What is privilege and cultural appropriation? and why is it so difficult to talk about?

On 15 February 2016, I spoke on 612 ABC Brisbane Afternoons with Kelly Higgins-Devine about cultural appropriation and privilege. Our discussion was followed by discussion with guests: Andie Fox – a feminist and writer; Carol Vale a Dunghutti woman; and Indigenous artist, Tony Albert. I’ve used the questions asked during the interview as a base for this blog with thanks to Amanda Dell (producer).

Why has it taken so long for the debate to escape academia to be something we see in the opinion pages of publications now?

Social media and online activism have catapulted questions about identities and politics into our screen lives. Where television allowed us to switch the channel, or the topic skilfully changed at awkward moments in work or family conversations, our devices hold us captive. Simply scrolling through our social media feeds can encourage, enrage or mobilise us into fury or despair. Whether we like it or not, as users of social media we are being interpolated into the complex terrain of identity politics. Merely sharing a link on your social media feed locates you and your politics, in ways that you might never reveal in real time social conversations. ‘Sharing’ can have wide ranging consequences, a casual tweet before a flight resulted in Justine Sacco moving from witty interlocutor to pariah in a matter of hours. The merging of ‘private’ and public lives never being more evident.

How long has the term privilege been around?

The concept of privilege originally developed in relation to analyses of race and gender but has expanded to include social class, ability level, sexuality and other aspects of identity. Interestingly, Jon Greenberg points out that although people of color have fought racism since its inception, the best known White Privilege educators are white (Peggy McIntosh, Tim Wise and Robin DiAngelo). McIntosh’s 1988 paper White Privilege and Male Privilege: A Personal Account of Coming to See Correspondences through Work in Women’s Studies extended a feminist analysis of patriarchal oppression of women to that of people of color in the United States. This was later shortened into the essay White Privilege: Unpacking the Invisible Knapsack (pdf), which has been used extensively in a a range of settings because of it’s helpful list format .

Many people have really strong reactions to these concepts – why is that?

Robin DiAngelo, professor of multicultural education and author of What Does it Mean to Be White? Developing White Racial Literacy developed the term ‘white fragility’ to identify:

a state in which even a minimum amount of racial stress becomes intolerable, triggering a range of defensive moves. These moves include outward display of emotions such as anger, fear and guilt, and behaviors such as argumentation, silence and leaving the stress-inducing situation

DiAngelo suggests that for white people, racism or oppression are viewed as something that bad or immoral people do. The racist is the person who is verbally abusive toward people of color on public transport, or a former racist state like apartheid South Africa. If you see yourself as a ‘good’ person then it is painful to be ‘called out’, and see yourself as a bad person. Iris Marion Young’s work useful. She conceptualises oppression in the Foucauldian sense as:

the disadvantage and injustice some people suffer not because of a tyrannical power coerces them but because of the everyday practices of a well-intentioned liberal society…

Young points out the actions of many people going about their daily lives contribute to the maintenance and reproduction of oppression, even as few would view themselves as agents of oppression. We cannot avoid oppression, as it is structural and woven throughout the system, rather than reflecting a few people’s choices or policies. Its causes are embedded in the unquestioned norms, habits, symbols and assumptions underlying institutional rules and the collective consequences of following those rules (Young, 1990). Seeing oppression as the practices of a well intentioned liberal society removes the focus from individual acts that might repress the actions of others to acknowledging that “powerful norms and hierarchies of both privilege and injustice are built into our everyday practices” (Henderson & Waterstone, 2008, p.52). These hierarchies call for structural rather than individual remedies.

We probably need to start with privilege – what does that term mean?

McIntosh identified how she had obtained unearned privileges in society just by being White and defined white privilege as:

an invisible package of unearned assets which I can count on cashing in each day, but about which I am meant to remain oblivious (p. 1).

Her essay prompted understanding of how one’s success is largely attributable to one’s arbitrarily assigned social location in society, rather than the outcome of individual effort.

“I got myself where I am today. Honestly, it’s not that hard. I think some people are just afraid of a little hard work and standing on their own two feet, on a seashell, on a dolphin, on a nymph-queen that are all holding them up.”
“I got myself where I am today. Honestly, it’s not that hard. I think some people are just afraid of a little hard work and standing on their own two feet, on a seashell, on a dolphin, on a nymph-queen that are all holding them up.”

From: The Birth of Venus: Pulling Yourself Out Of The Sea By Your Own Bootstraps by Mallory Ortberg 

McIntosh suggested that white people benefit from historical and contemporary forms of racism (the inequitable distribution and exercise of power among ethnic groups) and that these discriminate or disadvantage people of color.

How does privilege relate to racism, sexism? Are they the same thing?

It’s useful to view the ‘isms’ in the context of institutional power, a point illustrated by Sian Ferguson:

In a patriarchal society, women do not have institutional power (at least, not based on their gender). In a white supremacist society, people of color don’t have race-based institutional power.

Australian race scholars Paradies and Williams (2008) note that:

The phenomenon of oppression is also intrinsically linked to that of privilege. In addition to disadvantaging minority racial groups in society, racism also results in groups (such as Whites) being privileged and accruing social power. (6)

Consequently, health and social disparities evident in white settler societies such as New Zealand and Australia (also this post about Closing the gap) are individualised or culturalised rather than contextualised historically or socio-economically. Without context  white people are socialized to remain oblivious to their unearned advantages and view them as earned through merit. Increasingly the term privilege is being used outside of social justice settings to the arts. In a critique of the Hottest 100 list in Australia Erin Riley points out that the dominance of straight, white male voices which crowds out women, Indigenous Australians, immigrants and people of diverse sexual and gender identities. These groups are marginalised and the centrality of white men maintained, reducing the opportunity for empathy towards people with other experiences.

Do we all have some sort of privilege?

Yes, depending on the context. The concept of intersectionality by Kimberlé Crenshaw is useful, it suggests that people can be privileged in some ways and not others. For example as a migrant and a woman of color I experience certain disadvantages but as a middle class cis-gendered, able-bodied woman with a PhD and without an accent (only a Kiwi one which is indulged) I experience other advantages that ease my passage through the world You can read more in the essay Explaining White Privilege to a Broke White Person.

How does an awareness of privilege change the way a society works?

Dogs and Lizards: A Parable of Privilege by Sindelókë is a helpful way of trying to understand how easy it is not to see your own privilege and be blind to others’ disadvantages. You might have also seen or heard the phrase ‘check your privilege’ which is a way of asking someone to think about their own privilege and how they might monitor it in a social setting. Exposing color blindness and challenging the assumption of race-neutrality is one mechanism for addressing the issue of privilege and its obverse oppression.  Increasingly in health and social care, emphasis is being placed on critiquing how our own positions contribute to inequality (see my chapter on cultural safety), and developing ethical and moral commitments to addressing racism so that equality and justice can be made possible. As Christine Emba notes “There’s no way to level the playing field unless we first can all see how uneven it is.” One of the ways this can be done is through experiencing exercises like the Privilege Walk which you can watch on video. Jenn Sutherland-Miller in Medium reflects on her experience of it and proposes that:

Instead of privilege being the thing that gives me a leg up, it becomes the thing I use to give others a leg up. Privilege becomes a way create equality and inclusion, to right old wrongs, to demand justice on a daily basis and to create the dialogue that will grow our society forward.

Is privilege something we can change?

If we move beyond guilt and paralysis we can use our privilege to build solidarity and challenge oppression.  Audra Williams points out that a genuine display of solidarity can require making a personal sacrifice. Citing the example of Aziz Ansari’s Master of None, where in challenging the director of a commercial about the lack of women with speaking roles, he ends up not being in the commercial at all when it is re-written with speaking roles for women. Ultimately privilege does not gets undone through “confession” but through collective work to dismantle oppressive systems as Andrea Smith writes.

Cultural appropriation is a different concept, but an understanding of privilege is important, what is cultural appropriation?

Cultural appropriation is when somebody adopts aspects of a culture that is not their own (Nadra Kareem Little). Usually it is a charge levelled at people from the dominant culture to signal power dynamic, where elements have been taken from a culture of people who have been systematically oppressed by the dominant group. Most critics of the concept are white (see white fragility). Kimberly Chabot Davis proposes that white co-optation or cultural consumption and commodification, can be cross-cultural encounters that can foster empathy and lead to working against privilege among white people. However, an Australian example of bringing diverse people together through appropriation backfired, when the term walkabout was used for a psychedelic dance party. Using a deeply significant word for initiation rites, for a dance party was seen as disrespectful. The bewildered organiser was accused via social media of cultural appropriation and changed the name to Lets Go Walkaround. So, I think that it is always important to ask permission and talk to people from that culture first rather than assuming it is okay to use.

What is the line between cultural appropriation and cultural appreciation?

Maisha Z. Johnson cultural appreciation  or exchange  where mutual sharing is involved.

Can someone from a less privileged culture appropriate from the more privileged culture?

No, marginalized people often have to adopt elements of the dominant culture in order to survive conditions that make life more of a struggle if they don’t.

Does an object or symbol have to have some religious or special cultural significance to be appropriated? 

Appropriation is harmful for a number of reasons including making things ‘cool’ for White people that would be denigrated in People of Color. For example Fatima Farha observes that when Hindu women in the United States wear the bindi, they are often made fun of, or seen as traditional or backward but when someone from the dominant culture wears such items they are called exotic and beautiful. The critique of appropriation extends from clothing to events Nadya Agrawal critiques The Color Run™ where you can:

run with your friends, come together as a community, get showered in colored powder and not have to deal with all that annoying culture that would come if you went to a Holi celebration. There are no prayers for spring or messages of rejuvenation before these runs. You won’t have to drink chai or try Indian food afterward. There is absolutely no way you’ll have to even think about the ancient traditions and culture this brand new craze is derived from. Come uncultured, leave uncultured, that’s the Color Run, promise.

The race ends with something called a “Color Festival” but does not acknowledge Holi. This white-washing (pun intended) eradicates everything Indian from the run including  Holi, Krishna and spring. In essence as Ijeoma Oluo points out cultural appropriation is a symptom, not the cause, of an oppressive and exploitative world order which involves stealing the work of those less privileged. Really valuing people involves valuing their culture and taking the time to acknowledge its historical and social context. Valuing isn’t just appreciation but also considering whether the appropriation of intellectual property results in economic benefits for the people who created it. Kareem Abdul-Jabbar suggests that it is often one way:

One very legitimate point is economic. In general, when blacks create something that is later adopted by white culture, white people tend to make a lot more money from it… It feels an awful lot like slavery to have others profit from your efforts.

 

Loving burritos doesn’t make someone less racist against Latinos. Lusting after Bo Derek in 10 doesn’t make anyone appreciate black culture more… Appreciating an individual item from a culture doesn’t translate into accepting the whole people. While high-priced cornrows on a white celebrity on the red carper at the Oscars is chic, those same cornrows on the little black girl in Watts, Los Angeles, are a symbol of her ghetto lifestyle. A white person looking black gets a fashion spread in a glossy magazine; a black person wearing the same thing gets pulled over by the police. One can understand the frustration.

The appropriative process is also selective, as Greg Tate observes in Everything but the burden, where African American cultural properties including music, food, fashion, hairstyles, dances are sold as American to the rest of the world but with the black presence erased from it. The only thing not stolen is the burden of the denial of human rights and economic opportunity. Appropriation can be ambivalent, as seen in the desire to simultaneously possess and erase black culture. However, in the case of the appropriation of the indigenous in the United States, Andrea Smith declares (somewhat ironically), that the desire to be “Indian” often precludes struggles against genocide, or demands for treaty rights. It does not require being accountable to Indian communities, who might demand an end to the appropriation of spiritual practices.

Go West – Black: Random Coachella attendee, 2014. Red: Bison skull pile, South Dakota, 1870’s.
Go West – Black: Random Coachella attendee, 2014. Red: Bison skull pile, South Dakota, 1870’s by Roger Peet.

Some people believe the cuisines of other cultures have been appropriated – is this an extreme example, or is it something we should consider?

The world of food can be such a potent site of transformation for social justice. I am a committed foodie (“somebody with a strong interest in learning about and eating good food who is not directly employed in the food industry” (Johnston and Baumann, 2010: 61). I am also interested in the politics of food. I live in Melbourne, where food culture has been made vibrant by the waves of migrants who have put pressure on public institutions, to expand and diversify their gastronomic offerings for a wider range of people. However, our consumption can naturalise and make invisible colonial and racialised relations. Thus the violent histories of invasion and starvation by the first white settlers, the convicts whose theft of food had them sent to Australia and absorbed into the cruel colonial project of poisoning, starving and rationing indigenous people remain hidden from view. So although we might love the food we might not care about the cooks at all as Rhoda Roberts Director of the Aboriginal Dreaming festival observed in Elspeth Probyn’s excellent book Carnal Appetites:

In Australia, food and culinary delights are always accepted before the differences and backgrounds of the origin of the aroma are.

Lee’s Ghee is an interesting example of appropriation, she developed an ‘artisanal’ ghee product, something that has been made for centuries in South Asia.

Lee Dares was taking the fashion world by storm working as a model in New York when she realized her real passion was elsewhere. So, she made the courageous decision to quit her glamorous job and take some time to explore what she really wanted to do with her life. Her revelation came after she spent some time learning to make clarified butter, or ghee, on a farm in Northern India. Inspired, she turned to Futurpreneur Canada to help her start her own business, Lee’s Ghee, producing unique and modern flavours of this traditional staple of Southeast Asian cuisine and Ayurvedic medicine.

The saying “We are what we eat” is about not only the nutrients we consume but also to beliefs about our morality. Similarly ‘we’ are also what we don’t eat, so our food practices mark us out as belonging or not belonging to a group.So, food has an exclusionary and inclusionary role with affective consequences that range from curiosity, delight to disgust. For the migrant for example, identity cannot be taken for granted, it must be worked at to be nurtured and maintained. It becomes an active, performative and processual project enacted through consumption. With with every taste, an imagined diasporic group identity is produced, maintained and reinforced. Food preparation represents continuity through the techniques and equipment that are used which affirm family life, and in sharing this food hospitality, love, generosity and appreciation can be expresssed. However, the food that is a salve for the dislocated, lonely, isolated migrant also sets her apart, making her stand out as visibly, gustatorily or olfactorily different. The resource for her well being also marks her as different and a risk. If her food is seen as smelly, distasteful, foreign, violent or abnormal, these characteristics can be transposed to her body and to those bodies that resemble her. Dares attempt to reproduce food that is made in many households and available for sale in many ‘ethnic’ shops and selling it as artisanal, led to accusations of ‘colombusing’ — a term used to describe when white people  claim they have discovered or made something that has a long history in another culture. Also see the critique by Navneet Alang in Hazlitt:

The ethnic—the collective traditions and practices of the world’s majority—thus works as an undiscovered country, full of resources to be mined. Rather than sugar or coffee or oil, however, the ore of the ethnic is raw material for performance and self-definition: refine this rough, crude tradition, bottle it in pretty jars, and display both it and yourself as ideals of contemporary cosmopolitanism. But each act of cultural appropriation, in which some facet of a non-Western culture is columbused, accepted into the mainstream, and commodified, reasserts the white and Western as norm—the end of a timeline toward which the whole world is moving.

If this is the first time someone has heard these concepts, and they’re feeling confused, or a bit defensive, what can they do to understand more about it?

Here are some resources that might help, videos, illustrations, reading and more.

White privilege

Cultural appropriation

Review: Australian mental health nurses and transgender clients: Attitudes and knowledge

This is a longer version of a review of Damien Riggs & Clare Bartholomaeus’ paper published in the Journal of Research in Nursing: Australian mental health nurses and transgender clients: Attitudes and knowledge. Cite as: De Souza, R. (2016). Review: Australian mental health nurses and transgender clients: Attitudes and knowledge. Journal of Research in Nursing, 0(0) 1–2. DOI: 10.1177/1744987115625008

I have never forgotten her face, her body, even though more than twenty years have passed. She was not much older than me and she desperately wanted to be a he. I had no idea how to respond to her depression and her recent self-harm attempt in the context of her desire to change gender. There was nothing in my nursing education that had prepared me for how I might be therapeutic and there was no one and nothing in the acute psychiatric inpatient unit that could resource me. I feel embarrassed now that I had no professional understanding and experience to guide me to help me provide effective mental health care to my client. I was an empathic kind listener, but I had been immersed in a biologically deterministic (one’s sex at birth determines ones’ gender) and binary view of gender despite my own diverse cultural background which I had been socialized to see as separate from my mainly white nursing education. I had not been educated to critically consider discourses of sex and gender, to provide competent safe care to someone who wanted to change her gender and express her gender differently from normative gender categories (Merryfeather & Bruce, 2014). My work has since led me to consider the ways in which “differences” are produced culturally, politically, and epistemologically specifically in terms of categories including “race”, ethnicity, nationality, class, and more recently sexuality and gender.

Four critiques of biomedicine as a dominant framework for understanding ‘problems with living’ have inspired transformation of the mental health system. Firstly, the emphasis on participation and inclusion through consumer-led and recovery-oriented practice has profoundly changed the role of consumers from passive recipients of care to being more informed and empowered decision-makers whose lay knowledge and personal experience of mental illness are a resource (McCann and Sharek, 2014). This reconceptualisation has been formalised in the ‘recovery’ model, which has critiqued the stigmatising judgements of medico-psychiatric discourse about deviance and their accompanying social exclusion and disadvantage (Masterson and Owen, 2006). The third has been the recognition of cultural diversity and a critique of the limits of universalism. Finally, gender activism has exposed fractures in the sex/gender system and has led to a greater awareness of diversity, with regard to gender and sexual orientation.

Of these critiques, gender activism has received the least attention in mental health nursing; which is a concern, given the negative effects of heteronormativity and cisgenderism. Mental health nurses must continue to challenge or trouble the dominant binary views of gender and the discourse of biological determinism, the notion that the sex that one is assigned at birth determines ones’ gender (Merryfeather and Bruce, 2014). There is growing evidence of negative attitudes, a lack of knowledge, and a lack of sensitivity toward people whom are expressing diverse genders and sexualities. This discrimination creates barriers to the patients’ health gain and creates disparity (Chapman et al., 2012; McCann and Sharek, 2014).

The reviewed article on the attitudes of mental health nurses towards transgender people is therefore timely, given the relative invisibility of issues of gender identity within nursing theory, practice and research. As Fish (2010) wrote previously in this journal, the culture, norms and values of social institutions can inhibit access to healthcare and reinforce disparities in health outcomes. Cisgenderism (the alignment of one’s assigned sex at birth and one’s gender identity and gender expression with societal expectations) suffuses every aspect of clinical access to and through services, from written materials including mission statements, forms, posters and pamphlets; the built environment such as gender-specific washrooms; and interactions with both health professionals and allied staff, all of which reinforce a message of exclusion of transgender people (Baker and Beagan, 2014; Rager Zuzelo, 2014). In turn, these exclusionary practices are shaped through a dearth of policies and procedures, and scant educational preparation at the undergraduate and graduate levels (Eliason et al., 2010; Fish, 2010).

Nurses have a professional responsibility to challenge structural constraints and social policies, rather than passively accepting them. This paper provided compelling evidence for how nursing as a discipline and mental health nursing as a unique speciality can critically reflect on discourses regarding sex and gender; and on how these influence practice and consequently, can develop safer, ethical, effective and high-quality care for people whom either change their sex or express their gender differently from the standard culturally determined gender categories (Merryfeather and Bruce, 2014). Furthermore, this paper challenges mental health nurses to challenge heterosexism and cisgenderism; to speak out about social determinants of health that contribute to health inequities and health disparities, such as transphobia; and to address discrimination against transgender people. These challenges must be embedded into processes at the organizational, regulatory and political level (DeSouza, 2015).

References
Baker K and Beagan B (2014) Making assumptions, making space: An anthropological critique of cultural competency and its relevance to queer patients. Medical Anthropology Quarterly 28(4): 578–598. doi:10.1111/maq.1212.
Chapman R, Watkins R, Zappia T, et al. (2012) Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. Journal of Clinical Nursing 21(7,8): 938–945. doi:10.1111/j.1365-2702.2011.03892.
De Souza R (2015) Navigating the ethics in cultural safety. In: Wepa D (ed.) Cultural safety. Port Melbourne, Australia: Cambridge University Press, pp. 111–124.
Eliason MJ, Dibble S and Dejoseph J (2010) Nursing’s silence on lesbian, gay, bisexual and transgender issues: The need for emancipatory efforts. Advances in Nursing Science 33(3): 206–218. doi:10.1097/ANS.0b013e3181e63e4.
McCann E and Sharek D (2014) Challenges to and opportunities for improving mental health services for lesbian, gay, bisexual and transgender people in Ireland: A narrative account. International Journal of Mental Health Nursing 23(6): 525–533. doi:10.1111/inm.12081.
Masterson S and Owen S (2006) Mental health service user’s social and individual empowerment: Using theories of power to elucidate far-reaching strategies. Journal of Mental Health 15(1): 19–34. doi:10.1080/0963823050051271.
Merryfeather L and Bruce A (2014) The invisibility of gender diversity: Understanding transgender and transsexuality in nursing literature. Nursing forum 49(2): 110–123.
Rager Zuzelo P (2014) Improving nursing care for lesbian, bisexual and transgender women. Journal of Obstetric, Gynecologic and Neonatal Nursing 43(4): 520–530. doi:10.1111/1552-6909.1247.

Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health

This was first published in the Spring 2015 edition (Issue 41) of the Federation of Ethnic Councils of Australia (FECCA) national magazine, Australian Mosaic. Cite as: DeSouza, R. (2015). Medical pluralism: Supporting co-existing diverse therapeutic traditions in mental health. Australian Mosaic (FECCA). 41, 34-36.

Decades afterward, I still recall the frequent waking, getting out of bed and moving around our Nairobi house in the dark. Sometimes I moved pots and pans, re-arranged furniture, but mostly I caused a disturbance. My parents decided to address my distressing behaviour by taking me to an older woman from our Goan community who chanted
prayers and anointed me with chilli and garlic. Her incantations arrested the nocturnal disturbances, which never perturbed me again. The evil eye was diagnosed, the somnambulism caused by envy, inflicted on me with a look. I later learned that the
evil eye is seen as the cause of many problems and illnesses globally with a multitude of rituals and remedies to either prevent or cure it.

Charm- Niall Corbet on Flickr

My own experience of being a multiple migrant and then a clinician, led me to consider many possible antecedents to mental illness. The dominance of biomedicine to manage health and illness, assumes cross-cultural universals. Yet, mental health is a contested specialty with problematic treatments. Culturally derived norms and values from a specific location impose labels on behaviour from another context, which drive treatments, or management that flattens those contexts. Psychiatry and counseling are often viewed skeptically by people from refugee and migrant backgrounds who instead turn first to informal sources outside the health system including self-help, family, community, social networks, various forms of spirituality, religion and church. Increasingly, clinicians are appreciating the part these sources of support play.

Once mental health services are accessed, if staff focus on mental illness without understanding the cultural context or without realising that clients and their families might integrate both biomedical and more “traditional” beliefs, quality psychiatric assessment can be impaired and the potential for inaccurate diagnosis and inappropriate treatment and care can occur. Incorrectly identifying culturally appropriate behaviour or experiences as psychopathology is problematic, just as assuming that something is cultural rather than psychopathology or symptoms. However, every culture has frameworks for understanding health and illness and how these are demarcated.

In Aotearoa New Zealand, where I have spent most of my life, Maori psychiatrist Mason Durie has conceptualised Maori health as encompassing mental (hinengaro), physical (tinana), family/social (whänau), and spiritual (wairua) dimensions. In Australia, the National Aboriginal Health Strategy (1989) views wellbeing through a communal lens, broadening the concept of well-being beyond the to the social, emotional and cultural well-being of the whole community. Situating Aboriginal and Torres Strait Islander mental health within a framework of social and emotional wellbeing emphasise wellness, harmony and balance rather than illness and symptom reduction (AIHW 2012). Connection to land, culture, spirituality, ancestry, family and community, interdependence between families, communities, land, sea and spirit are also seen as necessary for health. The Ways Forward National Aboriginal and Islander Mental Health Policy Report 3 (pp19-20) adapted from Swan and Raphael also prioritises holism, self-determination, the need for cultural understanding, the impact of history in trauma and loss, human rights, acknowledges the impact of racism and stigma, kinship, cultural diversity and Aboriginal strengths.

Contemporary neoliberal health discourses have co-opted patient rights movements and positioned patients as consumers ­­-active partners in health who are responsible for their own health. Consumer engagement and health literacy form a suite of strategies for inducing medical citizenship, so that individuals can participate and become knowledgeable consumers. Some would argue these are assimilatory processes. However, in order for medical citizenship to be a two way process, one’s own beliefs about the causes of illness and the corresponding treatments must also be considered. Health literate organisations must also be open to a multiplicity of illness explanations and to those locations from which such beliefs are derived. As Beijers and de Freitas (p.245), note:

Health care is transforming social suffering into illnesses and diagnoses, while often denying the social and moral origins and implications of the suffering

David Ingleby suggests that two perspectives are available for thinking about culture and mental illness. A technical perspective assumes mainstream frameworks and treatments can be universalised to all patients/clients and that more sensitivity and overcoming linguistic and cultural barriers will assist therapeutic efforts. With a technical approach to mental health, the goal of care is to deliver it efficiently and increase utilization (efficacy). Strategies can include access to language matched information and professional interpreting services, or improving mental health literacy and awareness, supporting community resilience and coping strategies. However, technical approaches do not ask questions about power imbalances between groups.

On the other hand when care is given through a critical lens (equity), the questions become what is going on when interventions developed for one population are applied to another? What are the underlying power relations? Whose interests are being served? Is there a covert attempt to impose the values and perspectives of the dominant group? Ingelby suggests that becoming a user of Western health care involves accepting its underlying philosophy and values and “acquiring health literacy”.

It is important that collaborations between traditional healing mechanisms and western practice are made possible, however within professional discourses traditional healing is frequently viewed as primitive and unprofessional, yet people often utilize different health beliefs simultaneously in their search for optimal treatment. Furthermore, assimilation and acculturation into the dominant culture are thought to negatively impact on migrant health status and to contribute to migrant ill health and disparities as the healthy migrant advantage that people arrive with reduces after a year. Developing collaborative models that combine traditional and Western health knowledges and combining health literacy and consumer participation with better access and quality of staff can indeed facilitate better health outcomes.

As an educator, I am interested in how I can do my part to increase the awareness and openness to pluralism, so that the next generation of nurses can be effective and therapeutic. There is guidance available from The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services. There is an emphasis on being respectful and having non-judgmental curiosity about other cultures. Mental health workers are encouraged to seek cultural knowledge in an appropriate way, tolerate ambiguity and develop the ability to handle the stress of ambiguous situations. In addition, developing a family-sensitive practice, where family and community resources are viewed as partners in recovery as appropriate allow syncretism and innovation to take place. There are significant institutional barriers remaining to this in mental particularly the emphases on privacy, independence and the one-to-one relationship between consumer and professional.

Knowledge and action, developing evidence for an equity agenda

Speech given at the launch of a partnership between Monash University and Centre for Culture, Ethnicity and Health (CEH) April 29th 2015 and the celebration of CEH’s 21st birthday.

I would like to show my respect and acknowledge the traditional custodians of this land on which this launch takes place, the Wurundjeri-willam people of the Kulin Nation, their elders past and present. I’d also like to acknowledge our special guests: The Honorable Robin Scott – Minister for Multicultural Affairs/Minister for Finance, Phillip Vlahogiannis the Mayor of the City of Yarra, Chris Atlis the Deputy Chair of North Richmond Community Health (NRCH), Councillor Misha Coleman and Baraka Emmy, Youth Ambassador for Multicultural Health and Support Services. I’d also like to acknowledge: Professor Wendy Cross; CEO of the Centre for Culture Ethnicity and Health (CEH) Demos Krouskos; General Manager of CEH Michal Morris, representatives from the Department of Health and Human Services and other government departments, healthcare service partners, clients, NRCH and CEH staff and community members.

It’s an honour to take up this joint appointment between the Centre for Culture Ethnicity and Health (CEH) and Monash School of Nursing and Midwifery, there are some wonderful synergies which allow both organisations to jointly advance a shared goal of equity and quality in health care for our communities, and in particular for people from refugee and migrant background communities. As most of you know, Victoria is the most culturally diverse state in Australia, with almost a quarter of our population born overseas. Victorians come from over 230 countries, speak over 200 languages and follow more than 135 different faiths. This role is an acknowledgement of this diversity, and the need for health and social services that are equitable, culturally responsive and evidence based.

The gap this role addresses

Monash takes its name from Sir John Monash:  an Australian, well known for being both a scholar and a man of action. He is quoted as having said “…equip yourself for life, not solely for your own benefit but for the benefit of the whole community.” I am excited about the ways in which this new role can both strengthen CEH’s leadership and expertise in culture and health; and strengthen Monash’s position as a provider of dynamic and collaborative research-led education. In thinking about the world of the university and the world of practice, the words of Abu Bakr resonate: “Without knowledge, action is useless and knowledge without action is futile.”

What we have in common

I believe this relationship combines knowledge and action which will benefit both organisations and their staff, but even more importantly the communities that we are all here to serve. Key to this partnership success is the generous and collaborative spirit with which the leadership of both organisations have come together and which bodes well for the future. What we have in common as organisations is:

  • Firstly, a commitment to responsive clinical models of care that consider social determinants of health. In a world where health is increasingly industrialised and individualised, both Monash and CEH affirm the importance of communities in a healthy society
  • Secondly, both organisations aim to develop a health and social workforce that can work effectively and safely with our communities. CEH and NRCH know how to work with communities, having expertise in advocacy and community-building roles advocacy and community-building roles to contribute to healthier social and physical environments. Monash know how to educate and inspire practitioners to link their practical knowledge to the centuries of research and scholarship that universities are custodians of around the world.
  • Thirdly, the two organisations aim to keep clients and their families at the centre of care, to recognise that despite all our professional expertise it is the recipient of care who ultimately determines successful outcomes.
  • Fourthly, the organisations seek a system of care that is both just and equitable – just as the university seeks truths that are universal while we research in the here and now, so too we need more than ever to maintain our ideal of a healthy society for all.
Dr Ruth De Souza, Professor Wendy Cross, Michal Morris, The Hon Robin Scott – Minister for Multicultural Affairs/Minister for Finance.
Dr Ruth De Souza, Professor Wendy Cross, Michal Morris, The Hon Robin Scott – Minister for Multicultural Affairs/Minister for Finance.

 Benefits of the relationship

I forsee a number of benefits for both organisations from this role. CEH has a distinguished track record in supporting health and social practitioners to respond sensitively and effectively to the issues faced by people people from refugee and migrant backgrounds , and this will be of benefit to students and staff at Monash as we prepare a rapidly changing workforce for a  rapidly changing workplace.

Monash has an international reputation for high quality and research and education, and CEH will use this expertise to advocate and campaign for change. CEH will be exposed to the university’s dynamic intellectual environment and its knowledge of global currents in cultural research and health research, strengthening its expertise in cultural competence and giving the organisation a platform to lead a much needed translational research agenda.

There have been enormous amounts of work undertaken internationally in my own research areas of cultural safety and cultural competence. Yet there is still so much more to be known about what works and how institutions and practitioners can respond to our changing world. The relationship with Monash will provide both organisations with an opportunity for research output that is grounded, that can be disseminated both in academic settings such as conferences, academic  books and journals, into the sphere of practice and to a range of audiences. The relationship allows for a reciprocal re- examination of priorities and practices about equity in health in research, teaching, and service delivery. I am excited to be working in this dynamic partnership and look forward to helping the partners in their quest for an innovative, resilient and responsive health system for our changing world.

To conclude, I am grateful to the leadership that has made this role and partnership happen, my profound thanks go to the CEO of CEH Demos Krouskous, GM Michal Morris, Professor Wendy Cross, all the magnificent staff here at Monash and at CEH who have made me so very very welcome and lastly to all of you here who have made time to provide your presence and support.

Cultural safety in Aotearoa New Zealand 2nd Edition

Very excited about the 2nd Edition of Cultural safety in Aotearoa New Zealand being published by Cambridge Press in December 2015.

I’ve contributed two chapters and I have excerpted the introduction of each chapter below:

8. Navigating the ethical in cultural safety

Caring is an ethical activity with a deep moral commitment that relies on a trusting relationship (Holstein & Mitzen, 2001). Health professionals are expected to be caring, skilful, and knowledgeable providers of appropriate and effective care to vulnerable people. Through universal services they are expected to meet the needs of both individual clients and broader communities, which are activities requiring sensitivity and responsiveness. In an increasingly complex globalised world, ethical reflection is required so that practitioners can recognise plurality: in illness explanations; in treatment systems; in the varying roles of family/whanau or community in decision making; and in the range of values around interventions and outcomes. To work effectively in multiple contexts, practitioners must be able to morally locate their practice in both historical legacies of their institutional world and the diversifying community environment. This chapter examines the frameworks that health professionals can use for cross-cultural interactions.I then explore how they can select the most appropriate one depending on the person or group being cared for.

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13. Culturally safe care for ethnically and religiously diverse communities

Cultural safety is borne from a specific challenge from indigenous nurses to Western healthcare systems.It is increasingly being developed by scholars and practitioners as a methodological imperative toward universal health care in a culturally diverse world. The extension of cultural safety, outside an indigenous context, reflects two issues: a theoretical concern with the culture of healthcare systems and the pragmatic challenges of competently caring for ethnically and religiously diverse communities. As discussed throughout this book, the term ‘culture’ covers an enormous domain and a precise definition is not straightforward. For the Nursing Council of New Zealand (‘the Nursing Council’) (2009), for example, ‘culture includes, but is not restricted to, age or generation; gender; sexual orientation; occupation and socioeconomic status; ethnic origin or migrant experience; religious or spiritual belief; and disability’.

In an attempt at a precise two-page definition, Gayatri Chakravorty Spivak (2006, p. 359), captures the reflexive orientation required to grasp how the term ‘culture’ works:

Every definition or description of culture comes from the cultural assumptions of the investigator. Euro-US academic culture… is so widespread and powerful that it is thought of as transparent and capable of reporting on all cultures. […] Cultural information should be received proactively, as always open-ended, always susceptible to a changed understanding. […] Culture is a package of largely unacknowledged assumptions, loosely held by a loosely outlined group of people, mapping negotiations between the sacred and the profane, and the relationship between the sexes.

Spivak’s discussion of the sacred and the profane links culture to the more formal institution of religion, which has historically provided the main discourse for discussion of cultural difference. Particularly important for cultural safety is her discussion of Euro-US academic culture, a ‘culture of no culture’, which has a specific lineage in the sciences of European Protestantantism. Through much of the 19th century, for example, compatibility with Christianity was largely assumed and required in scientific and medical knowledge, even as scientists began to remove explicit Christian references from their literature. This historical perspective helps us see how the technoscientific world of the healthcare system, and those of us in secular education, are working in the legacy of white Christian ideals, where the presence of other cultures becomes a ‘problem’ requiring ‘solutions’. Cultural safety, however, attempts to locate the problem where change can be achieved in the healthcare system itself.

 

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Other contributors include: Irihapeti Ramsden, Liz Banks, Maureen Kelly, Elaine Papps, Rachel Vernon, Denise Wilson, Riripeti Haretuku, Deb Spence, Robin Kearns, Isabel Dyck, Ruth Crawford, Fran Richardson, Rosemary McEldowney, Thelma Puckey, Katarina Jean Te Huia, Liz Kiata, Ngaire Kerse, Sallie Greenwood and Huhana Hickey.

Book cover

The closure of remote Aboriginal communities: What is the role of nurses in Indigenous disadvantage?

Jeanie Govan

The view expressed by Tony Abbott (Prime Minister and the Minister for Indigenous Affairs), that taxpayers shouldn’t be expected to fund the “lifestyle choices” of Aboriginal people living in remote regions in support of Colin Barnett’s (West Australian Premier) decision to close 150 remote Aboriginal communities in Western Australia reflects the repetition of the colonial project and Aboriginal dispossession. One of the mythologies of a white settler society is that white people are the first to arrive and develop the land, with colonisation a benign force (rather than one enacted through the processes of conquest and genocide and displacing the indigenous (Razack, 2002)). Closing the community draws attention away from governmental failures to ‘Close the Gap’ and instead displaces the blame on the supposed inadequacies and problems of Aboriginal communities (Amy McQuire) thereby individualising socio-political inequalities rather than revealing them as historic and structural. The paternalism of closing the communities “for their own good” and for the common good, appears benign but hides the brutality of forced removal and in doing so denies the significance of indigeneity as Mick Dodson notes:

It is not a “lifestyle choice” to be be born in and live in a remote Aboriginal community. It is more a decision to value connection to country, to look after family, to foster language and celebrate our culture. There are significant social, environmental and cultural benefits for the entire nation that flow from those decisions.

 

Hamilton action

The protests against this cruel action have resounded around the world and have resonated in Aotearoa where I have lived for most of my life although I now live in the lands of the Kulin Nations in Gippsland as a migrant. As a nurse educator and researcher I am shaped by colonialism’s continuing effects in the white settler nation of Australia.

Nurses have often played an important part in social justice. Recently nursing professional bodies made a stand against violent state practices with the Australian College of Nursing (ACN) and Maternal Child and Family Health Nurses Australia (MCaFHNA) supporting The Forgotten Children report by the Australian Human Rights Commission against detaining children in immigration detention centres. Others like Chris Wilson wrote in Crikey  about the many limitations of the Northern Territory Intervention:

I am saddened that the intervention has wasted so many resources, given so little support or recognition to the workers on the ground, paid so little attention to years of reports and above all involved absolutely no consultation with anyone, especially community members. The insidious effect of highlighting child abuse over all the other known problems in Aboriginal health is destructive to male health, mental health and community health, is unfounded in fact and is based in the inherent ignorance of this racist approach.

It has made me think about how nurses and midwives don’t often problematise our locations and consider our responsibilities within a social context of the discursive and material legacies of colonialism, neoliberalism, austerity and ‘othering’ (of Muslims, of refugees of Indigenous people) and “the ways in which we are complicitous in the subordination of others” (Razack, 1998, p.159). As Razack notes, groups that see themselves as apolitical must call into question their roles as “innocent subjects, standing outside of hierarchical social relations, who are not accountable for the past or implicated in the future” (Razack, 1998, p.10).

Colonisation and racism have been unkind to Indigenous people (term often used to refer to both Aboriginal and Torres Strait Islander peoples) with the health status of Indigenous people often compared to that of a developing country as I have pointed out elsewhere. The Overcoming Indigenous Disadvantage 2014 report measures the wellbeing of Australia’s Indigenous peoples. Briefly, Indigenous people:

  • Experience social and health inequalities (Australian Institute of Health and Welfare, 2004).
  • Are over represented and experience a higher burden of disease and higher mortality at younger ages than non-Indigenous Australians (Australian Institute of Health and Welfare, 2012b).

So, the question for me as a researcher and educator are what responsibility do nurses and the discipline of nursing have to Aboriginal health?

1) Recognise colonisation as a determinant of health

Indigenous people enjoyed better health in 1788 than people in Europe, they had autonomy over their lives, (ceremonies, spiritual practices, medicine, social relationships, management of land, law, and economic activities), but also didn’t suffer from illnesses that were endemic in18th century Europe. They didn’t have smallpox, measles, influenza, tuberculosis, scarlet fever, venereal syphilis and gonorrhoea. However, they were known to have suffered from; hepatitis B; some bacterial infections; some intestinal parasites; trauma; anaemia; arthritis; periodontal disease; and tooth attrition.

What’s often difficult for many nurses and students to imagine is that the past could have anything to do with the present, however, research in other settler colonial societies shows a clear relationship between social disadvantages experienced by Indigenous people and current health status. Colonisation and the spread of non-Indigenous peoples saw the introduction of illness (eg smallpox); the devaluing of culture; the destruction of traditional food base; separation from families; dispossession of whole communities. Furthermore, the ensuing loss of autonomy undermined social vitality, reduced resilience and created dispossession, demoralisation and poor health.

The negative impacts of colonisation on Indigenous led colonial authorities to try to ‘protect’ remaining Indigenous peoples, which saw the establishment of Aboriginal ‘protection’ boards (the first established in Victoria by the Aboriginal Protection Act of 18690. However, ‘protection’ imposed enormous restrictions eg living in settlements; forced separation of Indigenous children from their families. With between one-in-three and one-in-ten Indigenous children forcibly removed from their families and communities from 1910 until 1970. The result was irrevocable harm as one of the Stolen Generations stated:

We may go home, but we cannot relive our childhoods. We may reunite with our mothers, fathers, sisters, brothers, aunties, uncles, communities, but we cannot relive the 20, 30, 40 years that we spent without their love and care, and they cannot undo the grief and mourning they felt when we were separated from them

 

For the pain, suffering and hurt of these Stolen Generations, their descendants and for their families left behind, we say sorry. To the mothers and the fathers, the brothers and the sisters, for the breaking up of families and communities, we say sorry. And for the indignity and degradation thus inflicted on a proud people and a proud culture, we say sorry.

Also watch Babakiueria which uses role reversal to satirise and critique Australia’s treatment of its Indigenous peoples. Aboriginal actors play the colonisers, while white actors play the indigenous Babakiuerians.

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2) Recognise continuing colonial practices

This blog started with the news of the closures of 150 remote Aboriginal communities in WA. Only one example of continuing colonial practices. Mick Dodson suggests that the closure of the 150 WA communities reflects an inability of the descendants of settlers to:

negotiate in a considered way the right of Aboriginal people to live as Aboriginal peoples in our own lands and seas, while also participating in every aspect of life  as contemporary Australian citizens.

 

You can also read about proposed alternatives to the closure by Rebecca Mitchell.

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3) Develop an understanding of racism as a determinant of health

Racism (racial discrimination) is linked with colonisation and oppression and is a social determinant of health. Nancy Krieger (2001) defines it as a process by which members of a socially defined racial group are treated unfairly because of membership of that group. Too often racism is seen as individual actions rather than as structural and embedded as this video shows. We know that racism damages health and in the health sector health systems and service providers can perpetuate Aboriginal health care disparities through attitudes and practices (Durey).

Anti-racist scholars suggest that there are three levels of racism in health.

  1. Institutional: Practices, policies or processes experienced in everyday life which maintain and reproduce avoidable and unfair inequalities across ethnic/racial groups (also called systemic racism);
  2. Interpersonal, in interactions between individuals either within their institutional roles or as private individuals;
  3. Internalised, where an individual internalises attitudes, beliefs or ideologies about the inferiority of their own group.

Krieger and others have written extensively about how racism affects health. People who experience racism experience the following:

  • Inequitable and reduced access to the resources required for health;
  • Inequitable exposure to risk factors associated with ill-health;
  • Stress and negative emotional/cognitive reactions which have negative impacts on mental health as well as affecting the immune, endocrine, cardiovascular and other physiological systems;
  • Engagement in unhealthy activities and disengagement from healthy activities

1 in 3 Aboriginal Victorians experienced racism in a health care setting according to a VicHealth survey. The respondents reported:

  • Poorer health status;
  • Lower perceived quality of care;
  • Under-utilisation of health services;
  • Delays in seeking care;
  • Failure to follow recommendations;
  • Societal distrust;
  • interruptions in care;
  • Mistrust of providers;
  • Avoidance of health care systems.

This video on understanding the impact of racism on Indigenous child health by Dr Naomi Priest is well worth a look.

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4) Develop a collective understanding of health and the importance of cultural determinants of health

Health is defined in the National Aboriginal Health Strategy (1989) as:

Not just the physical well-being of the individual but the social, emotional and cultural well-being of the whole community. This is a whole of life view and it also includes the cyclical concept of life-death-life

It is important that in considering the issues of colonisation, racism and inter-generational trauma that the diverse cultures and histories of indigenous people are not viewed through a deficit lens. So often mainstream media reinforce the myth that responsibility for poor health (whether it’s about people who drink, are obese or smoke) is an individual and group one rather than linked with social determinants including colonisation, economic restructuring or the devastating social consequences of state neoliberal policies. As Professor Ngiare Brown notes, there are significant cultural determinants of health which should be supported including:

  • Self-determination; Freedom from discrimination;
  • Individual and collective rights;
  • Freedom from assimilation and destruction of culture;
  • Protection from removal/relocation;
  • Connection to, custodianship, and utilisation of country and traditional lands;
  • Reclamation, revitalisation, preservation and promotion of language and cultural practices;
  • Protection and promotion of Traditional Knowledge and Indigenous Intellectual Property; and
  • Understanding of lore, law and traditional roles and responsibilities.

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5) Develop an understanding of the organisations, policies, levers and strategies that are available to support Indigenous wellbeing

  • Aboriginal Community Controlled Health Services (ACCHSs), which are primary health care services operated by local Aboriginal communities to deliver holistic, comprehensive, and culturally appropriate health care. There are over 150 ACCHSs in urban, regional and remote Australia.
  • Close the gap campaign targets (also see a recent blogpost) developed by a consortium of 40 of Australia’s leading Indigenous and non-Indigenous health peak bodies and human rights organisations, which calls on Australian governments to commit to achieving Indigenous health equality within 25 years.
  • 2007 United Nations Declaration on the Rights of Indigenous Peoples, Article 24 of which points out that Indigenous people have the right “to access, without any discrimination, [to] all social and health services” and “have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively full realisation of this right”.
  • Become familiar with the National Aboriginal and Torres Strait Islander Health Plan 2013-2023.
  • Support the WHO Closing the gap in a generation, which recommends three actions for improving the world’s health:
  1. Improve the conditions of daily life – the circumstances in which people are born, grow, live, work, and age.
  2. Tackle the inequitable distribution of power, money, and resources – the structural drivers of those conditions of daily life – globally, nationally, and locally.
  3. Measure the problem, evaluate action, expand the knowledge base, develop a workforce that is trained in the social determinants of health, and raise public awareness about the social determinants of health.

In recognising the linkages and operational relationships that exist between health and human rights, the nursing profession respects the human rights of Australia’s Aboriginal and Torres Strait Islander peoples as the traditional owners of this land, who have ownership of and live a distinct and viable culture that shapes their world view and influences their daily decision making. Nurses recognise that the process of reconciliation between Aboriginal and Torres Strait Islander and non-indigenous Australians is rightly shared and owned across the Australian community. For Aboriginal and Torres Strait Islander people, while physical, emotional, spiritual and cultural wellbeing are distinct, they also form the expected whole of the Aboriginal and Torres Strait Islander model of care

 

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6) Becoming a critical, reflexive, knowledgeable nurse who legitimates the  cultural rights, values and expectations of Aboriginal people

More than ever, social justice provides a valuable lens for nursing practice (see Sir Michael Marmot’s speech). Cultural competence and safety directly reduce health disparities experienced by Indigenous Australians (Lee et al., 2006; Durey, 2010). It makes sense that the safer the health care system and its workers are, the more likely Indigenous people are to engage and use the services available. Early engagement in the health care system results in early health intervention strategies, prevention of illness and improved overall health outcomes for Indigenous Australians. The key features of cultural competence identified in the Cultural diversity plan for Victoria’s specialist mental health services 2006-2010 are:

  • Respectful and non-judgemental curiosity about other cultures, and the ability to seek cultural knowledge in an appropriate way;
  • Tolerance of ambiguity and ability to handle the stress of ambiguous situations;
  • Readiness to adapt behaviours and communicative conventions for intercultural communication.

Nurses have a role in improving health outcomes, but this requires an understanding of the reasons why there are higher morbidity and mortality rates in Indigenous populations than in the general population. It requires that nurses engage in reflection and interrogate the existing social order and how it reproduces discriminatory practices in structural systems such as health care, in institutions and in health professionals (Durey, 2010). It’s important that as nurses we focus on our own behaviour, practice and skills both as professionals and individuals working in the health system.

I think this statement about Cultural security from the Department of Health, Western Australian Health (2003) Aboriginal Cultural Security: A background paper, page 10. is a valuable philosophy of practice:

Commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people. It is a recognition, appreciation and response to the impact of cultural diversity on the utilisation and provision of effective clinical care, public health and health system administration

To conclude, I leave the last words to Professor Ngiare Brown:

We represent the oldest continuous culture in the world, we are also diverse and have managed to persevere despite the odds because of our adaptability, our survival skills and because we represent an evolving cultural spectrum inclusive of traditional and contemporary practices. At our best, we bring our traditional principles and practices – respect, generosity, collective benefit, collective ownership- to our daily expression of our identity and culture in a contemporary context. When we are empowered to do this, and where systems facilitate this reclamation, protection and promotion, we are healthy, well and successful and our communities thrive.

 

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References

Universities of Australia. (2011). National best practice framework for indigenous cultural competency in Australian Universities.
Awofeso, N. (2011). Racism: A major impediment to optimal indigenous health and health care in Australia. Australian Indigenous Health Bulletin, 11(3), 1-8.
Best, O., & Stuart, L. (2014). An Aboriginal nurse-led working model for success in graduating indigenous Australian nurses. Contemporary Nurse, 4082-4101.
Chapman, R., Smith, T., & Martin, C. (2014). Qualitative exploration of the perceived barriers and enablers to Aboriginal and Torres Strait Islander people accessing healthcare through one victorian emergency department. Contemporary Nurse.
Christou, A., & Thompson, S. C. (2012). Colorectal cancer screening knowledge, attitudes and behavioural intention among indigenous western Australians. BMC Public Health, 12, 528. doi:10.1186/1471-2458-12-528
Downing, R., & Kowal, E. (2010). Putting indigenous cultural training into nursing practice. Contemporary Nurse, 37(1), 10-20. doi:10.5172/conu.2011.37.1.010
Durey, A. (2010). Reducing racism in Aboriginal health care in Australia: Where does cultural education fit? Australian and New Zealand Journal of Public Health, 34 Suppl 1, S87-92. doi:10.1111/j.1753-6405.2010.00560.x
Durey, A., Lin, I., & Thompson, D. (2013). It’s a different world out there: Improving how academics prepare health science students for rural and indigenous practice in Australia. Higher Education Research & Development, 32(5), 722-733.
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Kelly, J., West, R., Gamble, J., Sidebotham, M., Carson, V., & Duffy, E. (2014). ‘She knows how we feel’: Australian Aboriginal and Torres Strait Islander childbearing women’s experience of continuity of care with an Australian Aboriginal and Torres Strait Islander midwifery student. Women and Birth : Journal of the Australian College of Midwives, 27(3), 157-62. doi:10.1016/j.wombi.2014.06.002
Kildea, S., Kruske, S., Barclay, L., & Tracy, S. (2010). Closing the gap: How maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural and Remote Health, 10(1383), 9-12.
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Learning to listen: Mental health and migration for CALD communities

In Victoria the goal of the Victorian Mental Health Reform Strategy 2009-2019 is to achieve better social and economic outcomes for people with mental illness, their families, carers and friends. Specifically Reform Area 6 outlines areas for reducing inequalities. The Cultural Diversity Plan for Victoria’s Specialist Mental Health Services, 2006-2010 suggests that achieving more culturally responsive services for culturally and linguistically diverse (CALD) and refugee communities is a clear priority given that:

  • Victoria has a diverse population with 24 per cent of Victorians being born overseas.
  • A third of this group come from non-English speaking countries.
  • Culturally and linguistically diverse (CALD) groups often have poorer mental health outcomes compared to Australian-born people, because they tend to present to services when their illness is more severe and therefore are also likely to experience higher rates of involuntary treatment.
  • There are sub-groups articularly refugees and older people who are at risk of developing a mental health problem.
  • Each year Victoria accepts over 3,500 humanitarian entrants (refugees and asylum seekers).
  • Victoria’s CALD population is increasingly being dispersed across the state. in regional and rural areas which requires primary health and mental health services provide culturally appropriate care.
  • Almost half of all CALD Victorians report having experienced some type of discrimination based on their ethnicity or nationality.
  • Experiences of discrimination are associated with depression, stress, anxiety and problematic substance use.

Better mental health outcomes for people of CALD backgrounds must include:

  • Strategies to promote social inclusion;
  • Acceptance of cultural diversity;
  • Workforce development ie develop work practices and cultures in mental health services that support high quality, effective, consumer-focused and carer-inclusive care;
  • Improving access to culturally competent mental health care at earlier stages of illness;
  • Enhancing the capacity of primary health services and workers in CALD community settings to identify, respond earlier to, and refer people with emerging mental health problems;
  • Enhancing mental health literacy and reduce stigma among refugee and asylum seeker groups;
  • Provide mental health literacy training to multicultural, ethno-specific and refugee agencies to improve their understanding of mental illness, so that workers in these agencies can better navigate the mental health service system on behalf of CALD consumers and;
  • Encourage practical partnerships between these agencies and specialist mental health services to facilitate culturally-specific input into clinical treatment and psychosocial rehabilitation plans;
  • Address language needs of CALD clients in specialist mental health services and address supply of interpreters  and promote client and carer awareness of language services;
  • Build on the work of Victorian Transcultural Mental Health and the Action on Disability within Ethnic Communities (ADEC) to improve training.

Migrating minds

In the last week of March 2015 I was honoured to be one of six panelists ranging from consumers, carers, filmmakers, and mental health practitioners to be part of a panel at an event called Migrating Minds: A forum on mental health within Culturally and Linguistically Diverse (CALD) migrant communities.The panel was organised by Colourfest in partnership with Victorian Transcultural Mental Health and held at the State Library of Victoria (SLV). Colourfest celebrates films about diaspora and migrant experiences and shares them with the broader community through free events, professional development/training, distributing films and producing resources.

What was especially wonderful about Colourfest was that consumers and carers were central to the event and got to tell their own stories in the films at the start and in the panel discussion at the end. The event began with seven short films which were stories told by people with a personal experience of mental health issues and perspectives of relatives/carers. Five of the short films were produced by Multicultural Mental Health Australia (MHiMA) and Victorian Transcultural Mental Health. There was also an international short film produced by a second-generation Vietnamese-American who shares their experiences with Depression and Post-Traumatic Stress Disorder.

These fabulous examples of cross-sectoral collaboration were evident in the partnership between Mental Health in Multicultural Australia (MHiMA) in conjunction with the Australian Centre for the Moving Image (ACMI) to produce Finding our way. This unique project focused on migrant and refugee stories where the personal stories of people living with emotional and mental health issues who were negotiating migrancy. Managed by Victorian Transcultural Mental Health (VTMH), St Vincent’s Hospital, Melbourne and the Global and Cultural Mental Health Unit at the University of Melbourne. Erminia Colucci & Susan McDonough coordinated the project for MHiMA. We watched The Visual Conductor by Maria. A story about family expectations, taking charge and staying well involving art, personal goals and play. We also viewed Dear Self by Akeemi, which was about childhood memories, moving to a new country, feelings of isolation and efforts to connect including original drawings and paintings. Both Maria Dimopoulos  and Akeemi from the Finding Our Way film project were also on the panel.

The Our Voices project told the stories of carers from refugee and migrant backgrounds through five short films, showing a poignant insight into the lives of carers from migrant and refugee backgrounds. At the Colourfest panel we were fortunate to view Kevser‘s story. Kevser arrived from Turkey in the late 60’s with her husband and is the primary carer for her daughter. What was extraordinary about this film and the other four (from Afghani, Egyptian, Somali and Vietnamese communities) were the common challenges they faced in finding culturally sensitive and culturally-responsive mental health care and support. The aim of the forum was to help healthcare practitioners, community workers and the general population to understand some of the needs of the CALD community and the films were a powerful mechanism for leading the audience to empathise with the experiences of families. Leyla Altinkaya spoke on behalf of her mother, Kevser on the panel. Our other panelists were Munira Yusuf , a young person speaking from a youth perspective on their lived experiences with mental health issues and David Belasic: A psychologist based at Drummond Street Services. He has a strong interest in community psychology and queer mental health.

Me answering a question from Pham Phu Thanh Hang Colourfest Melbourne Coordinator. Also in the shot from left to right, fellow panellists Akeemi, Maria Dimopoulos, Munira Yusuf and David Belasic.
Me answering a question from Pham Phu Thanh Hang Colourfest Melbourne Coordinator. Also in the shot from left to right, fellow panellists Akeemi, Maria Dimopoulos, Munira Yusuf and David Belasic.

One of the priorities of The Framework for Mental Health in Multicultural Australia: Towards culturally inclusive service delivery is that services evaluate their cultural responsiveness and develop action plans to enhance their delivery of services to CALD communities as part of core business. Central to this responsiveness is having processes where consumers, carers and family members can have a say in the planning, development, delivery and evaluation of services. Particularly important given that CALD consumer and carer participation lags behind mainstream participation. Hence, the importance of this event which placed the experiences of consumers and carers at the forefront.

Cultural competence in mental health emphasises the attributes of the service provider and outcomes of the cross-cultural encounter rather than the unfamiliar culture of the consumer/carer. I love the key elements of cultural competence identified in the Cultural diversity plan for Victoria’s specialist mental health services 2006-2010:

  • Respectful and non-judgemental curiosity about other cultures, and the ability to seek cultural knowledge in an appropriate way;
  • Tolerance of ambiguity and ability to handle the stress of ambiguous situations;
  • Readiness to adapt behaviours and communicative conventions for intercultural communication.

What’s lovely about this list is that it does not constitute a recipe or tick box that can be memorised and then deployed in every intercultural encounter. These qualities are about how we developing a capacity for being in relationship with other people when we cannot assume common ground (which is really kinda always).  I believe that watching the films provided a way to facilitate the beginnings of such a journey..

I am grateful to all those who made the films happen and for making visible the experiences of CALD consumers and carers. A grateful thanks to Gary Paramanathan and Pham Phu Thanh Hang Colourfest Melbourne Coordinator for the opportunity to be part of this wonderful panel.

Note that the Victorian Mental Health Reform Strategy 2009-2019 defines Cultural and linguistic diversity as:

the diversity of society in terms of cultural identity, nationality, ethnicity, language, and increasingly faith. Individuals from a CALD background are those who identify as having a specific cultural or linguistic affiliation by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language, language(s) spoken at home, or because of their parents’ identification on a similar basis. CALD does not refer to an homogenous group of people, but rather to a range of cultural and language group communities.

Nursing in media-saturated societies: implications for cultural safety in nursing practice

Nairn, DeSouza, Moewaka Barnes, Rankine,  Borell, and McCreanor (2014). Nursing in media-saturated societies: implications for cultural safety in nursing practice in Aotearoa New Zealand. Journal of Research in Nursing September  19: 477-487,doi:10.1177/1744987114546724

Great to be published in the Journal of Research in Nursing September 2014 issue on ‘Race’, Ethnicity and Nursing, Edited by: Lorraine Culley. I had the pleasure of being included in a previous issue in 2007, so it’s great to be in this one.

Abstract

This educational piece seeks to apprise nurses and other health professionals of mass media news practices that distort social and health policy development. It focuses on two media discourses evident in White settler societies, primarily Australia, Canada, New Zealand and the United States, drawing out implications of these media practices for those committed to social justice and health equity. The first discourse masks the dominant culture, ensuring it is not readily recognised as a culture, naturalising the dominant values, practices and institutions, and rendering their cultural foundations invisible. The second discourse represents indigenous peoples and minority ethnic groups as ‘raced’ – portrayed in ways that marginalise their culture and disparage them as peoples. Grounded in media research from different societies, the paper focuses on the implications for New Zealand nurses and their ability to practise in a culturally safe manner as an exemplary case. It is imperative that these findings are elaborated for New Zealand and that nurses and other health professionals extend the work in relation to practice in their own society.

One of my favourite pieces of the article proposes some ways in which nurses can engage in critical assessment of mass media, by asking questions like:

  • From whose point of view is this story told?
  • Who is present?
  • How are they named and/or described?
  • Who, of those present, is allowed to give their interpretation of the matter?
  • Who is absent?
  • Whose interests are served by telling the story this way?

One of the things that I love about this journal is that they ask for commentaries from a reviewer. My former colleague Denise Wilson (Professor, Māori Health Taupua Waiora Centre for Māori Health Research/School of Public Health & Psychosocial Studies, National Institute of Public Health and Mental Health Research, Auckland University of Technology, New Zealand), has reviewed our paper and says:

I would urge nurses to read this paper and reflect on how the media influences their own practice and engagement with minority and marginalised groups. Media portrayals of minority groups often reflect negatively geared dominant cultural sentiments, becoming ‘accepted’ fact within our communities. Nurses need to be aware that their efforts to be culturally safe in their practice can be undermined by the normalisation and acceptance of what is portrayed in the media. Therefore, nurses are encouraged by the authors to come together and question the ‘taken-for-granted’ dominant cultural media portrayals to create a stronger platform for culturally safe practice.

Mind the gap: Cultural safety in Australia

In August 2014 there was a wonderful story of how “people power” had freed a man in Perth, whose leg had become caught in the gap between a platform and train on his morning commute. You can watch the video here. What struck me about this story was that people taking part in their “regular” commute noticed something out of the ordinary and used their combined energy to free the man. Someone alerted the driver to make sure that the train didn’t move, staff then asked passengers to help and in tandem they rocked the train backwards from the platform so it tilted and his leg could be freed. It made me think about the gaps people are stuck in, that exist all around us, that have become so routine, that we are habituated to, and fail to notice.

One of the biggest gaps is in the health outcomes between Indigenous and non-indigenous people in settler nations. Oxfam notes that Australia equals Nepal for the world’s greatest life expectancy gap between Indigenous and non-Indigenous people. This is despite Australians enjoying one of the highest life expectancies of any country in the world. Indigenous Australians (who numbered 669,900 people in 2011, ie 3% of the total population) live 10-17 years less than other Australians. In the 35–44 age group, Indigenous people die at about 5 times the rate of non-Indigenous people. Babies born to Aboriginal mothers die at more than twice the rate of other Australian babies, and Aboriginal and Torres Strait Islander people experience higher rates of preventable illness such as heart disease, kidney disease and diabetes.

One of the most galvanising visions for addressing the health and social disparities between Indigenous and non-indigenous people is  The Close the Gap campaign aiming to close the health and life expectancy gap between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians within a generation. By 2030 any Aboriginal or Torres Strait Islander child born in Australia will have the same opportunity as other Australian children to live a long, healthy and happy life.

Mind the gap

 

Nurses play an important role in creating a more equitable society and have  been forerunners in the field of cultural safety and competence. For the gap to close, nurses need an understanding of health that includes social, economic, environmental and historical relations. Cultural safety from Aotearoa New Zealand has been an invaluable tool for me as nurse for analysing this set of relations. However, as a newcomer to Australia, I have a lot to learn about what cultural competency means here and how I fulfil my responsibilities as a nurse educator to Aboriginal and Torres Strait Islander peoples. To that end, this blog piece focuses on some of the frameworks in nursing that might enable nurses to close the gap. I am particularly interested in frameworks that enable nurses to widen the lens of care beyond the individual and consider service users in the context of their families and communities and broader social and structural inequities. I’m also interested in policy frameworks that can support practice.

Gosford Anglican church

A social determinants of health approach takes into account “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics” (WHO, 2010). A health equity lens has also been invaluable to my own practice, it refers to the absence of systematic disparities in health (or in the major social determinants of health) between groups with different social advantage/disadvantage. Social inequalities refer to “relatively long-lasting differences among individuals or groups of people that have implications for individual lives” (McMullin, 2010, p.7). While an inequity, refers to an unjust distribution of resources and services. “equity means social justice” (see, Braverman 2003). The term “social and structural inequities,” refers to unfair and avoidable ways in which members of different groups in society are treated and/or their ability to access services.

Equality justice

Principle Four of the New Zealand Nursing Council: Guidelines for Cultural safety in Nursing and Midwifery Education (2011) pay great attention to the issue of power:

PRINCIPLE FOUR Cultural safety has a close focus on:

 

4.1 understanding the impact of the nurse as a bearer of his/her own culture, history, attitudes and life experiences and the response other people make to these factors

4.2 challenging nurses to examine their practice carefully, recognising the power relationship in nursing is biased toward the provider of the health and disability service

4.3 balancing the power relationships in the practice of nursing so that every consumer receives an effective service

4.4 preparing nurses to resolve any tension between the cultures of nursing and the people using the services

4.5 understanding that such power imbalances can be examined, negotiated and changed to provide equitable, effective, efficient and acceptable service delivery, which minimises risk to people who might otherwise be alienated from the service.

The Australian Code of Ethics for nurses and midwives in Australia also pays attention to the role of nurses in having a moral responsibility to protect and safe guard human rights as means to improving health outcomes and having concern for the structural and historical:

The nursing profession recognises the universal human rights of people and the moral responsibility to safeguard the inherent dignity and equal worth of everyone. This includes recognising, respecting and, where possible, protecting the wide range of civil, cultural, economic, political and social rights that apply to all human beings.

 

The nursing profession acknowledges and accepts the critical relationship between health and human rights and ‘the powerful contribution that human rights can make in improving health outcomes’. Accordingly, the profession recognises that accepting the principles and standards of human rights in health care domains involves recognising, respecting, actively promoting and safeguarding the right of all people to the highest attainable standard of health as a fundamental human right, and that ‘violations or lack of attention to human rights can have serious health consequences’.

 

In recognising the linkages and operational relationships that exist between health and human rights, the nursing profession respects the human rights of Australia’s Aboriginal and Torres Strait Islander peoples as the traditional owners of this land, who have ownership of and live a distinct and viable culture that shapes their world view and influences their daily decision making. Nurses recognise that the process of reconciliation between Aboriginal and Torres Strait Islander and non-indigenous Australians is rightly shared and owned across the Australian community. For Aboriginal and Torres Strait Islander people, while physical, emotional, spiritual and cultural wellbeing are distinct, they also form the expected whole of the Aboriginal and Torres Strait Islander model of care.

The Code stops short of using words like colonisation and racism, but the National Aboriginal Community Controlled Health Organisation background paper “Creating the Cultural Safety Training Standards and Assessment Paper” (2011, p. 9) points out that awareness and sensitivity training, result in individuals becoming more aware of cultural, social and historical factors and engaging in self-reflection however if there isn’t an institutional response and the responsibilities for institutional racism remain individualised:

Even if racism is named, the focus is on individual acts of racial prejudice and racial discrimination. While historic overviews may be provided, the focus is again on the individual impact of colonization in this country, rather than the inherent embedding of colonizing practices in contemporary health and human service institutions

The focus is on the individual and personal, rather than the historical and institutional nature of such individual and personal contexts.

Cultural Respect
The concept of cultural respect (Aboriginal Cultural Security: Background Paper, Health Department of Western Australia) comes the closest to embedding the health care system with policies and practices to help improve the health care outcomes of Aboriginal and Torres Strait Islander peoples. Having a cultural respect framework means that there is an acknowledgement that:

the health and cultural wellbeing of Aboriginal and Torres Strait Islander peoples within mainstream health care settings warrant special attention.   Cultural Respect is the:  recognition, protection and continual advancement of the inherent rights, cultures and tradition of Aboriginal and Torres Strait Islander Peoples. ….   [it] is about shared respect ….[and] is achieved when the health system is a safe environment for Aboriginal and Torres Strait Islander peoples and where cultural differences are respected. It is commitment to the principle that the construct and provision of services offered by the Australian health care system will not compromise the legitimate cultural rights, values and expectations of Aboriginal and Torres Strait Islander peoples. The goal is to uphold the rights of Aboriginal and Torres Strait Islander peoples to maintain, protect and develop their culture and achieve equitable health outcomes.

The framework includes the following dimensions:
Knowledge and awareness, where the focus is on understandings and awareness of  history, experience, cultures and rights of Aboriginal and Torres Strait Islander peoples.
A focus on changed behaviour and practice to that which is culturally appropriate. Education and training and robust performance management processes are strategies to encourage good practice and culturally appropriate behavior.
Strong relationships between Aboriginal and Torres Strait Islander peoples and communities, and the health agencies providing services to them. Here the focus is on the business practices of the organization to ensure they uphold and secure the cultural rights of Aboriginal and Torres Strait Islander peoples.
Equity of outcomes for individuals and communities. Strategies include ensuring feedback on relevant key performance indicators and targets at all levels.
What I like about this framework is that it goes beyond attitudes and knowledge-based to also demand changed behaviour and action that leads to culturally safe healthcare for Aboriginal and Torres Strait Islander peoples. Central to cultural respect is the need for organisations to engage with and seek advice from local Aboriginal or Torres Strait Islander communities.
Cultural Security
Another new term is the notion of cultural security (developed by the Department of Health, Western Australian Health, 2003, Aboriginal Cultural Security: A background paper, page 10) which focuses on behavior: the practice, skills and behaviour of both professionals as individuals and the health system:

commitment to the principle that the construct and provision of services offered by the health system will not compromise the legitimate cultural rights, values and expectations of Aboriginal people. It is a recognition, appreciation and response to the impact of cultural diversity on the utilisation and provision of effective clinical care, public health and health system administration

Cultural Responsiveness
Defined by the Victorian Health Department as: The capacity to respond to the healthcare issues of diverse communities. This term broadly considers diversity rather than the unique needs of Aboriginal and Torres Strait Islander peoples which are a consequence of colonialism and racism.
Cultural Competence

The term ‘Cultural competence’ originates from Transcultural Nursing developed by Madeleine Leininger. Borrowing from anthropology, the aim was to develop a model that encouraged nurses to study and understand cultures other than their own. You can read my paper on the complementariness of cultural safety and competence here. Wellness for all: the possibilities of cultural safety and cultural competence in New Zealand. Betancourt, et al., 2002, p. v define it as:

the ability of systems to provide care to patients with diverse values, beliefs and behaviours, including tailoring delivery to meet patients’ social, cultural and linguistic needs

The Australian National Health and Medical Research Council (NHMRC)’s  Cultural Competency in Health: A guide for policy, partnerships and participation supports the notion of the capacity of the health system to improve health and wellbeing by integrating culture into the delivery of health services, but the scope of the document does not extend to cultural competency as applied to Aboriginal and Torres Strait Islander health care.
Government interventions to address health inequities are being deployed in tandem with neoliberalism and economic globalisation, which push back responsibility to individuals. Now, more than ever, attention needs to be paid to power relations and structures that contribute to inequality in society and injustice within nursing, using approaches that consider equity and the social determinants of health. I personally am looking forward to the day when we don’t need this sign, because there isn’t a gap.
Mind-the-Gap
What you can do:
Support the Close the Gap campaign
Dr Tom Calma’s (Aboriginal and Torres Strait Islander Commissioner )  Social Justice Report 2005 instigated a human rights-based approach Campaign to close the gap in life expectancy between Indigenous and non-Indigenous Australians (up to 17 years less than other Australians at the time). This report called on all Australian governments to commit to achieving equality of health status and life expectancy within a generation (by 2030).
A coalition drawn from Indigenous and non-Indigenous health and human rights organisations formed the Close the Gap Campaign, which was launched in April 2007 by Catherine Freeman and Ian Thorpe, the Campaign’s Patrons.  The CTG Campaign is currently Co-Chaired by the Aboriginal and Torres Strait Islander Social Justice Commissioner Mick Gooda and Co- Chair of the National Congress of Australia’s First Peoples, Kirstie Parker. The Campaign Steering Committee is comprised of 32 health and human rights organisations. The members of the Campaign Steering Committee have worked collaboratively for approximately nine years to address Aboriginal and Torres Strait Islander health inequality through two primary mechanisms: attempting to gain public support of the issue and demanding government action to address it.
Some useful videos
Aboriginal and Torres Strait Islander health videos:
http://blogs.crikey.com.au/croakey/2013/08/04/youtube-an-excellent-resource-for-aboriginal-and-torres-strait-islander-health/Cultural competence video:
https://www.youtube.com/watch?v=JpzLzgeL2sADr Tom Calma – Cultural Competency
https://www.youtube.com/watch?v=tnYuTY0fn3s
White privilege: Unpacking the invisible knapsack
http://amptoons.com/blog/files/mcintosh.htmlWhat kind of Asian are you?
https://www.youtube.com/watch?v=DWynJkN5HbQReverse racism, Aamer Rahman:
https://www.youtube.com/watch?v=dw_mRaIHb-M
Terminology
Aboriginal and Torres Strait Islander peoples are the first inhabitants of Australia.  Aboriginal people are extremely heterogenous groups differing in language and tradition. Torres Strait Islander peoples come from the islands of the Torres Strait, between the tip of Cape York in Queensland and Papua New Guinea but who may live on mainland Australia. The term ‘Indigenous’ is often used to refer to both Aboriginal and Torres Strait Islander peoples. In the spirit of being both relational and political then I’d like to share with you my learning about cultural competency and Aboriginal and Torres Strait Islander health care.

‘This child is a planned baby’: skilled migrant fathers and reproductive decision-making

Article first published online: 13 MAY 2014  De Souza, Ruth Noreen Argie. (2014). ‘This child is a planned baby’: skilled migrant fathers and reproductive decision-making. Journal of Advanced Nursing. doi: 10.1111/jan.12448

Risk management and life planning are a feature of contemporary parenting, which enable children to be shaped into responsible citizens, who are successful and do not unduly burden the state (Shirani et al. 2012). This neoliberal project of intensive parenting and parental responsibility (typically gendered as maternal) involves child centredness and detailed knowledge of child development (Hays 1998). Simultaneously, contemporary masculinities are increasingly being situated beyond the traditional Western binary of the active home-caring mother and passive breadwinning father. Following Connell (1995), the plural word masculinities refers to the many definitions and practices of masculinity (See e.g. Archer 2001, Cleaver 2002, Finn & Henwood 2009, Haggis & Schech 2009, Walsh 2011). Broader and more inclusive repertoires of fathering emerge from diverse family practices and formations including queer/homoparental families; cohabitation; new technologies; changing domestic labour arrangements; the changing organization of childcare and growing involvement of fathers; and social policy initiatives including parental leave and family-friendly employment practices (Draper 2003).

These rapid societal changes have ushered in new forms of participatory fathering and family involvement for men in the Western world. However, the pressure to integrate traditional breadwinner and authority figure roles with contemporary demands for involvement in all aspects of the perinatal period has not been matched by reduced work pressures or the provision of active societal support and preparation (Barclay & Lupton 1999). As a result, men often feel isolated, excluded, uninformed and unable to obtain resources and support in the perinatal period placing pressure on relationships, challenging feelings of competence and requiring negotiation of competing demands (Deave & Johnson 2008). Furthermore, men have gender- specific risk factors for perinatal distress including their more limited support networks; dependence on partners for support; additional exposure to financial and work stresses; a more idealized view of pregnancy, childbirth and parent- hood stemming from a lack of exposure to contemporary models of parenting; and lastly being less keen to seek help with emotional problems (Condon et al. 2004). All of these factors are compounded by practitioners and services oriented towards mothers and babies marginalizing fathers (Deave & Johnson 2008, Lohan et al. 2013).