Course:SOWK551/2021/Supporting Culturally Diverse Patients
Short Summary
Literature review of social workers role in supporting culturally diverse patients navigate the healthcare system.
Author: Anonymous
Date: April 6th 2023
Introduction
Largely in part to the influx of immigrants settling in the country, Canada is quickly becoming one of the largest culturally diverse countries among the G7 nations (Statistics Canada, 2011; Lambert et al., 2021). In total, one-fifth of Canada's population comprises immigrants, including international students, temporary foreign workers and refugee claimants (Statistics Canada, 2017; Chowdhury et al., 2021). Therefore, as the country is both culturally and linguistically diversifying, there is an increased need for service providers, including social workers, to understand the existing barriers that put diverse patients at greater risk of experiencing adverse health outcomes (Lambert et al., 2021). Despite the well-documented "healthy immigrant effect," which suggests that upon arrival, new immigrants report better mental and physical health status compared to their Canadian-born counterparts, research argues that within five years, health status among immigrants significantly deteriorates (De Maio & Kemp, 2010; Lambert et al., 2021; Pandey et al., 2022). In addition, compared to the national average, culturally and linguistically diverse Canadians have lower levels of health literacy, making navigating the healthcare system and making informed decisions regarding treatment challenging (Lambert et al., 2021). The disparity in health knowledge highlights the need for service providers to thoroughly understand why immigrants face poorer health outcomes and what support can be provided to help them navigate the healthcare system. Overall, social workers can play an essential role in challenging the "one size fits all" approach in healthcare and consider other culturally appropriate and relevant strategies.
Shifting Model of Service Delivery
In order to appreciate why newcomers experience poor health outcomes in a country that prides itself on its robust universal healthcare system, it is first essential to consider the delivery model of healthcare services in Canada. Historically, healthcare providers were viewed as the experts in their patients' lives and important decisions were often made with limited patient input (Peterson, 2012). In addition, there was a strong emphasis on patients complying and adhering to physicians' orders regarding treatment (Bissell, et al., 2004). This model for healthcare service delivery was problematic because patients often did not have the autonomy and freedom to make informed decisions about their healthcare. Furthermore, there was a lot of stigma and blame directed toward patients if they did not comply with the expectations placed upon them by medical professionals (Bissell et al., 2004). Previously, there was a significant focus on treating medical deficits without understanding other aspects of patients' lives that might influence their health (Håkansson Eklund et al., 2019). Eventually, with the introduction of new laws and policies safeguarding patient's rights, there was a shift from the previous model to one that placed patients at the center of their care and assumed that all patients are capable of making decisions regarding their treatment and care (Campbell, Brophy, Davidson, & O'Brien, 2018). When assuming capacity became the standard of care, the service delivery model moved beyond just obtaining informed consent to include principles of informed choice (Handa & Donovan Sharpe, 2015). With this approach, service users could challenge the decisions of service providers as alternative treatment and care options began being explored. Scholars refer to this type of service delivery as person-centred care, which is not uncommon in social work practice.
According to research, other healthcare professionals typically focus solely on the patient's deficits or medical condition without considering the barriers preventing patients from achieving optimal health (Craig et al., 2015). For social workers, person-centred care requires a holistic understanding of the social determinants of health and other aspects of their lives to enhance patient health outcomes (Craig et al., 2015). Often, social workers are the professionals involved that have experience bringing patients' unique voices to the rest of the team and advocating for their patient's wishes (Turner et al., 2017). Overall, social workers can fulfill this role because of their skills in relationship building, displaying empathy and facilitating communication between patients and their families and the rest of the interprofessional team (Craig & Muskat, 2013). According to research, using a person-centred approach with diverse patients enhances health promotion, increases patient satisfaction and ultimately results in positive health outcomes (Håkansson Eklund et al., 2019). While this role is fundamental in social work practice, challenges arise when there is no clear understanding of what is meaningful to the patient. It may be challenging for immigrants to make decisions about their care, especially when navigating an entirely new healthcare system (Ratnayake et al., 2022). Due to this, significant research suggests that social workers should help all patients make decisions regarding their care by supporting them in identifying their core values (Cummings & Bentley, 2014; Entwistle, 2009). Once there is a holistic understanding of a patient's values and beliefs, social workers can position themselves to better support immigrants' work within the system and advocate for their wishes.
One effective strategy for understanding a patient's core values and beliefs is using shared decision-making (SDM) as it improves communication and fosters patient participation (Peterson, 2012; Patel et al., 2014; Dobler et al., 2017). Patient participation in the decision-making process is essential, especially with racially diverse patients as they have expertise regarding their unique experiences (Patel et al., 2014; Dobler et al., 2017). In addition, using SDM strategies is vital during the information exchange stage, where service providers attempt to understand the patient's unique position and the patient's attempts to understand the treatment options available (Patel et al., 2014). Research suggests that during this stage, it is crucial to involve the patient's social community and significant others whom the patient wishes to consult (Patel et al., 2014; Dobler et al., 2017). Next, due to cultural differences, patients might have illness narratives that do not align with their clinicians; therefore, a thorough understanding of those narratives can help service providers appreciate their patient's perspectives and decisions regarding treatment (Dobler et al., 2017). For example, culturally diverse patients might refuse recommendations for using Western medicines as they only trust traditional healers. In this situation, it can be effective to include traditional healers in the decision-making process to support the patient arrive at a decision regarding their treatment with individuals they trust. By using SDM strategies and person-centred care, social workers and other professionals can better understand what is meaningful for patients. Ultimately as both approaches seek to gain a holistic appreciation of a patient's unique experiences, it can also help service providers comprehend how their experiences lead to barriers and adverse health outcomes.
Barriers and Unmet Healthcare Needs
As mentioned earlier, over time, culturally diverse newcomers experience worse health outcomes once they arrive in Canada. The literature suggests many factors leading to lower health status, including discrimination and racism, that are perpetuated in our healthcare system (Ahmed et al., 2016; Pandey et al., 2022; Pollock et al., 2019). Other factors, such as preconceived assumptions by healthcare providers, language barriers, culture and the environment, also play a role (Ahmed et al., 2016). Overall, it can be easy to assume that immigrants understand Canada's healthcare system; however, doing so may result in service providers imposing their own beliefs on their patients. Despite the assumptions being intentional or not, it can be tough for culturally diverse patients to make informed decisions if the interprofessional team does not explain options regarding treatment and care in the language of the patient's choice (Pandey et al., 2022). Studies suggest that new immigrants report inadequate communication with healthcare providers due to language barriers alone (Pandey et al., 2022; Ahmed et al., 2016). Other research on the impact of language barriers indicates that even with a translator, patients had difficulty expressing their views effectively, as information can get lost in translation (Pandey et al., 2022). In addition, language barriers contribute to the spread of misinformation and confusion about the treatment process, making it challenging for patients to comprehend what is being communicated to them (Pandey et al., 2022; Ahmed et al., 2016). According to a study by Pandey et al., language barriers create a lack of knowledge regarding the healthcare system. Because of this, many diverse patients' understanding of healthcare is influenced by traditional practices from their country of origin that are inconsistent with the system in Canada (2022). Overall, there appears to be consensus in the literature that inadequate communication is a major obstacle to accessing healthcare services as it disrupts effective information exchange needed for proper treatment decisions and diagnosis (Pollock et al., 2019).
In addition to communications concerns, cultural factors and personal beliefs have been proven to adversely affect the health and well-being of diverse patients (Ahmed et al., 2016). According to research, educational materials provided to patients are not always culturally relevant, making it challenging to make informed decisions (Lambert et al., 2021; Ahmed et al., 2016). Notably, in a study by Lambert et al., many culturally diverse patients reported that following through with dietary recommendations was highly challenging when information regarding preferred diet was culturally irrelevant (2021). Furthermore, other studies highlighted the importance of developing culturally appropriate assessment tools, as many existing ones do not adequately depict the unique experiences of diverse patients (Kersey-Matusiak, 2012; Lambert et al., 2021). With the addition of relevant assessment tools, healthcare providers, including social workers, can be better positioned to determine each patient's specific beliefs, attitudes and values (Kersey-Matusiak, 2012). Aside from assessment tools, many studies have indicated concerns regarding the gender of service providers as one of the most prominent cultural barriers, particularly among immigrant women (Ahmed et al., 2016; Brar et al., 2009). Many immigrant women feel uncomfortable having physical exams even with female practitioners, primarily due to traditional values associated with modesty and not exposing their body parts (Ahmed et al., 2016). Finally, another key finding regarding cultural and personal beliefs suggests that there can be stigma associated with having a serious disease or mental illness; therefore, some newcomers are reluctant to seek healthcare support due to the shame and the fear of being ostracized (Ahmed et al., 2016; Teng et al., 2007). Overall, it is important to note that not all patients that identify as being part of a particular culture or ethnicity may have similar needs; therefore, all healthcare providers must avoid stereotyping and instead take the time to appreciate the uniqueness of all patients (Kersey-Matusiak, 2012).
Lastly, environmental factors can play a significant role in contributing to adverse health outcomes among diverse patients. Research suggests that immigrants are disproportionately exposed to hazardous environments, which puts them at greater risk of developing illnesses (Pollock et al., 2019). Exposure to these environments is partly due to the lack of access to appropriate housing, living conditions, parks and recreational facilities (Ahmed et al., 2016; Pollock et al., 2019). Furthermore, significant research has indicated that mental health can be influenced by the neighbourhood an individual is living (Kim et al., 2021). Reasons for poor health among new immigrants are associated with the constant fear of crime, the lack of local amenities and acculturative stressors due to discrimination and the lack of diversity (Kim et al., 2021; Hong et al., 2014). Finally, the lack of local amenities such as primary care clinics can cause even further barriers to accessing timely care as many new immigrants rely on others for their transportation needs (Ahmed et al., 2016). All of the barriers leading to unmet healthcare needs identified above highlight the need for all service providers, including social workers, to be mindful of the unique experiences diverse patients face when navigating Canada's healthcare system. Without knowing these experiences, service providers may inadvertently perpetuate oppressive healthcare systems that disproportionately affect diverse patients.
Application to Praction
As mentioned earlier, social workers can play an important role in supporting culturally diverse patients in several ways. Core strategies for working with patients new to the healthcare system require social workers to not only be knowledgeable about the barriers they face but also appreciate their strengths (Craig et al., 2015). This core strategy aligns with person-centred approaches to care that underscores the need for social workers to understand the person beyond their illness (Håkansson Eklund et al., 2019; Ekman et al., 2011; Craig et al., 2015). Research on what drives person-centred care suggests that service providers must be empathic and respectful as individuals sometimes share intimate details about their experiences with professionals they have just met (Håkansson Eklund et al., 2019; Craig et al., 2015). For social workers, supporting patients in navigating the healthcare system means applying mezzo and macro-level practice to understand the oppressive systems and policies in place and challenge them (Peterson, 2012). Trust and stronger relationships between service providers and service users were highlighted in the research when social workers and other professionals demonstrated cultural competency and preparedness working with immigrant populations (Ratnayake et al., 2022). The importance of prioritizing relationships with culturally diverse patients is also seen as essential for social workers as it challenges feelings of isolation and fosters the exchange of effective communication (Håkansson Eklund et al., 2019; Pollock et al., 2019; Pandey et al., 2022; Peterson, 2012). Research suggests relationship building is essential as it provides social workers with the foundation to have a holistic appreciation for their patient’s core values that must be explored in order to make informed decisions regarding treatment and care (Peterson, 2012; Craig et al., 2015; Ratnayake et al., 2022). Overall, being able to identify strengths, display empathy, foster respect, build relationships, and effectively communicate are imperative implications for practice among social workers in healthcare settings. While the research explored in this literature review focused on the role of social workers supporting culturally diverse patients, it is essential to note that the same strategies are effective when working with all patients. Each patient accessing support has unique experiences that may contribute to unmet healthcare needs; therefore, gathering a holistic understanding using various assessment tools can be extremely beneficial (Håkansson Eklund et al., 2019).
Conclusion
The findings in this review illustrate that despite the effort to provide quality healthcare to all Canadians, culturally diverse patients, including immigrants, international students, temporary foreign workers, refugees and temporary residents, experience worse health outcomes than the rest of the population (Pandey et al., 2022, Ahmed, at al., 2016; Chowdhury et al., 2021). As there are substantial factors contributing to unmet healthcare needs among migrants in Canada, there is an increased need to engage the communities that are impacted to make recommendations for policy changes and best practices. While the literature in this review explored the factors leading to inadequate healthcare experience and provided practice implications for social workers and service providers, there were limited recommendations for mezzo and macro-level change from migrants. Ultimately, Canada's healthcare system remains deeply rooted in colonial practices that prioritize Western ways of helping and healing. Therefore, this review hopes to challenge these structures that persist today and instead incorporate more inclusive strategies in supporting access to care for all patients.
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