Intercultural communication in health care: challenges and solutions in work rehabilitation practices and training: a comprehensive review

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1 Intercultural communication in health care: challenges and solutions in work rehabilitation practices and training: a comprehensive review Daniel Côté This article was published in Disability and Rehabilitation, vol.35, no 2, 2013, p

2 Intercultural communication in health care: challenges and solutions in work rehabilitation practices and training: a comprehensive review Daniel Côté Scientist, Occupational Health and Safety Research Institute Robert-Sauvé (IRSST) Associate professor, Department of anthropology, University of Montreal (Quebec, Canada) IRSST 505, De Maisonneuve West Blvd. Montréal (Québec) H3A 3C2 cote.daniel@irsst.qc.ca Office: (001) ext. 229 Fax. : (001)

3 Abstract Purpose. The purpose of this comprehensive literature review it to explore cross-cultural issues in occupational rehabilitation and work disability prevention. Method. A literature review on cross-cultural issues was performed in medicine, health sciences, and social sciences databases (PubMed, Ingenta, Canadian Centre for Occupational Health and Safety, Ergonomics Abstract, Google Scholar, OSH Update and the Quebec Workers Compensation Board data base). A total of 27 documents published until 2010 in English or French were selected and analysed. Results. Cross-cultural issues in occupational rehabilitation show that representations of pain, communication and therapist-patient relationship and intercultural competence could be presented as the major topics covered in the selected literature. As for the general topic of immigrant workers and OSH, barriers were identified revealing personal, relational, contextual and structural levels that put immigrant and minority workers in situation of vulnerability (ex. linguistic and cultural barriers, lack of knowledge of the system, precarious work or exposition to higher risk hazards, etc.). Cultural issues in occupational rehabilitation put less attention to work-related contextual factors but emphasized on attitude and pain behaviours, perceptions of illness and appropriate treatment, therapist-patient relationship and cultural competences among OT professionals. Conclusions. The growth of immigration in countries such as Canada poses a real challenge to the delivery of health care and rehabilitation services. Despite growing concerns in providing culturally appropriate heath cares, intervention models, tools and training tools are still lacking in occupational rehabilitation and disability management. Nevertheless, cultural competence seems to be a promising concept to be implemented in work rehabilitation and disability management. Keywords: culture; rehabilitation; therapeutic relationship; cross-cultural communication; work IRSST-OA 1

4 Introduction Western industrialized countries have experienced significant sociodemographic changes during the decades following the end of the Second World War. After a significant boost in birth rate until the late sixties, most industrialized nations have witnessed a decline in fecundity. Still nowadays, with the long-lasting decline of birth rates and ageing population many countries have to rely on immigration to counteract the effects of negative population growth (1). This is the case for industrialized countries such as Canada, USA, New Zealand, and Australia, among others, that have secular histories of continuous and sustained immigration. Immigration is not a recent phenomenon in those countries and as time goes by, immigrants and their descendants have constituted socalled ethnocultural communities to which new migrants may participate, contributing to the cultural diversity of the country. Immigrants are socially and culturally diverse and do not constitute a homogeneous group (2-4). Generally, health organizations neither recognize nor value culture-specific ways of doing things, nor do they expect clients to behave, feel or express emotion, or define health and illness the same way. That type of organization has been called monocultural in the literature (5-8). Such organizations may implicitly contribute to the exclusion of vulnerable social groups, to the benefit of the dominant majority (9;10). Health practices may result in cultural blindness (11), misconceptions (12) and even misdiagnosis (13). Workers may experience various and specific needs according to their daily situation (work environment), cultural background and personal experience (ex. previous sickness episode, social role construction, etc.) that ought to be understood and addressed properly in both occupational rehabilitation settings and research proposals. This means that diverging or even conflicting worldviews regarding health and illness may arise in the clinical encounter (14). Some researchers assume that understanding cultural representations of health and illness may help health professionals to facilitate intercultural communication (15). The importance of assessing representations of health and illness has been pointed out elsewhere in the field of occupational rehabilitation (16). If it is right that cultural backgrounds need to be taken into account, then, some questions arise. On the one side, are we providing health and rehabilitation professionals enough resources and training to understand and assess workers view of the illness and personal distress? On the other side, are we providing appropriate facilities to promote healthy behaviours among immigrant workers/ethnocultural minorities? Are we equipped (theoretical frameworks, interventions tools and guidelines) to provide a culturally appropriate response to disability management, return to work or work rehabilitation in regard to the diversity of workforce? This article looks at the cultural issues in occupational rehabilitation with a focus on return to work, when the information is available. In this article, occupational rehabilitation refers to various disciplines, health specialties or return-to-work specialists that have to get in touch with injured workers during the recovery process (ex. Occupational therapy, physical therapy, medicine, nursing, rehabilitation counselling, psychology, industrial relations and other social sciences, etc.). So, every discipline which has to enter into relation with injured workers at different steps of the recovery process is concerned by intercultural issues. Occupational rehabilitation and return to work processes encompass a set of complex relations between different stakeholders (e.g. Workers unions, employers, insurance companies, compensation boards, families, etc.); IRSST-OA 2

5 successful or unsuccessful rehabilitation may impinge upon multiple psychological, relational, legal, administrative, social, and political aspects (17). Work re-entry and job retention may be seen as other aspects of the rehabilitation process (18).Challenges in intercultural communication in the context of healthcare and compensation benefits may be additional hindrances to successful rehabilitation outcomes. Are we certain that our models of knowledge and practices in contexts of cultural diversity are sufficient to enable us to answer this challenge? Objective The general objective of this article is to identify and describe through a comprehensive literature review the emerging themes related to intercultural encounter in the field of occupational rehabilitation and work disability management. More specifically, it aims at: 1) identifying intervention modalities and conceptual framework proposed by researchers in occupational rehabilitation to improve the care of patients from different ethnocultural backgrounds and migration trajectories. Method A review of the literature on cultural issues in rehabilitation was undertaken. From a set of keywords, a documentary inquiry in French and English scientific literature was done. PubMed, Ingenta, Canadian Centre for Occupational Health and Safety (CCHST) data base, Ergonomics Abstract, Google Scholar, OSH Update and the Quebec Workers Compensation Board (CSST) data base were consulted. The following keywords were used: insertion, rehabilitation, occupational rehabilitation, return to work, retour au travail, therapy, treatment AND intercultural (and cross-cultural) communication, crosscultural comparison, cross-cultural differences, cultural characteristics, cultural competence, cultural diversity, cultural factors, culture, ethnic groups, ethnic minority, appartenance culturelle, Work AND immigrant workers, foreign, ethnic groups, occupation, workplace, accidents, occupational diseases, occupational health, occupational medicine. As the question of immigrant workers and occupational health and safety is not merely the primary topic, although it provides complementary comprehensive elements, only review articles were retained to help us grasp the essential themes. A review of the references attached to selected documents has been done to make sure that a maximum of relevant documents are included in our review. A total of 783 articles and reports published until 2009 were found. Inclusion criteria were that studies must: a) address the rehabilitation or return-to-work process in the perspective of immigrants workers or workers from diverse ethnocultural backgrounds; b) have been published over the past twenty years, at which time the biopsychosocial paradigm progressively replaced the biomedical paradigm in the field of occupational rehabilitation, and c) have been published either in French or English. Twenty-six articles and one report were retained and analysed for the purpose of this article. As this summary of the knowledge is exploratory in design and aims to describe emerging themes, quality evaluation of the studies varied from low to very high according to Malterud and Greenhalgh criteria (19;20). A qualitative content analysis was done for every document IRSST-OA 3

6 following some basic steps: thematic coding, categorisation, classification, description, and interpretation (21). Results Emerging themes from reviewed literature and content analysis may be grouped into two broad sections: 1) major themes associated with immigrant workers and occupational safety and health (OSH); 2) major themes on intercultural encounter in occupational rehabilitation and disability management. OSH and occupational rehabilitation are not the same, and yet they have commonalities when injured workers are back to work and the conditions for a sustainable and safe environment have to be settled in the workplace. A summary of the selected papers is presented in Table 1. It has to be specified that all references used in this section correspond to the reviewed literature. Immigrant workers and occupational health and safety Four reviews were retained in the field of immigrant workers and occupational safety and health (3;22-24). Generally speaking, health hazards in the workplace are well understood among OSH agencies, but these reviews highlight that, on the basis of their social position and status, some groups may be at higher risk than the average population and, therefore, be labelled as vulnerable populations or vulnerable workers. Immigrant workers are defined as a vulnerable group. Content analysis of the reviewed documents reveals seven principal themes describing the difficulties met by immigrant workers: 1) access to health care and compensation (3;22); 2) concentration of immigrant workers in high risk sectors (3;22-24); 3) concentration in small or medium-size industries (3;23); 4) division of labour based on immigration status (informal but operant) (3;24); 5) discrimination, bullying, and harassment (3;24); 6) lack of knowledge of laws and labour rights (22), and 7) language and cultural barriers (3;22-24). Regarding the former theme, it has to be pointed out that cultural barriers (eg. Conflicting or diverging world views hindering interpersonal communication and understanding) are often used in an interchanging manner with language barriers, and linguistic competencies more specifically. Cultural issues proper are not detailed and are rather pointed out as a hypothetical explanation for differences among immigrant workers when facing the health care and compensation system (3). A better understanding of migration trajectories according to specific nationalities or ethnic groups may provide a better understanding of possible work integration patterns among some specific groups (3;22-24). Regarding occupational rehabilitation and compensation systems, fewer studies are reported and very little is known, but recent studies held in the region of Montréal reveal that compensation claims are written both by family members and employers. Consequently, they are more likely to experience medico-legal litigation and less likely to obtain a precise or accurate diagnosis (25). IRSST-OA 4

7 Table 1. Summary of selected articles by first author alphabetical order, main topic, type of study, place of study, sample, type of illness, and principal results First author Main topic Type of study Place of study Sample Type of illness Quality Principal results [22] Immigrant workers Systematic literature review N/A 48 studies from diverse industrialized countries N/A Very high Concentration of immigrant workforce in high risk economic sectors. Access to health care and rehabilitation counselling is a major issue for those workers. Immigrant workers have to be considered aside with asymmetrical power relations, social stratification and social inequities in health. [33] Cultural competency [40] Cultural competency [36] Health disparities Literature review Review of practice guidelines Quantitative, retrospective transversal study USA 32 studies N/A High Synthesis aimed at developing cultural competence in the field of health care. Four main dimensions are described: self reflexive process, skills, knowledge, and attitudes. Institutional support is described as an issue for successful training in cultural competence and practical applications. USA Non-specified Disability Low Discussion about self-reflexive process to understand our own cultural determinants, and the stigma and discrimination attached to being labelled as a member of a racial or ethnocultural minority. Double discrimination among minority women (fear of being deported to country of origin in case of divorce, social and economic vulnerability, etc.) USA 3 million households medium Health disparities and unequal access to rehabilitation services. Disparities vary according to ethnic and racial belongings and incomes. Conclusion in favour of developing community-based health centres sensitive to cultural characteristics, and of adjusting public policies to improve access to health care. [34] Therapistpatient relationships Qualitative USA Porto Rico Transversal Back pain, arthritis, neuropathies Medium Two rehabilitation clinics based on biomedical paradigm, but different approaches to health care: dualism mind-body versus holism, focus on symptoms versus social relations, and the clinicians differential reactions to emotional displays and pain behaviours. [23] Immigrant workers [38] Therapistpatient relationships Literature review Literature review Non-specified, 28 cited references USA Non specified, 28 references cited various Low Concentration of immigrant workforce in high risk economic sectors and precarious job status. Harassment, bullying, linguistic and cultural barriers, little access to occupational health and safety information are common among newly arrived immigrants. Strategies to get closer to that population category are to be developed. N/A Low Ethncocultural belonging influences clinical judgment on pain experience. Therapist-patient relationship may be negatively shaded when clinicians base their interventions on their own cultural standards for defining treatment expectations. Cultural models in health and illness beliefs should be better understood to avoid false clinical judgments. IRSST-OA 5

8 [43] Culturally sensitive intervention models [29] Therapistpatient relationships [47] Therapistpatient relationships [30] Therapistpatient relationships [24] Immigrant workers [35] Pain and illness representation s Qualitative, longitudinal Literature review Literature review Ireland 2 participants. Convenience sampling Multiple sclerosis N/A 32 studies Musculoskel etal disorders N/A Non specified. 51 references cited Nonspecified pain Qualitative Austria 28 therapists Outpatient clinics in post-accident rehabilitation Literature review Quantitative, transversal Medium Good Medium Good The so-called Kawa interview model is presented as an effective tools for grasping patients perception of illness and meaning of life (including work), using a metaphoric style of expression. Its utilization among multiple sclerosis patients helps the clinicians to propose a rehabilitation protocol based on the patients characteristics. Pre- and post-treatment interviews have shown improvement in attitudes and emotions. Gender is described as a sociocultural category. Description of different issues related to prolonged work disability and how it can vary according to gender. Illness legitimacy, self-identity process and domestic strain are three emerging themes reported in this literature review. Gender roles and their impact on the rehabilitation process are also discussed. Clinicians cultural sensitivity has to be developed for addressing cultural variations in the meaning and behavioural/affective response to pain. The improvement of such consciousness about cultural issues should be encouraged and positioned as a preliminary condition for understanding pain experience and working towards personalized approaches to treatment. Language barriers and cultural aspects attached to pain behaviours and attitudes may influence therapist-patient relationships and the whole rehabilitation process. Cultural differences regarding daily life are perceived as more acceptable to clinicians, but less acceptable when such differences have an impact on rehabilitation. Linguistic barriers bring an additional barrier since language concerns the foundations of communication. This is particularly true when rehabilitation programs offer psychotherapy where dialogue and cross-personal interactions are important. In a context of growingly culturally diverse populations, structural or institutional solutions are needed to support people who intervene in the field. Europe N/A N/A Low Highlight the tendency of immigrants concentration in economic sectors known for higher risk exposure; immigrant workers more subject to work in hazardous conditions, to be subjected to harassment and bullying. Language limitations among immigrants urge us to use more suited and adapted means to disseminate information regarding occupational health and safety. Brazil / Australi a 153 physical therapy students None Good Physical therapy students from Brazil and Australia expose their views about pain. Resuming work activities despite pain and the role of family during the healing process are major points of disagreement among the two groups. Slight differences regarding the value of autonomy versus interdependence. Students cultural background clearly influences beliefs and attitudes towards pain. IRSST-OA 6

9 [28] Therapistpatient relationships Theoretical essay Australi a Author s self reflexion from his previous researches and from his own experience as a teacher in rehabilitation Educational project in cross-cultural interactions Medium Family and culture are defined as two related concepts to be included in rehabilitation. Clinicians tend to consider cultural issues only among people and families that they see as ethnically different (maybe on the basis of skin colour or most obvious or visible differences). Reflexive practices may help identifying clinicians own cultural influence and the work of culture in their professional and private lives, as well as in the meaning they attach to social roles, values and attitudes towards health and illness. [44] Culturally sensitive intervention models [37] Cultural competency [48] Cultural competency [39] Immigrant workers [45] Pain and illness representation s Theoretical essay Theoretical essay Literature review Qualitative, longitudinal Quantitative, transversal Japan / Canada N/A Occupational rehabilitation patients N/A Rehabilitation models available in Western countries are culturally conditioned according to the authors: individual autonomy, self-management and independence are not central in every culture. A culturally sensitive approach is flexible, adapted to individual characteristics and provides tools to understand to level to which personal characteristics may be enrooted into sociocultural milieu. Japan N/A N/A N/A Underlying logics in occupational therapy settings may also be culturally shaped. Social role construction and social hierarchy vary from one society to another. Concepts such as autonomy and independence are not equally meaningful from one society or culture to another. It has to be taken into account in the rehabilitation design. The meaning of work may also vary according to culture. USA 35 publications N/A Low Acquiring cultural competency is a long process including continuous training, immersion or practical training in multicultural clinical settings. Authors propose an intervention model for integrating cultural competency issues in post-graduate rehabilitation training programs. Discussion on cultural relativism and the importance of self-reflexive practice to become aware of one s own cultural conditioning and how it may influence their interventions. Sweden UK / India 26 first generation immigrants from Greece and Turkey. Mean age : 38, >6 weeks out of work 855 participants doing office repetitive tasks Chronic pain Good Focus on painful sensation or anticipation about the future may influence rehabilitation program outcomes. Anticipation about the future or emphasis on the meaning of pain tends to project a pessimistic view while emphasis on painful sensation helps the patients to accept pain and lead them to resume work. Focussing on painful sensations is accompanied with a fatalistic vision of one s own health condition. Anxious-pessimistic versus fatalisticoptimistic binary model is described. Discussions on the importance of dialogue during the healing process and the therapist-patient relationship for outlining pain representations. Acute pain Good Significant differences are shown in pain prevalence and disability due to musculoskeletal disorders among two groups of workers doing similar or identical tasks. Authors put forward the hypothesis of possible cultural differences, and especially health beliefs. IRSST-OA 7

10 [3] Immigrant workers [31] Culturally sensitive intervention models Literature review USA Non-specified. 51 references cited Qualitative USA 12 rehabilitation professionals (women); mean age : 48,3, convenience sampling, multiple variations Professional injuries N/A Medium Very high Immigrant workers are far from being an homogeneous group. Some ethnocultural minorities are over-represented in jobs with high levels of risk, especially those with lower incomes. Three main issues are presented: improving working conditions, giving easier access to health care and compensation, and training in cultural competency among health professionals. A group of rehabilitation professionals considers their training in cultural issues insufficient or inadequate and that cultural competency is essential for daily clinical practice. [6] Cultural competency [41] Immigrant workers [46] Cultural competency [49] Cultural competency Quantitative USA 72 rehabilitation students Quantitative, longitudinal Sweden 67 patients among whose 30 immigrants. Mean age : 40 Qualitative Japan 2 rehabilitation therapists reflexive practice Theoretical essay N/A Good A majority of rehabilitation students believe that cultural factors constitute an important issue in the occupational rehabilitation process. At the same time, they express their needs for a more appropriate training in cultural competence, including exposure to multicultural clinical settings or environment. Chronic and persistent pain Rheumatoid arthritis / Stroke Good Medium Pain intensity, perception of work disability, and the use of analgesic medicine seems to be higher among immigrants despite similar results in terms of return-to-work outcomes. Linguistic barriers and lower education among immigrants constitute additional limitations. Delay in case management is highly to negatively influence the RTW process among immigrants and natives as well. Two occupational therapists were interviewed about how they integrated cultural issues in treatment and intervention modalities so that the patients feel comfortable with the proposed treatments. Self-reflexive practices are described as basic conditions for cultural competency and the ability to acknowledge patients personal characteristics. Clinicians narrative show how they succeeded in helping the patients to reconstruct their own feeling of self-identity in a positive manner so they could manage to reorganize their life despite limitations due to pain. USA N/A N/A N/A Discussion on physical therapy programs in the United States with cultural competency as an integrative part of educational training. How should cultural competency training be taught? The authors suggest that cultural competency training has to be systematically evaluated in concrete or simulated conditions. Otherwise, there is a risk of students not taking that subject matter seriously. Simulated patient-type evaluation could be costeffective according to the authors. IRSST-OA 8

11 [27] Cross-cultural validity of assessment tools [32] Therapistpatient relationships Theoretical essay North Americ a N/A Qualitative UK 32 outpatient clinic s users (13 men, 19 women) from Afro- Caribbean and South Asian origin. Convenience stratified sampling Diverse non specified conditions Acute pain N/A Very high From the premise that rehabilitation assessment tools are culturally biased and reflect the Euro-American middle class, the author wonders whether we should use culture-fair or culture-specific assessment tools. Current norms and assessment tools may be a hindrance to successful rehabilitation in a multicultural context, especially the tools addressing psychosocial issues. Pain experience challenges the self-identity process as a part of a broader social identity construction. Representation of the causes of pain and coping strategies vary according to ethnocultural belonging. Such variations should be addressed in clinical perspectives, by example the value of autonomy versus interdependence. IRSST-OA 9

12 Intercultural encounter in occupational rehabilitation and disability management Twenty-three articles have been selected to document the intercultural encounter issues in occupational rehabilitation research and intervention. Our content analysis reveals many issues sometimes theory-driven and sometimes addressing specific clinical challenges. Applying the principle of condensation prevailing in qualitative research analysis (26), three major axes may be identified: 1) components of cultural material; 2) cultural differences in the representations of pain; and 3) the modalities of intervention in rehabilitation in the context of culturally diverse societies. Components of cultural material Consideration on the meaning of culture appears as a minor theme emerging from the rehabilitation literature. Defining culture proper is not subject to a sophisticated elaboration despite its broad use among researchers concerned by cultural issues. Stanley Paul, who insists on the fact that rehabilitation tools are biased and reflect the values and norms of Euro-American middle class, in the mid-1990s, proposed a definition referring to a learning process and way of thinking (values, goals in life), and way of acting out and expressing emotions. This definition includes social role constructions (gender roles, sexual division of labour) and treatment preferences (27). For his part, Fitzgerald, who recall the importance of reflexive practices to help clinicians identify and become more sensitive to their own cultural influences, and on how this may influence their professional and private lives, rather insists on the shared and dynamical character of culture, and on its changing nature (not being static) (28): culture is the learned, shared, patterned ways of perceiving and adapting to the world around us (our environment) that is characteristic of a population or society. This broad definition evokes cognitive (mode of perception) and adaptive (mode of adaptation) functions and is presented as the result of learning and collective sharing of values. In Fitzgerald s article (28), many themes or items were associated to the notion of culture without necessarily providing a formal or even explicit definition. For pedagogical purposes, we tried to build a synthetic review of selected documents as presented in the Figure 1 below. It represents the results of the reviewed articles. This schematic view distinguishes different levels and dimensions: there are normative elements (ex. values, norms, and family patterns) that have to be treated separately from cognitive and emotional elements, which may be regarded as personal. IRSST-OA 10

13 Social / political contexts Health / compensation systems Social position, class, status Culture Risks exposure Working conditions Gender & social roles expectations Religious beliefs Family patterns Norms, values Language & communication Emotional response to life circumstances Perceptions of healthy behaviours and risks Perceptions of treatment Occupational safety and health outcomes Intention, attitude, behavioural arousal Rehabilitation / RTW outcomes World economy / globalisation Economic wealth Figure 1 Synthesis of cultural categories and their possible influence in rehabilitation research and intervention Some items may be regarded as central: gender and social role expectations (27;29), religious beliefs (30;31), family patterns (28;32), norms and values (27;28), communication and language (30;33-35). Diverging values regarding proper or normal pain behaviours may influence the making of a therapeutic alliance if both parties generate misconception about each other. Cultural items are overlapped by sociodemographical elements, such as social position, class, and status, to insist upon the idea that assumed cultural differences may be rather the expression of social position (3;24;31;33;36). Cultural issues in occupational rehabilitation are complex and, according to Bass-Haugen cited below, should be analysed in relation to specific social interactions and political contexts (36), including health and compensation systems, world economy and globalisation as a watermark (30;37). Rehabilitation services should then actively seek to promote and maintain equal access and opportunities for every worker, while actively developing intervention practices that are consistent with the social and cultural diversity of their clients. Cultural differences in the representations of pain Content analysis and condensation brings to our attention seven topical clusters showing evidences that cultural differences in therapeutic relationships may hinder the healing process or even cause its failure. These clusters are: 1) attitude and pain behaviours (38;39); 2) perceptions of proposed treatment (32;34;38;39); 3) motivation in treatment seeking and adherence (40); 4) treatment expectancy (35); 5) perception of to resume IRSST-OA 11

14 work activities (35;41); 6) feeling of self identity (32); perception of family role during the healing process (28;30-32) Attitudes and pain behaviours is an important topic in rehabilitation literature in general, and cross-cultural comparisons have been done for decades (42). Attitudes toward pain are corollary to the meaning attached to pain. For example, Löfvander et al. (1999) describe different types of pain-related anxiety (fatalistic vs. pessimistic) and their possible impact on treatment outcomes among a Swedish groups of Greek and Turkish immigrants. In this study, pain may be described as an ordeal or attributed to fate or God s will and, for that reason, patients may tend to normalize pain and to serenely accept it (39). On the contrary, when no special meaning is attached to pain other than being disabling, people may develop a pessimistic attitude and focus attention on struggling against pain (39). Here, fatalism is seen as playing a helping role in the recovery process, yet we have to be careful that accepting pain does not become an express way to accept a corresponding occupational disability so that its positive aspect would soon turn into a harmful situation. Perception of appropriate pain treatment, for its part, may be corollary to the perception of cause and pain mechanisms. Focussing on biomechanics may lead to seeking biomedical pain treatment while focussing on social dimensions of pain experience may lead to better acceptance of a psychosocial type of intervention (34). This varies crossculturally as shown in a Bates et al. study (1997) where positive response to psychosocial intervention is higher among patients from Hispanic origin than those from North and Central European backgrounds. This research helps to understand how rehabilitation specialist would benefit a comparative approach when considering variations from one group to another. Few studies dealing with the perception and attitudes toward pain from the clinicians point of view were reviewed (34;35). Bates et al. show that despite supposedly similar institutional settings (biomedical treatment), clinicians from two different countries and cultural backgrounds express different views regarding the perception of the body in pain (mind-body dualism vs. holistic vision), emphasis (soothing of pain symptoms/functional restoration vs. expressed emotions/social relations), sensitivity to pain complaints (low vs. strong), and psychosocial intervention (low vs. strong) (34). According to Bates et al. clinicians cultural background may influence their representations of pain and subsequent interventions. It also suggests that the development of Intercultural competences would not only help communication between clients and clinicians, but also between clinicians who are expected to work in multidisciplinary settings as well as in multicultural settings (considering the growing cultural diversity of the workforce in health care too). In similar fashion, Ferreira et al. depict contrasting views of physical therapy students according to their nationality (35). Brazilian students seem to be more compliant to avoidance-like attitude compared to Australian students who believe that staying active is the most effective coping strategy despite persisting pain symptoms. Ferreira et al. used the Health Care Providers Pain and Impairment Relationship Scale (HC-PAIRS) among 618 Australian students between 1998 and 2001 and among 153 Brazilian students in IRSST-OA 12

15 2001 (who completed more than three years of training, but never attended the chronic pain teaching module). Modalities of intervention in rehabilitation in the context of culturally diverse societies Current models in occupational rehabilitation may rely on, even if implicitly, some cultural norms and values inherent to Western cultural heritage and philosophy (27;32;35;37;43-45). The most cited example is the value of autonomy (or empowerment) which is the landmark of most multidisciplinary rehabilitation programs (28;32;37;44). The therapeutic process may disadvantage or exclude patients whose underlying values may not have the same meaning or anchorage (44). According to Kondo (2004), values of autonomy are presented as universal and may interfere with other values such as community belonging, family hierarchy, and interdependence that are inherent to specific cultural areas like those of South-East Asia (37). In some cultural groups, therapeutic choices and process are a family concern (32). In this regard, it is highly recommended to find other sources of motivation than individual autonomy, and to establish intervention plans that better correspond to the treatment expectations and expressed needs of clients (9;46). In this summary of the knowledge, three dimensions of intervention in the context of cultural pluralism are highlighted by authors: 1) therapist-patient relationship (31;47) 2) organisational structure (3;30) 3) cultural competency (6;33;37;40;46;48;49) If the first dimension addresses cross-personal interactions, communication and therapistpatient relationship, the second and the third address more structural issues with a view to improving and optimizing health care provision. Organizational issues (clinical setting) along with educational issues (rehabilitation programs, workshops, etc.) are discussed. Cultural competence is defined as a set of attitudes, practices and policies needed to develop culturally responsive caring as mentioned by Muñoz (31). It is however transversal to therapist-patient relationships and organisational structures. Muñoz attempts to conceptualize cultural competence in a simplified version of Campinha- Bacote s model developed in the field of transcultural nursing in the early 1990 s (50). This model consists of four main elements: cultural awareness, communicative skills, cultural knowledge, and attitude (31). Cultural awareness is a self-reflexive process through which an individual develops a consciousness of his/her own cultural determinants (values, stereotypes, biases, ideologies, communication patterns, emotional displays, etc.), a reflexion on the Self as a cultural being (31). This self-reflexive process may also involve a reflexion about power relations and possible asymmetrical relations that may take place in the therapist-patient relationship (22). Cultural knowledge is the process through which an individual develops and acquires knowledge about different cultural groups, their histories, values and social structures, as well as their visions of the world, including health and illness (31). Muñoz specifies that acquiring cultural knowledge also provides tools that reach beyond race and ethnicity to explore intra- IRSST-OA 13

16 cultural variations taking place at the individual or subgroup level (31). Developing Communication skills is the process through which an individual develops a set of intervention strategies to adapt to his/her patients (31). This dimension, according to Muñoz, includes supportive institutional settings to help the therapists develop cultural competence (e.g. Workshops, cultural consultants, etc.). Attitudes in cultural competence involves an openness and a desire to get involved in dynamic of exchange and exploration with culturally diverse others (31). But how to teach and transmit knowledge in such a way that students or practicing clinicians come to develop that openness and desire? However, this is reduced to an individual level while it should also be addressed at an organisational level. For example, heath organizations are not seeking adherence of their staff regarding ethical issues; ethical issues are set in place and become a modus operandi for health practitioners as well as health researchers. Training in cultural competence stands out as a complex issue as it questions whether cultural knowledge should be disseminated or acquired through specialized courses (48;49). Lewis et al. propose a series of educational contents such as case studies, role-play or patient simulations, written exercises, introspective thought process, didactic presentations, and interpretation exercises (48). But to date, institutional assessments ensuring that acquired competencies can be transferred from one health care setting to another are lacking. Without an institutional platform to facilitate the circulation and use of information regarding culture and health, acquired competencies are likely to be lost. Concerned about the danger of stereotyping the individuals on the basis of patients ethnocultural belonging, Lewis and his colleagues warn against the reverse effect of training in cultural competence, considering the risk of maintaining a narrow view of culture as something static and homogeneous (48), neglecting other significant variables such as social position, status, and other contextual or interactional factors that may interfere during the therapeutic process (31). Here again, an efficient interview protocol is probably the best way to integrate the inner world of patients and to adjust treatment options accordingly (31;33). Still, the clinician s satisfaction regarding cultural competence training and its long term effects, relevance, and clinical/return-to-work outcomes have to be further explored. Discussion Intercultural issues in health are hardly a new topic, at least in medicine, transcultural psychiatry, and nursing studies. There is a sizable literature in sociology and anthropology documenting the diversity of worldviews regarding health, illness, treatment, etc. But it seemed more uncommon to find literature in OT to discuss such issues. That is why we aimed at documenting what has been undertaken in that field and how it manages to manage and deal with the inescapable diversity of the workforce. As for the general topic of immigrant workers and OSH, barriers were identified through four literature reviews: linguistic and cultural barriers, lack of comprehension of the system, context of work/employment, social disparities in health, etc. revealing personal, relational, contextual and structural levels that put immigrant and minority workers in situation of vulnerability. Intercultural issues in rehabilitation put less attention to workrelated contextual factors but emphasized on attitude and pain behaviours, perceptions, therapist-patient relationship and modalities of intervention in intercultural settings. IRSST-OA 14

17 Cultural items emerging from this review are manifold and may be situated from more general aspects to more specific health and illness related issues. General aspects have been reported to be gender and social roles constructions/expectations, family patterns and structures, norms/values, language and communication. If those cultural items may interfere or influence emotional responses to illness or pain, perceptions of pain, illness or health/unhealthy behaviours and preferred or most effective treatment, it is not clear how culture really works in influencing such psychosocial variables. Family has been presented by Fitzgerald as the primary cultural unit where an individual acquires a sense of normalcy, a vision of the world (life and death, social roles, etc.) and of appropriate behaviour to display in specific circumstances (28), an idea previously expressed in the 1960s by the anthropologist and psycho-analyst Abram Kardiner (51). There are growing concerns among health authorities worldwide as evidence concerning the impact of cultural issues during the occupational rehabilitation process continue to mount in. Among occupational rehabilitation specialties, occupational therapists have discussed the challenges and issues associated with intercultural communication and have proposed ethical guidelines in relations to intercultural encounters. According to the American Occupational Therapy Association (AOTA), cultural competence equips providers with tools and skills to manage these (cultural) factors appropriately [ ] Cultural competence is an evolving and developing process that depends on selfexploration, knowledge, and skills (52). In line with OT, rehabilitation counsellors in the United States, under the Commission on Rehabilitation Counselor Certification (CRCC), have shown concerns about cultural competence. In their Code of Professional Ethics for Rehabilitation Counselors it is written in preamble: rehabilitation counsellors recognize diversity and embrace a cultural approach in support of the worth, dignity, potential, and uniqueness of individuals with disabilities within their social and cultural contexts (53). But how to train health specialist in this respect is unclear in the selected literature. Who can be relied upon in case of cultural discrepancies: patients, co-workers, clinicians, health managers, interpreters, cultural brokers, etc.? This is not clearly discussed in the literature. Moreover, who is to teach students in their various rehabilitation disciplines? In which faculty does it belong, humanities or health sciences? Which organisational and structural changes should be advantaged to make sure newly acquired competencies are properly transferred to clinical settings? Cultural competence seems to be a promising concept for application in occupational rehabilitation in the context of demographic changes and increased transnational migrations, and despite the lack of evaluation of its efficiency for improving clinician/patient satisfaction and rehabilitation outcomes. This is a real challenge for our host structures and health systems. Tools have to be developed, implemented, tested and disseminated through knowledge transfer and brokering activities. Unfortunately, cultural competence still looks more like a wishful thinking than a clear commitment to provide students and practitioners with effective tools and skills and organisational support. Considering the importance of being exposed to multicultural clinical settings, things are presented as if being exposed to ethnocultural diversity would be sufficient to guard against stereotypes, generalizations, and reductionism (31). There is always the risk of overusing culture to explain what remains unexplainable to us, and turn it into an analytical shortcut to foster such stereotypes and generalisations. As stated by the IRSST-OA 15

18 medical anthropologist Arthur Kleinman, cultural factors are not always central to a case, and might actually hinder a more practical understanding of the situation (54). Every individual case expresses a complex situation at the interplay of personal (family, social network, medical history, quality of life, emotional distress, illness beliefs, coping behaviours, former work accidents, etc.), social/environmental factors (work environment, risk exposure, work relationships, work conditions, etc.) and structural factors (ex. health and compensation system, litigations, etc.). Is culture too abstract a concept, too idealistic a notion to help us analyse contemporary social situations? Why not just focus on individual representations? Because culture is a collective process of socialisation and, in an age of intensive migratory flux, what shapes diverse group identities and patterns of meanings, behaviours and emotional responses has to be understood by people, and especially by people who have to decide what kind of treatment is appropriate, and policy makers. In brief, culture influences health and illness representations, modes of understanding, and ways of doing things; and this is just as true for health service users as it is for health providers and policy makers. Misunderstanding of such complex issues could reinforce already (even though involuntary) existing institutional reproduction of discrepancies and inequities in health outcomes. According to the Council of Europe (55) this is a human rights issue. Knowledge in this field has some limits: many reviewed studies do not provide indications on selection criteria (inclusion/exclusion) and keywords. Another limitation would be the confusion between racial and ethnocultural categories. For example, despite a very enlightening discussion, Davidhizar and Giger (47) mix up phenotypes, national and religious labels, comparing Black (phenotype), Italians (national identity), and Jews (religious identity). Another limit is to present immigrants as a homogeneous group on the sole basis of being foreign-born. There are many different motives for migrating; and such motives may have an impact on the integration process: economic or political reasons (with possible trauma, war trauma, etc.), and humanitarian, environmental, or family unification [5). Migration trajectory and professional integration may be contrasting with regard to those motives. Moreover, comparing native with foreign-born does not take into account that in immigration countries like Canada, USA, UK, Australia, New Zealand, among others, a significant portion of the ethnocultural minorities are in fact native born. The question of cultural differences and barriers attached to these native (but minority) groups are lost in the majority. Among minority groups, studies should be more sensitive about the implementation level of ethnocultural communities and their ability/effectiveness in taking care of their own people. Some communities have long histories of integration in their host country, and have developed their own social and integration structures (i.e. schools, community centres, hospitals, newspapers, churches/temples, etc.), while people from groups with no historical background in the host country may feel more isolated and be forced to assimilate fast or face social deprivation/marginalization. In the field of occupational rehabilitation, future research agendas should pay attention to health and compensation trajectories of immigrants/minorities, as well as return-to-work barriers, and compare data regarding people from different ethnocultural backgrounds and migration trajectories. Studies should also pay attention to the experience of rehabilitation case managers with people from diverse cultures and attempt to describe their particular IRSST-OA 16

19 needs, expectations, and even frustrations. Pilot projects in cultural competence should also be implemented with an evaluation phase of their effectiveness and clinical outcomes. The ability (or inability) of health organisations to implement new competencies should also be explored further. Conclusion Industrialized countries that have to rely on immigration to sustain their own population growth and their economic needs (workforce) are facing intercultural communication issues at different levels. One of those expressed in this article concerns health care and occupational rehabilitation. Cultural and language barriers have been shown to impact negatively on the recovery process, and proper training in intercultural competence has been pointed out as a potential model to develop culturally adapted cares and services. Immigration countries with dominant or hegemonic cultural patterns have to consider their health care systems as cultural products, shaped in particular historical, social, religious and cultural contexts where science, among other categories of knowledge, has evolved. It poses real challenges in terms of intercultural communication, tolerance, and acceptance of the fact that various visions of the world are not only present, but may also contradict. What are the causes of disease or illness? What is to be considered normal in expressing emotions and painful sensations? What is the meaning attached to paid work, autonomy? These are some of the pragmatic questions that make interpersonal interactions difficult. Intercultural competence, by emphasizing self-awareness, is an important step to further develop communication skills and a prerequisite for improving cultural knowledge, skills, and attitude (56). Research in the field of health literacy have explored other facets of the issues, defining health literacy as the ability to function within the medical system, showing evidence that some minority groups and immigrant populations, among other vulnerable groups, do not have sufficient understanding of the system (57;58). Intercultural competence is expected to be a good step forward in avoiding such misunderstandings and a promising avenue for occupational rehabilitation to engage in. When put together, occupational health and intercultural issues are often regarded in terms of variations in perceptions and illness behaviours; this summary of the knowledge proposed another angle from which to define the problem, by replacing the centre of gravity from the field of cognition, strictly speaking, to that of intercultural communication. As suggested by Gratton (59), cultural expertise will remain incomplete as long as understanding cultural differences and how to handle them continues to be an issue. To ensure a proper knowledge transfer into health organisations, we need «learning organisations» because health management and cultural diversity management is also a matter of health policy, aiming at providing culturally-sensitive health care while seeking equal access and opportunity to all. This article provides new lights and research paths for those, clinicians or researchers, interested in the notion of cultural competence and its efficiency. Acknowledgements The author wishes to thank IRSST colleagues for providing fruitful critics and suggestions. Special thanks must also be addressed to Madame Danielle Gratton, psychologist and consultant in intercultural relations at Jewish Rehabilitation Hospital IRSST-OA 17

20 (Laval, Québec) and also president of Montreal Intercultural Council and researcher at Laboratoire de recherche sur les relations interculturelles (LABRRI) for her critical and very insightful comments. Declaration of interest This literature review was supported and funded by the Occupational Health and Safety Research Institute Robert-Sauvé (IRSST). The author reports no declarations of interest IRSST-OA 18

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