Mental health: Discrimination, Stigma and Cultural Safety

1. Mental health: Discrimination, Stigmaand Cultural Safety • What is discrimination? (please see diagram on next slide and handout) • Biased information leading to a stereotype (fixed image) • Prejudice (a way of thinking based on a stereotype) • Discrimination (action or inaction, based on prejudice) • What is stigma? • Refers to negative attitudes (prejudice) and negative behaviour (discrimination) (Canadian Mental Health Association, 2011)

2. 1. Biased information leads to stereotyping Stereotyping: An often negative exaggerated belief, fixed image, or distorted idea held by persons, groups, political/economic decision makers 4. Oppression Discrimination backed up by systemic power (e.g. government, education, legal, and health system policies; • The Cycle of Oppression 3. Discrimination Action or inaction based on prejudice 2. Prejudice A way of thinking based on stereotypes Source: Adapted from: McGibbon, E., Etowa, J. & McPherson (2008). Health care access as a social determinant of health. Canadian Nurse Journal, 104 (7), 22-27

3. What is cultural safety? • Was developed by Indigenous Maori nurses in New Zealand, originally meaning ‘no assault on a person’s identity’ • Cultural safety moves beyond the traditional concept of cultural sensitivity (being accepting of difference) to analyzing power imbalances, institutional discrimination, and colonization. • Current concepts of cultural safety are based on the Maori definition, and have been expanded to include a broad range of peoples and groups who experience discrimination and hence unsafe care…who are some of these groups?

4. Discrimination, stigma, cultural safety and the CNA Code of Ethics • Providing safe, compassionate, competent and ethical care • Promoting health and well being • Promoting and respecting informed decision-making • Preserving dignity • Maintaining privacy and confidentiality • Promoting justice • Being accountable

5. Something to think about: How are stigma, discrimination and cultural safety all connected?

6. Introduction to the Mental Status Exam • Clinical Purpose • Components (Text p. 138); Clinical documents for Addictions and Dementia

7. Introduction to the Mental Status Exam • Appearance, attitude, behaviour • Speech • Affect • Thought form • Thought content • Perceptions • Cognitive function • Judgment and insight

8. MSE: A beautiful mind

9. Introduction to Intersectionality • What is it? • Bringing together: • The social determinants of health • The ‘isms’ (e.g. racism, sexism, ageism, heterosexism...) • Geography (rural, urban, northern…)

10. An Intersectionality Framework for Nursing Practice, Education, Research, Policy Intersections of SOCIAL DETERMINANTS OF HEALTH (SDH) • early childhood development • employment and working • conditions • income and its equitable • distribution • food security • health care services • housing shortages • education • social exclusion • social safety nets

11. An Intersectionality Framework for Nursing Practice, Education, Research, Policy Intersections of SOCIAL DETERMINANTS OF HEALTH (SDH) Intersections of IDENTITY as a SDH (the “isms”) • early childhood development • employment and working • conditions • income and its equitable • distribution • food security • health care services • housing shortages • education • social exclusion • social safety nets • immigrant status • social class • gender • race • ethnicity • culture • age • (dis)ability • sexual orientation • spirituality • . . .

12. An Intersectionality Framework for Nursing Practice, Education, Research, Policy Intersections of SOCIAL DETERMINANTS OF HEALTH (SDH) Intersections of IDENTITY as a SDH (the “isms”) • early childhood development • employment and working • conditions • income and its equitable • distribution • food security • health care services • housing shortages • education • social exclusion • social safety nets • immigrant status • social class • gender • race • ethnicity • culture • age • (dis)ability • sexual orientation • spirituality • . . . NURSING Practice Education Research Policy Intersections of GEOGRAPHY as a SDH • rural, remote, fly-in • East, West, North, South • segregation and ghettoization • unfair geographic access to public services • lack of public transportation (or funds) • environmental patterns: weather, pollution • dispersion, toxin location . . . Source: McGibbon, E. (2009). Health and healthcare: A human rights perspective. In D. Raphael (Ed.). The social determinants of health. Toronto: Canadian Scholar’s Press.

13. Interectionality Example: The Social Determinants of Mental Health Employment and working conditions, i.e., meaningful employment, work safety, dependable, consistent work. Women with disabilities are twice as likely to be unemployed (Statistics Canada, 2005). Immigrant women face numerous stressors such as finding employment/ establishing income, which can have a serious health impact (Meadows, Thurston, & Melton, 2001). • Income and its equitable distribution, i.e., adequate annual income and a family’s capacity to meet basic needs. Overall income of most Canadian families has steadily decreased since 1986 (Curry-Stevens, 2001). In some provinces, almost 30% of children in minority families live in poverty (Canadian Council on Social Development, 2000).

14. Food security, i.e., a family’s capacity to provide minimum nutritious food. Food bank use doubled between 1989-2004. 41% of food bank users are children under 18 years (Toronto Charter, 2003). Child hunger is an extreme example of family food insecurity (McIntyre, 2004). If you experience food insecurity, you are significantly more likely to have Type II diabetes (Seligman, Bindman, Vittinghoff, Kanaya & Kushel, 2007). • Housing i.e., safe shelter, and green space for play. As more Canadians spend more of their income on shelter, housing security is threatened. Canada’s renter households have average incomes that are half that of home owners (Shapcott, 2004). Damp housing further exacerbates health problems such as childhood asthma (Bryant, 2002).

15. Early childhood development, education, and care, i.e., nurturing and abuse free environments; access to appropriate child care supports and early childhood education. Early childhood development is threatened due to continuing levels of family poverty (Raphael, 2004). There is a notable mismatch between known early childhood educational opportunities and public investment (McPherson, 2006). • Education, i.e., opportunity for post secondary education. Average yearly university tuition has tripled since 1991 (Statistics Canada, 2007). Health literacy is strongly related to level of formal education, health outcomes, and access to care. Except for Nova Scotia, Atlantic provinces have lower literacy rates than the national average (Murray, Rudd, Kirsch, Yamamoto, & Grenier, 2007).

16. Social exclusion, i.e., access to social supports and community participation. Groups experiencing social exclusion tend to sustain higher health risks and lower health status. These include Indigenous peoples; immigrants; refugees; persons of color; persons with disabilities; lone parents; children, youth in disadvantaged circumstances; women; the elderly; unpaid caregivers; gays, lesbians, bisexuals, transgendered people (Galabuzi, 2004). • Social safety nets, i.e., access to income supplements and publicly funded home care support. Maritime provinces have the lowest per-person spending on home care in Canada (Coyte & McKeever, 2001). Home care has been left out of the national policy agenda, which has grave consequences for the health of many vulnerable populations, including elders, and chronically ill children (Shamian, 2007).

17. Health services, i.e., access to specialist and multi-disciplinary services. Rural people have less access to health services and have poorer health than urban people. Women living in the most rural areas are most likely to report fair/poor health (CIHI, 2006). Racism in health care is an important barrier in access to health services (Etowa, Weins, Bernard, & Clow, 2007). • Identity, i.e., gender, race, ethnicity, culture, age, social class, (dis)ability, sexual orientation, and age, to name a few, all determine health care access and health outcomes. Gender and race have recently been added to earlier definitions of the SDH. These definitions have been expanded to include the broader notion of identity as a SDH (McGibbon, McPherson, & Etowa, 2008).

18. Handout: Racism as a Social Determinant of Mental Health