Chapter 3 Cultural Competence

Cultural Competence and Communication

After completing this chapter the reader will be able to:

Linking these topics to the Medical Council exam objectives, especially section 78-7.

Dr. Middleton meets Darryl Crow

In the clinic 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 said he 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 against which there was competition 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 box for definitions).

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 understanding 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.

Cultural competency in medical practice 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 and value diversity; 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 cultural 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 When a clinician is unfamiliar with a patient’s culture, a direct approach is often the best: ask the patient what you need to understand about her culture and background in order to be able to help her.

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 say “So, why are you consulting me, then?” Ethnocentrism is often unconscious and implicit in a person’s behaviour – perhaps you had little interest in reading up on 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 are universally applicable. Meanwhile, the culturally blind person is unaware of how they are making others feel, so cultural blindness becomes, in effect, 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 therefore requires adaptations and can be distressing. This is a common experience in those who have visited a slum in a developing country, but may also arise at home in confronting abortion, infanticide, or female circumcision.

Cultural conflict. Conflict generated when the rules of one’s own culture are contradicted by 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 seek peace and quiet.

Cultural imposition (also cultural assimilation or colonialism). The imposition of the views and values of your own culture without consideration of the beliefs of others. The history of residential schools in Canada is an illustration of cultural imposition, of which 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. Hence, 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 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.

Cultural safety refers to a doctor-patient encounter in which the patient feels respected and empowered, and that his or her culture and understanding has been respectfully acknowledged. 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 health service delivery. Taking 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

Dr. Rao and Mr. Crow

Dr. Rao explains to Dr. Middleton that he has had similar experiences with other dying patients from Mr. Crow’s First Nations community. He had discussed this with the palliative care staff and they agreed that people from that community would 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 preferential 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, there has been staff turnover so the needs of Mr. Crow’s community members are 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 the positive cultural influences on behaviours and practices. For example, Mormons and Seventh Day Adventists have been found to 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
  2. Health beliefs and attitudes. Culture influences what a person views as an illness that requires treatment, and 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 status of entire groups of people, placing them at a disadvantage. The resulting social inequality or even exclusion forms a health determinant. This may also happen within one 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. Population interventions are most successful when community members are actively engaged 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 behaviours 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 people 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 the short-term perspective.
  • A person living in poverty may not follow the doctor’s advice; he may not have the time, the money, or the opportunities that the doctor may take for granted. A poor person may not have a drug plan, so 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

Culture concerns patterns of behaviours and values. At a higher level, these patterns can themselves be grouped and classified to help make sense of differences that might otherwise seem somewhat random. A basic classification will be useful for the practising clinician. A distinction is often drawn between collectivistic and individualistic societies or cultures. Collectivist cultures (including some traditional Chinese families and some African groups) hold values of sharing, of group or family solidarity, and emotional interdependence that emphasize duties and mutual obligations, as well as 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 are often those who will place their aging relatives in residential care homes.

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 term, “power distance” is high and “everyone has his place”.

Relevance to medicine: Patients from a society that accepts unequal power relations tend to 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 tend to 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 provide clear guidance on what they must do. 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 to them. Gender roles are clearly distinguished: the husband may make decisions for the wife. By contrast, low masculinity cultures (e.g., Nordic countries) value quality of life and concern for others. Role differences are less marked.
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 dealing with 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 an insult: 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 the health of Indigenous peoples. These determinants include the creation of the reserve system, forced relocations, forced placement of children in residential schools, inadequate services for those living on reserves, systemic racism, and a lack of comprehension of the effects of these experiences by 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 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) 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 NAHO presentation11 refers to the adverse impact of colonization on environmental change; of the destruction of traditional economies and of self-sufficiency; of the damage of migration and cultural influences on traditional nutrition patterns; of the removal of traditional forms of care; and of the impact of loss of self-determination on identity and consequently on suicide rates.

A widely discussed issue is the impact of residential schooling. Residential schooling was a systematic attempt to assimilate Indigenous groups. The residential school programme started around 1874, taking over from the mission schools whose aim was to convert Aboriginal people to Christianity. Compulsory attendance began in the 1920s. The last residential school closed in 1996. Children were forced away 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. At school, children were forbidden to speak their native languages and they were expected to respect values and norms, which, particularly in relation to child-rearing practices, were very different from those in the children’s homes. The experience for the children was, at the very least, distressing. Some experienced sexual and physical violence. The residential schools programme did not succeed in its goal of destroying Indigenous languages and traditional cultures, but did erode those cultures and the people’s dignity. The residential school legacy includes a loss of identity and feelings of alienation and cynicism towards the rest of society. The spiral of personal health problems that have arisen 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 in turn tend to abuse others. Indigenous communities have been working hard to heal from this trauma and ensure the resilience of their young people and their cultures. A health care work force that provides culturally safe care is a necessary part of that healing.

The cultural trauma of colonization has lasting health effects: “. . . cumulative, emotional and psychological wounding across generations, including the life span, which emanates from massive group trauma.”12 The present-day effects of colonization include a lack of cultural understanding between Indigenous and non-Indigenous Canada and strong feelings of distrust between the two.

“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 that we routinely use in Western medicine. An example is the Pacific yew tree whose bark has been used for centuries and which was 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.

The contrasts between traditional Indigenous healing and Western medicine can 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 a good example. NAHO offers eight guidelines on practising culturally safe health care for Aboriginal patients. These cover the provision of Aboriginal rooms in the hospital; the need to allow Aboriginal 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, which are commonly performed by community elders:

Smudging
A smudge is smoke used for ritual cleansing. Smudging is a ceremony traditionally practiced by 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 have negative health effects; 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 symbolized 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 individual, 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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