more, my personal um feeling about it all was the stigma of being lumped into the same, just one of the statistics being admitted to hospital. That’s what really got me and I hated it…’

Arlidge B. 2009. Experiences of whanau/families when injured children are admitted to hospital: a multi-ethnic qualitative study from Aotearoa/NZ. Ethnicity and Health. 14 (2).

Stereotypes and stigma

‘…it was quite a fakama (shame) issue to talk about… it was not a spoken illness, it was something that families did not want to discuss…’

Pacific Perspectives. 2018. Evaluation of Rheumatic Fever Pacific Engagement Strategy.

Fakama/Shame

WhakamaFramework

Walker & Walker et al. 2017. Maori patients experiences and perspectives of chronic

kidney disease: a New Zealand qualitatuve Study.

BMJ Open

‘…I wanted the Sunday School teachers to be Tongan, I’m a firm believer in using the Tongan language… [and the messages] are taught in poetry, in poems, in songs, in skits, in plays…’

‘I looked around the crowd and everyone was paying attention to the story that was in front of them … even the spoken word, the poets, all the words you resonate with what they are sharing…’

Tongan community church Rheumatic Fever health promotion programme

Whakamana - using community resources and infrastructure

• Pacific people are a significant population in New Zealand.

• Cultural competence is promoted as a response to the persisting disparities in health and service outcomes.

• Culture is dynamic, … and identity is complex, contested

• CC approaches that may work include

• CC problems include stereotyping, victim blaming , focus on individual action rather than larger political and economic issues

Conclusion

Summary key themesPacific Services

Family is central Individual focus, privacy, autonomy, ‘self-care’

Multigenerational households Models of care do not reflect this understanding

Complexity Requires multilevel action but most programmes are monolevel

Communication and translation Awareness but not supported in policy, practice and funding

Support role of CHWs, CSW for people with long term, relapsing/progressive chronic conditions

CHWs, CSWs often lowest paid, low status

Agency and self determination Vulnerability, marginalised, powerless.

Fakama, shame, stigma Can contribute to whakamana (self esteem) through contributing to cultural identity through community resources