Training Trainers in Child Mental Health 22nd June 2000

1
Leicester Warwick Medical School
Cultural diversity and general practice Dr Nisha
Dogra Senior Lecturer in Child and Adolescent
Psychiatry Greenwood Institute of Child Health
2
Presentation plan
Defining cultural diversity Relevance of
diversity education Effectiveness of diversity
training Issues to consider (training workforce
issues ethnic specific services) What do
patients want? Self-reflection Summary
3
Your sense of self

•  Where were you born?
• Where were your parents born?
• What is your nationality?
• Do you feel you belong to an ethnic group?
• If yes which group do you feel you belong to?
• If not, can you give your reasons as to why you
  do not feel you belong to an ethnic group?
• Do you feel you belong exclusively to one
  culture?
• If yes which one?
• If no what cultures do you feel you belong to?
• What for you defines your sense of cultural
  belonging?

4
What does cultural diversity actually mean?

• Culture is not a value free concept.
• Many definitions of this
• The concept of culture, cultural identity or
  belonging to a cultural group involves a degree
  of active engagement by individuals and is a
  dynamic process.
• Problematic to assign cultural categories
  externally and based only on certain
  characteristics.
•  Frosh (1999 413) described the view that
  identity draws from culture but is not simply
  formed by it.

5
Association of American Medical Colleges (AAMC)

• Culture is defined by each person in
  relationship to the group or groups with whom he
  or she identifies. An individuals cultural
  identity may be based on heritage as well as
  individual circumstances and personal choice.
  Cultural identity may be affected by such factors
  as race, ethnicity, age, language, country of
  origin, acculturation, sexual orientation,
  gender, socioeconomic status, religious/spiritual
  beliefs, physical abilities, occupation, among
  others. These factors may impact behaviours such
  as communication styles, diet preferences, health
  beliefs, family roles, lifestyle, rituals and
  decision-making processes. All of these beliefs
  and practices, in turn can influence how patients
  and heath care professionals perceive health and
  illness and how they interact with one another
  (AAMC, 1999 25).

6
Why this definition?

• This is a patient-centred/individual-centred
  definition and can be applied to clinical
  situations. Suggests that individuals draw upon a
  range of resources
• Through the interplay of external and internal
  meanings construct a sense of identity and unique
  culture.
• Patients define which aspect of their cultural
  belonging is relevant at any particular point
• This may change in different clinical contexts,
  at different stages of an individuals life and
  may also depend on the clinical presentation
  itself

7
Diversity

• Diversity should perhaps be a more
  straightforward term
• However, again this term is used imprecisely.
• May mean diversity of ethnicity for which the
  term multiculturalism is often used (e.g.
  Culhane-Pera et al 1997, Loudon et al, 2001).
• May also cover the range of groups within society
  and so includes groups identified with
  characteristics other than ethnicity, such as
  sexual orientation. In other cases, it covers a
  much broader range of difference relating to
  individual characteristics beyond ethnicity.

8
Cultural competence

• Cross et al (1989) stated
• The model called cultural competence involves
  systems,agencies and practitioners with the
  capacity to respond to the unique needs of
  populations whose cultures are different than
  that which might be called dominant or
  mainstream American. The word culture is used
  because it implies the integrated pattern of
  human behaviour that includes communications,
  actions, customs, beliefs, values and
  institutions of a racial, ethnic, religious or
  social group. The word competence is used because
  it implies having the capacity to function in a
  particular way the capacity to function within
  the context of culturally integrated patterns of
  human behaviour as defined by the group. While
  this publication focuses on ethnic minorities of
  colour, the terminology and thinking behind this
  model applies to each person everyone has or is
  part of a culture (1989 3).

9
Use of terms

• Although the term is widely used, it often has
  different meanings (Henry J Kaiser Family
  Foundation 2003).
• No readily consistently used definitions
  regarding race and ethnicity (Bradby, 2003).
• For example, in the US the concept of race is
  still perceived more as a biological
  characteristic, whereas in the UK there is
  greater acceptability that it is a social
  construct (Dogra and Karnik, 2004).
• Two studies (Dogra, 2004 and Dogra and Karnik,
  2004) found that whilst there is some consistency
  in how culture is defined, there is little
  consistency in how it is subsequently used by a
  range of professionals and users. In the same
  studies, there was even less clarity about the
  terms, race and ethnicity.

10
Your sense of self

•  Where were you born?
• Where were your parents born?
• What is your nationality?
• Do you feel you belong to an ethnic group?
• If yes which group do you feel you belong to?
• If not, can you give your reasons as to why you
  do not feel you belong to an ethnic group?
• Do you feel you belong exclusively to one
  culture?
• If yes which one?
• If no what cultures do you feel you belong to?
• What for you defines your sense of cultural
  belonging?

11
Why is diversity important to health care
delivery?

• There are several key reasons, which include
•  
• -         Increasing diversity of populations
  (patients and workforce)
• -         There is increasing albeit limited
  evidence to show that taking a patient-centred
  approach which acknowledges patient perspectives
  and actively involves them in their own care
  improves outcomes
• -         Huge disparities in care accessed
• -         Disparities beyond the point of access
• -         Differential outcomes
• -         Legislative frameworks

12
Effective communication

• Evidence shows that communication skills diminish
  malpractice risk
• Enable the patients problems to be better
  identified with reduction in misdiagnosis and
  misunderstandings
• Increased compliance
• Improved outcomes including patient satisfaction
  (Levinson et al, 1997)
• Note however, the above does not just apply to
  communication with patients but with our staff
  and colleagues

13
Problems that may arise

•  Lack of knowledge resulting in an inability
  to recognise the differences
•  Self-protection/denial leading to an attitude
  that these differences are not significant, or
  that our common humanity transcends our
  differences
•  Fear of the unknown or the new because this
  is challenging and perhaps intimidating to
  understand something new that does not fit into
  ones worldview
• Feeling of pressure due to time constraints
  which can lead to feeling rushed and unable to
  look in depth at an individual patients needs

14
In turn may lead to

•  Patient-provider relationships are affected
  when understanding of each others expectations
  is missing
• Miscommunication
• The provider may not understand why the patient
  is non-compliant, how decisions in the family may
  be made especially about health care
• The patient may reject the healthcare provider
  because of the non-verbal cues given by the
  provider (DiversityRx, 2001).
• Conflict or isolation within staff groups

15
Relevance to general practice

• The above issues are compounded by the fact
  that we usually
• See members of the same families
• Different relationship with the community
• May be an integral part of the community
• AND
• The diversity within general practice is changing
• More applicants from the Indian sub-continent
  (remember 2 way street knowing about diversity
  from their perspective but also supporting them
  to work with diverse population they may have
  little experience of
• Course organisers have responsibility to recruit
  fairly how can they do that if are unaware of
  different value bases etc

16
Published evidence
Very few programmes have been subject to
evaluation beyond subjective student feedback.
Exceptions are Mao et al, 1988 Copeman, 1989
Rubenstein et al, 1992 Culhane Pera et al 1997
Majumdar et al 1999 and Dogra 2001 All used
pre- and post-teaching questionnaires. All
reported some degree of positive changes in
student perspectives but there was little follow
up
17
Published evidence
Webb and Sergison (2003) found that participants
stated that they found the training useful In a
follow up study commented on how they thought
their own behaviour had changed. Examples of
changes of practice included using more
culturally appropriate pictures for the ward not
using minors as interpreters.
18
Published evidence
A systematic review of five interventions to
improve cultural competence in healthcare systems
including cultural competency training for
healthcare providers was undertaken by Anderson
et al (2004). Identified only one study that
they felt had a fair quality of execution
Concluded that the evidence was insufficient.
19
Areas that need consideration

•          How patients are viewed
•         Training models
•         Whether or not there needs to be greater
  clarity regarding service models, and
•         What should policy say and
•         What should practitioners and services
  do to make a difference.

20
Ideal types for cultural expertise and cultural
sensibility

• Using Webers construct of ideal types, the
  concepts of cultural expertise and the proposed
  cultural sensibility are compared with regard to
  several characteristics.

21
Cultural expertise

• A dictionary definition of expertise (Thompson,
  1995) is expert skill, knowledge or judgement,
  with expert being defined as having special skill
  at a task or knowledge in a subject. There is
  notion that through learning knowledge about
  other cultures, one can develop cultural
  expertise. This model encompasses programmes
  trying to achieve cultural competence

22
Cultural sensibility

• A dictionary definition of sensibility is
  openness to emotional impressions,
  susceptibility, and sensitiveness. It relates to
  a persons moral, emotional or aesthetic ideas or
  standards.
• Cultural sensitivity is the quality or degree of
  being sensitive which is more limited than
  sensibility, and does not take into account the
  interactional nature of sensibility. If one is
  open to the outside, one might reflect and change
  because of that experience.

23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
Increasing the minority presence in the workforce

• Assumption that people form similar ethnic
  backgrounds have a common understanding based on
  one characteristic.
• Danger that seeing groups as homogenous promotes
  thinking in stereotypic ways rather than about
  individuals.
• The discussion also often appears to be
  one-sided, as if only the majority have negative
  views about minorities (Sue, 1991).
• May be unwise to make assumptions that minority
  professionals will understand the experience of
  other minority individuals (Gurung and Mehta,
  2001).

29
What do healthcare providers think?

• Study aim to explore what professionals working
  in a CAMHS thought of provision of mental health
  services to diverse groups and what their
  training needs in diversity might be.
•  
• No discernable pattern between sections of the
  sample, although this is clearly limited by the
  sample size and may not be surprising given the
  common professional context.
•  
• Study limitations

30
Perceptions of diversity

• Majority had a fairly traditional positivist view
  of culture
• Just under a quarter related diversity to
  individual sense of self.
• Implications for clinical practice.
•  
• Contrast to family therapy approaches which has
  now developed a much, more social constructionist
  perspective (Carr, 2000).
• Would GPs be any different?

31
Improvements to the service

• As identified by Draper et al (2003) staff were
  readily able to identify areas for improvement
• Two suggested that ethnic monitoring would be
  helpful, was not qualified how this might be
  helpful.
• Staff also made comments about learning from the
  community and engaging with them although few
  discussed specifics.
• Consistent with findings relative to community
  perceptions (Dogra et al, submitted), staff did
  feel that CAMHS needed to promote and advertise
  its services better.

32
Views about ethnic specific services

• Majority of staff perceived disadvantages and
  advantages of ethnic-specific services
• 3 respondents expressed discomfort at the idea,
  feeling it encouraged stereotypical thinking.
• 3 felt that ethnic-specific services were
  inappropriate, as we should be working towards
  improving services for everyone.

33
Training issues

• Majority of staff had been trained but only a
  minority were thought training was useful.
• Criticisms that
• Diversity training often assumes race to be the
  most important factor
• Often reinforced or created stereotypes.
• Not felt to be engaging

34
Training needs

• Majority identified needing more information
  about specific groups such as Muslims or
  Blacks.
• Internal inconsistency in that viewed diversity
  as related to individuals but wanted information
  about groups.
•  A smaller number felt awareness was needed.
• 3 said keeping an open mind was the most
  important issue
• Generally staff demonstrated little clarity or
  certainty about training needs which reflects the
  confusion there is in this area.

35
Training needs

• Majority identified needing more information
  about specific groups such as Muslims or
  Blacks. Some of these were internally
  inconsistent in that they viewed diversity as
  related to individuals but wanted information
  about groups.
•  
• A smaller number felt awareness was needed.
• Three identified very clearly that keeping an
  open mind was the most important issue
• Generally staff demonstrated little clarity or
  certainty about training needs which reflects the
  confusion there is in this area.

36
Training needs

• Culhane-Pera found that residents were resistant
  to training
• Tang et al found attendings less comfortable than
  residents and students regarding issues of
  diversity
• AMA found that physicians wanted information
  rather than to think about changing their
  practice
• What do you think GPS might identify as their
  needs?

37
Policy

• Most policy in this area is not evidence based
• Political agendas foremost
• Policy may be difficult to implement in any
  meaningful way

38
What has been covered?
Defining cultural diversity Relevance of
diversity education Effectiveness of diversity
training Issues considered - training workforce
issues ethnic specific services) What do
patients want? Staff views Finally a chance for
some reflection on your own practice
39
Reflecting on your own practice

• Think about how you view culture and sense of
  identity given the frameworks presented
• Justify your position in the context of your
  professional role
• Reflect on your own clinical and educational
  practice
• Evaluate how your own views influence the choices
  you offer your trainees or patients
• How often are you genuinely interested in asking
  individual patients what they might need?
• How often do you assume that the needs of
  patients or colleagues are already known on the
  basis of their diagnosis, ethnicity, gender or
  any other factor?
• What three things could you do to change your own
  practice?