3. CULTURAL DIFFERENCES
Both patients and providers suggested that cultural and religious factors pose challenges to access to care. Several common areas of concern were raised.
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➤ Prescription Medicines
Prescription medications may contain ingredients that are prohibited according to religious dietary restrictions. One of the most common errors is the prescription of pills that contain gelatin, which must be avoided by patients who do not consume pork, including followers of Islam, Judaism, and certain Christian denominations; strict vegetarians will also avoid gelatin. Patients may need to avoid specific medications that contain a prohibited ingredient, and be reluctant to ask the physician for an alternative.
An additional problem with prescriptions for drugs is the lack of understanding that concepts like “lunch”, “dinner”, and “supper” are cultural constructs. Confusion over when to take medication can happen when health care providers assume that Canadian lifestyle norms are the same for others. One refugee support worker described this as a common problem they have observed with prescription instructions, whereby patients are told to take medication “with supper” or “with breakfast”, but providers fail to appreciate that some patients will not know how to interpret that, when their own meals follow quite a different schedule [Formal support worker 6].
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➤ Modesty Requirements
Clinicians may or may not understand culturally-specific modesty requirements. For example, many clinicians understand the need for draping because it is similar to how modesty operates in Canada. However, they may disregard other less familiar modesty requirements such as hand shaking between different genders.
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A doctor came and shook her hand, you know, and she was so upset, like she was the whole way upset, because he shook her hand …. Like, ‘I didn’t want to shake hands with him, I didn’t want to shake’, and I was like ‘Calm down, that’s okay’ [Formal and informal support worker 5, interpreter, international student, recent immigrant patient]
For patients trying to convey modesty needs, part of the challenge is the power differential – patient to physician; female (patient) to male (health care provider); and newcomer with no political “clout” to established Newfoundlander are all power differentials that can complicate modesty requests.
“Sometimes you can come to the hospital, you see that your son is sick, and they just give you the appointment of three months, four months – and for a mom, she knows the thing that this is not right, you know. In the home country if someone sick and you come there so they have to treat you immediately; but here is different, you can come and they give you an appointment maybe two months after, three” [Refugee patient 8: formal and informal support worker and interpreter, man, Swahili speaking]
➤ Alternative conceptions of autonomy & decision making
Another source of frustration for patients is the lack of knowledge about and respect for traditions in which decision making is done by a family authority figure. Many providers may not appreciate that Canadian understandings of autonomy and decision making are not universal. Particular sources of tension were when decisions were made by a parent when the child had the capacity to decide, or when decisions were made by a man on behalf of a woman who had the capacity to decide. For staff, male-female power dynamics that do not map onto Canadian norms are deeply troubling, particularly when language barriers make it difficult to know whether coercion by a man may be happening.
“Culturally it’s accepted to have your parents also to be involved in your sort of health seeking behaviour. He was like, ‘If your dad has any questions’ – and I think he kind of said it sarcastically, it was like – ‘He can give me a call, I’ll explain it to him’” [Immigrant patient 7: woman, economic immigrant, student]
➤ Child Safety Practices
Differences in parenting have also been a source of dissension between providers and parents. A primary concern has been with visitor policies, where children accompany parents, and staff are concerned that children are not being appropriately supervised and are disrupting other patients. But concerns around child safety were also expressed by health care staff, who assume that the scientifically-grounded best practices of western child care norms are in the best interests of children.​
“A mother was taken to jail because she was ‘abusing the child.’ It was just a few days old child and the nurse said the mother was ‘abusing the child’ …. It lasted only a week because at that time there was a foreign judge who was replacing the family judge at the time, and that judge, she was saying, ‘How is that abuse?’” [Formal support worker 6]
Some of the specific concerns raised were choking hazards related to jewelry and the risks associated with family beds. There was a tension between, on the one hand, wanting to respect cultural practices; and on the other, worrying about the safety of small children and needing to communicate Canadian infant and child safety health expectations effectively in order to meet duty of care standards.
➤ Visitor Policies
Norms about visitation policies are also culturally specific. The different sets of expectations and different norms around what should be expected in a hospital can lead to tension and exacerbate mistrust and distance across cultures. These might include the insistence on specific visiting hours, or different understandings of who counts as “immediate family” or how many people are allowed in the room at a time.
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➤ Naming Systems
Related to confusion over visitor policies is the question of who is considered to be a husband or wife and is allowed to visit in cases where visitors are restricted. In the province of NL, it is the cultural norm for a wife to adopt her husband’s surname at marriage, a custom that is not common in many other parts of the world. The lack of appreciation for other naming systems could lead to immediate family members having to argue for visitor access.
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➤ Alternative Healing Modalities
Patients commonly use their own healing systems alongside western biomedicine, and reported to us that they are reluctant to share this information with physicians who, in their experience, are unreceptive to this. Patients discussed how providers may be dismissive of or even hostile to their healing systems.
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Participant: There’s other traditional medicine that works good, but in real life, you know, doctors they don’t believe in it … You can’t go to tell a doctor that I’m going to use this because for them – how come? … For me, no, I can’t tell a doctor that I’m going to use this.
Fern: So you wouldn’t just tell the doctor?
Participant: No I can’t tell. I can’t tell. I can’t tell him because he not accept, he not accept.
[Refugee patient 8: formal and informal support worker and interpreter, man, Swahili speaking]
➤ Provider distress at wanting to be more culturally competent
Some providers had gone out of their way to understand and address the cultural or religious needs of patients. They were very concerned about providing the most culturally competent care possible.
“The staff are nervous about the cultural [aspects of providing care to newcomers] … It’s the unknown … Nurses don’t like not being comfortable. They will not do it if they are not comfortable. The reason is because they feel like they’re the last buck in a lot of places and they are the one that is then providing the care. They will be the ones that their association is going to come back and judge them by a standard if an error occurs or an occurrence or an adverse outcome happens. So they’re very nervous when they’re not comfortable” [Nurse 2]
Some suggested that, if anything, health care workers struggle with wanting to do more and not having the resources to support them in that endeavor.
“I think the negative that I hear is the people wanting to do so much more but not feeling that they have the resources to do that and thinking that if they only had that, what a difference they could make, you know” [EH decision maker 4]
Health care workers are very concerned about cultural competency and not inadvertently causing harm to newcomers.
“People are really worried that they’re going to be inappropriate or insensitive … There’s always an enthusiastic bunch that want to learn more and do more. There’s an interest in skilling up, there’s an interest in becoming aware from a large number of clinical people who are just saying, ‘God I’d really like to do some of this work I’m really interested in but I don’t feel I know or I don’t want to be insensitive’; ‘I don’t want to be, you know … stupid about it’” [Social worker 1]
Additionally, patients are often very forgiving of provider blunders.
“My experience is most of the people [patients] I’ve worked with have been extremely forgiving of my stupidity, you know … I’ve never felt judged by a patient” [Social worker 1]