People of culturally and linguistically diverse (CALD) and Indigenous backgrounds often experience challenges in healthcare. This article, which is based on the CFI-SPIKES modified protocol 1, aims to provide practical guidelines for health professionals working with Indigenous and CALD people during the COVID-19 pandemic.
1. Setting up the interview
Ensure the room is arranged to provide privacy and prevent interruptions. Telephone interpreters should be used when a person’s language spoken at home is not English and they are not proficient in English. The Translating and Interpreting Service (TIS National: ph 1800 131 450) is an interpreting service provided by the Department of Home Affairs for people who do not speak English and for agencies that need to communicate with their non-English speaking clients.
2. Get to know the consumer
Many Indigenous and CALD populations operate from a high context culture 2 where direct communication of illness is not welcomed and where talking about the context and impact of the illness is more important. It is recommended that the health professional establish a respectful and trusting interpersonal relationship to ensure the person is open to the communication of health information. The health professional can facilitate this by taking some time to get to know a little about the person before communicating information about COVID-19 such as whether or not the person has a diagnosis of COVID-19 and information about quarantine or isolation.
3. Understand what the consumer understands
Build a respectful and trusting relationship by acknowledging the individual as their own cultural expert. The health professional can facilitate this by suspending their own beliefs about illness and by exploring the person’s understanding of COVID-19 and related issues. The DSM-V Cultural Formulation Interview (CFI) 3 provides a helpful framework by asking:
- How does the person culturally define the problem of COVID-19 and associated issues such as quarantine or isolation? Explore how the person understands social distancing and quarantine measures.
- How does the person explain the causes of COVID-19? This can be the most difficult part of the conversation, particularly when the person may have an explanatory model of illness that diverges from the predominantly medical model. Take time to listen, and be open and respectful to the different ways people explain the causes of COVID-19, including 5G networks, spiritual causes such as the work of evil spirits or a disturbance in the harmony between the land, the spirit and the people.
- How does the person’s cultural identity make having a COVID-19 diagnosis better or worse? Will a person suffer stigma or be cast out from their community as a result of the diagnosis, or will they receive support?
- What are the person’s cultural methods of coping and seeking help with a condition such as COVID-19?
- What barriers may they encounter when accessing help?
- What cultural factors affect their help-seeking and treatment preferences? If the person attributes the cause of COVID-19 to supernatural processes or as a disturbance of balance/harmony, treatment preferences may involve ritual and religious practices from spiritual healers and elders to dispel evil spirts and re-establish harmony and balance.
- It is important to explore cultural beliefs about social distancing and quarantine or isolation with Indigenous and CALD people. It may be helpful to explore what measures their communities have taken in the past when dealing with people with infectious disease. Where these measures differ from the current recommendations, a rationale can be provided about how the lack of social distancing and quarantine for 14 days may place their elders and others in their respective communities at very high risk.
4. Does the person want to know (about whether they have COVID-19)?
Some people may not want to know whether or not they have COVID-19. Hence, it is recommended that health professionals respectfully ask whether the person wants to know if they have the diagnosis of COVID-19? In instances where the person says NO, then information should be provided to the person about the possible risks of COVID-19 to their Indigenous or CALD communities. This can extend to a discussion about techniques such as social distancing, quarantine, and isolation.
5. Providing accessible knowledge
It is important to use non-technical language that is easy to understand when communicating information about COVID-19 and associated quarantine or isolation measures. Medical terms and abbreviations should be avoided. Discussion about the symptoms and quarantine or isolation measures associated with COVID-19 can be supported by interpreters and/or by direction to translated COVID-19 online resources (e.g. from the Department of Health).
6. Addressing emotional reactions and referral to culturally appropriate health services
People from Indigenous or CALD communities may experience shame and guilt in response to a COVID-19 diagnosis. For example, shame may be associated with beliefs that they are being punished by God for wrongdoings, or that their actions or those of another are responsible for the imbalance in the harmony and oneness of the community. Health professionals can support the person by listening to their concerns, normalizing and empathizing, and providing referral to culturally appropriate or Indigenous health services.
7. Provide a summary
Provide a summary of relevant information about symptoms, relevant diagnosis, quarantine or isolation measures and treatment to person. Then check how well they have understood this information. In this step, you could consider the following:
- Support the person to generate a list of questions regarding their treatment and health care: Consumer engagement and informed decision making are critical in health and mental-health communication, irrespective of ethnicity 2-4. Studies have found that providing good information and supporting people to generate a list of questions regarding their health care reduces barriers to communication and increases engagement levels by CALD populations 3,5.
- Warnings about social distancing: Remember that many Indigenous and CALD communities are collectivist cultures and may really struggle with the requirement of social distancing, so a very clear rationale about social distancing in terms of protecting their cultural group and other groups needs to be communicated to increase likelihood of adherence.
- Develop a support plan: Finally, assist people from Indigenous and CALD communities to develop a support plan, listing people they can call on if they run out of essential items or need emotional support.
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- Kayrouz R, Senediak CI, Laube R. Building a bridge: A case report on communicating mental-health diagnoses to patients of a culturally and linguistically diverse background. Australasian Psychiatry. 2017;25(5):478-480.
- Hall ET. Beyond Culture. New York: Anchor Books; 1976.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.
- Hawley ST, Morris AM. Cultural challenges to engaging patients in shared decision making. Patient Educ Couns. 2017;100(1):18-24.
- Hibbard JH. Patient activation and the use of information to support informed health decisions. Patient Educ Couns. 2017;100(1):5-7.
- Street Jr RL, Volk RJ, Lowenstein L, Michael Fordis Jr C. Engaging patients in the uptake, understanding, and use of evidence: Addressing barriers and facilitators of successful engagement. Patient Educ Couns.100(1):4.
- Deen D, Lu W-H, Rothstein D, Santana L, Gold MR. Asking questions: The effect of a brief intervention in community health centers on patient activation. Patient Educ Couns. 2011;84(2):257-60.