Adapting to New Zealand’s super-diversity

Originally published in  Contact: Newsletter for members of the Pharmacy Guild of New Zealand, December 2011-January 2012  (Issue 11), Pages 8-9.

New Zealand has earned the right to call itself super-diverse. this term refers to an unprecedented level and kind of complexity that surpasses anything previously experienced in a particular society. This super-diversity leads to new conjunctions and interactions, and outcomes that extend beyond the usual ways of understanding diversity.

Super-diversity is a relatively new phenomenon given the relative homogeneity of the New Zealand population. The arrival of super-diversity, its impacts and the relevance of super-diversity to pharmacy are the focus of this article.

Why is ethnic diversity and super-diversity relevant to pharmacy? And why is a nurse with a PhD writing about it? Perhaps it is because nurses and pharmacists have a lot in common. We see a lot of people and we tend to have very regular, intimate and long- term relationships with people (if we are doing something right). If we are not, people vote with their feet. Given this ubiquity, how can we ensure that we make a difference in the context of super-diversity?

New Zealand’s super-diversity kicked in with Asian migration in the 1990s. Prior to that, New Zealand had preferred particular “source countries” to select migrants from (Great Britain and Ireland). This homogeneity of migrants was altered by Polynesian Pacific migration from the 1960s, but it was the migration policy changes of 1987 that paved the way for skilled migrants from a range of countries to arrive, notably Asia.

These demographic changes led to a philosophical shift from assimilation to multiculturalism in the context of biculturalism. The expectation of newcomers to assimilate (give up their ways to fit into a new culture) was changed to reflect the notion of New Zealand as an inclusive society where the integration of newcomers was supported by “responsive services, a welcoming environment and a shared respect for diversity”.

But the effects of assimilation can be seen on the health of Maori and Pacific people who experience health inequalities and a lower life expectancy than Pakeha. We are beginning to see these same trends in Asian and MELAA (Middle-Eastern, Latin American and African) communities. It is easy to write-off the poor health of particular groups to their individual behaviour or their culture. But there is growing evidence that health professional behaviour contributes to creating and reproducing disparities as seen by the differential quality of healthcare different racial and ethnic groups receive.

Cultural competence is a strategy for reducing health disparities and activating health gain. The American Society of Health-System pharmacists (ASHP) suggests that medication therapy management is central to many health disparities including diabetes or end-stage renal disease which disproportionately affects particular groups (for example, Maori) that pharmacists are in a position to directly address these disparities or to change the language away from deficit to health benefit or gain.

The Health Practitioners Competence Assurance Act 2003 requires that all health professionals are competent and fit to practice. There are seven standards for New Zealand pharmacists that articulate the knowledge, skills, attitudes and behaviours necessary for competence. The standard that is most relevant to cultural competence is Standard One which requires that pharmacists practice pharmacy in a professional and culturally competent manner.

Cultural competence approaches require the health professional and the institutional system of health to adapt the ways in which they deliver services in order to accommodate difference. these require the health professional to focus on three main areas.

  • The first is to be aware of how the patient or client’s health beliefs, values and behaviours are shaped by their culture or religion.
  • The second is a focus on learning about what shapes health behaviours, disease epidemiology, ethno-pharmacology and complementary health practices located in different groups.
  • The final area is that of communication where the role of the health professional is to elicit the client’s health beliefs, develop a therapeutic alliance and utilise strategies that enhance communication such as working with professional interpreters (funded in some areas) or using the pharmacy translation Kit developed by the guild, for example.

New Zealand also has an indigenous strategy called cultural safety. The emphasis, here, is on the beliefs and attitudes of the health professional rather than that of the client. Careful reflection on the assumptions that underpin the culture of the profession or the service is required because these very assumptions can be assimilatory and disempowering for people who are not invested in them. Such assumptions as the belief that the individual is solely responsible for their own health, that Western medicine is the only valid mechanism for dealing with ill-health require conforming to the system, rather than the system adapting to the needs of the patient or client. These assumptions might pose a barrier to caring for someone who does not hold those beliefs.

Instead of doing what we’ve always done, we might be inspired to develop new ways of thinking and practicing that could benefit all people and communities in this super- diverse New Zealand.