DIS/COMFORT ZONES Comfort zone: boring, easy, safe: very little learning takes place Discomfort zone: interesting, challenging, scary: lots of learning takes place Alarm zone: overwhelming, difficult, terrifying: very little learning, damage, shutdown
DIS/COMFORT ZONES Learning takes place when people step out of their comfort zone into their discomfort zone. Once someone survives a trip into their discomfort zone, their comfort zone is enlarged. They know they can do that thing again. Activities which challenge people force them into a discomfort zone. * However, watch for those who have cross over into alarm – distressed, overwhelmed‌
WHAT IS CULTURAL HUMILITY?
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WHAT IS CULTURAL HUMILITY? • ‘The ability to maintain an interpersonal stance that is otheroriented (or open to the other) in relation to aspects of cultural identity that are most important to them.’ J.N. Hook, Cultural Humility: Measuring Openness
to cultural diverse clients
COMPARE:
HOW ABOUT A REWRITE…?
HEALTH CARE AS CULTURAL CONSTRUCT
HEALTH CARE AS CULTURAL CONSTRUCT Health care is a cultural construct because what we see and experience as health care emerges from a society’s or a culture’s answers to questions such as these: What constitutes disease? What does it mean to be sick? What is the human body all about? Therefore, cultural issues are central to prevention and treatment interventions.
HEALTH CARE AS CULTURAL CONSTRUCT From there, cultures ask and answer questions around: • How we talk about our health and to whom; • Whether or not/how rights related to health care and health information are safeguarded; • How we decide that some aspect(s) or one’s health has become a problem – and who decides; • How we talk about our dis-ease/concerns/symptoms and who’s going to be the one to deliver care; and • What that care might look like.
SO WHATEVER HAPPENED TO …
???
Cultural Competency
Cultural Humility
Goals
To build an understanding of minority cultures to better and more appropriately deliver services
To encourage personal reflection and growth around culture so as to increase service providers’ awareness
Values
WHAT’S THE DIFFERENCE?
• Knowledge • Training and Technique
• Introspection, consciousness/self-awareness, otherimaginative • Co-learning/Collaborative
WHAT’S THE DIFFERENCE? Flaws or Short-comings
Cultural Humility
• CC Re-enforces the idea that there can • There is no finish line, no end-point/ be ‘competence’ in a culture not your result, which some academic own. professionals or medical providers • CC supports the myth that cultures are often find frustrating, a struggle. monolithic and static. • It is based upon academic knowledge rather than lived experience • It posits that professionals can be ‘certified’ in another culture.
Strengths
Cultural Competency
• CC invites people to strive to obtain a goal. • CC promotes skills-building.
• CH encourages lifelong learning with no end goal but rather an appreciation of the journey of growth and understanding. • CH puts providers and clients in a mutually-beneficial relationship, evening out damaging power inequities.
MORE DOWNSIDES TO CC • Operationalisation of CC tends to leave untouched and unexamined structures of power and privilege within the organisation. • Cultural factors are crucial to diagnosis, treatment and care. But the large claims about the value of CC for the art of professional care-giving around the world are simply not supported by robust evaluation research showing that systematic attention to culture really improves clinical services. • The concept and practice of CC suggests that culture is (a) static and that (b) it can be reduced to a technical skill for which clinicians can be trained to develop expertise. Medicine’s/health care’s definition of culture (synonymous with ethnicity, nationality and language) needs to more closely reflect the definition used within anthropology, the field in which the concept of culture originated. • Historically, culture has referred almost solely to the domain of the patient and the family. But that leaves out the culture of the professional care-giver – including both the cultural background of the doctor, nurse or social worker, etc., and the culture of biomedicine itself – especially as it is expressed in institutions such as hospitals, clinics and medical schools. Indeed, the culture of biomedicine is often seen as key to the transmission of stigma, the incorporation and maintenance of bias – by race, language, ability, gender identity, income, etc., - in institutions and the development .
MORE DOWNSIDES TO CC… • Operationalisation of CC tends to leave untouched and unexamined structures of power and privilege within the organisation. • Cultural factors are crucial to diagnosis, treatment and care. But the large claims about the value of CC for the art of professional care-giving around the world are simply not supported by robust evaluation research showing that systematic attention to culture really improves clinical services. • The concept and practice of CC suggests that culture is (a) static and that (b) it can be reduced to a technical skill for which clinicians can be trained to develop expertise. Medicine’s/health care’s definition of culture (synonymous with ethnicity, nationality and language) needs to more closely reflect the definition used within anthropology, the field in which the concept of culture originated. • Historically, culture has referred almost solely to the domain of the patient and the family. But that leaves out the culture of the professional care-giver – including both the cultural background of the doctor, nurse or social worker, etc., and the culture of biomedicine itself – especially as it is expressed in institutions such as hospitals, clinics and medical schools. Indeed, the culture of biomedicine is often seen as key to the transmission of stigma, the incorporation and maintenance of bias – by race, language,ability, ability, gender identity, income, etc., - in institutions and the development of health disparities across disadvantage disadvantaged groups.
SO IF CH IS THE BETTER PATHWAY TO HEALTH EQUITY…
What is health equity?
INTRODUCING: THE BODY OF HEALTH EQUITY
The Head = • • • • •
• • • •
H.E. defined Information Knowledge Methods (HEIA, e.g.) Population Health Needs Planning Space Accessibility Skills
The Heart = • Attitude • Social Location • Having difficult conversations • Identifying and disrupting unconscious bias • Dealing well with conflict
The Feet = • All about building inhouse capacity
WHAT IS HEALTH EQUITY? We know that – Significant and persistent inequalities in health exist across population groups and communities in Canada whether measured by • • • • •
gender, socio-economic status or social class, racialisation, immigration situation or other intersecting dimensions of inequality.
Such inequalities are noted by differences in:
▪ life span ▪ self- reported health ▪ rates of disease.
At the same time, there are consistent and unequal disparities in access to care along the health gradient.
And, not surprisingly … Some of the most disadvantaged populations and communities are in very poor health and have very poor access to vital services and support… So which groups face the greatest health inequities? In Ontario, groups facing disproportionate social and health inequities include: • Indigenous communities • Rural communities • Racialised persons (newcomers to Canada as well as long term Canadian residents and citizens) • Women Intersecting factors include such things as disability, immigration status or sexual orientation.
… and therefore – Health disparities or inequities are differences in health outcomes that are
• Avoidable • unfair and • systematically related to social inequality, disadvantage and marginalisation.
This definition is: • Clear • Understandable • Actionable This definition – • Identifies the problem that activities will try to solve; • Is tied to widely-accepted notions of fairness and social justice.
Why Heath Equity?
The GOAL of Health equity is – • To reduce systemic barriers to equitable access to high quality health care for all; • To address the specific health needs of people all along the social gradient, including people who are most healthdisadvantaged; • To ensure that the ways in which heath services are provided and organised contribute to reducing overall health disparities.
And…
The potential impact of this goal would extend far beyond enhancing individual and collectivewell-being: It would also contribute to • overall social cohesion/belonging/vitality, • shared values of fairness and equality, • economic productivity and • community strength and resilience.
We also know that ‌ The Roots Of Disparities lie in:
The Determinants of Health
Summary: The HEAD of health equity 1. Health Equity defined
2. Health equity in the community: Knowing your communities and neighbourhoods through Community engagement that never ends 3. Health Equity in the Population: rethinking Population Health Needs Assessments to take into account the Determinants of Health 4. Health Equity in Planning: ensuring plays a prominent, indispensable role as strategic direction or priority, as a lens 5. Health Equity in the Space: creating an enabling environment, physical plant, structure, furnishings, people flows
6. Health Equity in Accessibility: stretching the meaning from ramps and doors to translation, resources, food,
scheduling, day care, transportation, income and other supports, etc. 6. Health Equity in People: finding and recruiting the right staff and volunteers and training in the principles and practices of health equity 7. Health Equity amongst People: putting in place measures and mechanisms for open, transparent, safe communication, addressing of conflicts and team-building
8. Health Equity in the Law and the MOHLTC: Keeping up to date on supportive legislation/mandates as well as initiatives, papers, new programmes by Ministries planning health-related activities. 9. Health Equity and the Toolboxes: understanding and making use of implementation tools such as the HEIA Tool.
HEIA:
But
that’s not enough… Ya gotta have …
THE HEART OF HEALTH EQUITY HEART of HE: Attitude, social location, having difficult conversations, interrupting unconscious bias. The HEART moves us beyond ‘knowledge transfer’ to a focus on people and the encounters that make up our work-days: with our clients, our funders, our colleagues and ourselves – ▪ how we are with one another, ▪ our behaviours and the impacts of often-unacknowledged social location and unrecognised privilege, ▪ cultural conditioning (on the part of both provider and client/patient), ▪ the constructs of power and stigma, unsurfaced attitudes, interests and motivations.
THE PATH – CULTURAL HUMILITY – IS EMBEDDED WITHIN THE DESIRED END – HEALTH EQUITY Builds skills in ▪ Self-awareness, other-awareness, ▪ What to do with our assumptions, ▪ How to welcome conflict as indispensable to creativity and innovation, ▪ How to have difficult conversations
▪ Asking the right questions… ▪ How to lead from a position of vulnerability ▪ Emotional intelligence
THE PATH – CULTURAL HUMILITY – IS EMBEDDED WITHIN THE DESIRED END – HEALTH EQUITY It moves us towards ▪ A true sense of community where equity lives, ▪ To respectful, honest and open conversation, ▪ A life-long commitment to self-evaluation and selfcritique, ▪ A redressing of power imbalances,
▪ The development of mutually-beneficial partnerships with individuals and populations.
WHEN CULTURAL HUMILITY IS ABSENT… ▪ There is a fragmented, hierarchical pseudocommunity and ▪ There are low levels of fairness, justice, value and trust;
▪ Measured in sick leave, burn-out, a fear of speaking one’s truth, ▪ More gossip, few are willing to offer anything extra, ▪ People are in survival mode ▪ Care teams are functioning at a low ebb and ▪ Health outcomes are impacted.
CULTURAL HUMILITY AND CONFLICT
HOW DO WE DEAL WITH CONFLICT WHEN CH IS ABSENT? • • • • • • •
What is conflict? … How do you respond to conflict? What tends to be the default response to conflict? How do we name the conflict no one wants to name? How do we intervene effectively in conflict? What’s the difference between calling in and calling out? How do we draw lines when norms and rules are violated?
THE CAUSES OF CONFLICT
THE COST OF CONFLICT
AVOIDANCE
WHAT DOES CULTURAL HUMILITY LOOK LIKE WITHIN ORGANISATIONAL STRUCTURES?
• What does LEADERSHIP look like? • What do you want leadership to look like?
WHAT DOES CH LOOK LIKE WITHIN ORGANISATIONAL STRUCTURES? → A WILLINGNESS TO BE VULNERABLE Seven Reasons Why VULNERABILITY is an attribute in a leader like? Vulnerability modelled from the top: 1. Decreases tension and stress in the workplace. 2. Increases flow of ideas, creativity, innovation. 3. Improves communication flow. 4. Ensures that problems are identified earlier. 5. Creates an environment conducive to better teamwork and co-operation. 6. Creates a fun workplace. 7. Emotional connections lead to lower turnover.
WHAT DOES CH LOOK LIKE WITHIN COLLEGIAL AND PROVIDER-CLIENT RELATIONSHIPS?
(1) IDENTITY
WHAT DOES CH LOOK LIKE WITHIN COLLEGIAL AND PROVIDER-CLIENT RELATIONSHIPS?
(2) MAKING ASSUMPTIONS
Assigning Meaning ‌
What it means to dominant culture What it means to me‌ What it might mean to someone else?
Making Assumptions …
Making Assumptions • What assumptions am I making in this situation? Why? • What in my life experience is affecting the way I see this situation? • What might I be missing? • What is social location?
Who am I? ▪ What do you notice about me? ▪ How old am I? ▪ Is there anything about me that makes you think I am a member of a sexual minority? ▪ What is my socio-economic status? ▪ What is my race? ▪ What is my gender? ▪ What is my religion? ▪ What is my nationality? ▪ What is the level of my education? ▪ What do I do for a living? ▪ How did I get to where I am today? ▪ What is my health status?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHO AM I?
WHAT DOES CH LOOK LIKE WITHIN COLLEGIAL AND PROVIDER-CLIENT RELATIONSHIPS?
(3) In our CONVERSATIONS
WHAT DOES CH LOOK LIKE WITHIN COLLEGIAL AND PROVIDER-CLIENT RELATIONSHIPS?
Difficult Conversations Crucial Conversations Dangerous Conversations Why bother? Why does it seem important?
Fairness and Conflict :
ALSO IN CANADA, YOU SAY?
REVERSE RACISM?
BEING AN ALLY
SILENT BEATS
BEING AN ALLY