Culture, diversity and health

What is culture?
The evolved human capacity to classify and represent experiences with symbols and to act
imaginatively and creatively.
The distinct ways that peoples who live differently, classify and represent their experiences.
Culture: the ideas, customs, and social behaviour of a particular people or society.
Sub-culture: A cultural group within a larger culture, often having beliefs or interests at
variance with those of the larger culture.
Counter-culture: a way of life and set of attitudes, opposed to or at variance with the
prevailing social norm
What is diversity?
Degree of variation of culture, identities and other social and economic factors within a
given society.
What is identity?
A persons conception and expression of their individuality or group affiliations.
What is social construction?
A perception of an individual, group or idea that is ‘constructed’ through social or cultural
practice.
WHAT? No such thing as Race?
“The expression of any trait represents a complex interaction of heredity and
environment. [… A] specific claim purporting to demonstrate a mean genetic deficiency in
the intelligence of American blacks rests upon no new facts whatever and can cite no valid
data in its support. An individual can't be judged by his group mean.”
Race
- The term began to be used to relate to physical traits in the 17th century. In the
early 20th century the term was often used, in a taxonomic sense, to denote
genetically differentiated human populations defined by phenotype (what we can
see with our eyes)
- Even though the genotype (genetic make-up of an organism), the invisible genetic
make-up of human types, is the same across all groups, there is a tendency to
emphasize the phenotype, the outwardly visible expression of the genes that varies
across human types.
- This socially constructed emphasis on the latter is deeply ingrained because of the
convenience it provides for creating hierarchies among humans, with attendant
power imbalances
Population
- In 2016, 649,200 people identified and were counted as being of Aboriginal and
Torres Strait Islander.
- Aboriginal and Torres Strait Islander people represented 2.8% of the 2016 Census
count, up from 2.5% in 2011.
Rationale
- Aboriginal and Torres Strait Islander Peoples are the First Peoples of Australia
- 17 year gap in life expectancy
- Twice as likely to have severe disability
- Higher rates of chronic diseases (i.e., kidney disease and diabetes)
- Why is that?
- Fulfils Graduate Attribute/Accreditation Expectations
Migrancy
- 25% all Australians are born overseas
- Top five places of birth?
- In NSW – 50% from Culturally and Linguistically Diverse (CALD) backgrounds
- One third of marriages are between people from different countries of birth
- 25% of Australians have a parent born overseas
- 150 languages spoken in Western Sydney
- 40%+ Christian, 1.7% Muslim
Cultures of Health
- Every culture views, understands and engages with health differently.
- Each ethnic groups’ perspectives must be included in the provision of health care for
members of their group.
Human Rights
- “All Australians have the right to access health care that meets their needs. In our
culturally and linguistically diverse society, this right can only be upheld if cultural
issues are core business at every level of the health system- systemic, organisational,
professional and individual”
The solution…
Cultural competence continuum
- Cultural destructiveness
- Cultural incapacity
- Cultural denial
- Cultural pre-competence
- Cultural competence
- Cultural proficiency
Intersectionality
- Impacted by multiple forces
- Overlapping that causes social injustice e.g. racism and sexism
- There wasn’t a name for intersectionality for so long. Therefore, it wasn’t talked
about, it wasn’t acknowledged or resolved.
- More recent developments of intersectionality focus on the interaction and mutually
constitutive nature of gender, sexual identity, race, social class, age and other categories of
difference in individual lives and social practices, and the association of these arrangements
with health and wellbeing
- This framework recognises that people from all backgrounds are characterised
simultaneously by multiple and interconnected social categories, and that these categories
are properties of the individual in terms of their identity, as well as characteristics of social
structures
- Analyses of single determinants—such as gender—independently are insufficient, as social
categories such as gender, race and sexuality are experienced simultaneously
- Intersectionality therefore recognises that people can be privileged in some ways and
definitely not privileged in others.
The health gap
- Focusing on equity rather than equality
- Equity = equitable distribution of money and resources
TEXTBOOK – CHAPTER 1
Diversity in Australia

- Australia is quickly becoming known as one of the most diverse Western nations in the
world.
- The most recent Census indicates that Australians represent over 300 separately identified
ancestries
- Australia is therefore well known for its multicultural population characterised by a vast
diversity of cultural, ethnic, religious and linguistic groups

Diversifying the term diversity

- When the term diversity is discussed, it is most often in the context of cultural, ethnic or
religious diversity as discussed earlier.
- However, multiple aspects of diversity need to be considered, especially when working in
the health sector.
- This diversity includes race, gender, sexuality, age, disability, socio-economic status and
education
- These elements of diversity, as well as culture, ethnicity and religion, are filtered through
social, political and cultural norms and expectations that determine how we experience
health in Australia

Social determinants
- The social determinants of health are the conditions in which people are born, grow, live,
work and age.
- These circumstances are shaped by the distribution of money, power and resources at
global, national and local levels.

What are social constructions, and why do they matter?

- Social constructions are based on a theory that people develop knowledge of the world in a
social context
- Social constructions dictate that much of what we perceive as our reality depends on shared
assumptions
o These assumptions are imbedded in our cultures and inform us on how we should
understand and interact with ourselves, others and the world
- Research consistently indicates that the concept of race is socially constructed and provides
no insights into the genetic and physiological characteristics of diverse people
- Social constructionists believe that things that are generally viewed as natural or normal in
society, such as understandings of gender, race, class, and disability, are socially constructed
and consequently are not an accurate reflection of reality.

Why is cultural safety important?

 - Cultural safety provides a means to examine how people are treated in society and how they
are affected by systemic and structural issues and social determinants of health.
- It represents a key philosophical shift from providing care regardless of who an individual is,
to acknowledging that each person’s identity is central to the provision of health care
- Cultural safety takes into account peoples’ unique needs and requires an ongoing process of
practitioner self-reflection, cultural self-awareness and an acknowledgement of how these
factors impact care
- Importantly, cultural safety uses a broad definition of culture that does not reduce it to
ethnicity only. Instead, it includes a range of variables, such as age/generation, sexual
orientation, socio-economic status, religious or spiritual beliefs, gender and ability

The role of health professionals in promoting cultural safety

- The process is a lifelong one and does not require the study of any culture other than one’s
own—so as to be aware of the impacts and implication of our own cultures, open-minded
and flexible in our attitudes towards others
- Ultimately, cultural safety is about the receiver of health services who determines if their
care was culturally safe or not

Lecture 2- Segregation and Ethnic Disparities in Health

Social Determinants of Health

 - The Great Outdoors
- Place and Space = Health
- Life Expectancy and Place
- Place: A matter of life and death
The impact of place + space
- Where people live = huge impact on health outcomes
Green space
- Improving health outcomes
- Decreasing mental health issue

Segregation
 - Segregation itself is defined by the European Commission against Racism and
Intolerance (1993)
Ethnic Concentration
Warning! This lecture is triggering!
- Harm-related appraisals: a process where the student consciously or subconsciously
appraises the topics presented to them as personally harmful or harmful to a group
the student affiliates with (i.e., “Learning about how the British colonised Australia
and harmed the first Nations Peoples makes me feel like I am being accused of being
racist/prejudiced towards minorities”).
- Beliefs rationalizing the appraisals: students’ beliefs that support their sense of
victimisation and/or reinforcing of the status quo (i.e., “Anglo/White privilege does
not exist because I know someone who got into a course because they were a
refugee”).
- Negative emotions: feeling emotions like anger, fear, sadness, and guilt which
students felt were triggered by diversity discussions (i.e., “tense”, “uncomfortable”,
“anxious”, “like stepping on egg shells”, “angry”, “pissed off”, “sucky”, “sad”,
“hopeless”, “White guilt”, “frustrated”, “jealous”, “need to chill”, and “bitter”).
- Defensive coping actions: this included avoiding race-related discussions; attacking
the person talking about racism and White privilege (i.e., “the teacher is herself
racist”); becoming resigned to racial injustice and doing nothing about it (i.e., “there
is nothing I can do about harmful social constructions”); and escaping responsibility
for racial injustice (i.e., “it is what it is”).
- These challenges result in student resistance and present obstacles to learning. Such
resistance precludes the development of therapeutic relationships with future
clients (Dune et al., 2018).
How diverse is my suburb?
Example: Income
- Mosman = 2.5x more than Fairfield
- In eight of Sydney's 64 local areas incomes failed to keep pace with inflation of 13.7
per cent
- smh.com.au (2010)
Place = Health
Mosman vs. Mt Druitt
- Mosman = diverse (largely European)
- Mt Druitt = very diverse (largely Asian background)
- Western Sydney = high diabetes rate compared to eastern areas (more wealthy)
- Mt Druitt = 1 park (not much green space)
- Mosman = lots of parks (more green space)
- Mt Druitt = lots more access to Mc Donalds and fast foods
o Fast food = cheap, easy, accessible. Therefore creating this behvaiour
- Mosman = only 1 maccas

Mt Druitt – Parks – Mosman

Mt Druitt – Food – Mosman
 - What you see is what you get!
- Obesity leads to diabetes
- 60% - 70% Obese in Australia
Student Feedback
- “Dr dune makes a strong habit of white-shaming in her lectures. Her stark contrasts
between aboriginal and non-aboriginal persons easily made me (and other people in
the room) extremely uncomfortable and…made me dread this unit altogether…what
I am left with is a strong sense of guilt for having more money than most… this does
not make me a bad person. Her contrast of mosman (near my place of residence)
and mt druitt quickly lead to students shaming me for having wealth.”
- “I am sorry dr dune for the vast abundance of parks in my area, I am sorry for the
huge amount of health services available locally to me, I am sorry dr dune for the
smaller number of fast food outlets in my surrounding suburbs. I am sorry I am
wealthy, I am truly, utterly sorry because all I can gather from this lecture is that the
fortunate, wealthy people that live on the beaches fault that mt druitt is worse off…
Please stop teaching this unit.”
Ethnicity and Income Poverty

Ethnicity and Employment

Ethnic Discrimination and Health

- Differences in BMI between ethnic groups and country of birth

 - Racism and pollution = increased risk of asthma and other respiratory problems
Segregation (of ethnic minorities) can lead to Poverty

Ethnic Discrimination and Health

Privilege and power
Racial privilege
- Some people may experience less privilege due to the colour of her skin
- Light skin = hierarchy, power, benefits (societal, systemic issue)
Privilege: White/Anglo-Heritage
- Sue (2003) defines White privilege as "unearned advantages and benefits" given to
White persons based on a system that was "normed on the experiences, values, and
perceptions" of White persons (p. 7).
- McIntosh (1989) characterizes White privilege as "an invisible package of unearned
assets which I can count on cashing in each day, but about which I was 'meant' to
remain oblivious" (p. 10). She likens it to "an invisible weightless knapsack of special
provisions, maps, passports, codebooks, visas, clothes, tools, and blank checks" (p.
10).
- Kendall (2006) describes White privilege as "an institutional, rather than personal,
set of benefits granted to" (p. 63) people whose race resembles that of the people
who are in power.
Social Constructions of Race/Ethnicity
Student Feedback
- “The lecturer was rude; pretty sure every single white person was wildly offended by
the content and the way the lecturer made white people feel belittled and as though
white people are to blame for the worlds problems. Not sure what most of the
content was, because all I heard was the lecturer rant on and on.”
Privilege: Minority Groups
- There is little research to support the idea that affirmative action/equity initiatives
for ethnic minorities result in systemic, organisational or professional level
disadvantages for White/Anglo-Heritage Groups (Kellough, 2006).
- However, the individual of a non-Minority background may feel disadvantaged by
affirmative action/equity initiatives.
Holistic approach to mental health (for aboriginal)
- 10x national rate of suicide
- Instead of talking about the sickness, focus on the person
- Aim: destigmatise mental health
o Preventative strategy
 Get clients to talk about their feelings
 Allow them to connect with land and sea e.g. fishing (esp for men)
 Hone visits (takes away from stigma), allows them to feel more
comfortable
 Relaxing environment for counselling sessions
Textbook chapter 2
The social determinants of health refer to the social, economic and environmental forces, such as
how much money a person earns, the type of job they have, and where they live, which matter more
to health outcomes than individual behaviours or biomedical risk factors
Closely linked are the cultural determinants of health, which refer to ethnic, religious, racial, class,
gender and sexuality differences that underpin social experiences leading to divergent health
experiences and outcomes across some groups.

Commission on the Social Determinants of Health (CSDH)

- In developing this definition, the CSDH focused on health inequalities and the negative
impact of the social determinants of health, but it is important to acknowledge social
determinants can also impact health in positive ways.

Cultural determinants of health

- Cultural determinants can impact the health of population groups that share cultural
identities, in both positive and negative ways.
- Cultural determinants can draw on the strengths of cultural identities, knowledges and
practices and are key to the health and wellbeing of cultural groups
- However, negative cultural determinants stemming from the dominant culture in a society,
such as racism and economic practices, can play a key role in driving inequalities, excluding
and discriminating minority cultural groups.

Understanding culture

- Most definitions of culture focus on collective, shared understandings and practices,

“customs, habits, language and geography that groups of individuals share”
- Culture is dynamic, changing and adapting to a complex social world.
- Culture is part of our everyday lives, the understandings and practices we have about the
social world around us
- Language is central to culture, providing structure to our thoughts, ideas, interpretations of
the world around us, and to our ways for understanding and expressing ourselves
- Importantly, cultures influence our understandings and experiences of health

Racism as a social determinant of ill health

- Race is a socially constructed label used to refer to the classification and stratification of
people based on phenotype (i.e., skin colour and other physical attributes), while ethnicity
categorises people by cultural group, which may include shared ancestry or nationality
- Racism refers to negative and prejudicial discrimination that can occur at individual,
interpersonal and structural levels. Racism can be detrimental to a person’s health.

The term structural violence is used to link unequal social structures to the harm done to people and
to the limiting impact of social conditions on individual opportunities and capabilities, particularly for
those from minority cultural groups

Explaining health inequalities

- The Black Report considered four explanations of health inequalities that provided the
foundation for subsequent research into the social determinants of health.
o The first explanation put forward in the report suggests health inequalities are
merely an “artefact of measurement”—a suggestion refuted by thousands of
studies, which confirm that the persistent relationship between social and health
inequalities is more than a statistical anomaly
 o The second explanation suggests health inequalities are the result of natural
selection, with healthier, hardworking people achieving social mobility and longer
lives
o The third explanation, which warrants detailed consideration, suggests health
inequalities are a consequence of behavioural factors.
- the Black Report’s authors sought to acknowledge the socially embedded nature of
potentially health-damaging behaviours that are distributed inequitably across societies.
- Despite the Black Report’s efforts to develop a socially embedded understanding of
behaviour, an individualised notion of “lifestyle choices” continues to dominate our
approach to prevention, health care and policy
o This assumption is embedded within a belief that individuals, who make poor
“lifestyle choices”, have access to the “time, resources, capability and motivation to
change their lifestyle”

LECTURE 3: The Culture(s) of Health and Healthcare

Overview
- Health as a socially constructed entity, which varies across and within cultures
(culturally constructed)
- The importance of understanding culture for better health servicing (healthcare)
- Links between this information and Assessment 1
Disease - Health Continuum

Culture and Health

- Cultural norms have a profound influence on health behavior, and ultimately health
outcomes.
The biomedical model of health and wellbeing

- In Western societies, the current approach to health and wellbeing stems predominantly
from a biomedical model of health
- Through the lens of this model, health is conceptualised as the absence of disease or illness
- the biomedical model maintains that illnesses will usually have a biological cause
- Furthermore, this model surmises that disease occurs due to the invasion of pathogens such
as a virus, bacterium or microorganism into the body
 - Despite this model evolving to adopt more holistic views of health, it still does not account
for non-biological factors. Examples of such factors include relationships with family, social
relationships with friends and community, and interactions within environments

Critiques of the biomedical model

- Consequently, the predominant weakness of this model is its minimal consideration and
adoption of psychological, sociological, environmental or behavioural variances associated
with illness
- The biomedical model focuses on the disease and takes the approach of cure rather than
prevention. It focuses attention primarily on the disease and specific part of the body or the
organ, often ignoring the social origins of the disease
- it does not account for the complexities of lived health
- Health is not simply the absence of illness; it encompasses a person’s environment, mental
and spiritual health, emotional state, connections to friends and family, the experiences
individuals have growing up and a lot more.
- The biomedical model does not recognise that health is multifaceted

Questioning the Western/Biomedical Model

- It is good in a lot of ways- benefits, changes life expectancy e.g. vaccinations
- If I get hit by a car, I don’t want acupuncture, I want to go to the hospital
- However, there are other factors that need to be considered e.g. lifestyle, that
contribute to health outcomes.
- Western medicine claims to be neutral, disinterested, abstract and objective.
However, Australian health services and programs derive from Eurocentric forms
and practices. The biomedical model appears monolithic and objective…(Coulehan et
al. 2005). Western healthcare providers are seen to be the norm and the recipients
of services are believed to be deficient in knowledge and practice. Target groups are
seen as needing help from the mainstream. Eurocentric structures and programs
marginalise non-Western cultural practices…people are made strangers to their
experiences of sickness and health (Heil 2003; Paul 2000).
Limitations of the Biomedical Model
- ‘the medical profession, including doctors, pharmaceutical companies, consultants,
etc., have a vested interest in making sure there is plenty of disease…’
FORBES 2000 LIST
Limitations of the Biomedical Model

- For the first time in recorded history, children are expected to live shorter lives than
their parents, due in large part to the ‘obesity-diabetes epidemic’ (Olshansky et al,
2005).
Lifestyle “Theories”
- Diseases have many causes, including modifiable (lifestyle-related) risk factors:
o Inactivity
o Westernized diet (cigarettes and alcohol)
o Stress (affected by different factors)
o Hygiene and unsafe sexual practices

Why and When Did this Happen?

When did it change?

- When society became capitalistic
- Getting more, having more (especially $$$)
- Came from colonisation, seeped through different cultures
- Therefore capital hierarchy dominated, changed ways traditional communities
engaged with their health
Colonisation in Australia
Consequences of colonisation/neocolonisation for the aboriginal people of Australia:
- Lower life expectancy (~20 year gap)
- Higher infant mortality
- Increased morbidity:
o Diabetes and complications (blindness, amputation, etc.)
o Renal failure and complications
o Infectious diseases (STDs, TB, Hep B)
o Nutritional deficits
o Disability
o Mental disorders/suicides
o Lower quality of life

Cultures and Lifestyles

- Accumulating evidence suggests that humans have lived longer and more fuller lives
in the past (i.e. less disease prevalence and better quality of life) due to better
lifestyle
- e.g. Okinawa Japan: highest concentration of centenarians in the world, prior to
“westernization”
Ancient Wisdom

Is it a “Lifestyle model” or simply “A way of life”?

Awareness of Culturally Influenced Behaviors
- “It may be our intention to try to modify the behaviors of other people in ways that
we consider beneficial. Such efforts are unlikely to result in the desired changes if we
do not understand why local conditions are as they are” (Basch, 1999).
Poor health and traditional culture
- Westernizing cultures e.g. islanders = diabetes, obesity, teeth issues
Hierarchy concept
- Things from western culture = better
- They have more money therefore, more food = better
Western society goes against nature
- Don’t sleep enough
- Don’t go outside enough
- Drink heaps of coffee
Dahlgren & Whitehead’s Social Determinants of Health

Examples to review in your own time:

- Various Cultures of Health
Health Models: Exploring Health Beliefs & Practices
- Folk models of healing (Willis & Elmer, 2007)
Folk Models of Healing
- Folk healing:
o ‘A set of health beliefs and practices derived from ethnic and historical
traditions that have the amelioration or cure of psychological, spiritual and
physical problems as their goal’ (Lozano Applewhite, 1995).
- Health beliefs
o ‘based on the notion that healing is an art, including culturally appropriate
methods of treatment delivered by recognized healers in the community who
capitalise on a patient’s faith and belief systems in the treatment process’
(Lozano Applewhite, 1995).
- Diverse, non-static models
o geographic and cultural variations
o like culture, they adapt and change when interacting with other models of
healing or social influences
o may now co-exist alongside other forms of healing, such as biomedicine
- Distinctive role of healer
Mexican Folk Medicine
- Lopez (2005) describes contemporary Mexican folk medicine as ‘a blending of Native
American religions and Roman Catholic ideas about healing and illness as being
God’s will.’
Mexican Health
Beliefs & Practices
 - A study by Lopez (2005) of 70 Mexican-American women explored their knowledge
of and use of alternative Mexican folk medical practitioners in their own health
maintenance.
- Even among highly assimilated Mexican-American women, there persist traditional,
indigenous beliefs, and practices.
- Folk health beliefs may interact with Western medicine, with consumers using both
methods, as they deem appropriate.
Common Beliefs & Cultural Practices
Asians
 Traditional Chinese Medicine (TCM):
 complex and well-established therapeutic tradition
 using acupuncture, acupressure, and herbs, often in combination with dietary
therapy, Western medicine, and supernatural healing.
Asians
 TCM classifies food, illness, and medications according to the perceived effects on
the body, as “hot” or “cold.”
 This approach is also true for the Ayurvedic system of medicine (from ancient India);
the Ayurvedic system also incorporates knowledge of the five elements to restore
balance to the body.
Pacific Islanders
 ‘Mana’
 Healing requires the restoration of the imbalance of ‘mana’
 Ideal concept of health:
 spiritual, psychological, physical, and relationship with family
Health in Australian Indigenous Cultures
- Cultural beliefs and values determine Aboriginal peoples view on wellness and
illness.
- Belief systems about health are connected with other aspects of life such as for
example land, kinship obligations and religion.
“Punya”
- ‘There is no Aboriginal word for health in most of the languages I know’ – Ian
Anderson, 1994
- In the Ngaringman language, ‘punya’ is is sometimes translated as ‘well-being’
 - The concept of ‘punya’ encompasses person and country, and connotations include
‘strong, happy, knowledgeable, socially responsible (‘to take care’), beautiful, clean
and safe
- The most important connotation is that of country, but can also be used to refers to
the individual self (strong, smart)
‘Life is Health is Life’
- In Aboriginal society there is no word, term or expression for ‘health’ as is
understood in Western society. It would be difficult from the Aboriginal perception
to conceptualise ‘health’ as one aspect of life. The word as it is used in Western
society almost defies translation but the nearest translation in an Aboriginal context
would probably be a term such as ‘life is health is life’. (National Aboriginal Health
Strategy Working Party 1989)
Healing System of the ‘Yolngu’ People
Yolngu’ meaning ‘person’
North-East Arnhem Land, NT
 Concept of cause and treatment of illnesses has a major assumption. That ‘humans
have the capacity to mobilise and to control the power which exists in the universe
and are themselves vulnerable to attacks by others using that power.’ (Yolngu belief)
 Illness can be caused by these attacks, or by natural processes (food, old age,
contagion, physical causes)
Australian Indigenous
Belief Systems
 Indigenous healing emphasizes:
 Connection to land
 Connection to each other
 Cultural rituals and practices
Culture is Central to Perception of Biomedicine
 Cultural perceptions and the social interactions surrounding them influence:
 whether or not individuals will access health services
 acceptance or rejection of offered treatment
 compliance to treatment
 success of prevention strategies
 the clients’ perception of standard of care
 the clients’ view of health care providers and personnel
Health Care is a
Cultural Construct
 arising from beliefs about the nature of disease and the human body.
 Therefore, cultural issues are central to the diversity of health services treatment
and prevention interventions.
 The lack of attention to cultural issues affects health care and its outcomes.
Recognition & Engagement of Cultural Sensitivity in Health Service Practice
 will improve the performance of both the individual and the organisation (Houston,
2009)
 offers opportunities to:
 improve quality
 improve outcomes
 reduce costs
 enhance effectiveness and efficacy, and
 improve customer satisfaction.
Cultural Competence in
Healh Care
 Be sensitive to the role that folk or traditional medicine may play in a patient’s
health strategy.
 Show tolerance of and respect for diversity in order to elicit and fully understand the
patient’s story and provide appropriate treatment.
 Ask patients what they think may have caused an illness and what they are already
doing to treat it.
 Ask patients whether the prescribed medical intervention conflicts in any way with
their beliefs and traditional practices.
The Cross Cultural Health Care Program (CCHCP)
 Primarily a training and consulting organization (non-profit) founded in 1992
 Mission is to help ensure underserved communities full access to quality health care.
 CCHCP endeavors to enhance the abilities of health professionals to provide
culturally competent and linguistically appropriate care.
Conclusion
 ‘Culture and healing are intermixed, emphasising that health practices are linked to
the social and cultural relations within differing cultural groups.’
  ‘The definition of disease found in societies that emphasise the biomedical healing
model is at odds with the cultural understanding of disease found in many non-
Western societal groups.’
Traditional models and social determinants of health
- We need to be aware!
- We need to dig deeper to figure out what aspects of health are going to help me
support the population Im working with
- Individual at the centre
Textbook Chapter 3
What is health?

- “health is a state of complete physical, mental and social wellbeing and not merely the
absence of disease or infirmity”
- It also suggests that it is the fundamental human right of every human being to attain the
highest standard of health irrespective of their race, religion, political belief, economic or
social condition.
- However, the definition is limited, as it does not cover the spiritual wellbeing of human
beings, which is an integral part of their complete wellbeing.

Ethnocentrism, Eurocentrism and health

- Ethnocentrism centres itself around the importance of one’s own cultural beliefs and values
as superior; therefore, every other culture is scaled in comparison, rated in reference to the
individual’s own culture
o ethnocentrism can impact an individual’s engagement with health practices, which
may not complement their own cultural health beliefs.
o For example, there may be a cultural clash with Eurocentric biomedical approaches
if the consumer is from a background that places greater emphasis on traditional
medicines such as Traditional Chinese Medicine or Indigenous Bush Medicine.
- Eurocentrism is a cultural phenomenon that views the histories and cultures of non-Western
societies from a European or Western perspective
o Europe, more specifically Western Europe or the West, functions as a universal
signifier in that it assumes the superiority of European cultural values over those of
non-European societies.
o Although Eurocentrism is anti-diversity in nature, it presents itself as a universalist
phenomenon and advocates for the imitation of a Western model of health based
on Western values. This model focuses on individuality, human rights, equality,
democracy, free markets, secularism, and social justice as a cure to all kinds of
problems, no matter how different various societies are socially, culturally, and
historically constructed

The biopsychosocial model of health and wellbeing

- It emerged from a realisation that the biomedical model was inadequate for comprehensive
health care.
 - the biomedical model lacked in versatility across the disease continuum, calling for models
that tie in the socio-environmental conditions that influence population health.
- A person’s biology, their psychological functions and their social environment underpin the
BPS model.
- BPS model attempts to answer the multifarious impacts of health contrasts to the traditional
biomedical model, which does not consider the social factors that underlie health conditions
- the BPS model considers social factors such as a person’s relationships, socioeconomic
status, religion, and access to social support as a direct influencer of their health outcomes
- BPS model began as an idea to answer these intersecting issues and as such address issues
concerning health to be more complex than one simply being sick with a disease or illness
- This model takes into consideration that when you are in an environment that may be
unhealthy, you take a person out of it to make them feel better but then do not change the
conditions in which they live and place them back, how does one expect a person to get
better

Critiques of the biopsychosocial model

- However, this model is under-researched and not as popular as the biomedical model,
despite this model encompassing more parts of human life
- While the model indeed explains that health is not simply not being burdened with disease
or illnesses, it is not as universal in Western nation-states.

Primary health care models and cultural safety

- Primary health care encompasses a philosophy that “is a whole-of-society approach to

health and wellbeing centred on the needs and preferences of individuals, families and
communities … addresses the broader determinants of health and focuses on the
comprehensive and interrelated aspects of physical, mental and social health and wellbeing”
- This model is centred on principles of social justice, equity and self-determination, where
individuals and communities are encouraged to actively participate in decisions and actions
regarding their health and wellbeing
- Furthermore, primary health care models look to address various determinants, including
social, economic, cultural and environmental that may impact health and wellbeing

Lecture 4: Human Rights & Health Literacy

What Are Human Rights?
• Human rights are what reason requires and conscience demands. They
are us and we are them. Human rights are rights that any person has as
a human being. We are all human beings; we are all deserving of human
rights. One cannot be true without the other
• Kofi Annan, Secretary-General of the United Nations
 • 1948, Human rights made in UN following WW2
• Notice that something had to be done
• Rights for women, indigenous, children, disability
• Notice lack of equity and equality
• Human rights are for all people
• The people in power decide who gets human rights (governments)
• Human rights are not laws, they are only laws in countries that enact
them in legal ways
• They are more of suggestions and guidelines
The Universal Declaration Of Human Rights (UDHR)

UN Declaration of Human Rights

- THE GENERAL ASSEMBLY proclaims THIS UNIVERSAL DECLARATION OF
HUMAN RIGHTS as a common standard of achievement for all peoples
and all nations, to the end that every individual and every organ of
society, keeping this Declaration constantly in mind…
The Australian Context
- The monitoring of governments adherence to the UN Conventions is
part of improving the health status of populations.
- Defining the needs of a population
 - Developing programs to meet those needs is essential to improving
population health.
UN Declaration and Australia
In 2008, the federal government took several steps towards improving
Australia’s protection of human rights, including the following:
Human Rights in Australia
- Ratifying the Convention on the Rights of Persons with Disabilities
- Holding consultations about ratification of the Optional Protocol to the
International Convention on the Elimination of All Forms of
Discrimination against Women (CEDAW) and the Optional Protocol to
the Convention against Torture (OPCAT)
- Expressing commitment to formally support the Declaration on the
Rights of Indigenous Peoples
- Issuing a standing invitation to UN human rights experts to visit and
report on Australia.
- Australian Human Rights Commission (2016)
- So what rights do we all have as Australians?
- Universal voting rights and rights to freedom of association, freedom of
religion and freedom from discrimination are protected in Australia.
- The government is monitoring the issues happening in Australia
concerning human rights, to help and rectify
o Monitoring may come short for all groups
- Australia is getting closer to equity and equality
o E.g. indigenous and disability
- Close the gap is not doing well at all
o Some changes, but not sustainable
- Northern territory emergency response (intervention), is not going well
o Indicated huge abuses toward young people in indigenous
communities
o Lots protested because laws just applied to indigenous. They did
not consult all aboriginal
UN Declaration on The Rights of Indigenous Peoples (2007)
- Article 21. Indigenous peoples have the right, without discrimination, to
the improvement of their economic and social conditions, including,
 inter alia, in the areas of education, employment, vocational training and
retraining, housing, sanitation, health and social security.
- Article 27 States shall take effective measures and, where appropriate,
special measures to ensure continuing improvement of their economic
and social conditions. Particular attention shall be paid to the rights and
special needs of indigenous elders, women, youth, children and persons
with disabilities.
Closing The Gap
Human Rights in Australia
- Northern Territory Emergency Response
- What is it? Health impacts?
- Video: https://www.youtube.com/watch?v=1cOoxU_-YvA
National Health Research Council (NHMRC)
“All Australians have the right to access care that meets their needs. In our
culturally and linguistically diverse society, this right can only be upheld if
cultural issues are core business at every level of health system – systemic,
organisational, professional and individual.” (NHMRC, 2005)
Human Rights and Health
Article ##
(1) Everyone has the right to a standard of living adequate for the health and
well-being of himself and of his family, including food, clothing, housing and
medical care and necessary social services, and the right to security in the
event of unemployment, sickness, disability, widowhood, old age or other lack
of livelihood in circumstances beyond his control.
 - Globally, ill-health can lead to, exacerbate and perpetuate poverty.
- As Freire argues: “Attempting to liberate the oppressed without their
reflective participation in the act of liberation is to treat them as objects
which must be saved from a burning building….”
Human Rights and Health Literacy
- People from affected communities should lobby against these initiatives
if they feel they are not meeting there needs.
- You don’t know what you don’t know until its too late
- Not being asked OR assumed not to know
- We have to engage as partners to improve health outcomes
- Health goes beyond objective facts. Recognises that it is not just up to
the individuals responsibility
- People often know wat they want to be helped, but are often not heard.
What is Health Literacy?
• Health Literacy has been defined as the cognitive and social skills which
determine the motivation and ability of individuals to gain access to,
understand and use information in ways which promote and maintain
good health (WHO, 2019)
Health literacy impacts & statistics
- E.g. disability group did not have sexual reproductive literacy. Therefore
more likely to contract STD’s or give STD’s. Sexual abuse more likely,
because they did not have health literacy knowledge
- This demonstrates how health literacy impacts health outcomes,
therefore, important for human rights
- More people with less health literacy are part of minority populations,
therefore, they have the least access.
Example of Impact
- Disability + sexual and reproductive health rights
Health Literacy Statistics (AIHW, 2018)

Strategies for health literacy

1. Empower people
2. Build capacity
3. Sustainable
Health Literacy Statistics
- 41% of Australians aged 15–74 were assessed as having adequate or
more than adequate health literacy skills (ABS 2008b).
 - Half (50%) of all people aged 30–39 had health literacy skills that were
adequate or better. Less than one-quarter (22%) of people aged 60–74
had health literacy skills that were adequate or better.
- Levels of health literacy skills were similar for males and females—40%
of males and 41% of females had adequate or better health literacy
skills.
What is Equity?
- Equity in health reflects a concern to reduce unequal opportunities to be
healthy associated with membership in less privileged social groups, such
as poor people; disenfranchised racial, ethnic or religious groups;
women; and rural residents
Equality vs Equity

Can we Actually Enact Equity?

- Concern for health equity implies a values-based commitment to tackle
poverty and health, with or without conclusive evidence of aggregate
utilitarian gains.
Human Rights and equity
- Equity to different to equality
- Equity – filling the gap to the disadvantage, relative to those who are
advantaged. Shift things around to give everyone a fair go
 - Equality = everyone gets the same
3 aspects of equity
- Eliminating systemic health disparities between social groups e.g.
women gets paid less than mean
- Correcting their fundamental causes
- Reducing their health- damaging effects
Can we make equity happen?
- We just need to chip away slowly
- Those experiencing advantage, might have to shift, in order to give
others a chance.
Human rights
- Strengths: we are all deserving of human rights. Encourages equality
- Limitations: There is still a lack of equity. People in power decide who
gets to access to human rights. They are not laws unless the country
decides to put in legislation. They are only a suggestion or guide. Human
rights are continuously being breached due to conflict between different
groups.
Violence
- Direct: normal violence, threaten life itself
- Structural: systemic ways that affect equal access to services, groups are
inhibited from access. E.g. limited access to education in marginalised
community
- Cultural: Prominent benefits become inevitable and reproduce. Often
normalised
Module 5 Intro to Cultural Competency
Cultural Competency Spectrum
- Cultural Destructiveness
o Colonization, forced assimilation, removal of rights, dominant
group takes this
- Cultural Incapacity
o Racism, maintenance of stereotypes, unfair job allocation
- Cultural Blindness
o Meting needs of dominant groups
- Cultural Pre-competence
o Exploring cultural issues, assessing needs of groups, start to
develop foundation of competence
- Cultural Competence
o Seek ideas, understand that you don’t know everything,
understanding diverse groups, value diversity
- Cultural proficiency
o Implementation of cultural needs, see what needs to be changed
- NHMRC (2014) indicates that competence is an “individual as well as
organisational, professional and system level capacity to act in order to
support culturally and linguistically appropriate services”
Assessment 2 Overview
- Cultural and social diversity are increasingly recognised as major issues
in the delivery of health care. As such, cultural competency and cultural
safety are important skills health professionals must have in order to
improve individual and population health outcomes.
- Job application
- 1500 words
- 6 main criteria
- Minimum of 10 references
- Focus on your specific profession/discipline
Assessment 2 Criteria
1. What about your profession/discipline, makes you the best candidate for
the role of ‘cultural liaison’ within the NSW [insert your discipline]
Health Service? (approx. 100 - 150 words)
2. Demonstrate your understanding of the theoretical relevance and
relationship between social determinants, human rights, cultural
competence and health outcomes. (approx. 150 - 200 words)
3. Identify, with practical examples and links to your professional
guidelines, how you would support and/or enact the five key constructs
of cultural competency within the NSW [insert your discipline] Health
Service. (approx. 300 - 400 words)
4. Demonstrate knowledge of your professional guidelines/policy and their
relationship to cultural safety. (approx. 250 - 300 words)
 5. Demonstrate an understanding of the barriers and facilitators to
culturally safe and competent professional practice for both staff in your
profession and health consumers. (approx. 200 - 250 words)
6. Given your disciplinary expertise, understanding of cultural competence
and cultural safety demonstrate how your understanding of health
theory (e.g., social determinants, human rights, etc.) makes you the best
person for this role/position at the NSW [insert your discipline] Health
Service? (approx. 150-200 words)
- Make sure you are providing the reader the following elements for each
selection criteria:
- Context – Provide a situation where this selection criterion would be
exercised in your profession.
- Action – Provide the professional actions you would take personally to
meet the selection criteria
- Result – What are the expected beneficial outcomes?
- Theory – Ensure the above is supported by relevant evidence based
literature and support from your professional associations principles for
cultural support.
Cultural Competence
 Goes beyond cultural awareness and sensitivity
 Support positive client/patient experiences and improved health
outcomes
 Integrated in health services to reduce institutionalised discrimination
 Building cross-cultural communication
 Looks to foster this constructive interaction, as well as
communication
 Promote understanding, harmony, respect between culture
 Recognise that you don’t know everything, we need to engage with
others to learn
Cultural competency
 Cultural competency aims to foster constructive interaction and
communication between members of different cultures
  Cultural competency is a set of congruent behaviour, attitudes and
policies that come together in a system or agency, or among
professionals, enabling them to work effectively in cross-cultural
situations
 Campinha-Bacote, J. (2002). The process of cultural competence in the
delivery of healthcare services: A model of care. Journal of transcultural
nursing, 13(3), 181-184.
Cultural Competency Model
 1. Cultural competence is a process, not an event.
 2. Cultural competence consists of five constructs: cultural awareness,
cultural knowledge, cultural skill, cultural encounters, and cultural
desire.
 3. There is more variation within ethnic groups than across ethnic groups
(intra-ethnic variation).
 4. There is a direct relationship between the level of competence of
health care providers and their ability to provide culturally responsive
health care services.
 5. Cultural competence is an essential component in rendering effective
and culturally responsive services to culturally and ethnically diverse
clients
FIVE KEY CONSTRUCTS
 cultural awareness,
 cultural knowledge,
 cultural skill,
 cultural encounters,
 cultural desire
Cultural awareness
- The health care worker becomes sensitive to the values, beliefs,
lifestyles and practices of the client and identifies their own values,
biases and prejudices.
- To know others, we must first know ourselves
- Ask yourself: “Am I aware of my biases and prejudices towards others
that I care for, including racism and other “isms” in health care?
- Be aware of your biases and prejudices
- Know thy self
- Be aware that things may be done differently in different cultures
- E.g. at the end of the week, reflect on potential biases
Cultural Knowledge
- The health care worker seeks information about other cultures and
different worldviews, and how these views impact a client’s health and
wellbeing.
- Acquire knowledge on ethnic communities’ health related beliefs and
constructs, main health conditions and their treatments.
 - Ask yourself: “Am I knowledgeable about the worldviews and
biocultural ecology of the clients for whom I care?”
- Clear understanding and evidence that it will be effective
- Social determinants
- Acquire knowledge from communities
- E.g. seeking out knowledge, do research. Include practical examples
(voluntarily attending training modules)
Cultural skill
Capability of the provider to:
- The health care worker collects relevant cultural data regarding the
clients presenting problem and accurately performs a culturally-
informed mental health assessment.
- gather relevant cultural information in relation to ethnic patterns of
health and disease
- ability to engage in culturally sensitive practice
- Ask yourself: “Do I have the necessary skills to assess the cultural needs
of my clients?”
- Do something with knowledge
- Conduct cultural assessment
- Refer people to appropriate services
- Gather relevant information
- Have toolkit to adapt
- E.g. having the ability to see if the situation might not be appropriate
Cultural Encounters
- The health care worker is involved in face-to-face encounters with
clients from diverse cultures. This helps refine or modify the
practitioners existing beliefs about a cultural group and prevent
stereotyping.
- Continuous engagement of professionals with clients from diverse
cultural and linguistic backgrounds.
- Ask yourself: “Do I seek out face-to-face and other types of interactions
with people who are different from myself?”
- Find opportunities to engage with communities
- Seek face to face? Or whats better for them?
Cultural Desire
 - The health care worker must be motivated to become involved in the
process of becoming culturally competent.
- The passion and enthusiasm of the professional to engage in the process
of becoming culturally competent
- Ask yourself: “Do I really ‘want to’ become culturally competent?”
- Consistent level of desire and engagement
- E.g. seeking out training and modules or cultural festivals to improve
cultural competence
Consolidating cultural competence
- Cultural desire = Catalyst to start the process of cultural competence
- From that the other aspects come together and are consistent
- This unit gives us knowledge and skills
- Your identity and inner self is linked to the idea of moving towards
change
- What drives you to more toward cultural competence
- Why might there be resistance toward cultural competence? Racial
privilege, feelings of anger, frustration and confusion
What barriers of being cultural competence?
- Haven’t had opportunity for cultural encounters
Barriers to Cultural Competency
 Why might people resist these steps?
 Why do people sometimes approach cultural competency with
hesitation?
 What might be some barriers which stop you from becoming culturally
competent?
Textbook chapter 5
Institutional discrimination

- Institutional discrimination is deeply embedded within institutional norms.

- It takes the form of racial, cultural and social discrimination based on a person’s race,
culture, choices, lifestyle, age or religion.
- Institutional discrimination includes the control of information, materials and resources that
disadvantage a sector of the population and advantage another; examples of these include
access to quality health care, housing and education
- A monoculturalistic ideology occurs when only one culture is considered. In the Australian
health system that is the dominant White culture.
- Institutional racism is often experienced by Aboriginal and/or Torres Strait Islander peoples
in many institutions including health
- Anti-racism policy is initially viewed as inclusive in an effort to reduce racism, although it can
result in paternalistic and disempowering actions undertaken by the health provider towards
the patient actions that thereby manifest themselves as racist, stripping the minority of their
voice and autonomy.

LECTURE 6- Cultural safety

Reviewing cultural competence
- It is on a spectrum
- You could reduce cultural destructiveness by engaging with cultural
encounters to help you towards that goal and that you are always
learning
- Cultural competency = toolbox
- Cultural safety = outcome (house)
o Without self-awareness it is difficult to be able to turn cultural
competency into outcomes of cultural safety
o Self-awareness/reflection = plan
Cultural Competency
- NHMRC (2014) indicates that competence is an “individual as well as
organisational, professional and system level capacity to act in order to
support culturally and linguistically appropriate services”
Cultural Safety
- Came about as a defence against the biomedical and Eurocentric model
- Talk about social diversity e.g. age, gender, sexuality etc.
- Culture is continually changing
- Linked to Primary Health Care (as described in the readings)
- Holistic View of Health Care
- Person-centred Care
Why the need for Cultural Safety?
- Cultural safety is a movement in defence against the Eurocentric and
biomedical systems which promote cultural violence, culture clash,
culture shock and ultimately cultural destructiveness.
What Cultural Safety is NOT!
- Protecting culture
- Protecting people from a different culture than yours
- NOT about PROTECTION in any way!
Measuring Cultural Safety
- No need to become an expert on culture
- No need to learn a new language
- No need to study world religions
Addressing cultural safety
- Barriers to cultural safety
o Not always aware of the need to reflect
o Might do things problematic to the people we work with or
people we provide care for e.g. unconscious bias
o Unconscious bias seen in social diversity e.g. gender

Self Reflection
 - “Many health professionals may find it difficult to believe that their
actions, attitudes and behaviours at times may ‘diminish, ‘demean’ or
‘disempower’ an individual.
- Why is that? Assessment 2 – barriers & facilitators
Unconscious Bias
- “Our cultural self is internalised. It is usually so thoroughly ingrained that
we don’t consciously think about it. However, it is often the basis of our
‘gut reactions’ when we judge other people and events.”
- Unconscious biases are social stereotypes about certain groups of
people that individuals form outside their own conscious awareness.
- Favouring your own culture without realising it vs people who are
different to us
- Important to be aware of this

Example: Ethnic Privilege

- Can having a “black” name keep you from getting a job?

Professional Culture(s)
- Every profession has a specific culture:
- What is specific about your professional culture?
- What are its values, beliefs, rituals and rules?
 - Does it have its own philosophy?
- These questions will help you with Assessment 2
- Who exercises power?
- Is it power with or power over?
- How will you use your professional power?
Professional culture
- How are we going to engage with the professional power that we have
in order to support health outcomes? Barriers/facilitators?
- Bystander anti-discrimination: actually step in to support health
consumers to help with health consumers. Support people we work with
as well
- What are some situations where you can step up for someone!
- Bystander anti-discrimination is something you can do to support
cultural safety.
Power and Trust
- The more vulnerable the client the more trust is needed on both sides
and the harder it is to generate.”
- “Like cultural safety, trust is the result of an experience by the recipient
of care.”
Bystander Anti-Discrimination
- Bystander anti-racism is action taken by 'ordinary' people in response to
incidents of interpersonal or systemic racism.
Self-Reflection = Respect
- Respect leads to trust
- Trust is necessary for negotiation
- Negotiation nullifies power imbalance
- Cultural safety flows from respect, trust and negotiation
The communication loop
Intercultural communication
- Cross-cultural
o Distinctive cultures are comparable
o One ‘cross cultural’ style works for every culture
- Intercultural
o Communication must be adapted to each culture
o But cultures are not homogeneous
- Interdiscursive
o Interpersonal professional communication
o Work with people to address their needs

Listening means Trusting

- Trust requires some reflective scrutiny of motives and reactions on the
part of the health professional and some active moral commitment to
try to see patients with attitudes of generosity, charity and compassion.
- Compassionate listening requires work, especially in cross-cultural
situations. We have to prepare ourselves to listen before we can engage
in a process that demonstrates real listening.
Deep vs Surface Listening
- “When people are not heard, when others do not listen to them or pay
attention to their being, they are diminished.” (Burton, 2002 p. 164)
- “Careful listening…is the starting point for careful thinking.”
Keys to communication
Textbook chapter 4
Principles of cultural safety

- Cultural safety is premised on working towards social justice and better health outcomes for
those experiencing health inequity.
- It is a philosophy of practice that is concerned with how a health professional does
something, not what they do, in order to engage in and support culturally safe practice
- Cultural safety provides a means to examine how people are treated in society and how they
are affected by the systemic and structural issues and social determinants of health
- Cultural safety takes into account peoples’ unique needs and requires an ongoing process of
practitioner self-reflection, cultural self-awareness and an acknowledgement of how these
factors impact on care
- Importantly, cultural safety uses a broad definition of culture that does not reduce it to
ethnicity only. Instead, it includes a range of variables, such as age/generation, sexual
orientation, socio-economic status, religious or spiritual beliefs, gender and ability

Access to health care

This section briefly refers to factors that impact on whether people from different cultures physically
access a health service and feel comfortable, culturally safe, happy and confident as service users.
Relevant issues will be addressed further on in the text and include

- Key attributes of culturally safe health care.

- Addressing racism in the health system is vital for improving health outcomes for any
cultural or ethnic minority.
- Whiteness and White privilege refer to systems that privilege some people while
disadvantaging others. In health care, sections of the population will experience institutional
racism and discrimination if they do not hold the social advantages of Whiteness
- Our current health care system is designed for the dominant group.
- Health systems that are culturally safe are more likely to be used by people in the greatest
need.

Effects of power and authority on health care

 - The question of the misuse of, or lack of awareness about, the power relationship between
health professionals and their clients lies at the heart of culturally unsafe practices.
- The cultural “unsafety” of the health system stems from people's inability to acknowledge
and legitimise difference, the centrality of culture and the integrity of identity
- It would appear that there is still a long way to go regarding the cultural unsafety of the
Australian health system, as Indigenous peoples have also been subject to non-Indigenous
medical treatment and health services, which have largely failed to recognise the cultural
bases of their traditional health care, or the ongoing impacts of colonisation

Whiteness

- Whiteness maintains its power because it is removed from scrutiny

- Whiteness is simultaneously a practice, a social space, a subjectivity, a spectacle, an erasure,
an epistemology, a strategy, an historical formation, a technology, and a tactic.
- Whiteness is a delineation of those who reap benefits from Whiteness and those who do not
—those who are White and those who are non-White
- “Whiteness as a racial identity… confers dominance and privilege (that) remains unmarked
and unnamed”.
- non-White refers to individuals who are excluded from being beneficiaries of Whiteness as a
result of their racial, ethnic, cultural, religious, linguistic or national identities
- Whiteness, White supremacy, and White privilege are three interlocking forces that disguise
racism so it may allow White people to oppress and harm persons of color while maintaining
their individual and collective advantage and innocence”.

White privilege

- White privilege is a way of conceptualising racial inequalities that focuses as much on the
advantages that White people accrue as on the disadvantages that people of colour
experience.
- White people are viewed by themselves as normal rather than advantaged.
o This normative assumption causes all discussion of racial inequality to focus on the
disadvantages of other racial groups

White fragility

- White fragility to describe the common reactions of “disbelieving defensiveness” that White
people exhibit when their ideas about race and racism are challenged.
- White people from racial discomfort and inculcates a sense of entitlement to peace and
deference, leading to an inability to engage in difficult conversations and challenge
assumptions.
- White fragility is the “state in which even a minimum amount of racial stress becomes
intolerable, triggering a range of defensive moves”

Module 7
NHMRC (2005) Model
 All Australians have the right to access health care that meets their
needs. In our culturally and linguistically diverse society, this right can
 only be upheld if cultural issues are core business at every level of the
health system – systemic, organisational, professional and individual.
 Interplay between dimensions

 Principles of the Model:

 engaging consumers and communities and sustaining reciprocal
relationships;
 using leadership and accountability for sustained change;
 building on strengths — know the community, know what works; and
 a shared responsibility — creating partnerships and sustainability.
Assessment Links
 Policies and guidelines influence the ability to enact cultural competency
in one’s health profession.
 This link to the following Assessment 2 criteria:
 Criteria 3
 Criteria 4
- Criteria 5
NHMRC (2005) Model
NHMRC LEVELS
 Systemic (the system supports the organisation)
 Organisational (the organisation and profession support the individual)
 Professional
 Individual (the individual informs the organisation, profession and
system by applying his/her knowledge, conviction and capacity for
action)

 Systemic — effective policies and procedures, mechanisms for

monitoring and sufficient resources are fundamental to fostering
culturally competent behaviour and practice at other levels. Policies
support the active involvement of culturally diverse communities in
matters concerning their health and environment.
 Acknowledge social diversity (disability, age, gender etc.) are
relevant and they could intersect.
 E.g. ratification of human rights. How might you engage with this?
 Organisational — the skills and resources required by client diversity
being in place. A culture is created where cultural competency is valued
as integral to core business and consequently supported and evaluated.
Management is committed to a process of diversity management
including cultural and linguistic diversity at all staffing levels.
 How systems in an organisation may work
 E.g. unconscious bias may develop in workplace, how will you
mange this. How will you change this at organisational level (the
more you reflect on your unconscious bias = move toward
conscious bias)
 Professional — over-arching the other dimensions, at this level cultural
competence is identified as an important component in education and
professional development. It also results in specific professions
developing cultural competence standards to guide the working lives of
individuals.
 Codes of conduct come in
 Part of the main issue = individuals contradicting their codes of
conduct
 Individual — knowledge, attitudes and behaviours. Defining culturally
competent behaviours are maximised and made more effective by
existing within a supportive health organisation and wider health
 system. Individual health professionals feel supported to work with
diverse communities to develop relevant, appropriate and sustainable
health promotion programs.
 E.g. stigma with mental health. There is effect of stigma impacting
access of health care (important to recognise that you can’t
necessarily see mental health) ( X “man up” not good)
 Think about attitudes or behaviours you might have (about mental
health), that might have a damaging or supportive effect on the
people you are working with.
 Our own personal ideas do impact others. Can see how this is
linked to professional level and engaging with social media or
discussion in a way that is align with our professional identity
 Individual level and self-awareness
 Look at cultural desire (want to improve, want to engage)
 Profession looks at holistic = easier
 Self-awareness: realising you might feel something towards a
particular group of people. What impact does this have on the
way I might engage with them. Reflect on these ideas! All humans
deserve respect. Respect breeds trust = better
negotiation/compromise and understanding. Negotiation = deal
with power balance = cultural safety. Understanding that not
everyone has health literacy especially low socioeconomic.
Key Areas within the Dimensions
- Systemic and Organisational:
 Consumer participation
 Education
- Professional and Individual:
 Self-reflection
 Information
Individual Example: Self-Awareness
  What is my ethnicity/culture? Am I part of the dominant culture
group in Australia? Am I not? What might this mean?
 What is my religious background? What do I think about other
religions?
 What is my culture of health? Western, Eastern and/or Other?
 How old am I? What might people assume about me because of
my age?
 What is my sex? Is it the same as my gender?
 What is my sexual orientation? What do I think about people
whose sexual orientation is different than mine?
 Do I have a disability or disadvantage?
 What level of education do I have? Does this mean I will make
more money and have more privilege and prestige than the
majority of Australians?
 Do I think people without a good education or money are just
lazy?
 What is my role in my family? Should that be the same for other
people?
 What phenotypical markers identify you?
Textbook chapter 6
Culturally safe practice recognises the importance of health care that is driven by the individual,
family and community

- Clients are more likely to participate in a trusting and respectful relationship with their
health professional if they feel they can rely on their health professional with confidence and
have a degree of control over their own situation
- Listening is a vital part of creating a shared dialogue with clients. Health professionals can
cultivate some habits of engagement with clients: listen to the reason the client is there;
elicit the client’s perspective—what do they think the problem is or what do they think the
solution might be
- Health professionals need to display empathy and compassion in their willingness to
understand the point of view and the feelings of the client.
- A key to a shared dialogue is, don’t assume, ask! Ask how someone wants to be addressed
and respect how they choose to identify without questioning, assuming or stereotyping
- Health care practice that is collaborative, builds partnerships and shares power enables
individual clients, their families and communities to be active participants in health. This
 includes regarding clients as partners in health care, involved in the decision making and
part of a team effort to maximise the effectiveness of the care
- Collaboration and partnership also underpin how health professionals can work with bi-
lingual health workers, cultural liaison workers, and Aboriginal and Torres Strait Islander
health workers—health professionals who clarify client-centred issues and enable more
culturally congruent care for clients.

Week 9- Indigenous health

Multicultural heath
 All Australians have the right to access health care that meets their
needs. In our culturally and linguistically diverse society, this right can
only be upheld if cultural issues are core business at every level of the
health system – systemic, organisational, professional and individual.
 National Health Medical Research Council 2005
From multicultural to Indigenous health
- All aspects of social determinants = important for human rights in
relation to health
Culture
 Totality of a group’s behaviours, values and beliefs, as well as its art,
language, tools, world views, symbols (Hunt and Colander, 1984)
 Dynamic and influenced by the whole environment
 Cultures adapt and cultures clash
 Culture shock involves uneasiness, anxiety and stress
 The melting pot of cultures can also enrich
Health History
 The National Aboriginal Health Strategy (NAHS) was written in 1989.
 “Prior to colonisation Aboriginal peoples had control over all aspects of
their life. They were able to exercise self-determination in its purest
form. They were able to determine their ‘very being’, the nature of
 which ensured their psychological fulfilment and incorporated the
cultural, social and spiritual sense.”
 “Talk about boat people I wish they’d all bloody go home! Go back to
England! I wish they’d all bloody go home! Jump back on your boat and
go home!”
Colonisation
- Key point linked to the deterioration of health outcomes for Aboriginals
- Major impact of colonisation = lack of control of autonomy and agency
(robbed of having any control over their lives)
- Colonisation = first boat people (hypocrites for refugees)
Ethnocentrism
- Who you are influences how you see the world! (ethnocentrism), focus
on the way you see the world through a lens
- Start to trade glasses to learn new ideas
- The tendency to view the world through ones own cultural filters which
can create negative dynamics with and perceptions of those we deem to
be the ‘other’
- Because we are humans we categorise people, situation etc. and make
decisions
- We make decisions based on prejudices every day! Prejudices can be
based on post experience or what you have heard. Prejudice can evolve
to discrimination. Prejudice is usually based on limited information and
over generalization
Prejudice and Discrimination
- The English have a lot to answer to because of how they treated people
across the world.” – Aboriginal woman from Nambour, QLD
- “I like their food…but I think they smell” discrimination
- “Can I get a nurse who doesn’t have dirty skin” discrimination
- “They all look the same” prejudice
- “I’m quite surprised you speak English so well” prejudice
- “I don’t serve Aboriginals” discrimination
- “We’re not looking to hire someone of your type” discrimination
- Direct discrimination (directly to someone that involves prejudice)
- Indirect discrimination, e.g. not getting a job (gender, race, disability
etc.)
- We need to suspend our judgement before we understand (yake off
glasses)
Implications for Indigenous people?

Stolen Generations
 “we started asking each other questions like, ‘when the flash car comes
around why do we always have to run to these houses?’ I mean it was
just normal practice in our lives. We all had safe houses but we weren’t
allowed to go to the same house. We had to go to different houses. That
was to improve the odds – so if one was taken they wouldn’t take all of
us. So we all had our own house that we had to go to when the flash cars
 come. Everyone had to do this while growing up. That’s just the way it
was. It was!”
What does this mean for Indigenous people?
"colonizer’s model of the world"
– Racial Hierachies
– Blaut (2000)
Institutional racism
– Modern day examples?
So what makes someone Indigenous?
The three-part definition
 Item 36.14: In the early 1980s, the Commonwealth Department of
Aboriginal Affairs proposed a new three-part definition of an Aboriginal
or Torres Strait Islander person.
 An Aboriginal or Torres Strait Islander is a person of:
 1) Aboriginal or Torres Strait Islander descent
 2) Who identifies as an Aboriginal or Torres Strait Islander and
 3) Is accepted as such by the community in which he [or she] lives. [16]
Assessment 1: What have been the consequences of this history (past, present
and future)
Impact of colonisation, ethnocentrism, xenophobia and institutional racism:
 Lowered self-esteem
 Distrust and scepticism of government/public services
 Employment opportunities
 Poverty and limited educational prospects
 Housing availability and assistance
 Poor health outcomes and life expectancy
Assessment 4: Consequences
“It’s like, even if society is starting to change you’re still an Aboriginal woman,
even if you adapt and try and integrate you still live on the edge of two lives.
One where you might be a leader and a role model and another where you are
never, and were never good enough, you know. Even when I do great things at
work I always feel like I’m under scrutiny, like I’m expected to fail, like, like I’m
just never good enough…It means I’ve had a self-esteem issue my whole life…I
mean the entire thing!!”
Indigenous Culture of Health
 In contemporary terms Aboriginal people are more concerned about the
quality of life. Traditional social systems include three dimensional
model that provides a blue-print for living. Such a social system is based
on inter-relationships….
 Crucially it must be understood that when the harmony of this inter-
relation is disrupted. Aboriginal and Torres Strait Islander health
deteriorates persistently.
Indigenous Resilience
- Indigenous Australians have shown incredible resilience by continuing to
work in many ways to recover from the on-going impacts of
colonisation.
Assessment 1: What can we learn from Indigenous resilience, strengths and
contributions?
 Indigenous Australians have contributed much to the broader public
good in the mining and cattle industries, by showing ‘explorers’ how to
find their way around the country, in politics, the arts, environmental
movements, sports, cultural awareness and understandings of
spirituality and place.
 The European colonisers however did not seem to appreciate these
contributions (see Lumholtz, 1889/1979)
Population
 The Australian Bureau of Statistics estimates that:
 669,736 Indigenous people living in Australia in 2011.
 NSW had the largest number
  NT had the highest percentage
 Indigenous people made up 3.0% of the total Australian population
 90% Aboriginal, 6% Torres Strait, 4% both
- One-third of Indigenous people lived in major cities
‘Closing the Gap’
 What are the aims?
 Think about Assessment 1:
 What skills and information will you need?
 How can you become culturally competent?
 Challenges and needs must be addressed?
 How will your team improve (or Close the Gap?) Indigenous health
Population
 The Aboriginal and Torres Strait Islander population has a younger age
distribution than the non-Indigenous population
 Average age of 21 years compared with 38 years for non-Indigenous
people.
 The average age for Aboriginal and Torres Strait Islander males and
females was 20 years and 22 years respectively.
 Children under the age of 15 years made up 36% of the Aboriginal and
Torres Strait Islander population
 Compared with 19% of the non-Indigenous population
 The proportion of Aboriginal and Torres Strait Islander people aged 65
years and over was considerably smaller than for non-Indigenous people
(4% compared with 14%).
Indigenous Health Statistics
 Expectations of life at birth for Indigenous and non-Indigenous males
and females 2005-2007

Indigenous Health Statistics

 2x more infant deaths
 babies born 200grams less than non-Indigenous babies and 2x more
likely to have a low birth weight
 Low birth weight = later health problems
- Indigenous women are 5x more likely to become teen moms
- Primary causes of death:
o Cardiovascular disease (including heart attacks and strokes)
o smoking tobacco, not eating well, and having diabetes
o one-in-eight Indigenous people reported having a long-term heart
or related condition (National Aboriginal and Torres Strait Islander
Health Survey, 2005)
Diabetes
- Diabetes as a long-term health condition, by age-group (years) 2004-
2005

Indigenous Health Statistics

 Primary causes of death:
 Cancer
 lung, liver, cervical, pancreas
 breast, bowel, prostate, skin and immune
 Injury (traffic, self-harm/suicide, violence)
Disability
 Indigenous and non-Indigenous adults with a profound/severe core
restriction, by age-group (years), Australia (non-remote areas), 2008

Physical Activity
 - Levels of physical activity, Australia, 2004-2005

Indigenous Health Statistics

 Eye health
 Oral health
 Kidney health
 Nutrition
 Mental health
A clash of cultures: experiences and impacts
- Land = very important to Indigenous people. Connects them to
responsibilities. Land is the co-inhabitor, they just take what they need
and take care of land
- Lore = history, connects to ancestors and identity
- Language = link to ethnic/cultural group
- Law = ways of doing things make up how we understand ourselves
- Result of prejudice and discrimination = indigenous did not feel
culturally safe in healthcare and couldn’t afford it
Institutional and systemic racism
- Xenophobia = a deep rooted, irrational hatred towards foreigners based
on an unreasonable fear or hatred of the unfamiliar
- The sense of ‘other’ and managing difference = understanding of
xenophobia
- When white people took the stolen generation children into their
homes, based on if they are fair-skinned of if they are strong (for labour
work)
Consequences of colonisation
- There are a lot of Aboriginals in the stolen gen, that don’t even know
their heritage or that they were adopted
- Light skin aboriginals experience “You are not really Aboriginal” even
though they have the lineage. It is not about how much heritage, it is
about relos and acceptance and identity
- Colonisation has had a huge impact
Stolen generations
- Forceful removal of Aboriginal children from their families through
government policies
- Had to do with assimilation “Aboriginal needs to be breed out” (false
belief that they were helping them by being apart of white society)
(paternalistic idea)
Closing the gap
- Fight for equality for indigenous
- Said ‘sorry’ about stolen generation
- Declared to close the gap for health
- Needs to work together with the first nations people (they did not really
do this)
- Listening to different needs of local communities
- ‘unfulfilled promises’
- Needs to be focused and necessary for communities
- Government needs to work with ATSI people to review/manage the
strategy,
Textbook week 7
Aboriginal health
- Aboriginal health means not just the physical well-being of an individual but refers to
the social, emotional and cultural well-being of the whole community in which each
individual is able to achieve their full potential as a human being, thereby bringing
about the total wellbeing of their community. It is a whole-of-life view and includes
the cyclical concept of life-death-life.
Aboriginal and Torres Strait Islander peoples and their health

- Aboriginal and Torres Strait Islander peoples in very remote areas have much more
disadvantage and difficulty relative to non-Aboriginal people, and even compared to urban
Aboriginal people, across a range of socio-economic indicators, including high
 unemployment, decreased economic development, less education and inadequate access to
food
- Disparities in health between Aboriginal and Torres Strait Islander peoples and other
Australians are shown in many reports, including the annual Close the Gap report and the
Australian Institute of Health and Welfare (AIHW) biannual Australia’s Health. Reasons for
such inequalities include structural inequity, intergenerational trauma, racism and the
economic consequences of dispossession

We need to be mindful and respectful of the lived experiences of Aboriginal and Torres Strait
Islander peoples. Accessing and using health care can trigger negative reactions that lead to trauma
for individuals, families and the whole community. So, we need to be compassionate, conscientious
and mindful to:

- Advocate for, and to be culturally sensitive to, the needs of population groups such as
Aboriginal and Torres Strait Islander peoples.
- Call out individual and institutional racism within health care settings and among service
providers.
- Acknowledge our own biases. The way we communicate needs to be open and honest to
make a difference in the care of Aboriginal and Torres Strait Islander people and their health
outcomes.
- Acknowledge the diversity within Aboriginal and Torres Strait Islander populations.
- Look for best practice in health-promotion and primary health care activities.
- Collaborate with health service providers and network with Aboriginal communities with
respect and openness to benefit all stakeholders in our quest for better health.
- Take time to build trust in relationships for long-lasting outcomes and change for the good.

Module 10 Australians of Culturally and Linguistically Diverse Backgrounds

(CALD)
Human Rights, Equity & Health
- “All Australians have the right to access care that meets their needs. In
our culturally and linguistically diverse society, this right can only be
upheld if cultural issues are core business at every level of health system
– systemic, organisational, professional and individual.” National Health
Medical Research Council - 2005
Overview
- CALD definitions
- CALD health experiences and needs
- Expectations in the workplace
- Links to Assessment 1 throughout
Assessment 1 Made Easy!
- Pick 2 groups: 1 specific Indigenous group and 1 CALD group (e.g.,
Gamilaroi teenagers & Sudanese teenagers)
- Decide which group you would like to develop your strategy primarily for
(Gamilaroi teenagers)
- Decide what health issue your strategy will address (reduce smoking)
- Develop your stop smoking strategy with all your disciplines in mind.
How will you all participate? How will all your skills be used in the
strategy.
- Explain how your strategy would need to be adapted to reduce smoking
amongst your 2nd population group (e.g.,) Sudanese teenagers.
Who are CALD?
- Definition?
- “CALD communities are those which comprise people for whom English
is not their primary language, or who were born into a culture
significantly different to the dominant Australian culture.”
- This definition can be problematic because it does not consider religion
and does not consider whether individuals have adapted appropriately
Problems with this terminology
 What is the problem with the term CALD?
 Diverse from what?
 Diverse from whom?
 What is the ethnicity being centred or assumed in this term?
What this might look like
 Migrant from
Significantly
Different
Culture

Anglo-
Aboriginal Australia(ns)
and Torres
Strait Non-English
Islanders Speaking
Migrant

Critiquing CALD
- They stick with this definition because it allows for reference to this
group of people without being specific (race and religion)

What’s the point?

- “identification always relies upon a difference that it seeks to overcome,
and that its aim is accomplished only by reintroducing the difference it
claims to have vanquished. The one with whom I identify is not me, and
that 'not being me' is the condition of the identification.”
- Being identified as CALD is being different from central (ethnocentrism)
- We often pretend that these differences don’t exist
Social Example: ‘Handsome’
 What trends do you see?
Australian Bureau of Statistics, 2009
 For the purpose of this analysis, CALD status has been divided into four
categories:
 Born in Australia, mainly speaks English at home
 Born in Australia, mainly speaks a language other than English at home
 Born overseas, mainly speaks English at home
 Born overseas, mainly speaks a language other than English at home.
Measuring assimilation
 Socioeconomic status
 Spatial concentration
 Language attainment
◦ Name changing
 Intermarriage
Demographics
 24.6 million Australians
 400 languages, including Indigenous languages (of which there are 300+)
 270+ ancestries
  a wide variety of cultural and religious traditions.
CALD Statistics and Info
 Among 15-64 year olds, 68% were born in Australia and mainly spoke
English at home
 14% were born overseas and mainly spoke English at home
 14% were born overseas and mainly spoke some other language at
home
 4% were born in Australia and mainly spoke a language other than
English at home
Demographics
 In NSW – 50% from Culturally and Linguistically Diverse (CALD)
backgrounds
 One third of marriages are between people from different countries of
birth
 150+ languages spoken in Western Sydney
 40%+ Christian, ~2% Muslim
Education
 Migrants, 20-24yo, who spoke another language at home were more
educated than those who spoke English
◦ Why is that?
◦ What does that mean for the face of the Australian workforce?
◦ What does this mean for perceptions of health care?
English Proficiency
 Among 20-24 year olds: migrants who were not proficient at speaking
English were half as likely as those with greater proficiency to have
completed or be studying towards a Bachelor degree or above (30%
compared with 58%).
 Among 25-64 year olds, the difference was even more pronounced (16%
compared with 43%).
Work
people aged 15-24 years, engagement in work

Basis of Health Inequality

 Income + standard of living = population health
 Residential segregation diminishes the opportunities for social cohesion
 Indigenous populations are experiencing poor health
 Migrants (especially those with low English proficiency) are experiencing
poor health
Is Australia Racist?
 A recent study by the Public Religion Research Institute found 52
percent of whites agreed, "Today discrimination against whites has
become as big a problem as discrimination against blacks and other
minorities."
 A 2011 study led by a Harvard Business School professor went deeper to
find that "whites see race as a zero sum game they are losing." Over the
last five decades both blacks and whites think racism against Blacks has
been slowly declining, but white people think racism against whites is
growing at a fast rate.
Stereotyping Whiteness
 Recent research by Hilary Bergsieker, Nicole Shelton, and Jennifer
Richeson in the Journal of Personality and Social Psychology
 https://www.psychologytoday.com/au/blog/are-we-born-racist/
201103/racism-against-whites-whats-the-problem
 “the stereotype of whites is that they are prejudiced, intolerant, and
callous.”
 “when whites interact across the racial divide, they are particularly likely
to worry about the stereotype of being seen as bigots, so they
compensate by trying to be super nice.”
The problem (as noted in research)
 on the other side of that racial divide, minority groups are dealing with
their own painful stereotype: being seen as unintelligent and
incompetent.
 So they adopt a goal of inspiring respect.
 They focus on signaling their achievements, on being a little more
serious.
 These divergent goals are especially toxic during interracial interactions.
 Rather than being able to relate, we grow ever more separate.
Take Away Message
 “It's important to see that even when stereotypes are directed against
groups that have not been historically stigmatized, they still perpetuate
the cycle of inequality.
 Why?
 Because these stereotypes prevent us from being able to sit down
together at the same table, to hire each other, to elect each other to
boards, to become friends.”
Two views of Multiculturalism
 Blindness to difference
 Recognition of difference
Close the Gap targets
from 2007
 Close the gap in life expectancy within a generation.
 To ensure all Indigenous four-year olds in remote communities have
access to early childhood education within five years.
 To halve the gap for Indigenous students in year 12 equivalent
attainment by 2020
 To halve the gap in employment outcomes between Indigenous and
non-Indigenous Australians within a decade.
  To halve the gap in mortality rates for Indigenous children under five
within a decade.
 To halve the gap in reading, writing and numeracy achievements for
Indigenous children within a decade.
East Meets West
Exploring cultural diversity in the Blue Mountains
 Prompted by concerns from service providers about providing culturally
appropriate services for CALD residents in the area
 Absence of locally based multicultural workers (funding withdrawn in
2006)
 Limited impact of previous studies
 Issues and practical steps identified by CALD communities and by service
providers
East Meets West issues
 Mainstreaming service delivery = Western culture of health
 Cultural difference seen as a problem = makes CALD ‘invisible’
 Shortage of locally based support
 CALD residents don’t make use of the local services
 Healthcare is a Supply > Demand business!
CALD Status
- Born in Australia, mainly speaks English at home
- Born in Australia, mainly speaks language other than English at home
- Born overseas, mainly speaks English at home
- Born overseas, mainly speaks language other than English at home
- This includes everyone, but targets a specific group, this isn’t specific
Understanding assimilation
- Racial, cultural, ethnic hierarchy’s all around. We are working to chip it
away.
Cultural assimilation
 - The process in which a minority group or culture comes to resemble
those of a dominant group
- People try to become more like the group e.g. straitening hair
Completed assimilation
- Assimilation ends at the moment when our language culture and
ethnicity become that of our country of migration
- Because we where our ethnocentric glasses, we find it hard to wear
someone elses
Assimilation is usually gradual and takes place in varying degrees.
Full assimilation occurs when new members of a society, become
indistinguishable from older members
Measuring assimilation
- Socioeconomic status (education attainment, occupation, income)
- Spatial concentration (geographical location, residential concentration)
- Language attainment (loss of mother tongue, name changing)
- Intermarriage (mixed ethnicity children, being socially integrated into
mainstream group)
Inequities and barriers to health
- Australia is hard to get into, has high standards (English proficiency)
- Majority of migrants come from UK
- Money (low SES = CALD)
- Societal responsibilities
o Increased rate of crime and violence
o Impeded productivity and economic growth
o Overall impaired functioning e.g. health (stress), mental health

Multiculturalism
- Blind to groups
- Everyone should be treated the same
- This unit is focused on recognition of difference
Barriers to health
- Language
- Difference cultures of health
 - Transport
- Not enough money
- Knowledge of their rights
- Humility
- Undertrained workforce
- General ignorance (now knowing how to engage)
Textbook chapter 10
- The White Australia Policy was instituted via legislative amendments from federation until
the late 1950s, with some elements of the policy continuing as late as the 1970s
- This policy sought to prevent immigration into Australia from non-European countries. The
primary mechanism by which people were excluded from Australia was the dictation test.
o This test, instituted between 1901 and 1958, required a person seeking entry into
Australia to write out a passage dictated to them in any European language, at the
discretion of an immigration officer. In a fundamental example of racial exclusion
and discrimination, the test was applied selectively to non-European migrants and
always in a language that the applicant was known not to speak

Who are culturally and linguistically diverse Australians?

- CALD as a term adopted in Australia to describe people with a cultural heritage differing
from that of the Anglo-Australian majority
- . This term includes diversity in terms of country of birth, preferred language, English
proficiency, and other ethnocultural characteristics such as year of arrival in Australia,
religious affiliations, and birthplace of parents
- Indigenous Australians are generally not included when referring to CALD communities
(because their experiences and needs as First Nation peoples are considered to differ
significantly from other ethnocultural groups)
- Although CALD is now the preferred term in Australia, it is important to note that the term is
indeed uniquely Australian, and no other countries have formally adopted this label.

The relationship between culture and health

- Culture and health practices are inextricably linked, and belief systems greatly influence our
perceptions of health and illness.

Barriers to CALD health care

- Expectations regarding the accessibility and effectiveness of services may also influence
help-seeking behaviour, which has been shown to be lower among migrant populations
- Another one of the most apparent barriers to health care is limited English proficiency.
- there remains an unmet need for interpreters across many health systems

Ethnocentrism, both conscious and unconscious, has also been shown to impact health care
delivery.

- Ethnocentrism refers to the tendency of individuals to view the world and people of other
cultures through the lens of their own cultural group.
 - Clinicians may perceive their views to be the “correct” one, limiting exploration or
understanding of patient perspectives.
- Likewise, patients may not be willing to accept advice given to them by clinicians whose
broader belief systems do not align with their own.

Culturally safe health care with CALD communities

- Developing culturally safe professional practice requires a concerted effort at all levels of the
health care system.
- Practical approaches such as cultural safety training and case management across health
care providers and community leaders have been shown to enhance access and
effectiveness
- In some cultures, offering gender-specific clinicians or the option to preferentially select
providers has also been shown to improve outcomes
- Beyond these steps, clinicians should be encouraged to reach a mutual understanding of
their patient’s presentation, health beliefs, assumptions, support networks, and treatment
preferences.
- Rather than assuming the traditional biomedical role of an “expert” seeking to educate, it is
often beneficial to first understand the patient’s perspective and generate a therapeutic
relationship
- Clinicians focused on client cultural safety will appropriately consider the clinical
environment and utilise open-ended questions combined with active listening

Lecture 11- Understanding gender and health

Gender equity means big changes
Late last year, a car was sent to pick up one of our female professors to take
her to a gala event for the university. She appeared at her door and was
immediately ushered into the back seat of the car by the driver. After some
time, she noticed the driver pacing up and down the footpath and she asked
him if he was all right. He said. ‘Yes I am just waiting for the professor’.
- This is a true story.
- It is humorous, but it also has an underlying message – It is still difficult
for some men to even countenance that a woman could be a professor.
What we will cover…
 Concepts of sex and gender
 Gender roles
 Sexual division of labour & gender pay gap
  Gender inequality
 Gender violence
 Implications for health providers
Understanding Sex and Gender
 What is Sex?
 Biological characteristics (therefore it is scientific) enabling sexual
reproduction; being male or female.
 What is Gender?
 Social and cultural construction of a person; masculine or
feminine characteristics.
Understanding Gender
Gender identity
- The term ‘gender identity’ refers to a person’s deeply held internal and
individual sense of gender.
Gender expression
- The term ‘gender expression’ refers to the way in which a person
externally expresses their gender or how they are perceived by others.
(how they start to manifest individual sense of self, e.g. female might
wear masculine clothes)
Gender is on a spectrum, e.g. children (boy has to be tough, girl has to be
pretty and be submissive). Gender is a personal identity (has to make sense to
the person it is reflecting). Gender is not defined by body parts. Female and
male are not the only genders. Gender is not determined by DNA or biology.
Gender roles
- Wide historical and cultural variations of what it means to be a man or a
woman
- Compounded by other social and cultural variables such as ethnicity,
religion, class and age.
- Public (men supposed to work) and private spheres (women stay at
home) – gender role division.
- Sexual division of labour
 - What women and men are expected to perform and the reward (?) that
comes with it (unlikely to see a male take paternity leave)
- Variables are dependent on particular kinship structures, gender
inequalities, and levels of structural violence in the wider society.
Gender stereotypes – Women
- Women produce children;
- Women are mothers and wives;
- Women do the cooking, cleaning, sewing and washing;
- Women take care of men and are subordinate to male authority;
- Women must look attractive for men;
- Women are largely excluded from high-status occupations and from
positions of power.
- (Women are objectified by these ideals) But women in an objective
desire (they are owned). This is problematic.
Gender stereotypes – The Man Box (set of stereotypes are expected to
adhere to)
- Self-sufficiency: Talking with others about your issues and concerns is
weak; Men should figure out their personal problems without asking for
help.
- Acting tough: A guy who doesn’t fight back is weak; Guys should always
act strong even if they feel scared and nervous. (Increasing mental
illness)
- Physical attractiveness: Successful men look good; But spending too
much time on your looks is not manly.
- Rigid gender roles: Men don’t do household chores; Men should be the
financial providers for their family. Men are the breadwinners.
- Heterosexuality and homophobia: A gay guy is not a real man; Straight
guys should not have gay friends.
- Hypersexuality: A real man has as many sexual partners as possible; A
real man never says no to sex. (problematic in terms of rape, a man can
say no to sex, but if he does he is considered weird)
- Aggression and control: Men should use violence when necessary; A
man always has the final say in a relationship.
Gender Inequity in Australia
 Gender representation in Australia
https://www.youtube.com/watch?v=uLXjULf4hlo
The Household, Income and Labour Dynamics in Australia (HILDA) survey tells
the stories of the same group of Australians over the course of their lives.
Starting in 2001, the survey now tracks more than 17,500 people in 9,500
households, asking about their economic well-being, health and family life.
Showed that women are just as violent as men.
Sexual division of labour
- Women are more likely to be social worker or teacher
- Men more likely to be at frontline positions like police officer and
engineer etc

Average weekly earnings in main job (full-time), and gender pay gap, by
occupation of main job
- The pay gap is significantly dropping, but there is still a gap
Gender Pay Gap
Factors that contribute to the gender pay gap include:
- women and men working in different industries (industrial segregation)
and different jobs (occupational segregation).
- a lack of women in senior positions, and a lack of part-time or flexible
senior roles.
- women’s more precarious attachment to the workforce (more likely to
take time off if family is sick or if they need to take a career’s
responsibility)
- differences in education, work experience and seniority
- Discrimination both direct and indirect
Gender Inequality
 In all countries of the world, there are cultural practices that hinder, and
in some cases prevent women’s and entire communities’ full enjoyment
of their human rights.
 Why/How?
 cultural and religious interpretations and practices are
institutionalised through unequal family laws,
 laws and policies restricting reproductive and economic choices, &
  the absence of laws banning gender-based violence and harmful
traditional practices.
 Gender inequality doesn’t make sense on any level. Promoting gender
equality can reduce extreme poverty and hunger and boost shared
prosperity for girls and boys, women and men, around the world.
Gender-Based Violence – Women
 In Australia one woman is killed by her partner or ex-partner every week
(AHRC, 2016)
 40.8% of women have experienced some form of violence since the age
of 15 (ABS, 2012)
 Intimate partner violence accounted for 5.1% of the disease burden
amongst women aged 18 to 44 years — more than other any other risk
factor (ANROWS, 2016)
 Women who experience greater intersectional inequality due to race,
disability, age, sexual orientation, gender identity or socio-economic
status often experience higher rates of domestic violence and face
additional barriers to seeking help and support.
Implications of Gender on Health
 Men - Approximately half (49%) of respondents indicated that the
messages they receive about ‘how to be a man’ supported the above
negative stereotypes.
 Men who agreed with the ‘Man Box’ stereotypes experienced a host of
negative physical, mental and social health outcomes in their lives,
including:
 64% had suicidal thoughts in the last two weeks.
 55% had been involved in a road traffic accident in the last year.
 71% had physically bullied someone else in the last month.
 Increased risk-taking behaviours
 Reduced help-seeking for general and mental health
 Reduced reporting of domestic and intimate partner violence
Does gender make us sick?
 All of the top ten biggest causes of premature death and disability, and
all top ten behavioural risk factors driving rates of ill-health around the
world, affect men more than they affect women.
 In every region of the world, men die at a younger age than women do.
 This talk explores the evidence of why men suffer a higher burden of ill-
health than women, what might be driving institutional responses, and
what we can do to achieve Health for All.
Implications for Health Providers
What are the implications of these gender inequalities for health provision and
you as health care providers?
 Understand gender differences/inequalities that impact on health &
well-being of consumers.
 Attempt to provide sensitive care to people appropriately to their
gender.
 How can you use gender to describe actions in cultural competence
and/or the NHMRC levels
Textbook chapter 11
Constructions of masculinity

- Through media and popular culture, we are often exposed to images reinforcing the ways in
which men and women “should” perform their masculine and feminine roles, respectively.
- These images have been shown to reinforce societal barriers, depicting men as absent
fathers, violent football fans, or underachieving students
- Men are stereotypically characterised as inherently aggressive, with this trait manifesting
itself in the form of “taking charge”, exhibiting dominating behaviours or violence
- Hegemonic masculinity describes practices that legitimise the “dominant” position of
heterosexual white men in society and justify subordination of other gender identities or
sexual orientations
o The hegemonic male must be successful, athletic, competitive and stoic, taking risks
and engaging in aggressive or thrill-seeking behaviours.
o Physical fitness may be prioritised along with work success, and mental or emotional
difficulties are kept hidden from all but the most intimate of female partners
- Hyper-masculinity, which is characterised by callous sexual attitudes towards women, the
belief that violence is acceptable or “manly” and the perception of danger as exciting
o Such individuals are more likely to drink alcohol to excess, be involved in fatal car
accidents and commit acts of violence, online bullying or sexual harassment
 o are less likely to engage with health professionals for fear of being considered
“weak” and consequently demonstrate poorer health outcomes
- Anxiety and depression are common amongst men who believe they do not possess
hegemonic masculine qualities
- The societal advantages seen amongst hegemonic males may also cause resentment or
frustration amongst those who do not receive such advantage. This frustration may elicit
protest masculinity, whereby males actively protest the “ideal” of hegemonic masculinity
o Protest masculinity can be “anomic”, where men exert their masculinity by
suppressing health- and help-seeking behaviours, engaging in criminal activities and
pursuing multiple female sexual partners, or “disciplined”, where men institute
social controls and behaviours (e.g., de-emphasising sexual prowess) to increase
solidarity amongst others in similar positions

Constructions of femininity

- many traditional feminine “characteristics” are those that appear to serve men, such as
being slim and attractive, wearing makeup, exhibiting submissiveness and fulfilling one’s
“duty” as a caring mother.
- The same qualities that characterise depression and low social rank, including subordination,
lack of autonomy, and wishing to escape a scenario but remaining “trapped” due to fear or
obligation, are often regarded as normal and even desirable qualities of femininity
- Hyper-femininity is characterised by the belief that success is determined by maintaining
one’s romantic relationship with a man, and that sexuality can be used to maintain this
relationship
o Women in this category are less likely to report instances of domestic violence or
advocate for severe punishment following sexual abuse, reinforcing their
institutionalised view of themselves as “objects”
- Hegemonic femininity may share characteristics with hegemonic masculinity, rather than
simply being subordinate to it
o hegemonic females are not subservient or male-focused, instead positioning
themselves as strong, independent, and mobilising power in relation to other
females and non-hegemonic males

The relationship between gender constructions and health outcomes

- Sex and gender are being increasingly recognised as important determinants of health.
- Biological differences notwithstanding, gender roles and societal expectations influence the
ways in which people access and experience health services.
- Gender-sensitive and culturally safe practitioners must appreciate the varying needs of
individuals across all gender identifies and understand the interrelationship between these
identifies and health outcomes.

Men’s Sheds

- Men’s Sheds represent a growing movement within Australia in the form of community
locations where men engage in a variety of activities and socialise with peers.
- These “Sheds” seek to address issues of social isolation and promote emotional wellbeing
among men.
 - Sheds offer a “safe space”, where the focus is often not exclusively on discussing mental
health, but instead seeking to instil a sense of mutual support that fosters acceptance and
openness over time

African Women Australia Inc.

- African Women Australia Inc. (AWAU) is a non-profit organisation focused on the holistic
development of African women in Australia in terms of social, health, economic and civic
participation
- The organisation represents a hub for the most comprehensive and up-to-date resources
regarding African women in Australia.
- AWAU operates within a strengths-based human rights framework, recognising and
centralising diversity

The role of the health professional

- Gender-sensitive and culturally safe practice requires a concerted effort not only across
governmental and organisational levels, but also at the level of the health professional.
- A gender sensitive approach involves understanding and appreciating gender as a social
determinant of health.
- Health professionals should recognise gender as a spectrum, striving to educate themselves
regarding individual patient needs rather than developing assumptions based upon certain
observable characteristics.
- Gender-sensitive practice acknowledges the influence of gender in all interactions and
appreciates the different experiences, expectations, pressures and inequalities faced by
men, women and gender-diverse populations

Module 12- SEXUALITY AND GENDER DIVERSITY: LGBTIQ

SEXUAL DIVERSITY?

- Heterosexual
- Homosexual
- Bisexual
- Transgender or Transexual
- Intersex
- Queer or Questioning (Queer has changed over time)
- GLBTIQ
- G = Gay (male or men that are homosexual)
- L = Lesbian (females that are homosexual)
- Bisexual = no specific preference or orientation towards male or female
- Transgender = born male or female and then they identify with the other gender (therefore
they transition to the gender they identify with)
- Intersex = born with female and male reproductive parts (sometimes problematic because it
may not be considered queer, as it isn’t always about gender identity, it is more biological)
- Queer or Questioning = fluid and on a spectrum

SEXUAL ORIENTATION SPECTRUM

-  Alfred Kinsey (Sexual Behavior in the Human Female, 1953)

 - There are few people who are exclusively homosexual, they are usually between this
spectrum.
GLBTIQ

- Natural human variation: https://www.youtube.com/watch?v=wwG_udXu7XI

o Nature
o Nurture
- Being homosexual is not a choice, who would choose to be discriminated against
- 1 in 10 people are not heterosexual

WHO CARES?! LOVE IS LOVE! As long as everyone is consenting and no one is getting hurt

SEXUALITY-BASED PREJUDICE AND DISCRIMINATION

- Homophobia/transphobia/biphobia/queerphobia:
o thoughtless and hurtful comments about GLBTIQ+ people
o do not always intend to hurt or offend someone their comments can have a
detrimental effect
o attraction that is not between people of the opposite sex may be perceived as
wrong or immoral
o Homophobia is the term to describe the irrational fear, hatred, aversion to or
discrimination against people who identify as or are thought to be gay, lesbian,
bisexual, transgender, intersex or queer (GLBTIQ). “That’s so gay” reinforcing
homophobic behaviour.
o Homophobia is not like a regular phobia or morbid fear like in the way people are
afraid of spiders. 
o The “fear” of homosexual people or behaviour is usually displayed through attitudes
varying from indifference through to anger and contempt, more so than fear.
o Homophobic behaviour is discriminatory and offensive and is based on a general
attitude of intolerance, ignorance or disregard for the needs, rights and experiences
of GLBTIQ people. 
o Such homophobic attitudes are widespread throughout Australian society
REASONS FOR HOMOPHOBIA

- 1. The belief that homosexuality is a sin – this is mostly in relation to religion.

 - 2. The belief that homosexuality is an illness – this was mostly in relation to the fields of
psychiatry & psychology
- 3. The belief that homosexuality or homosexual behaviour is a crime – this is in relation to
the law

HETEROSEXUAL PRIVILEGE

-  What are some heterosexual privileges?

- You don’t have to ‘come out’, don’t have to carry that burden

COMING OUT ACTIVITY

- Think about something you did or said in the past.

- This event should be something that very few (if any) people know about.
- Think about how you feel about what you had done or said.
- Think about how you would feel if you had to tell someone about it right now.
- What is your emotional reaction?
- What is your physical reaction?

CONSEQUENCES

- These erroneous and negative beliefs are sometimes used to stop people from having same
sex sexual encounters, from feeling good about themselves and from enjoying the same
rights as straight people
- The mental health impact of homophobia can be devastating.
- Higher incidence, than heterosexual people, to abuse alcohol and other drugs.
- Between 30% and 40% of GLBTIQ youth have attempted suicide, which is up to four times
higher than heterosexual people.

WHERE DOES HOMOPHOBIA EXIST?

- It exists at all levels of NHMRC

- Schools,
- Communities,
- Workplaces and
- Leisure activities

SCHOOLS

- The right to education – According to UNESCO (2012), “homophobic bullying is a threat to

the universal right to education as reflected in the Millennium Development Goals”.
- Safe schools –
o According to UNESCO homophobic bullying “makes schools unsafe for those who are
subjected to it, is detrimental to other learners and has an adverse effect on the
whole school environment.
o If a school is not safe, vandalism against school property increases, abusive
behaviour toward school staff escalates, conflict among peer groups heightens and
learning becomes difficult.”

WORKPLACES
 - Where we spend the majority of waking hours
- Communicate and get to know one another
o their likes,
o dislikes and
o details about each other’s lives
- Discrimination against GLBTIQ people may be worst in the workplace.
o Pictures
o Goodbyes
- Being fired
- Being “outed”
- Finding employment or successful promotion
- Depression, stress-related illness, substance abuse and even suicide

“Homophobia is NOT here to stay, and it takes people like you to say no to it.”

GLBTIQ PRIDE!

- International Festivals
o New York City Gay Pride
o Amsterdam Gay Pride
o San Francisco Pride
o Atlanta Gay Pride
o Chicago Gay Pride
o Sydney Gay and Lesbian Mardi Gras
o Toronto Canada Gay Pride
o Long Beach, California Gay Pride Festival and Parade
o São Paulo, Brazil Gay Pride
o Montreal Divers Cité
GLBTIQ PRIDE

- Acceptance;
- Belonging;
- Joy and;
- Support.

WHY?

- Review your codes of conduct with regards to gender and sexual diversity.
o Israel Folau - $4m contract — and rugby career — officially wiped off the map.
o Rugby Australia boss Raelene Castle announced the termination of the fullback’s
employment on Friday after the controversial star’s “high level” contract breach.
o “Mr Folau knew when he pressed that button there were the implications that post
was going to have,” - “His actions left us with no choice but to come to today’s
outcome.”

WHAT YOU CAN DO?

- Ask yourself:
 o Why does it matter whether another student or colleague is not heterosexual?
o How would I feel if someone treated me badly because of something I could not
change?
- Assessment 2:
o How will you demonstrate understanding of your codes of conduct in relation to
gender and sexual diversity?
o What examples will you use to demonstrate your ability to apply cultural
competence to support cultural safety for this population group?

Textbook chapter 12
Relevant terms

- LGBT acronym was considered to be a more inclusive descriptor than the general term in
usage, “gay community”
- In more recent years, “I” for Intersex and “Q” for Queer or Questioning, have sometimes
been added to the acronym, as have the “A” for asexual, and “+” to indicate other
communities that may fall outside gender and sexual norms.
- However, there are critiques of this acronym, including the lack of focus of the specific and
diverse issues experienced by each of these identities or labels included under the umbrella
term.

Gender

- The terms sex and gender are often used interchangeably in health policy and practice, but
they have distinctly different meanings.
- Gender refers to the range of characteristics that a culture identifies as masculine or
feminine
- Gender is constructed through relationships, expectations and practices that are
institutionalised, for example, through the family, education, religion, cultural practices and
rituals and health care systems and settings.
- Gender binary refers to a classification system consisting of two genders, male and female,
and underpins the social foundations of Australian society and many other societies globally.
- Gender norms determine what is expected, allowed and valued of girls and women, boys
and men, and transgender, gender diverse and non-binary people.
- Gender identity refers to a person’s internal view of their gender—that is, one’s innermost
sense of themselves as a gendered person. A person’s gender identity may or may not
correspond with their sex presumed at birth. Gender identity often influences the name and
pronouns people use.
- Gender expression refers to outward gender presentation and behaviour that may
communicate gender to others.
- Non-binary, which is when a person’s gender identity does not align with binary gender,
male/female. Non-binary people may identify as gender fluid, trans masculine, trans
feminine, agender, bigender, gender queer and a multitude of other such terms.
- Transgender refers to people whose gender is not aligned with the gender presumed for
them at birth.
- In Australia, sistergirls and brotherboys are terms used in some Aboriginal and Torres Strait
Islander communities to describe being trans in a way specific to First Nations people.
 o Sistergirls are First Nations women presumed male at birth, and brotherboys are
First Nations men presumed female at birth.
- Cisgender refers to a person whose gender identity and gender expression matches the sex
they were presumed at birth.
- Gender affirmation refers to processes that a person undertakes to align their internal sense
of gender with their gender expression

Intersex

- Intersex people are born with physical sex characteristics that do not fit medical norms for
female or male bodies
- There is a debate about ‘intersex’ being included in the acronym as it is a biological condition
rather than a gender preference. But some are happy to be included in the acronym
- While intersex is often included in the Lesbian, Gay, Bisexual, Trans*/Transgender— LGBTI
acronym, health concerns faced by people with intersex variations are unique and require
different frameworks to address issues encountered within the Australian health care
system.
- Intersex traits vary across individuals, with some visible at birth, or for others, these traits
are not evident until puberty

Sexuality

- Sexuality encompasses who a person may be attracted to romantically and sexually

- Sexual orientation refers to the set of meanings through which people describe their sexual
attractions. Sexual orientation includes attraction, behaviour and sexual identity
- Sexual behaviour refers to what a person does sexually and/or with whom.
- Sexual identity refers to the language and terms a person uses to refer to their sexual
orientation, which may be influenced by attraction, behaviour, family, culture and
community.
- Together, sexual attraction, behaviour and identity form what is known as the sexuality triad
- The acronym MSM is frequently used, especially in health research, to refer to men who
have sex with men, but who may not identify as gay or bisexual

Gender and sexuality diversity

- Lesbian refers to a cisgender, trans or gender diverse woman or non-binary person who is
emotionally and physically attracted to other women.
- Gay is the term used for someone who is emotionally and physically attracted to people of
the same gender.
- Bisexual refers to people whose sexual, romantic or physical attraction is to people of more
than one gender.
- Pansexual refers to a person whose sexual, romantic or physical attraction is not limited by
sex, gender or gender identity (they are attracted to all genders including those who are
fluid, transgender, intersex etc.)
- Asexual refers to people who do not experience sexual attraction. Asexual people can
experience platonic attraction but may have no sexual desire or need within relationships.
- Fluid- describes an identity that may change or shift between or within the mix of options
available
 - Gender questioning- someone is processing, exploring or questioning how they express
gender identity
- Heterosexual- A sexual orientation that describes those who feel attracted to a sex different
from theirs
- Monosexual- The sexual attraction to members of one sex or gender only. Can identify as
heterosexual, lesbian or gay.
- Non-binary- Describes someone whose gender identity falls outside of the traditional gender
binary of male and female.
- Polygender- A term referring to individuals who identify as more than one gender
- Queer- An umbrella term used to describe people who think of their sexual orientation of
gender identity as outside of societal norms

Bi-erasure- Bisexual people experience erasure in the ways that monosexual people do not. Erasure
not only exacerbates the marginalization of bisexual people. It also resides in heterosexual
understanding of sexuality as bisexual people are neither 100% straight nor 100% gay either, and
when they are in a relationship with opposite or same-sex, they must conform to those ideals
prescribed with what is required in those relationships.

Biphobia- Refers to the prejudices people who are bisexual encounter.

Cis-heterosexism- Represents a prejudicial hierarchy that privileges those who are both cisgender
and heterosexual.

Transphobia-Refers to the prejudicial attitudes directed at people who identify as transgender. This
includes taking positions which exclude transgender people from participating in sports.

Heteronormativity

- Within the Australian health care system, heteronormativity prevails, and this refers to the
way that everyday interactions, practices and policies construct individuals as heterosexual.
- Through heteronormativity, a culture of power is institutionalised through structures,
systems and everyday practices that reinforce heterosexuality as normative
- Cisnormative refers to the assumption that all people are cisgender (have a gender identity
that matches the sex they were presumed at birth).
- The assumptions of heteronormativity and cisnormativity in most institutions means there is
often no designated space for inclusion of transgender, gender and sexuality diverse people
in health care settings.

Minority stress

- Gender and sexuality diverse people can experience minority stress

- This refers to the impact of internal and external stressors, such as stigma and
discrimination, or the distress experienced as a result of having to conceal one’s sexual
orientation and/or gender identity due to fear or discrimination, rejection or violence.
- Internalised homophobia or transphobia, refers to internalised negative beliefs and
attitudes about one’s own sexuality, or gender identity;
- Concealment, refers to stress associated with concealing sexual orientation and/or gender
identity for fear of harm; and
- Stigma consciousness, refers to the increased vigilance and expectations or rejection in
social interactions based on sexuality or gender identity
Stigma
- “stigma is defined as the co-occurrence of labeling, stereotyping, separation, status loss, and
discrimination in a context in which power is exercised”
- Stigmatisation occurs in situations when social, economic or political power allows for and
supports the identification of difference leading to disapproval or rejection.
- Internalised stigma refers to negative stereotypes about a person’s identity that they
believe applies to them (e.g., others say people with mental illness are weak therefore I am
weak).
- Enacted stigma is discrimination as a direct result of a disclosed stigmatised identity (e.g.,
the local baker refuses to make the cake for a gay wedding).
- Anticipated stigma refers to the negative treatment people with a concealed stigmatised
identity believe they might receive if their identity was known (e.g., an employee has not
told their boss about having a history of depression due to a fear of not being promoted).

Barriers and facilitators to culturally safe health care for gender and sexuality diverse Australians

- Doctors and allied health professionals often lack appropriate skills in providing best practice
health care to gender and sexuality diverse people
- Compared to the general population, gender and sexuality diverse people experience higher
rates of illness and morbidity.
- Young gender and sexuality diverse people experience specific barriers to accessing quality
health care, which is further impacted by their age and other intersectional aspects of their
identities.
- barriers to accessing health care reported by participants included fears of homophobia,
transphobia and other discriminations, judgmental responses, gendered assumptions,
concerns regarding confidentiality, prohibitive cost of the service, difficulty getting to the
service, and young people not having their own Medicare card.
- Fear of disclosing and non-disclosure of sexuality and/or gender diversity to health
professionals can be major barriers to preventive health practices, including screening, and
have been associated with lower mental health outcomes

Module 13- Understanding (Dis)ability & Ageing

Prevalence

- Roughly 1 in 5 Australians (18.5%) reported having a disability in 2009 (ABS, 2009).

o 6.5% Musculoskeletal conditions
o 3.1% Mental and behavioural disorders
o 1.4% Diseases of the circulatory system
o 1.2% Diseases of the respiratory system
Defining disability

- “Disability is a...controversial concept, defined as physical functioning by some, and as social

discrimination by others” (Gabe et al., 2004, p. 77). (it can include mental health, physical
impairment, something that interferes with activities of daily living)
o Broad
o The extent of the disability
o Impairment / disability / handicap
Defining disability: Broad definitions

- The Commonwealth Disability Discrimination Act (1992) defines disability as including

“physical, intellectual, psychiatric, sensory and neurological impairments, learning
difficulties, physical disfigurement and the presence of HIV/AIDS” (as cited in NSW
Department of Health, 2010, p. 5). (this definition is very broad!)

Terminology of disability
- Generally like to use language that focuses on the person “person living with a
disability” instead of “disabled person”. Put person first
- Not use term handicapped! (this is often considered offensive) (older cohorts might
use this terminology)
Defining disability: The extent of the disability

- Example:
o ‘Severe disability’ refers to disability that profoundly affects everyday functioning,
including self-care, mobility and communication (Baum, 2008, p. 244).
o In 2003, 6.4 % of all disabilities were categorised as severe and 14% as less severe
(Baum, 2008, p. 244).

Society and disability:

- The Disability Action Plan (2009-2014) defines disability as “people who face social,
architectural, environmental and/or attitudinal barriers restricting their full participation
in society due to the impairments covered by the DDA” (NSW Department of Health, 2010,
p. 5).
- “Throughout the world, even in those countries with effective anti-discrimination legislation
and where social provision is comprehensive...disabled people remain an extremely
disadvantaged minority. Disabled people are still routinely discriminated against in
education, employment, access to all kinds of social and cultural activities as well as access
to health care...”
- STIGMA: “Disability is stigmatised which not only means disabled people may be seen as
lesser beings by others, but worse, many disabled people internalise this and see
themselves as inferior. They also remain the poorest of the poor, in every country in the
world. For example...in the UK most disabled people live near or below the poverty line”
(Albert, 2010, p. 269)

Society and disability: Employment/Education

- In terms of employment, more people who are typically bodied or typically functioning are
more likely to be hired then individuals with a disability or impairment of functioning. More
people who are typical are completing high school, compared to those with additional
needs. (due to unconscious biases that reduce opportunities for those with disability)
- Often those with disability are not able to complete education, impacting their ability to get
a job.
- In Australia, the disabled are disadvantaged:
o 54% vs 83%
o 25% vs 50%
Society and disability: Structural barriers

- Typically functioning people don’t think of this, because the world is designed for these
people.
- The infrastructure is not typically designed to be inclusive (because it is designed for
majority).

Society and disability: Social Stigma

- Making Sense of Sex with Cerebral Palsy (Dune, 2011) – PhD thesis
- People with CP experience high levels of social stigma which restrict them from experiencing
sexual health and wellbeing
- One of the major themes was Feeling Worthy of Sexual Experiences with Others

Society and disability: Social Stigma

Society and disability: Social Stigma

- John: I mean the issue really is if you really claim that you really love someone and that you
want to spend your life with them under what terms is that mediated. I mean, again, I think I
said to you last time, the standard marriage vows go in sickness and in health and that’s fine.
But it doesn’t go in sickness and in constant disease and in constant doctor’s appointments
and in constant co-morbidities.
 - Dune, T. M. (2014,). “You just don’t see us”: The influence of public schema on constructions
of sexuality by people with cerebral palsy. World Journal of Social Science, 1 (1), 1-19
- Stigma can be broken down is by engaging people to do things with others (SOCIAL
INCLUSION)
- Social stigmas can be persistent. We need to think about working on awareness, improve
social determinants at each level of NHMRC

Culture and Disability

- Aboriginal perspective on disability

o https://www.youtube.com/watch?v=zxsppNq69T0 (first minute) (In the indigenous
community there is no such thing as disability, it is just part of who you are, they
don’t look at disability, they look at the person)
- Islamic engagement with disability:
o There are different ways of doing things that are reinforcing the positive ways
people engage with and perceive disability
o https://www.youtube.com/watch?v=JYR-GyynFqU
Ageing Statistics

- Disability and aging can intersect

- Over the next 40 years, the proportion of the population over 65 years will almost double to
around 25 per cent
- Some regional areas attract retirees = more rapid ageing of their populations
- Between now and 2040 every State and Territory is expected to experience a significant
ageing of its population
- Ageing is an issue in which everybody has an interest
- Why are we having an increasing ageing population?
o 1. People are having less babies
o 2. We are living longer!
Fertility Rate

Population Growth: by age

 - With older age comes a lot of health issues
- Need to consider social determinants that contribute to ageing process (its hard to eat well,
exercise, therefore leading to disability with ageing)
- There are stigma towards ageing and disability (these come together as social determinants,
they intersect)

Ageism

- Focuses on the stereotyping or age discrimination

- We see it in the workforce where older workers are undermined. Older workers are pushed
out or fired. (unconscious biases)
- “it is perfectly normal for some 80 year olds to be working, driving and active in their
community, while others may be restricted in movement and require high levels of care.”
- ageing, age stereotyping and age discrimination, three elements of our contemporary
society which interrelate in ways that severely restrict the rights of older people.
- Age discrimination is widespread in our community. It mainly affects older people and it
permeates many aspects of life. Like other forms of illegal discrimination, it damages
individuals, it demeans our society, and it violates human rights.
- Age discrimination acts in two ways:
o first, it undermines older workers currently in jobs by excluding them from training
and promotion, and creating a hostile atmosphere that destroys confidence and
makes older workers more likely to take up redundancies.
o The second major effect is on older unemployed people trying to get back into the
workforce.
- The Rights of Older People and Age Discrimination in Australia (2012)
- The Hon. Susan Ryan AO - Age Discrimination Commissioner:
https://www.humanrights.gov.au/news/speeches/rights-olderpeople-and-age-
discrimination-australia-2012

Social and disability

Healthcare shifts

- A half a century ago, healthcare followed a “total” care model (Goffman, 1968).
- Asylum

Healthcare shifts

- 1970s – 1990s Care in the community Care by the community

Healthcare shifts

- Now, carers are relied on to provide much of the care at home.

- Informal caregivers now supply 55 - 80 % of patient care (Jansma et al., 2005; Lewis, 2006).
- We are thinking about people who are families to do more of caring for disability. But people
who are ageing go into institutions
- For people with disability- increased advocacy, decreased institutionalisation (therefore
decreasing the strain on health care). However, carers are often underpaid and are usually
women.

Carer concerns
- Suffer from high rates of: major depression, anxiety, panic attacks and stress
- Financial hardships
- Increased physical health problems
Disability in Australia: Carers

- In 2009 2.6 million carers provided assistance to others who needed help because of
disability or old age.
- Roughly 55% of all carers were women (ABS, 2009).
- Men are more likely to leave the family or relationship if a member becomes disabled (The
Journal of Sex & Marital Therapy).

Disability in Australia: Carers

- Fifteen percent of Australians are involved in unpaid informal caregiving (Howe et al., 1997).
- Carers suffer from higher rates of:
 - Carers experience:

Disability in Australia: Carers

- Respite
- Financial Aid
- Centrelink
- carer payment
o ~$580 AUD a fortnight
o discount prescriptions
o rent assistance
o subject to means testing
- carer allowance
o ~$200AUD a fortnight
Disability in Australia: NDIS

- To support people to work through issues of disability by increasing engagement and

awareness outside of institutions so that people with disability could have better access to
places outside in the world
- NDIS case study Western student Chris Turnbull: http://www.abc.net.au/ne ws/2013-05-
08/ndis-casestudy-chris-turnbull/4676616
- “[The NDIS] would mean a greater independence. It would allow me to feel more like a
person. Sometimes, depending on the people, we don’t actually feel like people ourselves.
Chris Turnbull

Summary: What can health professionals /educators do? Are we reinforcing self-determination. Are
we holding onto stereotypes?

- Be aware of implications of disability

- Be aware of physical barriers
- Be aware of stigma
- Include carers in plans and treatments
- Have client-centred care to give patients autonomy

Textbook chapter 10- Disability

Understanding disability

- defines a person with disability as someone who has a permanent limitation, restriction or
impairment that restricts their everyday activities.
- These impairments could be physical, mental, neurological, intellectual, or sensory.

Australian context

- People with disability account for 17.7% of Australia’s population, with the prevalence of
disability increasing with age
- The prevalence of disability rapidly increased for ageing populations over the age of 80.
- The National Disability Insurance Scheme (NDIS) funds disability specific supports for people
with disability and their families and carers. It is governed by federal and participating
state/territory governments.
 - The NDIS has changed the way the disability service sector has been funded, shifting funding
away from block funding of services to individualised funding for consumers.

Overlap between disability and health issues

- According to data from the Australian Institute for Health and Welfare (2019) in 2017–18, an
estimated 24% of adults with disability reported good or excellent health, compared to 65%
for those without disability.
- People with disability were 10 times more likely to report poor physical health than those
without disability.
- People with disability were also more likely to experience significant psychological distress
and mental health issues across the life course
- There is a significant gap in life expectancy between people with and without disability,
markedly so among people living in supported accommodation settings.

The medical model and the social model in health care

- There is evidence that the medical model still tends to dominate views and understandings
of disability in some areas of allied health, nursing and medical sciences.
- This can be seen in the prevalence of negative language and a strong focus on investigating,
identifying and accurately diagnosing conditions along with treatment, “management” or
cure and eradication of conditions
- When the social model of disability is adopted in practice, health professionals expand on
their knowledge by examining not only the biology, but also the social and environmental
factors that arise as part of the experience of disability.

Social determinants of health and why these matter to people with disability

- When considered together, it becomes apparent that prevalent issues of disability

discrimination, harm, abuse, and neglect are significant policy issues significantly impacting
wellbeing and leading to poorer health outcomes.
- Ableism refers to attitudes, stereotypes, ideas, practices and physical and social structures
that presume all are able neurotypical people
- In doing so, people with disability are excluded and seen as Other, marginalised and
devalued. Ableism may not be intentional, but results in many aspects of society being
exclusive and oppressive to anyone who does not fit the “norm” of able and neurotypical

Systemic and systematic disability discrimination

- People with disability are more likely to be exposed to social, cultural and material
disadvantage across the life course, and this has a significant influence on health, particularly
such people with complex support needs or with intellectual disability
- Live on or below the poverty line • Experience social exclusion and discrimination from the
community • Be exposed to harm, exploitation and neglect • Face barriers to accessing
education (across the life course) • Face barriers to work participation • Have insecure and
unstable access to housing and especially specialist housing • Lack access to health care • Be
over-represented in legal and criminal justice systems

Textbook chapter 13- Ageing

Ageing in Australia
 - Australia’s ageing population is on the rise
- Older Australians with CALD backgrounds can experience barriers to service access due to
differing languages, norms and cultural practices and have lower socio-economic status
compared to Anglo-Australians in the same age group

Ageing, health and wellbeing

- Older people face a range of physical and mental health challenges

- Multimorbidity (multiple morbidities) has proven negative effects on wellbeing, function and
mobility, which in turn can impact on societal participation activities, such as employment,
volunteering, and informal caregiving, as well as participation in educational activities, social
leisure activities and religious activities.
- Depression, for example, is a significant problem in older cohorts and may contribute to
lower levels of independent functioning, increased perceptions of poor health, and use of
health services

Social dynamics of ageing

- Unfortunately, negative attitudes towards ageing fail to recognise strengths, and many older
adults report being discriminated against because of their age
- Ageism involves negative attitudes towards older people and is a significant social issue.
- As life expectancy continues to rise, so too will the age at which Australians are eligible for
the age pension. In turn, older Australians will need to remain in the workforce for longer
and often extend their working career beyond the point at which they would like to retire.
- To maintain social connectedness and a sense of purpose, it is imperative that older adults
are treated with respect and dignity, and that their valuable contribution to the community
is recognised
- Elder abuse is defined as “a single or repeated act, or lack of appropriate action, occurring
within any relationship where there is an expectation of trust, which causes harm or distress
to an older person” (Physical abuse, Psychological or emotional abuse, Sexual abuse or
neglet)
- Loneliness is a negative feeling that can occur when social and emotional needs are not
being met through existing relationships and interactions
o Evidence suggests that loneliness, particularly in older adults, is associated with a
range of health outcomes, including reduced physical activity, impaired cognitive
performance, psychological distress and chronic conditions risk
- Caregiver burden: Informal caregiving is characterised by the unpaid support and assistance
provided by family members, friends or neighbours to those with chronic or disabling
conditions
- Health literacy in older adults: In Australia, it is estimated that only 40% of adults have a
level of health literacy required to navigate the health system, understand and engage with
health messages, make appropriate health decisions and function effectively in the health
care environment.
o Adults over the age of 65 years tend to have lower rates of health literacy
particularly mental health literacy

Ageing and the health system

 - The ageing population presents significant economic challenges for Australia’s Health care
System. There is an increased health care demand and use with age
- Challenges to accessing health care for older adults vary based on geographic location and
transport access to health services, comorbidity, as well as cultural background
- Health care systems require further adaptation and reform to effectively support the
challenges associated with the rising ageing population.

Module 14- Religious Diversity

Religious VS Spiritual

Religion

- Community focused (community comes together)

- Observable, measurable, objective (might pray X amount of times)
- Formal, orthodox
- Organized (churches, mosques)
- Behaviour oriented
- Outward practices
- Authoritarian (there is a leader or supreme deity)
- Doctrine of good/evil

Spiritual

- You don’t have to have a religion to be spiritual

- Individualistic
- Less visible and measurable, subjective (not demonstrated through clothing or rituals)
- Less formal
- Less orthodox, less systematic
- Emotionally oriented
- Inward directed
- Not authoritarian (it is more self-directed)
- Not doctrine oriented

Religion

◦ Religion – is an organized system of beliefs, practices, rituals, and symbols designed to:

o facilitate closeness to the sacred or transcendent (God, Allah, higher power,

ultimate reality) and
o to foster an understanding of one’s relationship and responsibility to others in living
together in community. (Koenig, 2006)

◦ The Great World Religions provide people with a story (history); feast days; sacred
writings, art and music; clergy; architecture – churches, synagogues, mosques, temples --
and, a philosophy or worldview (for living in this world and the next) (Graham, 2011)

Spirituality
 ◦ Spirituality – is the personal quest for understanding and it seeks answers to ultimate
questions about life, about meaning, and about relationship to the sacred or transcendent,
which may (or may not) lead to or arise from the development of religious rituals and the
formation of a community (Koenig, 2006)

◦ Spirituality is the quest for the sacred

Statistics on religiosity in Australia

◦ How likely a person was to identify as religious in 2016 had a lot to do with their age.

◦ Young adults aged 18-34 were more likely to be affiliated with religions other than
Christianity (12 per cent) and to report not having a religion (39 per cent) than other adult
age groups. (probably due to increasing in multiculturalism in younger generations. Young
people are engaging in more education, therefore, question religion and able to decide
religion for themselves)

◦ Older age groups, particularly those aged 65 years and over, were more likely to report
Christianity.

◦ In terms of states, New South Wales had the highest religious affiliation (66 per cent of
people reporting a religious affiliation), while Tasmania (53 per cent) was the lowest.

◦ Christianity is the majority religion, but non-religion is on the rise.

Statistics on religiosity globally

◦ Globally, the relatively young population and high fertility rates of Muslims lead to a
projection that between 2030 and 2035, there will be slightly more babies born to Muslims
(225 million) than to Christians (224 million), even though the total Christian population will
still be larger.

◦ By the 2055 to 2060 period, the birth gap between the two groups is expected to approach 6
million (232 million births among Muslims vs. 226 million births among Christians). (Pew
Research Center, 2017)

◦ What are some theories about the increase for Muslim populations and less amongst
Christian populations?
The rise of secularity – non-religiosity

- The growing percentage of Australia’s population reporting no religion has been a trend for
decades, and is accelerating. Those reporting no religion increased noticeably from 19 per
cent in 2006 to 30 per cent in 2016. The largest change was between 2011 (22 per cent) and
2016, when an additional 2.2 million people reported having no religion. (ABS, 2016)
- Religiously unaffiliated people currently make up 16% of the global population (majority of
people from anglo background)
- Only an estimated 10% of the world’s newborns between 2010 and 2015 were born to
religiously unaffiliated mothers.
- People who are religiously unaffiliated are projected to decline as a share of the world’s
population in the coming decades.
- By 2055 to 2060, just 9% of all babies will be born to religiously unaffiliated women, while
more than seven-in-ten will be born to either Muslims (36%) or Christians (35%). (Pew
Research Center, 2017)
- Education = access to scientific advancement = more likely non-religious or atheism

Why?

- The way Australia is run, is quite secular, in terms of government process e.g. health care
favours secularity
- In his speech to the 1897 Constitutional Convention, future Prime Minister, Edmund Barton,
encapsulated the view of the role of government over religion at the time:
o secular expressions should be left to secular matters while prayer should be left to
its proper place (AHRC, 2015)
- There are four essential points about keeping the State separate to religion.

◦ First, it ensures a secular State and alleviates tensions that can arise between
different faiths by not fuelling religious sectarianism and factions.

◦ Second, it limits the risk that the State can intrude between an individual and their
God.

◦ Third, it does not create barriers for individuals that have no faith.

◦ Fourth, it protects faiths from the intrusion of government into its activities.

- The Australian way of life?

 - The contemporary Australian health care system is mostly secular and built for those who
are secular
- The same can be said for our public education system and government systems

Religion-related stereotypes and discrimination

- Nearly one in three Australians have negative feelings towards Muslim Australians, with
63% saying they would be concerned if a relative married a Muslim, according to a Western
Sydney University study commissioned by SBS. (why are they afraid, what are the
stereotypes that make them think like this?)
- 70% of Muslims surveyed said they had experienced racism on public transport or on the
street (compared to 27% Christian). (Challenging Racism Project, 2017) (these people were
also of colour, it may not have been on based on religion, but on race)
- Western Sydney created special hijab’s for students to wear on placement as they
recognised the need for acceptance and inclusion, they feel that religion is an important
aspect for someone. The community can also see that it is important and accepted.

Religious discrimination

- We have freedom of religion, but not freedom of speech in Australia

◦ Discrimination on the basis of religion alone is not unlawful under federal anti-discrimination
law. However in some cases people have been found to be covered by the term ‘ethnic
origin’ in the Racial Discrimination Act, and discrimination on this basis is against the
law. (AHRC, 2019). (it is not appropriate to discriminate based on religion!)

◦ The Challenging Racism Project (2017) found that:

◦ 80 per cent of respondents were of the view that it is a good thing for a society to be
composed of cultural diversity

◦ 49 per cent believed that people from racial, ethnic, cultural and religious minority
groups should behave more like 'mainstream Australians'

◦ Older participants and those with non-tertiary education levels were more likely to
say that some cultural/religious groups do not belong

◦ Three quarters of Hindu and Buddhist respondents (75%) had experienced

discrimination on public transport or on the street (Challenging Racism Project,
2017)

Religion and health intersect

The role of spirituality in health and wellbeing

◦ Religion as a social determinant of health (religion connects us to others, allows us to feel

safe, access to education) (therefore it changes and impacts how people of a particular
religion engage with health).Religion impacts mental health, social support and health
behaviours. When religious people feel that their deity is engaged, mental health issues are
very low. E.g. people may feel judged for LGBTIQ community especially from religious
perspective, therefore increasing mental health issues in this pop.

◦ Positive impacts of religion

 ◦ Negative impacts of religion

Positive Impacts of Religion

1. Going to religious services, it turns out, can protect against age-related memory loss and
thinking problems.

2. Weekly attendance at services and regular religious study at home may cut your risk for high
blood pressure by 40 per cent (as it is like a meditation). Going more often than weekly may
nudge your systolic blood pressure down by three points.

3. Sending up a simple prayer for your mate’s well-being could help you feel less wronged and
more ready to forgive.

4. People who go to services more than once a week have half the risk of major depression as
those who attend less often.

5. Regular prayer increases your concern for other people (compassion), say researchers from
Florida State University, which could help you make your part of the world a brighter, better
place. (decreasing mental health)

6. Stressed out? Focusing on your spiritual values can quiet the anterior cingulate cortex – a
collection of hair-trigger brain cells that fires up when things start going wrong in your life,
raising your stress levels. Having spiritual values can calm this down.

7. Thinking about God or other spiritual beliefs keeps you calm under fire, according to new
research from the University of Toronto.

Negative Impacts of Religion

◦ Religious beliefs may adversely impact health particularly physical health in a number of
ways:

- Stopping life-saving medications/treatment

- Failing to seek timely medical care (e.g. people who were religious were less likely to seek
health care for sexual reproductive issues)
- Defending the rights of children to receive medical care
- Condoning forms of religious abuse (e.g. catholic church and child abuse)
- Replacing Mental Health care with Religion
- Unhealthy Belief systems – God as distant, wrathful
- Folk healers – sham treatments
- Authoritarianism
- Prejudice
- Reduced social cohesion

Negative Impacts of Religion

◦ Mental health – Sigmund Freud, in one of his first papers was entitled, “Obsessive Acts and
Religious Practices” (1907), he compared religious practices such as prayer and religious
rituals to the obsessive acts of a neurotic.

◦ Identity – (Albert Ellis, 1980, 1988) - Religiosity discourages self-acceptance, self-interest,

and tends to make human-to-human relationships difficult, are prone to fanaticism,
 encourages inflexibility and intolerance of others, too suffused with guilt to pursue their
goals, and find it difficult to live in the real world.

◦ Social cohesion – (Graham, 2011) - Devoutly religious persons may have high expectations of
themselves and of others. They may condemn themselves for having difficulties that they
think religious people should not have. They may judge themselves and others harshly and
alienate those who do not believe or act as they do.

Please take with a Grain of Salt…

◦ The claims of negative effects of religion rest largely on isolated case reports and highly
selected case studies, rather than on population based systematic research studies (RCTs).

A Note for Health Professionals

◦ Whilst discrimination on the basis of religion may not be illegal it may go against your codes
of conduct!

◦ When you sign a contract for employment (at any organisations) it means you are
consciously and fully agreeing to abide by their policies and perspectives on ethical
behaviour and representation of attitudes.

Textbook chapter 9- Religion

What is religion?

- Religion is important in health care settings because respecting people’s religion can have a
major impact on their care and recovery.
- Respect over tolerance
o . The idea of respect means that the person is seen as an equal member of society
and therefore deserving of equal rights to other people. Some people talk about
“tolerance” as a way to approach religious diversity. However, the idea of
“tolerance” is problematic because it suggests that what is “tolerated” is somehow
of less worth or inappropriate
o Aiming for “respect” suggests that we accept that there is a diversity of approaches
to religion and nonreligion, and that we accept that other people will make different
choices to our own
- Religious diversity—the variety of religious and not religious people in Australia. Australia’s
changing religious diversity includes the rising numbers of people who are not religious, the
decline of traditional Christianity and the increasing ethnic diversity within Christianity, the
growing numbers of Buddhists, Muslims, Hindus, and Sikhs, mostly as a result of migration,
the growth of Pentecostals, and the rise of alternative spiritualities such as the New Age and
meditation

The Australian Census statistics demonstrate that religion in Australia is changing. Traditional forms
of Christianity are in decline, particularly Anglicanism. Non-Christian religions, such as Islam,
Buddhism, Hinduism and Sikhism, are growing, mainly as a result of migration. The number of
people identifying as having “no religion” is also rapidly growing.

Non-religion

- Among those who say they are “not religious”, only a small minority are atheists
 o Atheists are confident that religion is wrong, that that there are no supernatural
deities.
o People who have “no religion” might be an agnostic, who say they do not know what
they believe.
o The category of “no religion” also includes people who are disinterested in religion
and choose not to think about it.
o Even more confusingly, there is another category of people who say they have “no
religion” but identify as “spiritual but not religious”

Respect and methodological agnosticism

- Agnosticism is a way of thinking about religion where the person says they “do not know”
whether religion is true or not.
- Methodological agnosticism- as a form of practice facilitates relationships of respect and
open-mindedness. Simply accepts statements about religious ideas or practices at face
value. Makes no attempt to judge or correct religious ideas or beliefs.
o a way of thinking that makes no judgement on the truth or falsity of religious beliefs
and practices, but that still allows the individual to have their own views on these
matters. Their practice is agnostic, although the health care worker themselves may
not be an agnostic.
o As health professionals this means that we can interact with people who are
religious, or not religious, without having to either convince them that they are
wrong, or having to accept their religious ideas as correct of ourselves.

TERMINOLOGY

- Cultural safety: An environment that is spiritually, socially and emotionally safe, as well as
physically safe for people; where there is no assault challenge or denial of their identity, of
who they are and what they need.
- Culture: The evolved human capacity to classify and represent experiences with symbols and
to act imaginatively and creatively. Cultures are differentiated by the distinct ways that
people, who live differently, classify and represent their experiences.
- Diversity: Degree of variation of cultures, identities and other social and economic factors
within a given society.
- Ethnicity: A category or group of people who identify with each other, usually on the basis of
presumed similarities such as common language, geography, ancestry, history, society,
culture and/or social treatment.
- Identity: Identity is a person’s conception and expression of their individuality or group
affiliations.
- Intersectionality: The interconnected nature of social categorisations such as race, class, and
gender as they apply to a given individual or group, regarded as creating overlapping and
interdependent systems of discrimination or disadvantage.
- Race: A socially constructed grouping of humans based on shared physical categories
generally viewed as distinct by a society.
- Social construct: A perception of an individual, group, or idea that is “constructed” through
cultural or social practice.
- Social determinants of health: Conditions in which people are born, grow, work, live, and
age, and the wider set of forces and systems shaping the conditions of daily life. These forces
and systems include economic policies and systems, development agendas, social norms,
social policies and political systems.
- Agency: Individuals’ capacities to take actions, which can be constrained by social structures.
Artefact of measurement: A widely disproved explanation discussed in the historic Black
Report, which suggests health inequalities are merely a statistical anomaly.
- Assimilation: Processes of adopting the cultural practices of the dominant group in a society,
often encouraged, sometimes enforced, by the majority group.
- Behavioural factors: An explanation, accounting for approximately 20% of disparities in
health outcomes, discussed in the Black Report, which attributes health inequalities to
individual lifestyle choices.
- Colonisation: A process of subjugating a people to gain access to their territory and its
resources.
- Cultural determinants of health: Ethnic, religious, racial, but also class, gender and sexuality
differences that underpin behavioural patterns and social experiences leading to divergent
health outcomes across minority and majority groups.
- Cultural identity: Affinity with and sense of belonging to a culture or cultural group.
- Culture: The evolved human capacity to classify and represent experiences with symbols and
to act imaginatively and creatively. Cultures are differentiated by the distinct ways that
people, who live differently, classify and represent their experiences.
- Endemic: A disease that is consistently present within a population.
- Ethnicity: A category or group of people who identify with each other, usually on the basis of
presumed similarities such as common language, geography, ancestry, history, society,
culture and/or social treatment.
- Fundamental social causes of health inequalities: A theory that explains health inequalities
by emphasising access to material and immaterial resources to mitigate the effects should
disease occur.
- Natural selection: An explanation supported by only modest evidence discussed in the Black
Report, which suggests health inequalities are the result of the downward social mobility of
people with poor health.
- Midstream factors: Intermediary determinants of health, such as material resources,
psychosocial and behavioural factors.
- Neoliberalism: An extreme form of capitalism characterised by a political and economic
ideology supporting economic growth through the privatisation of public goods and services,
and most recently, through new strategies of relying on insecure and precarious forms of
labour.
- Othering: Practices of division and exclusion that can result when cultural groups cast
outside groups as morally inferior.
- Pathogenic: Conditions or factors that pose risk to health.
- Psychosocial explanation: A theory that points to the higher levels of stress and anxiety
experienced by those in lower positions within a social hierarchy in explaining persisting
health inequalities.
- Race: A socially constructed grouping of humans based on shared physical categories
generally viewed as distinct by a society.
- Racism: Any cognition, affective state, or behaviour that advances the differential treatment
of individuals or groups due to their racial, ethnic, cultural or religious background.
- Salutogenic: Conditions or factors that promote health.
- Social democracy: A state, party or sovereignty that enacts policies to redistribute wealth,
support primary health care and prioritise illness prevention through collaboration across
sectors.
- Social determinants of health: Conditions in which people are born, grow, work, live and
age, and the wider set of forces and systems shaping the conditions of daily life. These forces
and systems include economic policies and systems, development agendas, social norms,
social policies and political systems.
- Social gradient of disease: The graded relationship between social position and health
outcomes, with those at the bottom experiencing the worst health outcomes, those in the
middle experiencing better health outcomes, and those at the top experiencing the best
health outcomes.
- Social structure: The way social systems are organised and work to shape individual
behaviour and life chances.
- Socio-economic status: A term describing a person or group’s social standing, typically
assessed using a combination measure of income, occupation and education.
- Structural/materialist explanation: The reason for health inequalities that gets the most
support in the
- Black Report: differences in living and working conditions, material and economic resources.
- Structural racism: The way social systems are organised to favour the majority group and
exclude, subjugate or disadvantage minority groups.
- Structural violence: The harm inflicted through social systems designed to limit
opportunities and capabilities, particularly for those in minority groups.
- Upstream factors: Health determinants that can be intervened in well before they pose a
risk to health, such as socio-policies related to education and income.
- Biomedical model of health and wellbeing: The biomedical model of health and wellbeing
focuses on biological factors. In this model, health is conceptualised as the absence of
disease or illness.
- Eurocentrism: A cultural phenomenon that views the histories and cultures of non-Western
societies from a European or Western perspective.
- Ethnocentrism: Evaluation of other cultures according to preconceptions originating in the
standards and customs of one’s own culture.
- Primary health care model: The entry level to the health system and, as such, is usually a
person’s first encounter with the health system.
- Non-Western models of health and wellbeing: Non-Western models of health and
wellbeing embrace more than just the disease or illness an individual may experience. These
models also focus on developing a deep connection to the region’s philosophical and
spiritual values.
- Biopsychosocial models of health and wellbeing: An interdisciplinary model that looks at
the interconnection between biology, psychology, and socio-environmental factors.
- Immigrational/emigrational experiences of health: The experiences of health over the
course of immigration/emigration, including increases/decreases in vulnerability to health
diseases and conditions or the development and occurrence of health problems.
- Cultural safety: An environment that is spiritually, socially and emotionally safe, as well as
physically safe for people; where there is no assault challenge or denial of their identity, of
who they are and what they need.
- Racism: Any cognition, affective state or behaviour that advances the differential treatment
of individuals or groups due to their racial, ethnic, cultural or religious background.
- Respect: An essential component of a high-performance organization. It helps to create a
healthy environment in which clients feel cared for as individuals, and members of health
care teams are engaged, collaborative and committed to service. Within a culture of respect,
people perform better, are more innovative and display greater resilience. On the contrary,
a lack of respect stifles teamwork and undermines individual performance. It can also lead to
poor interactions with clients. Cultivating a culture of respect can truly transform an
organization and leaders set the stage for how respect is manifested (James, 2018).
- Self-awareness: The capacity to become the object of one’s own attention. In this state one
actively identifies, processes and stores information about the self.
- Self-reflection: A genuine curiosity about the self, where the person is intrigued and
interested in learning more about his or her emotions, values, thought processes and
attitudes.
- Social justice: A political and philosophical theory that broadens the concept of justice
beyond those embodied in the principles of civil or criminal law, economic supply and
demand or traditional moral frameworks. Social justice tends to focus more on just relations
between groups within society as opposed to the justice of individual conduct or justice for
individuals.
- Trust: Refers to people’s expectations, typically for goodwill, advocacy, and competence
(and/ or good outcome). As such, it is future-directed; although past experiences and other
forms of knowledge influence the degree of current trust in another; measuring trust itself
requires measuring the beliefs of the person who trusts about the trustee's behaviour
(Goold, 2002). Patient or client trust in their health care professional is central to clinical
practice. Clients must be able to trust health professionals with their health and to work in
their best interest and outcome. Trust in the health care professional is a central factor in
effective treatments and fundamental for patient-centered care (Australian Commission
Safety Quality Health Care, 2011; Birkhäuer et al., 2017).
- Whiteness: Whiteness and White privilege are ways of conceptualising racial inequalities
that focuses as much on the advantages that Whites accrue as on the disadvantages that
people of colour experience. Unlike theories of overt racism or prejudice, which suggest that
people actively seek to oppress or demean other racial groups, theories of White privilege
assert that the experience of Whites is viewed by Whites as normal rather than advantaged.
Whites as a group hold social advantages rather than experiencing a “normal” state of
existence.
- Aboriginal and Torres Strait Islander peoples: The first peoples of this land now called
Australia are the Aboriginal peoples; however, they also have other names that they use to
refer to themselves: Goori, Koori, Arrernte, Kamilaroi, Yungl, Yaegl and so on. Torres Strait
Islanders are a seafaring peoples, whose traditional countries are in the Torres Strait, off the
Australian mainland’s northernmost point. The region has over 270 islands in the strait of
 ocean between the northern tip of Queensland, Cape York, and the south-east coast of
Papua New Guinea.
- Cultural diversity: The presence of many different cultural or ethnic groups within a society.
- Cultural safety: An environment that is spiritually, socially and emotionally safe, as well as
physically safe for people; where there is no assault challenge or denial of their identity, of
who they are and what they need.
- Culture: The evolved human capacity to classify and represent experiences with symbols,
and to act imaginatively and creatively. Cultures are differentiated by the distinct ways that
people, who live differently, classify and represent their experiences.
- Health advocacy: Means providing care to health care consumers that includes the
promotion of health and access to services.
- Institutional discrimination: A form of racism expressed in the practice of social and political
institutions. It affects racial minorities but is also a term used to describe the discrimination
experienced by people of minority such as, but not limited to, ethnic, cultural, sexual
orientation, gender identity and religious groups. It is reflected in disparities regarding
wealth, income, criminal justice, employment, housing, health care, political power and
education, among other factors.
- Institutional racism: A form of racism expressed in social and political institutions that
devalue and ignore people of a racial minority
- Bias: Refers to “generally negative feelings and evaluations of individuals because of their
group membership (prejudice), overgeneralised beliefs about the characteristics of group
members (stereotypes) and inequitable treatment (discrimination)” (van Ryn et al., 2011, p.
201).
- Client-centred care: Health care where a person’s cultural values, needs and preferences are
placed at the forefront of their ongoing medical care.
- Collaboration: Working together to achieve greater impacts than can occur in isolation.
- Cultural safety: An environment that is spiritually, socially and emotionally safe, as well as
physically safe for people; where there is no assault challenge or denial of their identity, of
who they are and what they need.
- Intersectionality: The interconnected nature of social categorisations such as race, class, and
gender as they apply to a given individual or group, regarded as creating overlapping and
interdependent systems of discrimination or disadvantage.
- Partnership: Two or more individuals or groups or coming together to achieve a common
purpose.
- Racism: Any cognition, affective state, or behaviour that advances the differential treatment
of individuals or groups due to their racial, ethnic, cultural or religious background.
- Self-awareness: The capacity to become the object of one’s own attention. In this state one
actively identifies, processes, and stores information about the self.
- Self-reflection: A genuine curiosity about the self, where the person is intrigued and
interested in learning more about his or her emotions, values, thought processes and
attitudes.
- Social construct: A perception of an individual, group, or idea that is “constructed” through
cultural or social practice.
- Social determinants of health: Conditions in which people are born, grow, work, live, and
age, and the wider set of forces and systems shaping the conditions of daily life. These forces
 and systems include economic policies and systems, development agendas, social norms,
social policies and political systems.
- Social justice: Social justice is a concept of fair and just relations between the individual and
society, as measured by the distribution of wealth, opportunities for personal activity and
social privileges.
- Stereotypes: An expectation that all people within the same racial, ethnic or cultural group
act alike and share the same beliefs and attitudes.
- Aboriginal Community Controlled Health Organisations (ACCHOs): A non-profit
incorporated Aboriginal Community Controlled Organisation that provides wholistic and
culturally appropriate Primary Health Care and Aboriginal health-related services to the
community it serves. An ACCHO is governed by an Aboriginal board of management elected
by a local Aboriginal community membership.
- Aboriginal Health & Medical Research Council of NSW (AHMRC of NSW): Aboriginal Health
& Medical Research Council of NSW was established in 1985. Members are ACCHOs led by
their respective Aboriginal Communities to deliver comprehensive and culturally appropriate
primary health care services.
- Aboriginal Medical Service (AMS): First established in 1971 in Redfern (Redfern AMS). There
are now around 140 Aboriginal Medical Services across Australia.
- Aboriginal: The first peoples of this land now called Australia are the Aboriginal peoples;
however, they also have other names that they use to refer to themselves: Goori, Koori,
Arrernte, Kamilaroi, Yungl, Yaegl and so on.
- Australian Health Practitioner Regulation Agency (Ahpra): The national association of 15
professional boards that regulate and enforce standards in health. Australian Institute of
- Aboriginal and Torres Strait Islander Studies (AIATSIS): An independent government
statutory authority for research, collection, and publication. A premier resource for
Aboriginal and Torres Strait Islander peoples learning and record-keeping.
- Invasion: An occasion when a country and its army uses force to enter and take control of
another country.
- National Aboriginal Community Controlled Health Organisation (NACCHO): The peak body
representing 143 Aboriginal Community Controlled Health Organisations (ACCHOs) across
the country on Aboriginal health and wellbeing issues. It has a history extending back to a
meeting in Albury in 1974.
- Penal colony: A type of prison, especially one that is far away from other people, as Australia
was set up by the British.
- Torres Strait Islanders: Torres Strait Islanders are a seafaring peoples, whose traditional
countries are in the Torres Strait, off the Australian mainland’s northern-most point. The
region has over 270 islands in the strait of ocean between the northern tip of Queensland,
Cape York, and the south-east coast of Papua New Guinea.
- Wholistic: Placing a “w” in front of holistic makes us reflect that the process, design, and
collaboration would look at the whole approach—not a hole that the approach could fall or
sink into. It would be circular in its wholeness, which conceptualises the way we have grown
up and the cycle of life, including our connection to land and country.
- Colonisation: In this chapter, colonisation refers to a group of people seeking to extend their
territories through the subjugation of other people in a new territory.
- Asylum: The right to international protection within a particular country. An “asylum seeker”
describes someone who is seeking such protection but whose claim for refugee status has
not yet been determined.
- Culturally and linguistically diverse (CALD): A term adopted in Australia to describe people
with a cultural heritage differing from that of the Anglo-Australian majority. This term
includes diversity in terms of country of birth, preferred language, English proficiency and
other ethnocultural characteristics such as year of arrival in Australia, religious affiliations
and birthplace of parents.
- Culture clash: Conflict or tension arising between individuals attributable to dissimilarities in
cultural values and practices.
- Culture shock: A sense of disorientation or unfamiliarity when experiencing a new cultural
environment.
- Discrimination: Occurs when a person is excluded from benefits generally available to other
members of a society because of a perceived difference or a stigmatised identity.
- Ethnicity: A category or group of people who identify with each other, usually on the basis of
presumed similarities such as common language, geography, ancestry, history, society,
culture and/or social treatment.
- Ethnocentrism: Evaluation of other cultures according to preconceptions originating in the
standards and customs of one’s own culture.
- Migration: The movement of people from one place to another with the intention of
settling.
- Prejudice: A preconceived belief regarding another individual based upon their membership,
affiliation or affinity with a particular group or cultural identify.
- Race: A socially constructed grouping of humans based on shared physical categories
generally viewed as distinct by a society.
- Racism: A socially constructed grouping of humans based on shared physical categories
generally viewed as distinct by a society.
- Refugee: An individual who is forced to leave their country of origin and is unable to return
due to the threat of persecution or harm. Refugees have been formally recognised under the
1951 Convention Relating to the Status of Refugees.
- Culturally safe health care practice: Health care that aims to be guided by the recipient of
the health care, noting in particular what they consider to be important and appropriate
practices and beliefs, and respecting these.
- Death bed visions: The experience of a person who is dying. They see loved ones and family
members who have already died.
- Methodological agnosticism: A way of thinking that makes no judgement on the truth or
falsity of religious beliefs and practices, but that still allows the individual to have their own
views on these matters. Their practice is agnostic, although the health care worker
themselves may not be an agnostic.
- Nonreligion: People who do not identify with any particular religion. This includes atheists
(who reject religion), agnostics (who are not sure about religion), people who are just not
very interested in religion, and people who are “spiritual but not religious”.
- Religion: Ritual practices, typically as part of a community, that draw on symbols and beliefs
that guide how people behave and relate.
- Religious diversity: The variety of religious and not religious people in Australia. Australia’s
changing religious diversity includes the rising numbers of people who are not religious, the
 decline of traditional Christianity and the increasing ethnic diversity within Christianity, the
growing numbers of Buddhists, Muslims, Hindus, and Sikhs, mostly as a result of migration,
the growth of Pentecostals, and the rise of alternative spiritualities such as the New Age and
meditation.
- Respect: “An essential component of a high-performance organization. It helps to create a
healthy environment in which clients feel cared for as individuals, and members of health
care teams are engaged, collaborative and committed to service. Within a culture of respect,
people perform better, are more innovative and display greater resilience. On the contrary,
a lack of respect stifles teamwork and undermines individual performance. It can also lead to
poor interactions with clients. Cultivating a culture of respect can truly transform an
organization, and leaders set the stage for how respect is manifested.” (James, 2018).
- Spirituality: The individual experience of ritual practices, symbols and beliefs that guide
behaviour and relationships. Individual spirituality may be part of a person’s participation in
a religious group, or may be completely separate from organised religion.
- Ableism: Refers to attitudes and beliefs that infer ableness as superior and disability as
inferior.
- Accessibility: Mobility, environmental, information, communication and sensory access
needs met with minimal effort or stress on the part of the individual with disability.
- Disability: Disability is an umbrella term for impairments, activity limitations and
participation restrictions (World Health Organisation, 2011). This chapter occasionally uses
the phrase “people with disability”, which is an example of person-first language and
appropriate for professional writing. The chapter occasionally uses the phrase “disabled
people” as an example of identity-first language. The phrase “disabled people” recognises
the experience of disability as a core part of identity, equal to being identified as a gay
woman, an African woman.
- Discrimination: Occurs when a person is excluded from benefits generally available to other
members of a society because of a perceived difference or a stigmatised identity
Impairments: Refers specifically to biological or psychological characteristics that impact on
how a person functions.
- Respect: “An essential component of a high-performance organization. It helps to create a
healthy environment in which clients feel cared for as individuals, and members of health
care teams are engaged, collaborative and committed to service. Within a culture of respect,
people perform better, are more innovative and display greater resilience. On the contrary,
a lack of respect stifles teamwork and undermines individual performance. It can also lead to
poor interactions with clients. Cultivating a culture of respect can truly transform an
organization, and leaders set the stage for how respect is manifested.
- Cisgender: A term used to describe individuals whose gender identity and expression
matches the biological sex with which they were presumed at birth.
- Femininity: A socially constructed set of attributes, behaviours and characteristics
considered “typical” or “appropriate” for girls and women.
- Gender diverse: A term used to describe individuals whose gender identity does not
necessarily align with their presumed sex.
- Gender sensitivity: An iterative process by which people demonstrate awareness and
responsiveness to the influence of gender on behaviour and wellbeing. A gender-sensitive
clinician appreciates and positively responds to the differences, inequalities, and varying
needs of individuals of differing gender identifies.
- Gender: A socially constructed characterisation of people based on their roles, attitudes,
behaviours, attributes and opportunities. There are many ways in which an individual may
choose to define their gender, including those who identify as being agendered or non-
binary (neither a man nor a woman).
- Hegemony: The social dominance of one group over another, supported by legitimising
norms and the subordination of other social groups or identities.
- LGBTIQA+: An evolving acronym that stands for lesbian, gay, bisexual, transgender, intersex,
queer/questioning, asexual and other terms (such as non-binary and pansexual) that people
use to describe experiences of their gender, sexuality and physiological sex characteristics.
- Masculinity: A socially constructed set of attributes, behaviours and characteristics
considered “typical” or “appropriate” for boys and men.
- Sex: The term sex can have different meanings in different contexts. Sex can refer to a
person’s physical characteristics, including their genitals and reproductive organs, or to their
assigned or legal status. Sex can also refer to engaging in sexual activities.
- Culturally sensitive care: Care that reflects the ability to be appropriately responsive to the
attitudes, feelings or circumstances of groups of people that share a common and distinctive
racial, national, religious, linguistic or cultural heritage.
- Discrimination: Occurs when a person is excluded from benefits generally available to other
members of a society because of a perceived difference or a stigmatised identity.
- Gender binary: A classification system consisting of two genders, male and female, and
underpins the social foundations of Australian society and many other societies globally.
- Gender diversity: An umbrella term that is used to describe gender identities that
demonstrate a diversity of expression beyond the binary framework.
- Gender dysphoria: In medical discourse, gender dysphoria refers to distress arising from
incongruence between one’s internal sense of gender, the sex they were presumed at birth
and/ or their body.
- Gender expression: Outward gender presentation and behaviour that may communicate
gender to others.
- Gender fluidity: A spectrum of gender identities that are not exclusively masculine or
feminine—identities that are outside the gender binary.
- Gender identity: A person’s internal view of their gender—that is, one’s innermost sense of
themselves as a gendered person. A person’s gender identity may or may not correspond
with their sex presumed at birth. Gender identity often influences the name and pronouns
people use.
- Heteronormativity: Everyday interactions, practices and policies that construct individuals
as heterosexual.
- Homophobia and biphobia: Negative beliefs, prejudices and stereotypes that exist about
people who are not heterosexual.
- Intersectionality: The interconnected nature of social categorisations such as race, class and
gender as they apply to a given individual or group, regarded as creating overlapping and
interdependent systems of discrimination or disadvantage.
- Non-binary: When a person’s gender identity does not align with binary gender,
male/female. Non-binary people may identify as gender fluid, trans masculine, trans
feminine, agender, bigender, gender queer and a multitude of other such terms.
- Sexuality: Encompasses who a person may be attracted to romantically and sexually.
- Social and medical gender affirmation: Social affirmation is when a person makes changes in
appearance and social situations to reflect their gender. This may include changes to
hairstyle and clothing, name and pronoun changes, and use of different
bathrooms/gendered facilities. They may choose to do this all at once, or only in specific
social circles such as with close family and friends. Medical affirmation could include
hormone therapy to help develop secondary physical characteristics of gender (such as voice
deepening or development of breast tissue) or gender affirmation surgery so that genitalia
reflects the person’s gender.
- Stigma: Defined as the co-occurrence of labeling, stereotyping, separation, status loss and
discrimination in a context in which power is exercised.
- Transgender: People whose gender is not aligned with the gender presumed for them at
birth.
- Transphobia: Negative beliefs, prejudices and stereotypes that exist about
transgender/trans and gender diverse people.
- Ageing: The process of growing old. Ageism: Discrimination or prejudice based on age.
- Caregiver burden: A multidimensional response to the psychological, emotional, physical,
social and financial stress of caring for a family member who is elderly, disabled or ill.
- Chronic conditions: Health conditions lasting 3 months or more.
- Dementia: Cognitive impairment that interferes with everyday functioning.
- Elder abuse: A single or repeated act, or lack of appropriate action, occurring within any
relationship where there is an expectation of trust that causes harm or distress to an older
person (World Health Organisation, 2020).
- Health care system: The system in which the purpose of all the services and activities are to
promote, restore or maintain health.
- Health literacy: The ability to obtain, process, and understand basic health information and
services in order to make appropriate health decisions.
- Residential aged care: Care options and accommodation for older people who are unable to
live independently in their own homes.
- Social isolation: The state of lack of contact or minimal contact between an individual and
society