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Discussions in Disability
DISABILITY AND ETHNIC MINORITIES
University College DublinCentre for Disability Studies UCD School of Psychology28TH July 2017
“Navigating Health Systems”
Dr. P.J. Boyle
Clinical Nurse Specialist
DProf (Health), M.A. (Dev. St). RCN., RGN.,
HSE Refugee Clinic
Balseskin Refugee Accommodation Centre
Dublin
Temitope Olarinoye Born 14th September 2008
Departed this life 21st April 2015
What you may have seen or heard?
Global movement of people has resulted in a shift in
thinking…
Where are YOU positioned as a client, health professional, manager, organisation in this process?
National immigration law is often the arena where human rights and national self interests clash and the principle of promoting the best interests of vulnerable groups can be over looked.
Migration means of access…
Immigration Processes – Visas, work / study permit, others
In the main - rigid administrative system (? Overly bureaucratic,
complex / lengthy, ?? Person centred?? - Economy / society
Protection System
6 ways of getting access into the Irish protection system:
1. Existing Refugee Programme – “Programme Refugees”
2. Medical Programme Refugees
3. “Ordinary” Asylum Seekers
4. Family Reunification Programme / other mechanisms
5. No status – e.g. ‘undocumented’
6. IRPP programme – “ EU Relocation”
Responding to migration and ‘ethnic minority’ health
issues….
Health care Sector ?
All people (Staff & patients/clients) approach encounters with their own unique attitudes, communication, behaviour, expectations of services, expected outcomes, beliefs about illness & types of treatment.
Cross-cultural health / social care situations may be challenging due to: fear, embarrassment, lack of clinical and cultural knowledge, pre-occupation with medical condition,theoretical models, time constraints, communication difficulties, interpersonal issues e.g. trust,
FACT
• Language & cultural factors combine to
produce a failure to communicate and
frustrating even dangerous results.
• To offer culturally competent care
requires being open to the experiences,
expectations, perceptions, and realities of
various individuals & communities.
Dignity
‘Quality of being
worthy of respect’
‘self-importance’
‘pride’ ‘self-esteem’
self-respect’
Understanding Migration….asylum / refugee
population…
‘Push & Pull’ Factors
Socio-Political Factors
Experiences prior to arrival, en route, current – regardless of migrant status - Access to “health care” prior to arrival (type, frequency, cost)
Cultural adaptation / integration
Physical /Psychological
Biological Variations - ethnic minority epidemiology
At risk sub-groups – life-limiting illness, disability, elderly, unaccompanied children,
Understanding migration….asylum seekers /
refugees
•Loss & Bereavement
•Trauma / Torture
•Security / Safety / Trust
•Access to services – health & illness – cultural interpretations / health help-seeking behaviours
•Effects of living in and navigating the asylum process
•Future Prospects – access to specialist services, community peer supports, shared understandings of experiences – staff and organisations.
Understanding the complexity….ethnic minorities
and disability…concept and context.
Intersectionality - common experiences – challenges and
opportunities
In general ambiguity exists in the use of language & terminology
within the discourse of ethnic / cultural diversity and health and
disability sectors / disciplines – at practice and policy level
Categorizations – by whom / what / FOR WHAT PURPOSE?
(administrative, social, cultural, language, medicalization immigration
status)
Ethnic minorities, migrants, refugees NOT homogenous groups –
terminology /definitions - attention to the diversity ‘within’ and
‘between’
Understanding the complexity….
Intersectionality (contd).
Disability increasing globally as a consequence of civil conflicts, war,
natural disasters – impact on MRDPs - who become asylum seekers.
Labelling, Stigma, Taboo, “othering”
Prejudice and discrimination (Direct / Indirect /Conscious /Unconscious)
Entitlements - Basic Needs – ‘who is entitled to what?
In the first instance are those people affected by or living with
‘disability’ coming forward for support, advocacy , services etc ?
WHAT IS THE IMPACT ON CLIENTS, HEALTH / SOCIAL
CARE STAFF / SERVICES……SOCIETY ?
Disability and ‘ethnic minorities’ cultural
understandings…(Helman 2007)
The ‘able’ body and ‘disabled’
body
Disability versus Impairment
Disability and Stigma
Theories of causation of
Disability
Positive Aspects of Disability
Wide variations within and
between different social and
cultural groups.
Narrow definitions -Shift from
individual (physical
impairment/medical) to social
pathology.
Social sitgma associated with
disability in some cultural
groups… ‘normal life –
pathways’ (milestones, rituals)
become interrupted or not full-
filled – what is accpetable as a
potential wife / husband, home
maker / provider?
Health and social care provision….
WE need to look at ourselves
& how we do things (plan, practice, deliver services)
Socio-Cultural
Political / Legal
Organisations / Systems
Professional Education
Leadership / ‘Ignorance’
“HEARTS & MINDS”
Cultural competence
Partnership +
Empowerment =
Equality “The elephant in the room”
(ETHNOCENTRISM)
Health sector considerations…
Awareness of our own and other’s deep cultural, ethnic and spiritual frameworks of being in the world. Culture as learned.
Acknowledging diversity of worldviews in understandings & explanations of wellbeing, illness, inherited conditions, behaviours, treatment, life-ways etc.
Significance of language as an expression of culture (not all words / concepts are transferable)
•Health care anthropologists speak of “symbolic anatomy” within traditional health systems e.g. Chakras (Hinduism, Buddhism), bhutas (5 earthly / universal elements) in Indian Ayurvedic, Yin and Yang (hot / cold -male / female) in Chinese.
•Harmony between human body and the universe (Cosmos) - religious, cultural, social rituals)
•Balance and imbalance - health maintained by the harmonious balance between two or more elements or forces within the body. To a variable extent this is dependent on external forces such as diet, environment, and /or supernatural agents.
•Causation of illness, disease, disability, morbidity –varies across and within ethnic / cultural groups and the subsequent treatments / cures / rituals accessed.
•Western bio-medical health care and systems mostly derived from scientific models, paternalistic, ethnocentric - may see these approaches as merely symbolic –mystical metaphors that bear no relation to physical reality.
Cultural competence in nursing & primary
healthcare
‘The ability to function effectively in the context of cultural
differences’ (CCHCP 2001)
This is informed by attitude, motivation, knowledge and skills
Cultural competence is not about knowing all there is to know about a
particular culture
Cultural competence is NOT an end point – it is a continuous process
of learning and development – which is constantly evolving in
response to new cultural and health care contexts (PTT 2006)
Cultural Competence Continuum – (Cross et al 1989)
“Always becoming…” (Camphina-Bacotte 2002).
Characteristics, determinants and Perceptions of
Race, Ethnicity and Culture (PTT 1995 / 2006)
Characterised
by
Determined
by
Perceived to be
‘Race’ Physical appearance
Genetic ancestry Permanent (genetic /
biological)
Culture Behaviour / attitudes
Up-bringing choice / learned / socialised
Changeable (assimilation / acculturation)
Ethnicity Sense of belonging
Group Identity
(physical / biology)
Social Pressure
Psychological Need
Partially Changeable
PTT Model for Developing Cultural Competence -
Underpinning Values used in Migrant Health (Papadopoulos Tilki Taylor 1998)
Human Rights
Socio-Political Systems
Intercultural Relations
Human Ethics
Human Caring
“The failure to provide culturally appropriate services is not always deliberate but is underpinned by ethnocentricity which assumes people of other cultures find mainstream provision acceptable and effective”
Tilki 2006
Cultural Competence in Practice
General Information
Current affairs / media
Geography
History / Heritage
Languages / Dialects
Communication styles – verbal / non-verbal
Ethnic Groups
Religion / Spirituality
Socio-economic
Percieved Roles - gender, age, martial status, education, professionals
Health Specific
Cultural Health Beliefs
Cultural Types of care: Popular, Folk / Traditional, Professional
Sick / Care Behaviour
Ethnic Biological Differences
Pharmokenitics
Healthcare relationships: prescribed roles / Prof. / Lay
Involvement in Care / decisions / Patterns e.g. consent, families role in ‘life’ / hospital care etc
Cultural Competence…some
practicalities….specific issues re: disability?
Modesty / Privacy
Communication / language / gestures / expressions
Touch Practices / Proxemics / Space
Perceptions of Time & Date – different calendar
Diet / food / nutrition / medications / pharmacology
Cultural manifestations - Reactions to Pain (Psych / Physical)
Understanding of ‘the human body’ / causation
Understanding illness, disability, ‘misfortune’ (Illness V’s Disease Models)
Folk Understandings & popular beliefs - healthcare systems
Rituals & Milestones :Birth, naming, coming of age / independence, marriage, death, etc – impact for disability
Childrearing Practices: Parenting / Discipline
Value of Play / Education / Careers
Prescribed Roles – gender, age, class, (intergenerational issues)
Religion / Faith
Cultural Competence in Community Public Health
Nursing (Boyle 2014)
Experiencing change in
population
Racism
Focus on ‘Difference’
Building relationship and
communication
Professional Preparation and
Support
Overall nurses were interested
and ‘aware’ - - doing enough
‘just to get by’ (as per CCAT /
PPT)
Mostly Practice / experiential
knowledge - undervalued /
lacking confidence
Personal, professional and
organisational barriers led to
tension and ambiguity -
conflict and complacency
Unfamiliar with TCN / CC
theory
Why do we do what we do? How do we respond?
Obligations :
• Moral & Ethical
• Professional
• Statutory &
Legislative
Useful references / Biblography:
Bhopal R (2012). ‘Research agenda for tackling inequalities related to migration and ethnicity in Europe’, Journal of Public Health, Vol.
34, No.2, pp. 167-173.#
Boyle, P.J. (2016) “Health Needs of refugees - Are we prepared”? in World of Irish Nursing and Midwifery Vol.23 No.10. pp 52-53.
Irish Nursing and Midwifery Organisation Dublin.
Boyle, P.J. (2015) “Health Needs of refugees - Are we prepared”? in World of Irish Nursing and Midwifery Vol.23 No.9 pp 50-51. Irish
Nursing and Midwifery Organisation Dublin.
Boyle, P.J. (2014) ‘Care of Asylum Seekers & Refugees in Schools’ in O’ Higgins-Norman, J. (ed.) Education Matters: Readings in
Pastoral Care for School Chaplains, Guidance Counsellors and Teachers. Veritas. Dublin.
Brennan, M. et al (2013) “Health of Asylum Seekers- Are We Doing Enough”? in FORUM Journal of the Irish College of General
Practitioners Vol. 30, No. 1.
Boyle P.J. et al, (2009) Background Paper for European Union & International Organization for Migration, Lisbon 2009 on Health
Services for Migrant Children.
Boyle P.J., et al (2008) “The Complex Health Needs of Asylum Seekers” in FORUM Journal of the Irish College of General
Practitioners Vol.25, No. 1
Boyle P.J. & Tilki M. (2008) ‘Interculturalism in Nursing’ World of Irish Nursing Journal of Nursing and Midwifery Nov. 2008 INMO
Dublin.
Cross, T., Barzon, B. et al (1989).Towards a culturally competent system of care: a monograph on effective services for minority children
who are severely emotionally disturbed. CASSP Technical Assistance Centre. Georgetowm University. Washington
Camphina-Bacote J (2003). ‘Cultural desire: The key to unlocking cultural competence. Journal of Nursing Education, Vol.42,
No.6, pp. 239-240.
Helman, C. (2007). Culture Health and Illness (5th ed.). London. Hodder Arnold.
HSE (2008). HSE National Intercultural Health Strategy 2007-2012. Health Service Executive Dublin.
Useful references / Biblography:
HSE (2012) ‘Lost in Translation? Good Practice Guidelines for HSE Staff in Planning, Managing and Assuring Quality Translations
for Health Related Material into Other Languages’. Health Services Executive Social Inclusion Unit. HSE Integrated Services
Directorate. Dublin.
HSE (2009) On Speaking Terms: Good Practice Guidelines for HSE Staff in the Provision of Interpreting Services. Health Service
Executive. Dublin.
HSE (2008) Consultation Report HSE National Intercultural Health Strategy. Health Service Executive Dublin.
ICN (2008) International Council of Nurses Position Statement on Health Services for Migrants, Refugees and Displaced People. ICN.
Geneva www.icn.ch/positionstatements/publications/
Leininger, M. & Mc Farland, M. (2002). Transcultural Nursing: Concepts, Theories, Research and Practice (3rd ed.). New York. Mc
Graw Hill.
Leininger, M. (1970). Nursing and Anthropology: Two Worlds to Blend. New York. Wiley and Sons.
Mac Farlane, A. et al (2009). ‘Language barriers in health and social care consultations in the community: A comparative study of
responses in Ireland and England’, Health Policy, Vol. 92. pp. 203-210.
Markey, K. et al (2012). ‘Strategies to surmount the potential to providing anti-discriminatory care in Irish healthcare settings’,
Contemporary Nurse Vol. 40, No.2 pp. 269-276.
Markey, K. & Tilki, M. (2007). ‘Racism in nursing education: a reflective journey’, British Journal of Nursing, Vol. 16 No.7 pp 390
393.
Papadopoulos I., Tilki, M., & Taylor G. (2004). ‘Promoting Cultural Competence in Healthcare through a research based intervention
in the UK’, Diversity in Health and Social Care, Vol. 1, pp. 107-115.
Tilki, M. et al (2007). ‘Racism: the implications for nursing education’, Diversity in Health and Social Care, Vol. 4, No. 4, pp. 312-
313.
Tilki, M.(2006). ‘Human Rights and Health Inequalities. UK & EU policies and initiatives relating to the promotion of culturally
competent care’ in I. Papadopoulos (Ed) Transcultural Health and Social Care: Development of Culturally Competent Practitioners.
London: Churchill Livingstone.
Tilki, M.(1998). ‘The Health of the Irish in Britain’ in I. Papadopoulos, M., Tilki, G. Taylor (Eds) Transcultural Care: A Guide for
Health Care Professionals. Sailsbury. Quay Books.
Useful Sources of Information www.icn.ch
www.unhcr.org
www.healthequity.ie
www.tnn.ie
http://www.europeantransculturalnurses.eu
http://www.hpsc.ie/A-Z/SpecificPopulations/Migrants/
www.hse.ie
Further statistical information on asylum system / refugees.
www.inis.gov.ie
www.ria. gov.ie
www.integration.ie
http://www.integration.ie/website/omi/omiwebv6.nsf/page/statistics-en
www.equality.ie
www.mrci.ie
www.unhcr.org
www.paveepoint.ie
www.irishrefugeecouncil.ie
www.cso.ie (Central Statistics Office)
Go raibh míle maith agaibh!
Contact Details:
Dr. P.J. Boyle
Clinical Nurse Specialist (Migrant Health)
HSE Balseskin Refugee Clinic
Balseskin Refugee Reception Centre
St. Margaret’s Road.,
Finglas,
Dublin 11
Tel; 01-8569015 / 8569080
Mobile: 087-9120382
Email: [email protected]
