Karl Atkin and Sangeeta Chattoo discuss their most recent paper in Policy & Politics, Clinical encounters and culturally competent practice
A recent Guardian Roundtable in association with the British Academy identified the increasingly ethnically diverse nature of British society, while acknowledging the contested nature of multiculturalism. Such debates are now a regular occurrence as the UK struggles to accommodate what Bhiku Parekh called back in 2000 a ‘community of communities’. The prime minster, David Cameron, no supporter of multiculturalism, has criticised the passive tolerance of different cultural values, which he sees as potentially undermining the nation’s collectively agreed sense of British-ness. Nor is this an isolated view and others go as far as to attribute the failure of multiculturalism to minority ethnic populations’ continued ability to be ‘different’. While concerns about being swamped by alien cultures remain a longstanding (and unhelpful) feature of political discourse.
We accept the need to reflect on the past and learn from previous mistakes. For us, however, the problem of multiculturalism is more about collective engagement, active citizenship, the tackling of social exclusion and elimination of social inequalities. It is also about understanding how our failure to accommodate multiculturalism has direct consequences for individuals, whether it is expressed in terms of lower life expectancy or an inability to exercise choice over one’s life. As our research demonstrates, the experience of infertility following cancer treatment provides a case in point.
We have conducted research in multi-cultural contexts for nearly thirty years; seeing significant changes in how ethnic diversity is responded to by Government agencies. Our early work demonstrated how essentialised and often crude racist stereotypes disadvantaged black and ethnic minority communities. ‘Black’ patients, for example, found themselves dismissed for having lower pain thresholds, while ‘South Asian’ women found themselves criticised for their passive acceptance of ‘oppressive’ cultural practices. As the years have gone on, we have seen more subtle albeit equally discriminatory cultural stereotypes emerge. For example, the use of fatalism to explain everything from poor representativeness of ethnic minorities in research studies to the inability to take responsibility for their own health has become especially pervasive. On the more positive note, however we are beginning to see more instances of good and sensitive practice.
A commitment to culturally competent care has been long established as a way of meeting the needs of an ethnically and culturally diverse society. It has been used by successive Governments to demonstrate a commitment to social justice, while practitioners rely on it to ensure their practice is non-discriminatory. This commitment reflects a genuine effort to improve the experience of health care provision. Implementation, however, is far from straightforward. Culturally competent care, despite being associated with a range of positive outcomes (and it is important to acknowledge this), can perhaps counter-intuitively also generate the potential for further discrimination, generating new and diverse forms of discriminatory practices, which belie its original intent. This is where the failure of multiculturalism lies. Overcoming this failure is the challenge facing health and social care agencies.
The experience of infertility following cancer treatments enabled us to explore the nuanced consequences of how culturally competent care is expressed in clinical practice (in partnership with our colleague Marilyn Crawshaw). Infertility is an excellent case study. In addition to demonstrating ethnic disparities, it generates complex moral and ethical questions, in which cultural values require sensitive negotiation.
We were especially interested in exploring the dilemmas faced by practitioners. Encouragingly, we identified many examples of good practice, demonstrating that sensitive care is consistent with professional practice. Nonetheless, we also became aware of how practitioners often rely on static and idealised views of culture, which give little room for individual agency. Despite practitioners’ best intent, some of their activities could be seen to reinforce cultural stereotypes rather than challenge them.
Practitioners were especially thrown when people did not act in ways they assumed they should. Common assumptions included the over-bearing and suffocating nature of ‘South Asian’ family life; and the predetermining nature of tradition, culture and religious belief. This contrasted with views of white British families, whose behaviour – while subject to similar stereotypes – was explained by active preference and choice. Muslim men’s struggle to bank sperm, for example, was associated with their faith. Such explanations were seen by practitioners as providing a welcome opportunity to express their culturally sensitivity. However, men – irrespective of faith – found the process socially embarrassing and emotionally difficult, especially within the context of having been diagnosed with cancer and feeling seriously ill.
Other behaviours could be interpreted very differently by practitioners, dependent on the ethnicity of the person. These imagined differences then led to a culturally refined response. South Asian people’s ‘obsession’ with having children was seen to create tensions within families, which required intervention. ‘White’ families desire to have children, however, was taken for granted and rarely questioned. Similarly, parents accompanying a South Asian daughter to a consultation could be seen as controlling, presenting a problem to be solved. For a white family it was seen as an expression of care and support, and something to be encouraged.
‘Cultural’ explanations of ethnic differences in health can often emphasise the idiosyncrasies of particular ethnic groups and has arguably led to a narrow focus on aspects such as dietary requirements and religious, cultural and spiritual practices. The problem is not with culture per se but with how it assumes meaning. When used in clinical practice, culture tends to be stripped of context and simplified, so as to make it useable. Consequently, cultural understanding becomes uncontested; another technical act, in which active agency is disregarded. Encouraging assumptions about how culture might play out in any particular encounter – especially when it becomes associated with risk – is particularly problematic. A concern to standardise is ultimately counter-productive and can render practice insensitive; in complete contradiction of its intention. A more reflexive approach is required, in which practitioners have the confidence and understanding to ask sensible and meaningful questions, without assuming they know what the response is likely to be. In this respect, understanding one’s own cultural values can be as important as understanding the cultural values of the patient and their family being offered care.
Read Karl, Sangeeta and Marilyn’s full paper here.