Cultural Safety,Healthcare and Vulnerable Populations

A Critical Theoretical Perspective

Lucy Mkandawire-Valhmu

• Editorial: Routledge
• Año: 2018
• ISBN:
  9781317483663
• Edición: 1
• Categoría: Medicine
• Categoría: Health Care Delivery

Culturally safe healthcare is rapidly challenging previous notions of cultural competency or cultural sensitivity in healthcare provision. The increasing number of vulnerable populations means healthcare must be given by a healthcare provider who has developed a social consciousness in relation to his or her own socio-cultural positioning versus that of the patient. A culturally safe practitioner has engaged in an active examination of the power differences existing in this patient-provider relationship.

In this book, Lucy Mkandawire-Valhmu critically analyzes the complex issues affecting the health of vulnerable populations. Written from a critical theoretical perspective she seeks to enhance the ability of the healthcare student to develop a social consciousness about the realities faced by many populations living on the margins of society, and thereafter make an active and conscious decision to engage in culturally safe healthcare and contribute to the elimination of health disparities. Through the application of postcolonial feminist theory this book conceptualizes health as being historically situated in social relations of power and emphasizes health interventions that are potentially empowering, and enhance emancipatory change.

Through discussions of health provision for ethnic minorities, immigrant populations, and refugees, the book seeks to provide pragmatic guidance for culturally safe care for a variety of marginalized populations and invites students and professionals to think deeply about the implications of power, culture and health.

1

Developing a Social Consciousness

In this first chapter, drawing from feminist standpoint theory, I will analyze the importance of understanding one’s positioning or socio-cultural location based on traditional, analytical categories (race, class, gender). I will describe how our understanding and perspectives of the people around us are often informed by our own socio-cultural location. How are we similar to or different from those around us, and how does this affect how we interact or do not interact with others?

Drawing from the tenets of feminist standpoint theory, we will learn about the importance of developing a social consciousness and how to go about doing so. Feminist standpoint theory stipulates that all knowledge is situated. In drawing from a feminist standpoint, we are able to recognize that our perceptions of how people experience health and illness are situated in the sociopolitical location in which we find ourselves. We also come to realize that our knowledge is not only situated but that it is also limited, based on our own life experiences or lack thereof (Intemann, 2010). Our aim is therefore to expand our understanding of the sociopolitical location of those we seek to serve by gaining the necessary knowledge that would ensure that our interventions are realistic to that location and are therefore effective.

In this chapter, we will focus on the concepts of power and privilege based on traditional analytical categories such as race and class, and how this power and privilege affect interactions between those who have it and those who do not. The focus will be on power and privilege as they relate to race as a category and as an identity, considering that race is one of the most important categories that affect not only human relations in the United States but more especially healthcare provider-patient interactions in the provision of healthcare.

Additionally, drawing from the idea of the “danger of a single story” from the highly acclaimed Nigerian author, Chimamanda Adichie, I will analyze how the media affects our perceptions of different people groups and how we need to engage in a contestation of the common misconceptions we might have of others, based on the stereotypical images to which we have been exposed. Finally, I will explore the concept of social justice as it relates to healthcare and its relevance to healthcare practice. This first chapter will conclude with an encouragement to the reader to begin to consider how they envision their role as a healthcare provider, the kind of healthcare they seek to provide and how they intend to accomplish their professional goals in relation to providing culturally safe healthcare to vulnerable populations.

Feminist Standpoint Theory

Harding (2009) makes the case that another term that could be used for standpoint in regular speech is perspective. Our standpoint or perspective in life is informed by the values and beliefs taught to us at an early age, values and beliefs often embraced by the community in which we grew up. In the United States, there are many communities that are homogeneous, wherein everyone looks the same and behaves the same way. We eventually see our values and beliefs as normative and sometimes, whether consciously or unconsciously, expect everyone else to share the same beliefs and values and find it problematic if they do not.

Growing up in homogeneous communities inadvertently protects us from valuable critique that could come from those who are from a different social location with different perspectives and experiences, who can question the practices and beliefs that we deem normative (Intemann, 2010; Olson & Gillman, 2013). It is unlikely, however, that, in our professional life, we will serve the same people who made up our community when we were growing up. It is therefore important to seek opportunities that would enable us to broaden our perspective in an effort to better understand people who might be different from us. To give an example, I grew up in a middle-class family in the small Southeast African country of Malawi, where human labor is very cheap and most families who lived in our community had domestic workers. Domestic workers work long days, often waking up at 4 in the morning and not going to bed until everyone else has gone to bed, which is often after 9 at night. In most homes, they do not share the same eating utensils as their employers and their children, let alone sit at the same dining table with them. This is normative in the society from which I come. Nobody really questions the treatment of domestic workers or thinks it problematic because it is so commonplace. While there are now labor laws in place to protect the rights of workers, monitoring the treatment of domestic workers and enforcing laws remain a challenge.

After stepping outside of my own community, when I traveled to the United States to further my studies, and after learning about human rights in a number of classes, I started questioning some of these practices. My PhD dissertation study was focused on female domestic workers and their experiences of violence. This study enabled me to personally interact with domestic workers and gain an understanding of what life is like for them in this role and how they perceive their treatment, particularly this delineation between them as domestic workers and their employers. It took stepping outside of my community, where this interaction with domestic workers is normative, developing a knowledge base about human rights and purposively engaging with domestic workers through research, for me to question what I had grown up believing to be normative.

Like me, based on categories or social identities such as race or class, many of us grow up privileged, some of us more so than others. Whether actively or passively, we benefit from the oppression of others, as I benefited from the labor of domestic workers even as a child. The lives of the domestic workers who were employed in my home were made challenging so mine could be easier.

Based on this privilege, there are certain values and beliefs that we acquire in our homes of origin and in the communities in which we have grown up. Many of these should be questioned; some need to be unlearned if we are to become culturally safe healthcare providers, who can be trusted by those most marginalized in our society, and if we are to render effective healthcare that would enhance health outcomes. I consider this questioning and unlearning of certain values and beliefs that could potentially hinder us from becoming culturally safe healthcare providers as an important part of developing a social consciousness. Part of developing a social consciousness is recognizing when we are privileged and how our privilege can frequently contribute to the oppression of those around us.

White Privilege

Kwate and Goodman (2014) define White privilege as, “The benefits and unfair advantage accorded to whiteness” (p. 151). White privilege enables those of us who are White to take for granted what non-Whites cannot. The notion of White privilege is one that creates much discomfort for those who are White because it frequently creates feelings of guilt with which they are unprepared or unwilling to deal. It is important to note that, just as with any other form of privilege, White privilege has positive implications on health for those who have it, while in turn leading to poor health outcomes for those who do not. Inherent in this notion of White privilege, and privilege in general, is the concept of power. Some people have power while others do not. The social location that we occupy informs the power that we have or do not have, based on various social identities, such as race, class, gender and sexual orientation, to mention a few. It is important to note that these identities can overlap, sometimes placing us at an advantage through one identity while marginalizing us in another or perhaps enhancing our experiences of marginalization, if a number of the identities we possess are those that place us in categories in which we experience oppression. The power dynamics inherent in society also impact how we provide healthcare to our patients. Being a culturally safe healthcare provider requires that we acknowledge these power relations and strive to ensure that the power we possess as healthcare providers does not negatively impact those already marginalized by power structures in society (Van Herk et al., 2011).

In the United States, one of the major social identities that informs power relations is race. Contrary to what many of us would like to believe, the USA is not a post-racial society (Gnanadass, 2014). For those who are not privileged and live on the margins of society, insisting that we live in a post-racial society only serves to exacerbate the lack of trust that they have in the healthcare system and in the predominantly White healthcare workforce. Trust is indeed the basis of the healthcare provider-patient relationship (Cruess, 2010), and our goal must be to establish trust with our patients and their communities and to re-establish it with those who have lost their trust. This requires us to be socially conscious or aware, to avoid being dismissive of the concerns expressed by those who are less privileged and to work toward a social justice agenda.

I grew up during the height of the HIV infection, with my native country of Malawi being at the epicenter of the epidemic. In our small community, as in every other community in Malawi, men, women and children became sick and died. A common AIDS-related condition for many was tuberculosis. Tuberculosis is a communicable and highly infectious disease, so our parents often did not allow us to associate with anyone who was known in the community to have AIDS. Friendships were forced to come to an end. Visits to friends’ homes, friends with whom we had a close relationship, came to an end. It was only after I started conducting research with women living with HIV that I reflected on my childhood experiences and the privilege that I had experienced, coming from a household where, at least in our nuclear family and the household in which I lived, no one was HIV-infected. It was only then, about a decade later, that I considered what it must have been like as a child to have a brother get sick and die; then to see your mother follow suit and then finally to be the one, along with your siblings, to bathe your father and to care for him in sickness and in death. And in the midst of it all, to have your neighbors and your community stay away from you and not assist you, for fear of catching whatever it is that was ailing and killing the members of your household with impunity. I vividly remember one instance in which I had disobeyed my parents and gone to visit a friend’s dying parent. I remember that parent’s words to me, urging me, begging me to continue being a friend to their daughter in the face of imminent death. The parent knew that their child would need a friend especially after they were gone. But it was hard to be friends with someone who had been so affected by AIDS in the environment of stigma in which we lived. In order to ease my own guilt, I spent some time talking to my father about these experiences, trying to establish why my parents and the rest of our community had responded in the way they did. In my conversations with my father, I have learned that the history and the trajectory of HIV, the fear that it ignited in communities, and our lack of understanding at the time, caused people to respond in ways that were less than desirable, at best, and, at worst, did little to bring hope and healing to those who needed it the most.

I share this story in recognition that acknowledging privilege is hard, often painful and it brings up immense feelings of guilt for those of us who have been protected and have benefited from our privilege. Acknowledging privilege is uncomfortable, as it often places us in a position where we must accept that we have been complicit in the oppression of our fellow humans, something we would rather ignore in order to cope with the reality of our complicity. But as Olson and Gillman (2013) point out, “ignorance of privilege is not merely neglectful, it is substantive” (p. 73). Nevertheless, those of us who choose to become healthcare providers must acknowledge where we have been privileged, the history of our privilege, be it a history of living at the epicenter of the HIV epidemic, where we were on the giving end of stigma, or a history of racism, where we were on the receiving end of its benefits. In acknowledging where we have been and continue to be privileged, we are better able to understand how our privilege affects others and how we can improve health outcomes for those who are less privileged.

Because I have been able to reflect on my own privilege in relation to those living with HIV, as a researcher who frequently interacts with women living with HIV, I am now more sensitive to issues of stigma and how they impact the health of women living with HIV. I am thus better able to document their health needs and to think critically and provide recommendations about workable health interventions that could contribute to HIV prevention and treatment efforts. This does not mean that I do not make mistakes. I often find myself reflecting on what I have said and done in my interactions with women and questioning whether my interactions were indeed supportive. In one particular instance, I was interacting with orphaned children on the premises of a local non-governmental organization that provides community-based orphan care support. One of the children, who was known to be living with HIV, was eating from the same bowl as a group of her friends. She asked me to join them. I refused because I was more concerned about ensuring that the children’s nutritional needs were met. I did not want in any way to deprive them of food by partaking of the little that they had, knowing that this was likely to be the only substantial meal they would have that day. I reflected on my refusal several months later after that little girl died and wondered if I had not lost out on an opportunity to share in a common humanity by sharing her food along with her friends. Since that experience, whenever I find people eating and they ask me to eat with them, I do not refuse. I have learned that, for African people, it is often not about meeting nutritional needs but about the togetherness and connection that comes from dipping our hands in the same bowl to share a meal. I still have a lot to learn. Our shortcomings as health professionals provide us with an opportunity to reflect on who we are and who we ultimately want to be, both in our professional lives as well as in our humanity.

I do not think there is anyone in my community alive today who would not say that, given the chance, we would want to do things differently. I cannot undo the past, but moving forward, I can continue to reflect on these experiences, understanding my history, the history of my people and can live determined now to treat those living with HIV and AIDS today in a manner that brings about both physical and emotional healing.

The Impact of the Media in Shaping Our Perception of Various Racial Categories

In the United States, where communities are often segregated by race, our perspectives of who people are, based on their race, is often informed by what we grew up hearing and how the media we are exposed to depict various groups of people, based not only on race but also on other analytical categories, such as class and gender. In the Introduction, I pointed out the challenges with using the term “race,” which is generally used to classify groups of people with similar characteristics, including facial features, physical attributes, skin color and general appearance (Coleman, 2011); yet, race is a social construct, rather than a biological or genetic reality (Gnanadass, 2014).

The perspectives we develop, based on what we see in the media and coupled with growing up in a homogeneous environment where such perspectives have not been contested, can result in stereotypes. The Institute of Medicine (2002) defines stereotypes as “the process by which people use social categories (e.g., race, sex) in acquiring, processing, and recalling information about others” (p. 4). It is well documented that, in the United States, Whites unintentionally and unconsciously show negative attitudes and stereotypes toward ethnic minorities, with over half believing that African Americans specifically have less intellectual capacity, are more predisposed to violence and have a preference for living on welfare (Institute of Medicine, 2002). These stereotypes, which we will revisit in Chapter 5, often develop as a result of what we are exposed to, including through the media.

Various groups of people have been narrowly and unfairly depicted in the media, including African-American men, who are often depicted as hypersexual, violent and criminal-like in movies, such as Blood Diamond; Latinos as primarily domestic workers, as in movies such as Maid in Manhattan; Native Americans in Western movies as dangerous bandits and savages, while their White counterparts are depicted as noble cowboys and heroes (Federov, 2015); and people living with mental illness in series such as Criminal Minds, where they are depicted as harmful criminals and murderers. Indeed, ethnic minorities, in particular, are frequently depicted in a stereotypically negative fashion, and this can impact not only our perception of different groups of people but also our attitudes and how we interact with them (Berman & White, 2013; Scharrer & Ramasubramanian, 2015). For those of us coming from homogeneous communities, where we have little to no exposure to people who are different from us, unless we engage in a critical analysis of what we see in the media, it can be easy to embrace the depictions we see as normative if we have no other frames of reference. This lack of exposure to diversity, with the only exposure being through media, can lead to what Chimamanda Adichie, in her Ted Talk, calls a single story.

We must recognize that the production and consumption of media are driven by an economic agenda. We must therefore be conscientious about what we allow ourselves to be exposed to and endeavor to become media-literate, so that we are engaged in critical thinking and a deconstruction of stereotypical portrayals as informed consumers of media (Berman & White, 2013; Scharrer & Ramasubramanian, 2015).

Consider a White female nursing student who grew up in a homogeneous environment, where the majority of those with whom she interacted were White and middle class. During her first clinical rotation, she is placed in a long-term care facility where she is to care for an older adult African-American male resident. Her knowledge of African-American males is based on what she sees in th...