Chapter 3 Cultural Competence

Cultural Competence and Communication

After completing this chapter the reader will be able to:

These topics address the Medical Council exam objectives, especially section 78-9. https://www.mcc.ca/objectives/expert/key/78-9/

Note: The colored boxes contain optional additional information; click on the box open it and to close it again.
Words in CAPITALS are defined in the Glossary

Dr. Middleton meets Darryl Crow

In the staff room, Dr. Rao is having lunch with the most recent recruit to the clinic. Dr. Middleton joined the practice six months ago, after her residency training. She has had a difficult morning. During her rounds of the palliative care unit, the chief nurse was having problems with the family of one of the dying patients, Darryl Crow, who is a member of a local First Nations community.  Five or six family members are in the room with Darryl and they often pray out loud together with him. Other patients in the unit and their families were finding this behaviour disrespectful of their need for tranquility.

Cultural Awareness, Sensitivity, and Safety

In Chapter 2 we defined culture in terms of the shared knowledge, beliefs, and values that characterize a social group. Humans have a strong drive to maintain the sense of identity that comes from membership in an identifiable group. In hunter-gathering and nomadic times, a person’s survival likely benefited from establishing strong bonds with an in-group of trusted clan-mates with whom one co-operated and shared, versus out-groups with whom one competed for scarce resources. Within the intermixing of modern society, many of us seek to retain a sense of cultural identity and may often refer to our cultural roots, for example using double-barrelled descriptions such as African-American or Ukrainian-Canadian.

Culture and individual identity

Everyone is unique, but there are patterns of similarity. Culture refers to the shared parts, but of course we all belong to many different sub-cultures (your medical class, the soccer team, Irish descent, etc.), so the joint influence of all of these may make a seemingly unique individual. But even though we are unique, most elements in our makeup are shared with some identifiable group.

We all perceive others through the filter or perspective of our own cultural upbringing, often without being aware of it: communication can go wrong without our understanding why. This can easily occur in the doctor-patient encounter and the clinician must become culturally aware and sensitive, then culturally competent so that she or he can practice in a manner that is culturally safe (see the Definitions box for details).

Cultural concepts

Cultural awareness refers to observing and being conscious of similarities and contrasts between cultural groups, and understanding the way in which culture may affect different people’s approach to health, illness, and healing.

Cultural sensitivity is being aware of (and understanding) the characteristic values and perceptions of your own culture and the way in which this may shape your approach to patients from other cultures.

Cultural competence refers to the attitudes, knowledge, and skills of practitioners necessary to become effective health care providers for patients from diverse backgrounds. “A culturally competent physician considers a patient’s cultural background when discussing and providing medical advice and treatment, and communicates effectively to enable patients to understand their treatment options.”1

Cultural safety goes a step beyond cultural competence (adapting to differences) to recognizing that there exist inherent power imbalances and possible institutional discrimination that derive from historical relationships between people of different origins. It implies that the care provider has reflected on her own identity and on the perceptions of her that others from different cultures may hold. Culturally safe practice implies the ability to keep these differing perspectives in mind whilst treating the patient as a person worthy of respect in his own right.

In medical practice, cultural competency requires that the clinician respects and appreciates diversity in society. “As physicians, we must make multiple communication adjustments each day when interacting with our patients to provide care that is responsive to the diverse cultural backgrounds of patients in our highly multicultural nation.”2 Culturally competent clinicians are self-aware; they acknowledge differences without feeling threatened by them. Awareness of one’s own culture is an important first step towards cultural competency. Clinicians who are not aware of their own cultural biases may unconsciously impose their values on other people (more detail in the Nerd’s Corner box “The cultural lens”). A culturally competent clinician is aware of the dynamics when cultures interact: “Culturally competent communication leaves our patients feeling that their concerns were understood, a trusting relationship was formed and, above all, that they were treated with respect.”2 For clinicians unfamiliar with a patient’s culture, a direct approach is often best: ask the patient what you need to understand about her culture and background in order to be able to help her.

Cultural safety refers to a consultation in which the patient feels respected and empowered, and that his or her culture and understanding of health has been acknowledged and respected. Cultural safety concerns protecting the patient’s feelings in the health care encounter, while cultural competence refers to the practitioner’s skills in ensuring that the patient feels safe.3 Culturally safe practice requires the practitioner to reflect on, and work to avoid, the power differentials inherent in delivering health services; it implies acting as a health advocate. A culturally safe approach also implies acting as a health advocate: working to improve access to care; exposing the social, political, and historical context of health care. A patient may exist simultaneously within several caring systems – influenced by their family, community, and traditions – so the culturally safe practitioner allows the patient to define what is culturally safe for them.4, 5

The cultural lens

Our culture influences the way we perceive virtually everything around us, often unconsciously. Here are some biases that can arise:

Ethnocentrism. The sense that one’s own beliefs, values, and ways of life are superior to, and more desirable than, those of others. For example, you may be trained in Western medicine, but your patient insists on taking a herbal remedy. You may be tempted to ask “So, why consult me, then?” Ethnocentrism is often unconscious and implicit in a person’s behaviour – perhaps you have little interest in learning more about the herbal remedy. Personal reflection is a valuable tool for physicians to critically examine their own ethnocentric views and behaviours.

Cultural blindness. This refers to attempts (often well-intentioned) to be unbiased by ignoring the fact of a person’s race. It is illustrated in phrases such as “being colour blind”, or “not seeing race”. A person who is culturally blind may feel they are being fair and unprejudiced. However, ignoring cultural differences may make people from another culture feel discounted or ignored; they may receive the message that their race or culture is unimportant, and that values of the dominant culture should take precedence. Meanwhile, cultural blindness makes the person unaware of how they are making others feel, so it becomes the opposite of cultural sensitivity.

Culture shock. Most physicians come from middle-class families and have not experienced poverty, homelessness or addictions. Exposure to such realities in their patients can be distressing and requires adaptation. This is a common experience in those who have visited a slum in a developing country, but shock may also arise at home in confronting abortion, infanticide, or female circumcision.

Cultural conflict: tensions that arise when the rules of one’s own culture are in contradiction with the rules of another. For example, in Mr. Crow’s First Nation culture it is normal when a person is dying to invite extended family members to the bedside, to sing songs and undertake rituals to help the person’s soul on its journey; the noise can easily frustrate other dying patients who wish for peace and quiet.

Cultural imposition (also cultural assimilation or colonialism). The imposition of the views and values of  dominant culture without consideration of the beliefs of others. The history of residential schools in Canada illustrates cultural imposition, and the CBC web archive gives an excellent overview, including government propaganda video clips.

Stereotyping and generalization. What may be true of a group need not apply to each individual, so talking  about cultures can lead to dangerously prejudicial generalizations. Prejudice is the tendency to use preconceived notions about a group in pre-judging one of the group’s members, so applying your cultural awareness to individuals can be hazardous. Yet, on the other hand, ignoring culture (cultural blindness) can be equally detrimental. The key is to acknowledge and be respectful of differences, and to ask patients to explain their perspective when you are in doubt.

Dr. Rao and Mr. Crow

Dr. Rao describes to Dr. Middleton how he has had similar experiences with dying patients from Mr. Crow’s First Nations community. After discussions with the palliative care staff they agreed that people from that community should be admitted to a room at the end of the corridor, from which other patients would not hear the prayers. He recalls that it was difficult to get agreement on this solution as some staff members were concerned about the impression of discriminatory treatment for members of Mr. Crow’s community. The matter was eventually resolved after a community spokesperson was invited to a staff meeting to discuss the community’s practices and beliefs relating to death. Unfortunately, since that time, staff turnover has led to the needs of Mr. Crow’s community members being forgotten again.

The Relevance of Culture for Health

Culture influences health through many channels:

  1. Positive or negative lifestyle behaviours. While we often focus on the negative influences of cultures on health behaviours—drug cultures, or the poor diet of some teen cultures, for example—we should not neglect positive cultural influences. For example, Mormons and Seventh Day Adventists live longer than the general population, in part because of their lifestyle including the avoidance of alcohol and smoking, but also because of strong social support.6 (See the Illustration box “Reactions to poverty”).
  2. Health beliefs and attitudes. Culture influences what a person views as an illness that requires treatment; and also which treatments and preventive measures he or she will accept (as with the Jehovah’s Witness prohibition on using whole blood products).
  3. Reactions to being sick. A person’s adoption of the sick role (and, hence, how he or she or he reacts to being sick) is often guided by his or her cultural roots. For instance, “machismo” may discourage a man from seeking prompt medical attention, and culture may also influence from whom a person will accept advice.
  4. Communication patterns, including language and modes of thinking. Beyond these, however, culture may constrain some patients from expressing an opinion to the doctor, or may discourage a wife from speaking freely in front of her husband, for example. Such influences can complicate efforts to establish a therapeutic relationship and, thereby, to help the patient.
  5. Status. The way in which one culture views another may affect the relative status of entire groups of people. The resulting social inequality or even exclusion forms a health determinant. This may also happen within a culture, as when women in some societies have little power to insist on condom use.
  6. Interventions. Individual or public health interventions that do not respect the culture and values of the target group are likely to fail; interventions are most successful when members of that community  actively engage in their design.7 Similarly, patients should be involved in the planning of their own care.

Reactions to poverty

Sociologists in the 1960s and 1970s discussed “the culture of poverty”. The core idea was that people living in poverty tend to develop patterns of attitudes and behaviors that contribute to perpetuating their poverty (and thereby their poor health). This idea attracted major criticism because it seemed to blame the poor for their condition and direct attention away from the root causes of poverty, which lie in social structures. However, people living in poverty may share some attitudes that are relevant for the clinician to understand. These perspectives may originate as survival mechanisms; for example,

  • When you are poor and sick the future looks bleak so you try to ignore it, to live in the present, and plan only in the short term
  • When a person with few choices is trying to survive from day to day, long-term health is less of a priority than getting through today
  • Behaviours that may seem irresponsible to those who are living comfortably often have a different meaning to people in marginal situations.  For instance, adolescent pregnancy may offer a route to self-esteem; substance use may be an antidote to reality. Both, ultimately, serve to maintain poverty, but reflect a short-term perspective
  • A person living in poverty may not follow the doctor’s advice; he may lack the time, money, or opportunity that the doctor may take for granted. A person without a drug plan may not be able to afford the antibiotic you just prescribed
  • Poverty feeds feelings of vulnerability, dependency and marginality; these erode belief in the possibility of change
  • Do not confuse schooling with intelligence. Many people with little formal schooling have no difficulty understanding new concepts when they are properly explained.8 “When you don’t got a lot of education, you sure gotta use your brains” (attributed to Yogi Berra).

Types of Cultures

Cultural characteristics can be classified into patterns to help make sense of differences that might otherwise seem somewhat random. A useful classification for the practising clinician distinguishes between collectivistic and individualistic cultures or societies. Collectivist cultures (which include some traditional Chinese families and certain African groups) hold values of sharing, of group or family solidarity, and emotional interdependence that emphasize duty and mutual obligations, including group decision making. By contrast, individualistic societies (such as mainstream North America) value autonomy, individual initiative and emotional independence, the right to privacy, pleasure seeking, and financial security. People from collectivistic cultures who come to North America often feel isolated and find the way we expect people to take responsibility for their own health difficult to understand. Families from collectivist cultures commonly care for elderly relatives in the family home, forming three-generational families. By contrast, families from individualistic cultures often place their aging relatives in residential care homes. For a more extensive cultural classification, click on the “Further details” box.

Further details on cultural types

The following table was based on the work of a Dutch sociologist, Geerd Hofstede, and portrays an extension of the individualist-collectivist contrast into other areas of daily life.9 Some general implications for health and medical care are suggested.

Identity: individualism vs. collectivism.
Are people seen as unique and valued for their personal achievements?
Or, are they seen as members of a social group (family, class, organization, or team) that takes precedence over the individual?
In individualistic countries (Canada, USA), people are responsible for themselves and initiative is valued; people have relatively weak ties to their group (work, university, organization). In collectivist societies, such as China or Japan, a person’s identity is based on their group membership, so they value tight social frameworks and a feeling of belonging to a group. Mutual obligations between people will be strong.
Relevance to medicine: People from individualistic cultures may expect to make their own decisions regarding their health. It is common for people from collectivist cultures to make therapeutic decisions as a member of a group; group pressures may strongly influence the individual, who may fear a sense of shame if he or she does not comply. Collectivist societies value harmony, whereas individualistic societies value self-respect and autonomy.
Power distance:
How does the society deal with inequality? How tolerant is it of unequal power?
In cultures such as those in Arabic countries, or in Mexico or India, subordinates tend to follow authority, to respect and accept their boss merely because of his position. In Hofstede’s phrase, “power distance” is high and “everyone has his place”.
Relevance to medicine: Patients from a society that accepts power hierarchies commonly follow the doctor’s orders without question. By contrast, patients from societies with lower power distance may not automatically respect a doctor’s opinion and may question the reasons for making a recommendation.
Avoidance of uncertainty:
The norms and beliefs regarding how people react to ambiguous situations.
Countries such as Japan, France, or Greece tend to avoid uncertainty; they prefer predictability and, therefore, develop strict hierarchies, laws, and procedures. Deviant ideas are discouraged and consensus is important; there is typically a strong sense of nationalism. In Nordic or Anglophone countries, people seem more tolerant of ambiguity; they dislike structure and are less nationalistic. But they are viewed as disorganized and confused by people from uncertainty-avoidant countries.
Relevance to medicine: People from cultures that avoid uncertainty may wish their doctor to present a clear and specific therapeutic plan. People from cultures that tolerate uncertainty may accept that there are always alternative approaches; a therapy may be tried and if it works, great, but if it does not, another one may.
Masculinity:
How polarized are men’s and women’s roles in society? Are men assertive and women submissive, or are they more equal?
Countries such as Mexico, Germany, or Japan espouse traditional masculine values such as assertiveness, materialism, and limited concern for others. People work long hours and their job is of central importance. Gender roles are clearly distinguished: the husband may make decisions for the wife. By contrast, in low masculinity cultures (e.g., Nordic countries) role differences are less marked and they value quality of life and concern for others.
Note, however, that universal trends such as the women’s movement and dual-career families are eroding the gap between high- and low-masculinity cultures.
Relevance to medicine: Masculine values tend to coincide with a clear distinction between gender roles: often the husband will make decisions for the wife.
Orientation to time:
Do people focus on long-term or short-term goals?
Western societies typically have a short-term focus and view time as a valuable resource. There is an emphasis on attending to one thing at a time. For other societies (African, Caribbean, and some Indian groups) time urgency is much less central. They may be polychronic (lots of things can happen at once and things can be put off to later: mañana).
Relevance to medicine: Patients from less time-urgent cultures may not be punctual (“eight o’clock Jamaica time” means any time after around nine or nine-thirty – roughly). In some Arabic cultures, setting a deadline may be viewed as insulting: important things take a long time and cannot be rushed.

Indigenous Peoples in Canada

A prominent Canadian cultural theme concerns the history of our Indigenous peoples, and many historical events have exerted a lasting effect on their health. These determinants include systemic racism, seen in the inadequate services for those living on reserves, forced relocations and placement of children in residential schools, or the sixties scoop policies that enabled child welfare authorities to place indigenous children in foster homes. All these are compounded by ignorance of the impact of these experiences in the mainstream society.

By imposing Western cultural values and laws, Canada profoundly influenced many determinants of health for First Nations, Inuit and Métis peoples. This colonization has been described as a “process of encroachment and subsequent subjugation of Indigenous peoples since the arrival of the Europeans. From the Indigenous perspective, it refers to the loss of lands, resources, and self-direction and to the severe disturbance of cultural ways and values.”10 Through attempts at cultural assimilation, Indigenous groups lost their land, self-government systems, cultures, languages, health care and education systems and their traditional economies. This has left Indigenous peoples worse off than other Canadians in social and economic terms, with profound implications for their health. The National Aboriginal Health Organization (NAHO) refers to the adverse impact of colonization on environmental change; on the destruction of traditional economies and self-sufficiency; on damage to traditional nutrition patterns and traditional forms of care; and NAHO documented the impact of loss of self-determination on identity and consequently on suicide rates.11 NAHO suggests that there is some preliminary evidence that the transfer of authority over service delivery will lead to better health outcomes for Aboriginal Peoples.

A widely discussed issue is the impact of residential schooling. Residential schools formed a systematic attempt to assimilate Indigenous groups. The government educational program started around 1874, working with mission schools whose aim was to convert Indigenous people to Christianity. Compulsory attendance began in the 1920s and the last residential school closed in 1996. Children were taken from their families and communities into the schools, although some families, believing that school would enable their children to live in the white society, were not against it: see, for example, Tomson Highway’s autobiographical novel Permanent AstonishmentAt school, children were forbidden to speak their native languages and were expected to respect values and norms very different from those in their homes. The experience for most children was distressing and for some, devastating. Many experienced sexual and physical violence, described in Tomson Highway’s novel Kiss of the Fur Queen. The residential school program failed in its goal of destroying Indigenous languages and traditions, but did erode those cultures and the people’s dignity. The legacy includes a loss of identity and feelings of alienation and cynicism towards the rest of society. The spiral of personal health problems arising from this trauma include addictions, abusive relationships and suicide. These are at risk of being transmitted to younger generations – victims who have been abused and have not healed may in turn abuse others. The truth and reconciliation movement has worked hard to heal from this trauma and ensure the resilience of young Indigenous people and their cultures. A health care work force that provides culturally safe care is a necessary part of that healing.

Colonization has exerted lasting health effects, the “cumulative, emotional and psychological wounding across generations (…) which emanates from massive group trauma.”12 The legacy includes a lack of cultural understanding between Indigenous and non-Indigenous Canada and feelings of distrust between the two. However, “At the same time, First Nations, Inuit, and Métis peoples have shown great resiliency in dealing with these challenges and have a rich body of knowledge and traditions to share. Traditional knowledge and ways of healing continue to be facilitated through healers, midwives, and traditional medicine persons who constitute a significant Indigenous health provider system.”5 Indigenous medicine contains innumerable herbal remedies, some of which have formed the basis for pharmaceutical treatments  routinely used in Western medicine. The bark of the Pacific yew tree was used traditionally for centuries and formed the source of taxol for breast cancer. Indigenous healing approaches are holistic in that they consider mind, body and spirit, as implied in the WHO definition of health. Indigenous medicine is distinguished from healing, which goes beyond mere treatment of sickness and often involves a spiritual dimension (see the Illustration box).

The contrasts between Western medicine and traditional Indigenous approaches to healing may make it challenging for practitioners of Western medicine to meet Indigenous patients’ needs; tension and misunderstandings can arise. Accordingly, in many cities medical facilities are being developed that try to integrate Western medicine with Aboriginal teachings; the Anishnawbe Health centre in Toronto is an example. NAHO offers guidelines on practising culturally safe health care for Indigenous patients. These cover the provision of separate rooms in the hospital; the need to allow Indigenous patients access to ceremony, song and prayer; respect for a patient’s need for ceremonial items; the need for information and for family support; guidelines for the appropriate disposal of body parts; and guidelines for handling death.3

Indigenous healing practices

The following are some healing practices associated with First Nations cultures, commonly performed by community elders:

Smudging
A smudge is smoke used for ritual cleansing. Smudging is a ceremony traditionally practiced in some First Nations cultures to physically or spiritually purify or cleanse negative energy, feelings, or thoughts from a place or a person. Sacred medicines such as cedar, sage, sweet grass, or tobacco are burned in an abalone shell. The person puts their hands in the smoke and carries it to their body, especially to areas that need spiritual healing (mind, heart, body).

Healing circles
Meetings held to heal physical, emotional, and spiritual wounds. A symbolic object, often an eagle feather, may be given to a person who wishes to speak, and then it is passed around the circle in sequence to others who wish to speak. Shamans may conduct the ceremony.

Sweat lodge (a.k.a. purification lodge)
A ceremonial sauna used for healing and cleansing. It is made of a wooden framework covered by blankets or skins, usually dome-shaped, about 1.5 metres high, and large enough for eight people to sit in a circle on the ground. Hot stones are placed in a shallow hole in the centre of the lodge. A medicine man pours water on the stones to produce steam and participants may spend an hour sweating in the lodge. The lodge combines the four elements of fire, water, air, and earth. Ceremonies include offerings, prayers, and reverence. At times, excessive exposure to the heat of the lodge may be damaging; environmental toxins can also be released if grasses that have been exposed to pesticides are placed on the rocks.

Sun Dance (a.k.a. Rain Dance, Thirst Dance, Medicine Dance)
Rituals that celebrate the harmony between man and nature, and spiritual dedication. Originally practiced at the summer solstice, the sun dance represents continuity between life, death, and regeneration. The symbolism often involved the buffalo, on which Plains Indian groups depended and so deserving reverence, but which they also had to kill for sustenance. Four days before the ceremony, the dancers prepare by purifying themselves, at times in a sweat lodge, by meditating and collecting ceremonial items of dress to use in the sun dance. The sun dance itself takes another four days and generally involves drumming, singing and dancing, but also fasting and, in some cases, self-inflicted pain. This symbolizes rebirth and often involved piercing the skin and attaching cords that the person had to tear out. This element led governments to suppress the sun dance around 1880, but it has since been revived.

Pipe ceremony
The pipe is used individually and in groups for prayer and ceremonial purposes. Participants gather in a circle. A braid of sweet grass is burned to purify the area and those present to make a sacred place for the spirits to visit. Tobacco or kinnickkinnick, a traditional mixture of bearberry and wild herbs or red willow shavings, is smoked so that prayers can be made to the Great Spirit or requests made of the spirits. The pipe may also be smoked to open other meetings or ceremonies. When not in use, the bowl and stem are separated and carried by one person, the pipe holder.

Potlatch
A ceremonial feast among northwest Pacific coast Native peoples held to celebrate major family events, such as a marriage or birth. The host distributes gifts according to the status of each guest, reinforcing the perceived hierarchical relations between groups. On occasion the gift-giving becomes competitive, the host giving away personal possessions in anticipation that others would reciprocate in their turn. Such largesse enhanced the host’s prestige. Missionaries encouraged the government to outlaw the Potlatch around 1885, but this ban proved impractical to enforce and was eventually repealed. The ceremony is now commonly practiced.

Self-Test questions

1. What elements of a patient’s culture would you consider when deciding how best to manage the case?

Cultural influences may affect the patient’s reaction to the disease, to your suggested therapy, and to your efforts to help them prevent recurrences by changing risk factors. Therefore, it may be important to find out about such possibilities; you can explain that you need them to tell you about their family’s and community’s feelings about your recommendations. Explain that you are not familiar with their community and want them to tell you if they may have beliefs or obligations that you should be aware of, such as any restrictions on diet, medications, etc., if these could be relevant.

2. Outline at least one difference between cultural competence and cultural safety.

Cultural competence is included within cultural safety, but safety goes beyond competence to advocate actively for the patient’s perspective, to protect their right to hold the views they do. When a patient knows that you will honour and uphold their perspective and not try to change it, they will be more likely to accept your recommendations. A physician who practices culturally safe care has reflected on her own cultural biases recognizes them and ensures that her biases do not impact the care that the patient receives. This pattern of self-reflection, education and advocacy is also practiced at the organizational level.

3. How do the effects of colonization continue to impact on the health of Indigenous Peoples in Canada?

By imposing Western cultural values and laws, Canada profoundly influenced all the determinants of health for First Nations, Inuit and Métis peoples. Through attempts at cultural assimilation, they lost their land, self-government systems, cultures, languages, health care and education systems, economies, etc. One cannot have health and wellness when so many of the determinants of health are not met.  A more recent issue has been the lasting impact of residential schooling. This formed a systematic attempt to destroy the languages, traditional cultures and thereby the dignity of First Nations, Inuit and Métis peoples. Most Canadians are only now learning about the abuses of this system which began with the forcible removal of children from their parents, families, communities and cultures and sometimes included sexual and physical violence against children. This has left a legacy among Indigenous peoples of feelings of a loss of identity, alienation and cynicism towards the rest of society. The spiral of personal health problems that have arisen as a result of this trauma include addictions, abusive relationships (victims who have been abused and have not healed in turn abuse others) and suicide, which are at risk of being transmitted to younger generations. Indigenous communities have been working hard to heal from this trauma and ensure the resilience of their young people and their cultures. Having a health care workforce that can practice culturally safe care is part of that healing.

References

  1. Hruschka DJ, Hadley C. A glossary of culture in epidemiology. J Epidemiol Community Health. 2008;62:947-51.
  2. Caron N. Caring for Aboriginal patients: the culturally competent physician. Royal College Outlook. 2006;3(2):19-23.
  3. National Aboriginal Health Organization. Cultural competency and safety: a First Nations, Inuit, and Métis Context & guidelines for health professionals 2007 [May, 2015]. Available from: http://www.naho.ca/documents/naho/publications/UofT2007.pdf.
  4. Spence D. Hermeneutic notions illuminate cross cultural nursing experiences. J Adv Nurs. 2001;35(4):624-30.
  5. Indigenous Physicians Association of Canada. First Nations, Inuit, Métis health: core competencies: a curriculum framework for undergraduate medical education Ottawa: Association of Faculties of Medicine of Canada; 2008 [cited 2010 Web Page]. Available from: http://www.afmc.ca/pdf/CoreCompetenciesEng.pdf.
  6. Merrill RM. Life expectancy among LDS and Non-LDS in Utah. Demographic Research. 2004;10(3):61-82.
  7. Panter-Brick C, et al. Culturally compelling strategies for behaviour change: a social ecology model. Soc Sci Med. 2006;62(11):2810-25.
  8. Benson DS. Providing health care to human beings trapped in the poverty culture: reconciling the inner self with the business of health care. Physician Executive. 2000;26(2):28-32.
  9. Hofstede G. Cultures and organizations: software of the mind. London: McGraw-Hill; 1991.
  10. National Aboriginal Health Organization. Broader Determinants of Health in an Aboriginal Context Ottawa: NAHO; [cited 2011]. Available from: http://www.naho.ca/documents/naho/publications/determinants.pdf.
  11. LaRocque E. Violence in Aboriginal communities Ottawa: Royal Commission on Aboriginal Peoples; 1993 [cited 2011 Web Page]. Available from: http://dsp-psd.pwgsc.gc.ca/Collection/H72-21-100-1994E.pdf.
  12. Dodgson J. Indigenous women’s voices. J Transcult Nurs. 2005;16(4):339.
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