Yasmin Ibison, Programme and Partnerships Manager (Employment) at Black Thrive Lambeth, kicks off our new series of guest blogs in response to our #YouOnlyHadToAsk report on what people with multiple conditions say about health inequality.
The stories in the recently published ‘You only had to ask’ report by The Richmond Group of Charities evidence the fact that the health and care systems are not adequately serving some groups. For instance, Sabba, a Pakistani resident of Bradford, is advised by her GP to go to mixed-sex physio sessions; she doesn’t attend as feels uncomfortable exercising in front of men. For Kumar, who is Indian, interacting with the healthcare system is difficult; he struggles to understand the language used and advice given by his doctor and reports not having connections with the professionals working in his local community. In both cases, it is clear how a more holistic approach to understanding these individuals and their needs would have led to more appropriate care.
In response to a growing conversation around racial and social inequalities and their impacts on health, there has been a shift to focus on ensuring that systems and services provided to communities are “culturally appropriate”. On the surface, providing culturally appropriate care seems like a well-conceived solution and one that might have resolved the issues faced by Sabba and Kumar. It places the onus on the system itself to respond to the “culture” of the communities it serves. However, understanding culture, and delivering 'culturally appropriate’ services, is a much more complex and nuanced process than may initially be imagined.
Landing on a singular definition or common understanding of culture is tricky. In “Culture: a critical review of concepts and definitions” published in 1952, Alfred Kroeber and Clyde Kluckhohn compiled a list of 164 definitions of the word! Here is the paradox of language, in which a single word can be so divergent in meaning. Helen Spencer-Oatey describes culture as a “fuzzy” concept with unclear delineations and boundaries – it is made up of a jumble of things from values to behaviours to habits. Culture is universal; yet it also varies, in that it can be heterogenous within and across groups.
Conceptions of culture are often wrongly perceived as dovetailing with protected characteristics - such as race, religion, and sexual orientation. That is not to disregard the shared experiences between members of marginalised groups, resulting from systems of oppression. Nor am I denying the importance of providing environments which prioritise these shared experiences – such as identity affinity groups. In fact, I have seen first-hand the power of these spaces, through facilitating Black Thrive’s Employment Working Group, in which all members are Black and have experience of managing a long-term physical and/or mental health condition. There is certainly a degree of trust, mutual understanding and positive affirmation that arise from such spaces. However, I would not describe this working group as ‘culturally appropriate’ or pertaining to a single ‘Black culture’. While they are all racialised as Black, the idea that group members come from ‘similar cultural backgrounds’ centres upon the misguided assumption that people who have similar phenotypic traits (such as skin colour) will share what we deem to be a ‘culture’.
We must therefore ensure that conversations about ‘cultural appropriateness’ are nuanced. There is a danger that endeavours to provide culturally appropriate interventions will reproduce rigid frameworks that flatten culture to a set of (discriminatory) stereotypes or assumptions applied to ‘race’ groups. This can already be seen in ‘cultural awareness’ courses which ‘aim to define or predict the characteristics of certain ethnic groups, along with a set of standard responses by professional workers, by means of overarching generalisations.’ In essence, cultural appropriateness must be more than a reminder that “not all South Asian or African people like spicy food”; it must not homogenise individuals or stereotype communities.
Such narrow approaches to understanding a person’s culture, in which generalities are extrapolated and haphazardly applied, may prevent needs-led approaches to care. The quest for culturally appropriate services may inadvertently overlook crucial factors that influence a person’s decision-making with regards to their health, leading to interventions which are de-personalised and inappropriate. For example, the report profiles Roger who declined moving to assisted living as it would mean giving up his cats. It also mentions Charlie who, to keep his dog, accepted the offer of moving into suitable housing despite it being 200 miles away from his hometown. In these instances, managing their health was a balancing act informed not by culture but by a love for their pets.
There is a desire at times to create pure and uncontaminated categories for people and things. We can rely on binaries and thought systems that depend upon orderly separation and partition. These people like this, those people do that. This approach is dangerous and can lead to one-size-fits-all solutions to remedying racial inequality via ‘culturally appropriate’ services. If there is one thing that I’ve learned from my work on the Black Thrive Employment Project in Lambeth, it is that “culturally appropriate” should not be used to describe a service, system, or intervention. Instead, we should use this term to refer to a process or mindset, guided by a set of universal values - grounded in active enquiry, genuine listening, and empathy. This should lead to support and care that is person-centred and needs-led; care that affords agency, empowers, and humanises.
Keating, F, Robertson, D, Francis, E & McCulloch, A (2002). Breaking Circles of Fear: A Review of the relationship between mental health services and African and Caribbean communities. Sainsbury Centre for Mental Health, London.
Kroeber, A. L., & Kluckhohn, C. (1952). Culture: a critical review of concepts and definitions. Papers. Peabody Museum of Archaeology & Ethnology, Harvard University, 47(1), viii, 223.
Spencer-Oatey, H. (2012) What is culture? A compilation of quotations. Global People Core Concept Compilations. Available at www.warwick.ac.uk/globalknowledge