Week 4B: Culture and Health Inequities

Culture and Health Inequities Readings: pg. 243-261, 1187-1206 (CH 13 and 39) + 2 articles Understanding Culture: The Canadian Context (243-261) - Canadians often pride themselves on living in a fair, tolerant, multicultural society. However, our colonial history, immigration policies, and the inequities that structure relationships among diverse groups of people in Canada present significant challenges to fairness and tolerance - Colonization and colonialism: refers to the processes in which a population is taken over and governed by a nation-state such that power and authority are exercised in ways that consciously and unconsciously subordinate that population - Eg. indigenous populations and residential schools - Neocolonialism: refers to new, evolving, and ongoing colonial policies and practices that continue to govern, oppress, and subordinate certain groups - Involves more direct forms of control through economic and cultural dependence, without the development of infrastructure in the subordinated lands as was characteristic of European colonialism - Groups affected experience oppression, and shows detrimental effects on health - Individualism: the valuing of individuals over the collective that is common to liberal democracies. Individualism is based on the idea that society is essentially an equal playing field, that people have fairly similar choices, and that individual rights are of greatest importance - People are viewed as separate rational beings who can be understood apart from their social, economic, political, or historical contexts - Individualistic values shape Canadian health and social policy, including multiculturalism policy and immigration policy, and shape how culture is understood in Canada, which in turn shapes people’s experiences of culture - Canadian Multiculturalism Act: this Act recognizes the freedom of all Canadians to preserve, enhance, and share their cultural heritage and promotes “the full and equitable participation of individuals and communities of all origins in the continuing evolution and shaping of all aspects of Canadian society and assists them in the elimination of any barrier to such participation” - However, there are still barriers such as participating through employment, obtaining resources adequate for safe shelter and adequate nutrition, civic engagement, playing a role in shaping policies that affect them, voting, discrimination, and barriers to health care - The Federal Indian Act: In part, this law recognizes the unique status of First Nations people. However, until amendments were made in 1960, in many ways (including restriction from voting or leaving reserves without permission) with serious effects on their ability to earn a living, obtain education, stay connected to family members, and participate in political decision-making - Culture is often used as a cover for stigmatizing practices. Ex: immigrants being portrayed as vectors of disease in the SARS outbreak - - Democratic racism: the Canadian tendency to espouse equity and social justice, yet practice discrimination. Democratic racism uses “cultural differences” as a euphemism for racial differences to explain health, social, and economic inequities. - The difference in health/economics is explained as resulting from cultural differences instead of examining the social and economic dynamics that might shape such divergence Nurse are obliged to uphold fairness, dignity, and respect for all persons as noted in the Canadian Nurses Code of Ethics Conventional Understandings of Culture - Culture is often defined as the values, beliefs, and practices common or inherent to a group of people. This understanding can be problematic when: - Identifying a person’s culture depends on associating them with a particular group, whereas most people affiliate with multiple groups - People affiliate with multiple groups, which may imply diverse, or even conflicting values and beliefs - Ascribing assumed group values to individuals suggests a static set of values, beliefs, and practices that do not change over an individual’s life - Culture is often narrowly conflated with ethnicity - Ethnicity: refers to a group or community defined by a shared heritage, culture, language, or religion - In Canada, ethnicity is often a polite term for race Culture as Process: Contemporary Understandings: - Culture is in constant motion, and many people identify with many cultures. - Nurses cannot understand a person simply by knowing what culture they fall into because they may be involved in many cultural beliefs, values, and practices so you need to be able to ask more questions than simply the group to which they belong. - Meaningful knowledge about an individual person cannot be gained simply by identifying the groups to which that person belongs - Cultures are shaped by sociohistorical, political, and economic contexts and by power dynamics within those contexts. Understanding culture as an ongoing, dynamic process requires considering how contexts and power dynamics operate Conventional Understanding of Culture in the Health Care Context - Racialization: the process of categorizing people into racial categories that are constructed as different and unequal in ways that lead to negative social, economic, and political impacts - Categorizing people based on ethnicity is usually done to racialized groups and thus generally a racializing process - Racialization is also a form of “othering” that is a projection of assumed cultural characteristics, differences, or identities onto members of particular groups, a process that divides people into “us and them” → leads to ideas of superiority Cultural Sensitivity - When culture is thought of as something that belongs to people, including values, beliefs, and practices, it is thought of as something static, permanent, and unchanging - The obligation of the nurse is to find out what a person’s culture is and to be sensitive to, and tolerant of, differences from the presumed norm, with tolerance often implying a tolerating majority and a tolerated minority - Consider these limitations: - The diversity within any group often exceeds the diversity between groups - People often disagree with the classifications to which other people assign them - Many people claim membership in a group but do not subscribe to all the practices associated with that group - Inventories of cultural values, beliefs, and practices can be stereotypical and can lead nurses to make erroneous assumptions about individuals - People from racialized groups, in particular, may find the process of being categorized by ethnicity offensive - Cultural sensitivity focuses attention on and tightness emphasis on individuals, often in isolation of, and overlooking, the broader context of peoples lives In Anticipation of Cultural Safety in the Practice Context - Cultural safety always begins with self-reflection on how our biases, assumptions, norms, and ways of being influence our viewpoints, interactions, and practices. Cultural safety also requires being able to critically analyze the culture of health Anticipating the Practice of Culturally Safe Care - The practice of any nurse is shaped by his/her own values and beliefs, colleagues, and the wider culture of health care in which care is provided - Students are also influenced by the values of their nursing programs and their instructors, values that may be at odds with some values of practice settings Applying Cultural Safety in the Practice Context - Interacting with and understanding culture as it relates to nursing involves both interacting with and understanding clients and colleagues. Cultural safety requires developing skills to challenge stereotypes, assumptions, and generalizations and shifting the way we interact and practice with others from the stance of expert to a stance of inquiry - Practice from a stance of inquiry and active listening - Practice nonjudgmental acceptance of people - Anticipate where you will be most judgmental and how you will practice in those circumstances - Pay attention to when people say they are being discriminated against - When you are uncomfortable and don't know what to say or do, or feel you have done the wrong thing, be honest with others - Ensure that people have the opportunity to communicate in the language that - - they are able to speak and understand Working with language interpreters - Conversations are longer, find a competent interpreter, speak as if you are talking to them normally Interacting and understanding colleagues - Be good, listen, etc. What Does Vulnerability Mean? (1187-1206) - Vulnerability suggests that individuals or groups are in need, at risk of, or susceptible to harm because of their exposure to particular social conditions placing them at a greater risk of harm in comparison to others in the population - Vulnerability means there is a potential for harm to occur - Structural vulnerability: defined as “a positionality that imposes physical/emotional suffering on specific population groups and individuals in patterned ways… which is a product of class-based economic exploitation and culture, gender/sexual, and racialized discrimination, as well as complementary processes or depreciated subjectivity formation” - Being in a hospital increases vulnerability because patients are in unfamiliar situation and away from their families and friends - Stigma, discrimination, previous trauma, violence, or abuse are also part of the conditions that contribute to vulnerability to poor health and of concern in public health - Vulnerability can be understood as an individual problem and/or a product of social conditions - Lifestyle approaches have not typically worked with low-income groups because of unaddressed factors, such as precarious employment or inability to find employment, long work hours, and lack of affordable transportation, all of which impede participation in health education or a healthier lifestyle - An individual approach to vulnerability contributes to viewing poor health as a problem or failing of a person and consequence of poor choices - Living and working conditions or the social and material circumstances of a person’s life have been found to have a greater impact on health than individual choices and lifestyle factors - Materialist explanations focus on how the social determinants of health, such as housing, employment, income, social support, education, and so on, influence health - A neomaterialist approach focuses on the dynamics that result in an unequal distribution of resources that impact living and working conditions - A life course approach highlights the cumulative impact of social and economic conditions on health throughout the lifespan - Psychosocial explanations focus on the stress associated with uneven distribution of resources in society - Health inequities: differences in health that are unfair or unjust and are created by social conditions that are potentially remedial - Health inequalities: differences in health that may be positive or negative - Health disparities: differences in health status among ethnic groups and as a consequence of racism What Living Conditions Contribute to Vulnerability? - Poverty - Physical and built environment - Housing - Homelessness - Food insecurity - Social exclusion What Social Processes Contribute to Vulnerability and Poor Health? - Although vulnerability is produced in certain living conditions, those living conditions and associated vulnerabilities are created and sustained by intersecting social, political, and economic factors. These dynamics are due in part to the fact that political systems, social structures, and economic arrangements determine who has power and control in decision making about resources and who has access to these resources - Consider stigmatization, racialization, marginalization, discrimination associated with class, age, sexual orientation, ethnicity, gender, and ability Are People Merely Victims of Circumstance? - Individuals do not have unlimited choice but make choices within a set of life circumstances that vary based on social positioning and accompanying resources and power What Can Nurses Do to Reduce Vulnerability to Poor Health? - Reducing vulnerability to poor health requires policy to ensure that the structural determinants of health are in place and that where inequities exist additional resources are available to assist those vulnerable to poor health - Community empowerment - Inclusion https://onlinelibrary.wiley.com/doi/10.1111/nin.12171 https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca863c-5ebf0a138d5e/UploadedImages/documents/ Position_Statement_Promoting_Cultural_Competence_in_Nursing.pdf