Epistemic racism in the health professions: A qualitative study with Black women in Canada

Systemic racism within health care is increasingly garnering critical attention, but to date attention to the racism experienced by health professionals themselves has been scant. In Canada, anti-Black racism may be embodied in structures, policies, institutional practices and interpersonal interactions. Epistemic racism is an aspect of systemic racism wherein the knowledge claims, ways of knowing and 'knowers' themselves are constructed as invalid, or less credible. This critical interpretive qualitative study examined the experiences of epistemic racism among 13 healthcare professionals across Canada who self-identified as Black women. It explores the ways knowledge claims and expert authority are discredited and undermined, despite the attainment of professional credentials. Three themes were identified: 1. Not being perceived or portrayed as credible health professionals; 2. Requiring invisible labour to counter professional credibility 'deficit'; and 3. Devaluing knowledge while imposing stereotypes. The Black women in our study faced routine epistemic racism. They were not afforded the position of legitimate knower, expert, authority, despite their professional credentials as physicians, nurses and occupational therapists. Their embodied cultural and community knowledges were disregarded in favour of stereotyped assumptions. Adopting the professional comportment of 'Whiteness' was one way these health care providers strived to be perceived as credible professionals. Their experiences are characteristic of 'misogynoir', a particular form of racism directed at Black women. Anti-Black epistemic racism constitutes one way Whiteness is perpetuated in health professions institutions.

Interpersonal, institutional, and structural racism in Canadian nursing: A culture of silence

BACKGROUND

Alongside declarations against racism, the nursing profession in Canada needs examination of experiences of racism within its ranks. Racism at multiple levels can create a context wherein racialized nurses experience barriers and ongoing marginalization.

PURPOSE

This critical interpretive qualitative study asks how interpersonal, institutional, and structural racisms intersect in the professional experiences of racialized nurses in Canada, and how nurses respond.

METHODS

Self-identified racialized nurses (n = 13) from across Canada were recruited primarily through snowball sampling, and each was interviewed by phone or in person. Once transcribed, interviews were analyzed inductively, which led to the levels of racism as a guiding framework.

RESULTS

From entry to nursing education throughout their careers participants experienced racism from instructors, patients, colleagues and managers. Interpersonal racism included comments and actions from patients, but more significantly lack of support from colleagues and managers, and sometimes overt exclusion. Institutional racism included extra scrutiny, heavier workloads, and absence in leadership roles. Structural racism included prevalent assumptions of incompetence, which were countered through extra work, invisibility and hyper-visibility, and expectations of assimilation. Racialized nurses were left to choose among silence, resisting (often at personal cost), assimilation and/or bolstering their credibility through education or extra work. Building community was a key survival strategy.

CONCLUSIONS

Everyone in nursing needs to challenge the culture of silence regarding racism. White nurses in particular need to welcome discomfort, listen and learn about racism, then speak out to help disrupt its normative status.

"Ah, it's best not to mention that here:" Experiences of LGBTQ+ health professionals in (heteronormative) workplaces in Canada

Introduction

Despite human rights protections for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) people, LGBTQ+ professionals may continue to experience discrimination working in heteronormative systems and spaces.

Methods

In this qualitative study 13 health professionals (nurses, occupational therapists, and physicians) from across Canada participated in in-depth qualitative interviews to explore their experiences with work-related microaggressions and heteronormativity.

Results

Heterosexist microaggressions from both patients/clients and colleagues were the norm, perpetuating and bolstered by heteronormative workplace and professional cultures. In turn, LGBTQ+ professionals navigated disclosure-decision-making, in power-laden contexts where all options carried potential negative consequences.

Discussion

Drawing on the notion of "heteroprofessionalism," we argue that the concept of professional carries encoded within it demands that the occupant of that category be-or present as-heterosexual, an unmarked status that can be readily desexualized. Acknowledging sex and sexuality disrupts "professionalism." We argue that such disruption, indeed dissention, is necessary to open (hetero)professional spaces to LGBTQ+ workers.

Systemic Racism in Canadian Occupational Therapy: A Qualitative Study with Therapists

Background. Research on racism within occupational therapy is scant, though there are hints that racialized therapists struggle. Purpose. This paper examines experiences of racism in occupational therapy, including coping strategies and resistance. Method. Ten therapists from racialized groups (not including Indigenous peoples) were recruited for cross-Canada, in-person or telephone interviews. Transcripts were coded and inductively analysed, with data thematically organized by types of racism and responses. Findings. Interpersonal racism involving clients, students, colleagues and managers is supported by institutional racism when incidents of racism are met with inaction, and racialized therapists are rarely in leadership roles. Structural racism means the experiences of racialized people are negated within the profession. Cognitive sense-making becomes a key coping strategy, especially when resistance is costly. Implications. Peer supports and community building among racialized therapists may be beneficial, but dismantling structures of racism demands interrogating how whiteness is built into business-as-usual in occupational therapy.

Experiences of epistemic racism among occupational therapists

Abstract Objective Epistemic racism establishes the knowledges and ways of knowing of a dominant group as legitimate, invalidating those of groups marked by racialization. Professions are demarcated by their knowledge claims, making epistemic racism a powerful mechanism of exclusion within professions. This paper examines experiences of epistemic racism in occupational therapy across Canada. Method Using a critical interpretive qualitative approach, ten therapists from racialized groups were interviewed (in-person or telephone), with transcripts coded and analyzed iteratively. Results Participants routinely experienced epistemic ‘mis/fit’ with the profession, rarely seeing themselves reflected in the profession’s knowledge base, leadership, values or assumptions. Racialized therapists were routinely denied expertise and authority, by students, clients and colleagues. They walked a tightrope between professional assimilation and marginalization. Conclusion The presence of racialized therapists is insufficient, when their authority is consistently delegitimized and they are required to assimilate. Leadership roles for racialized therapists must be accompanied with epistemological multiplicity, destroying the domination of whiteness.

The Concept of Oppression and Occupational Therapy: A Critical Interpretive Synthesis

Background. Occupational therapy and occupational science literature include growing attention to issues of justice, marginalization, and rights. In contrast, the concept of oppression has scarcely been employed. Purpose. This paper investigates how adding the concept of oppression may enhance occupational therapy approaches to injustice, prioritizing a focus on structural causes, and facilitating conscientious action. Method. A critical interpretive synthesis explored insights from authors who name oppressions in occupational therapy and occupational science literature. In total, a sample of 28 papers addressing oppression, ableism, ageism, classism, colonialism, heterosexism, racism, and/or sexism was selected for inclusion. Findings. Four themes were identified: oppression and everyday doing; effects of structures and power; responding and resisting; and oppression within occupational therapy. Implications. Incorporating oppression within the plurality of social discourse may help occupational therapists to avoid individualistic explanations, attend to relationships between social structures and constrained occupations, frame intersectional analysis, and engage in praxis.

Occupational Therapy Roles in an Indigenous Context: An Integrative Review

BACKGROUND.

Indigenous peoples experience health inequities linked in part to lack of access to culturally-relevant health care. The Truth and Reconciliation Commission of Canada (TRC) calls on all health professionals, including occupational therapists, to reduce health inequities through improved work with Indigenous communities.

PURPOSE.

This integrative review of the literature explores how occupational therapists can improve their work with Indigenous peoples.

KEY ISSUES.

Communication and building relationships are central to effective work with Indigenous communities, along with reciprocity regarding knowledge exchange. Issues surrounding service provision are a significant concern, yet improvements are unlikely to be effective unless therapists can critically examine the (mainstream) Western cultural assumptions that infuse the profession and their own practices.

IMPLICATIONS.

Though nascent, there are identified directions for occupational therapists to meet the TRC's calls for more competent health care. Researchers should explore best ways for therapists to critically interrogate taken-for-granted professional assumptions mired in Western colonialism.

"You Always Remain Slightly an Outsider": Workplace Experiences of Academics from Working-Class or Impoverished Backgrounds

Debates surrounding class inequality and social mobility often highlight the role of higher education in reducing income inequality and promoting equity through upward social mobility. We explore the lived experience of social mobility through an analysis of 11 semistructured interviews with Canadian academics who self-identified as having working-class or impoverished family origins. While economic capital increased substantially, cultural capital and habitus left many feeling like cultural outsiders. Isolation-both chosen and imposed-reduced professional networks, diminishing social capital. Caught between social worlds, participants mobilized symbolic capital in moral boundary marking, aligning themselves strategically with either their current class status or their working-class roots. While upward social mobility is a path toward reducing economic inequality, the lived experience of social mobility suggests it may exact a high emotional cost.

Indigenous perspectives on health: Integration with a Canadian model of practice

BACKGROUND.

The Canadian Association of Occupational Therapists and the Truth and Reconciliation Commission recommend change within the Canadian health care system, respecting and valuing Indigenous health and healing practices. Adjusting the lens through which occupational therapists practice to incorporate Indigenous views of health and wellness is one potential change.

PURPOSE.

This critical interpretive synthesis of the literature incorporates Indigenous perspectives on health and wellness into the Canadian Model of Occupational Performance and Engagement (CMOP-E) framework, strengthening that model to better serve all peoples in Canada.

KEY ISSUES.

Integrating Indigenous worldviews can add to the CMOP-E the importance of balance among physical, emotional, spiritual, and mental health; the inseparability of person, community, and land; and understanding occupations as dimensions of meaning. These are incorporated in a proposed integrated model (ICMOP-E).

IMPLICATIONS.

Effectively integrating Indigenous perspectives may be an important first step in a longer journey toward engaging more respectfully with Indigenous perspectives on health and wellness.

What about the men? Gender parity in occupational therapy: Qu'en est-il des hommes? La parité hommes-femmes en ergothérapie

BACKGROUND

Gender parity is frequently raised as an equity issue in occupational therapy, with strategies proposed to recruit more men.

PURPOSE

This article explores whether this is a legitimate equity concern.

KEY ISSUES

Most employment is gender segregated; when gender balances change, the field either re-genders feminine or creates gender-segregated internal divisions. Men avoid feminized jobs because they pay less and hold less social status. They are a "step down" for men. In such jobs, men are disproportionately pushed into management positions, with better pay, more prestige, and less hands-on care. Equity issues concern structural barriers to success in particular employment fields. Though they may feel discomfort in a feminized field, men do not face structural barriers in occupational therapy.

IMPLICATIONS

Broader challenges to traditional gender norms are needed, but there is no evidence that gender parity is an equity concern or that recruitment targeting masculinity would make a difference.

Experiences of Social Class: Learning from Occupational Therapy Students

Background and Purpose. Despite the potential in occupational therapy models, there has been little investigation of the ways social class may affect occupations or occupational therapy. This paper explores the occupational impacts of poverty.Methods. Essays by 17 occupational therapy students, who identify as lower class, were coded and analyzed inductively.Results. Class-based shame and stigma led to attempts to “pass” as middle class-an occupation consuming time and energy. Exclusion from middle-class leisure occupations left students with gaps in their adult knowledge. Family was a site of both shame and safety, as well as pressure to succeed. Educational occupations embody marginalization.Practice Implications. Class is not only about money, but also having the right norms, values, and experiences to fit easily in middle-class society. Educational and health care institutions epitomize middle-class assumptions. The experiences of these students may help therapists to examine where they unwittingly enact middle-class norms in practice.

Approaches to culture and diversity: A critical synthesis of occupational therapy literature

BACKGROUND

The 2007 position statement on diversity for the Canadian occupational therapy profession argued discussion was needed to determine the implications of approaches to working with cultural differences and other forms of diversity. In 2014, a new position statement on diversity was published, emphasizing the importance of social power relations and power relations between client and therapist, and supporting two particular approaches: cultural safety and cultural humility with critical reflexivity

PURPOSE

This paper reviews and critically synthesizes the literature concerning culture and diversity published in occupational therapy between 2007 and 2014, tracing the major discourses and mapping the implications of four differing approaches: cultural competence, cultural relevance, cultural safety, and cultural humility.

KEY ISSUES

Approaches differ in where they situate the "problem," how they envision change, the end goal, and the application to a range of types of diversity.

IMPLICATIONS

The latter two are preferred approaches for their attention to power relations and potential to encompass a range of types of social and cultural diversity.

Working with transgender clients: learning from physicians and nurses to improve occupational therapy practice

BACKGROUND

Gender identity disorder and the process of transitioning involve both mental and physical health, yet there is virtually no discussion of transgender health care in occupational therapy.

PURPOSE

This study draws on interviews with primary-care nurses and physicians about their experience with transgender health care, extending the insights gleaned there to make suggestions for occupational therapy practice with this population.

METHOD

Semi-structured interviews were conducted with 12 primary care nurses and 9 physicians who had clinical experience with lesbian, gay, and bisexual patients.

FINDINGS

Participants felt uncertain about transgender care, wanting more specialized knowledge. Collaborating with patients, acknowledging stigma, ensuring inclusive systems and procedures, navigating health care, and providing holistic care emerged as key elements for best practice. Advocacy was a crucial part of care provision.

IMPLICATIONS

Suggestions are provided for therapists to ensure that space and interactions are welcoming to transgender clients as well as suggestions for occupational therapy intervention in the transitioning process.

The practice experience of evangelical Christian occupational therapists

BACKGROUND

Occupational therapists who are religious are more likely to address spirituality in practice; however, little is known regarding the practice experience of therapists who hold particular faith perspectives.

PURPOSE

To examine the practice experience of evangelical Christian occupational therapists in the context of professional emphasis on spirituality as a largely secular domain of practice.

METHODS

. A qualitative, interpretivist approach was used for this study. Seven evangelical Christian occupational therapists were engaged in in-depth interviews; verbatim transcripts were thematically coded.

FINDINGS

Christianity was viewed as a practice resource through the use of private prayer and Christian values to support compassionate practice. Evangelical Christian occupational therapists navigated the tensions of working in a secular healthcare system through awareness of work environment and client cues, restrained expression of faith, as well as the experience of increased scrutiny for potential boundary violations.

IMPLICATIONS

Evangelical Christian therapists may struggle with secular interpretations of spirituality in practice. Yet they may also display heightened awareness concerning potential boundary violations.

The rural and the rotund? A critical interpretation of food deserts and rural adolescent obesity in the Canadian context

Resting on the notion that rural spaces are "food deserts," rural adolescents are increasingly regarded as a "problem population" in Western obesity narratives. Using qualitative data gleaned from interviews with 51 teenage participants from rural areas across Canada, this paper focuses on the ways in which obesity is constructed as a rural disease in the Canadian context, demonstrating in particular how discourses of food deserts and related rural obesity rely on classist imaginings of obesity as a working-class embodiment. The paper will further question the understanding of the rural as a food desert, showing the ways in which rural teens acquire fresh, healthy foods in part through an informal economy of food growing and sharing.

Nurses' work with LGBTQ patients: "they're just like everybody else, so what's the difference"?

Informed by critical feminist and queer studies approaches, this article explores nurses' perceptions of practice with patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Qualitative in-depth, semi-structured interviews with 12 nurses in Halifax, Nova Scotia, illuminate a range of approaches to practice. Most commonly, participants argued that differences such as sexual orientation and gender identity do not matter: Everyone should be treated as a unique individual. Participants seemed anxious to avoid discriminating or stereotyping by avoiding making any assumptions. They were concerned not to offend patients through their language or actions. When social difference was taken into account, the focus was often restricted to sexual health, though some participants showed complex understandings of oppression and marginalization. Distinguishing between generalizations and stereotypes may assist nurses in their efforts to recognize social differences without harming LGBTQ patients.

Culture and Diversity among Occupational Therapists in Ireland: When the Therapist is the ‘Diverse’ One

Introduction:

Literature in occupational therapy, although paying increased attention to cultural differences and diversity, has largely ignored the situation of therapists who are themselves members of social and cultural minority groups. ‘Difference’ is assumed to be exclusively an attribute of the client.

Method:

This qualitative study explored the professional experiences of 12 occupational therapists in Ireland who self-identified as disabled or ethnic minority group members.

Findings:

Participants reported challenges with colleagues and managers, which revolved primarily around cultural differences in the norms and expectations guiding social interactions, communications and practice styles. Overt discrimination was reported only by disabled therapists. With clients, again there were clashes of cultural values, but participants also experienced overt and covert prejudice and intolerance. This was particularly difficult to respond to in the context of client-centred practice.

Conclusion:

Cultural competence, as the prevailing approach to diversity, emphasises suspending one's own values to facilitate those of clients. This demand may be inappropriate for minority therapists who may face prejudice and discrimination. In contrast, cultural humility and critical reflexivity emphasise negotiating values in the context of social power relations, an approach that may better position occupational therapy to benefit from a diverse workforce.

Meanings of food, eating and health among African Nova Scotians: 'certain things aren't meant for Black folk'

OBJECTIVE

Most research on food, ethnicity and health in Canada is focused on the dietary acculturation of first of second generation migrants. 'Failure' to adopt nutritional guidelines for healthy eating is generally understood as lack of education or persistence of cultural barriers. In this study we explore the meanings of food, health, and well-being embedded in the food practices of African Nova Scotians, a population with a 400-year history in Canada.

DESIGN

Qualitative interviews were conducted with 2 or 3 members of each of 13 families who identified as African Nova Scotian. Interviews asked about eating patterns; the influence of food preferences, health concerns, cost, and culture; perceptions of healthy eating and good eating; how food decisions were made; and changes over time. In addition, research assistants observed a 'typical' grocery shopping trip and one family meal.

RESULTS

Participants readily identified what they perceived to be distinctively 'Black ways of eating.' Beyond mainstream nutrition discourses about reduction of chronic disease risk, participants identified three ways of thinking about food, health, and well-being: physical well-being, emphasizing stamina, energy and strength; family and community well-being; and cultural or racial well-being, emphasizing cultural identity maintenance, but also resistance to racism.

CONCLUSION

While culturally traditional eating patterns are often understood as costly in terms of health, it is equally important to understand that adopting healthy eating has costs in terms of family, community, and cultural identity. Dietary change unavoidably entails cultural loss, thus resisting healthy eating guidelines may signify resistance to racism or cultural dominance. Several suggestions are offered regarding how community strengths and beliefs, as well as cultural meanings of food and health, might inform effective healthy eating interventions.

"Too much of that stuff can't be good": Canadian teens, morality, and fast food consumption

Recently, public health agents and the popular media have argued that rising levels of obesity are due, in part, to "obesogenic" environments, and in particular to the clustering of fast food establishments in Western urban centers that are poor and working class. Our findings from a multi-site, cross-national qualitative study of teenaged Canadians' eating practices in urban and rural areas offer another perspective on this topic, showing that fast food consumption is not simply a function of the location of fast food outlets, and that Canadian teens engage in complex ways with the varied dimensions of choosing (or rejecting) fast foods. Drawing on evidence gleaned from semi-structured interviews with 132 teenagers (77 girls and 55 boys, ages 13-19 years) carried out between 2007 and 2009, we maintain that no easy relationship exists between the geographical availability of fast food and teen eating behaviors. We use critical obesity literature that challenges widely accepted understandings about obesity prevalence and etiology, as well as Lamont's (1992, 2000) concept of "moral boundary work," to argue that teen fast food consumption and avoidance is multifaceted and does not stem exclusively nor directly from spatial proximity or social class. Through moral boundary work, in which teens negotiated with moralistic notions of healthy eating, participants made and re-made themselves as "good" and successful subjects by Othering those who were "bad" in references to socially derived discourses of healthy eating.

Being a ‘good mother’: Dietary governmentality in the family food practices of three ethnocultural groups in Canada

In this qualitative study with three ethnocultural groups in two regions of Canada, we explore how official dietary guidelines provide particular standards concerning ‘healthy eating’ that marginalize other understandings of the relationship between food and health. In families where parents and youth held shared ways of understanding healthy eating, the role of ‘good mother’ was constructed so as to include healthy eating expertise. Mothers expressed a perceived need to be personally responsible for providing skills and knowledge about healthy eating as well as guarding children against negative nutritional influences. Governing of family eating practices to conform to official nutritional advice occurred through information provision, monitoring in shopping and meal preparation, restricting and guiding food purchases, and directly translating expert knowledges into family food practices. In families where parents and youth held differing understandings of healthy eating, primarily families from ethnocultural minority groups, mothers often did not employ the particular western-originating strategies of conveying healthy eating information, or mentoring healthy meal preparation, nor did they regulate or restrict children’s food consumption. Western dietary guidelines entered into the family primarily through the youth, emphasizing the nutritional properties of food, often devaluing ‘traditional’ knowledge about healthy eating. These processes exemplify techniques of governmentality which simultaneously exercise control over people’s behaviour through normalizing some family food practices and marginalizing others.

The Impact of Everyday Racism on the Occupations of African Canadian Women

Background. Occupational therapy has increasingly explored the impact of cultural differences on occupations but has not yet begun to explore the impact of racism on human occupation. Purpose. This study with 50 African Canadian women used mixed methods to explore the effects of racism on their occupational experiences. Methods. Women aged 40–65 were interviewed in-depth about everyday experiences with racism and overall well-being. Three standardized instruments assessed frequency and stressfulness of race-related experiences. Findings. Everyday racism had subtle, almost intangible, impacts, shaping women's engagement with and the meaning of leisure, productive, and caring occupations. Implications. As occupational therapy increasingly attends to issues of cultural difference, it is critical to also attend to racism. This means learning to ask thoughtful questions about how racism may shape clients' occupations. Attention to this aspect of the social environment will enhance practice with African-heritage clients and clients from other racial minority groups.

Approaches to diversity in family medicine: "I have always tried to be colour blind"

OBJECTIVE

To explore family physicians' perceptions of and experiences with patient diversity, including differences in sex, race, ethnicity, social class, sexual orientation, and abilities or disabilities.

DESIGN

Semistructured, in-depth, qualitative interviews. SETTING Halifax metropolitan region, Nova Scotia.

PARTICIPANTS

Twenty-two family physicians who ranged in age (25 to 65 years) and in years of practice (< 5 to > 20). Participants included both sexes, members of racialized minority groups, and those who self-identified as gay, lesbian, or bisexual.

METHODS

Physicians were recruited through information letters distributed by mail and through professional networks. Interviews and field notes were recorded, transcribed verbatim, and coded using data analysis software. Weekly team discussions enhanced interpretation and analysis.

MAIN FINDINGS

Family physicians employed 5 main approaches to diversity: maintaining that differences do not matter, accommodating sociocultural differences, seeking to better understand differences, seeking to avoid discrimination, and challenging inequities. Quotes from interviews illustrate these themes.

CONCLUSION

Most approaches assume that both medicine (as a profession) and physicians are and should be socially and culturally neutral; some acknowledge that the sociocultural background of patients can raise tensions. Most participants in our study seek to treat patients as individuals in order to not stereotype, which hinders recognition of the ways in which sociocultural factors-both patients' and physicians'-influence health and health care. Critical reflexivity demands that physicians understand social relations of power and where they fit within those relations.

Engaging with healthy eating discourse(s): Ways of knowing about food and health in three ethnocultural groups in Canada

The aim of this study was to increase our understanding of how people make sense of healthy eating discourses by exploring the 'ways of knowing' about healthy eating among members of three different ethnocultural groups in Canada: African Nova Scotians, Punjabi British Columbians and Canadian-born European Nova Scotians and British Columbians. Data for this paper come from in-depth, individual interviews with 105 adults where they described their experiences, interpretations, and reasoning used in learning and deciding what to believe and/or reject about healthy eating. Between and within ethnocultural group differences in how people come to know and use practices about healthy eating were examined as they were represented through three broad healthy eating discourses: cultural/traditional, mainstream and complementary/ethical. The discourses represented different ways to interpret the food-health relationship and make sense of the evidence about healthy eating in the everyday experience. Engagement with different discourses led participants to undertake different practices upon themselves in the name of healthy eating. We suggest that each of the discourses has a significant contribution to make in a dialogue about how healthy eating, as part of health and well-being, should be conceptualized by a society.

Autonomy and control: the co-construction of adolescent food choice

We explored how adolescents and parents negotiate adolescents' increasing food choice autonomy in European Canadian, Punjabi Canadian and African Canadian families. Data were collected through semi-structured interviews with 47 adolescents and their parents, participant observation at a family meal and a grocery shopping trip with the family shopper(s). Thematic and constant comparative analyses were used. Adolescents exercised considerable autonomy over much of their food choice and their parents monitored and controlled the environment within which adolescents were given independence and responsibility. Parents used strategies of coaxing, coaching and coercing, while teens responded by complaining, ignoring and refusing their parents' advice. At the same time, teens took responsibility and reflected on their behaviours while keeping in mind their parents' advice, even if in some cases they were as yet unable to act upon it. Food choice autonomy is not simply a negative act of teenage defiance. Instead, it is actively co-constructed by both teens and their parents as each resists and responds to the others. Studies of adolescent autonomy related to food choices, and interventions based on nutritional autonomy as a risk factor for poor nutrition would do well to take account of the co-constructive parent-adolescent process of teen autonomy.

Experiences of Social Class: Learning from Occupational Therapy Students

Background and Purpose. Despite the potential in occupational therapy models, there has been little investigation of the ways social class may affect occupations or occupational therapy. This paper explores the occupational impacts of poverty. Methods. Essays by 17 occupational therapy students, who identify as lower class, were coded and analyzed inductively. Results. Class-based shame and stigma led to attempts to “pass” as middle class-an occupation consuming time and energy. Exclusion from middle-class leisure occupations left students with gaps in their adult knowledge. Family was a site of both shame and safety, as well as pressure to succeed. Educational occupations embody marginalization. Practice Implications. Class is not only about money, but also having the right norms, values, and experiences to fit easily in middle-class society. Educational and health care institutions epitomize middle-class assumptions. The experiences of these students may help therapists to examine where they unwittingly enact middle-class norms in practice.

Everyday classism in medical school: experiencing marginality and resistance

OBJECTIVE

To explore the medical school experiences of students who self-identify as coming from a working-class or impoverished family background.

METHODS

A questionnaire was administered to Year 3 medical students at a Canadian medical school and in-depth interviews were held with 25 of these students (cohort 1). The same methods were repeated with another Year 3 class 3 years later (cohort 2).

RESULTS

While having (or not having) money was the most obvious impact of social class differences, students also discussed more subtle signs of class that made it easier or more difficult to fit in at medical school. Students from working-class or impoverished backgrounds were significantly less likely to report that they fitted in well, and more likely to report that their class background had a negative impact in school. They were also more likely to indicate awareness that a patient's social class may affect their health care treatment.

CONCLUSION

Students from working-class or impoverished backgrounds may experience alienation in medical school. Through the commonplace interactions of 'everyday classism' they may experience marginalisation, isolation, disrespect and unintentional slights. At the same time, they suggest that their experiences of exclusion may strengthen their clinical practice.

Family influences on food choice: context of surviving breast cancer

OBJECTIVE

To explore women's perceptions of family influences on food decision-making in the context of having had breast cancer or not having had breast cancer.

DESIGN

Individual interviews exploring women's perceptions of their eating habits, health status, and diet, health, and breast cancer beliefs.

SETTING

In Vancouver, a large, multicultural, Canadian city, interviews were held in women's homes or offices or at the university.

PARTICIPANTS

A culturally diverse convenience sample of women aged 40 to 60 years, including breast cancer survivors (n=29) and women who had not had breast cancer (n=32).

ANALYSIS

Verbatim interview transcripts were coded by one of the authors, and themes were developed by sorting and summarizing transcript segments.

RESULTS

Women who had not had breast cancer believed that they were catering to family preferences, even at the expense of their own health. In particular, men's "meat and potatoes" diet proved to be a barrier to dietary change. Breast cancer survivors experienced family members more as supporting than resisting healthful eating. Believing that the diagnosis had shifted their priorities, some women made healthful dietary changes regardless of family response.

CONCLUSIONS AND IMPLICATIONS

Women experience family influence as significant in food decision-making. An illness diagnosis may alter women's and their families' negotiations of competing values, such that healthful eating takes on greater priority than food preferences or maintaining social relations through catering to others' tastes. This may be an opportune time to help women introduce healthful eating.

The patient as text: a challenge for problem-based learning

OBJECTIVES

To explore the values and assumptions underlying problem-based learning (PBL) cases through narrative analysis, in order to consider the ways by which paper cases may affect student attitudes and values.

METHODS

Randomly chosen PBL cases from the first year curriculum at Dalhousie University medical school (n = 10) were coded by 3 independent reviewers attending to narrative components.

RESULTS

The cases generally used spare, objective language, used the passive voice, eliminated agency, and employed linguistic markers to encode scepticism about patient reports. There was almost no sense of the presence of the patient as person in these cases in terms of their words, feelings, or their social and cultural context. The almost complete exclusion of the preferences and priorities of the patient was striking.

CONCLUSION

The sample is small, the results only suggestive. Yet it appears that the cases used in PBL may unnecessarily, even unintentionally, encourage student detachment from the messiness of real patients' lives and emotions. Positioning a particular way of seeing - the doctor's gaze - as normative renders less visible the choices that are being made whenever an account is constructed. Including multiple voices in a case would complicate that tidy reduction of choices. Ongoing attempts to enrich the case format should be encouraged. At the same time, students may benefit from being taught the skills for critical analysis of the case itself.

Eating after breast cancer: influences on women's actions

OBJECTIVE

To explore women's dietary actions after a breast cancer diagnosis and the factors influencing those actions.

DESIGN

Individual interviews exploring women's perceptions.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A culturally diverse convenience sample of women (N = 30) aged 40 to 60 years diagnosed with breast cancer 6 months to 15 years previously.

PHENOMENON OF INTEREST

Social and personal factors that influence dietary actions.

ANALYSIS

Verbatim interview transcripts were coded and themes developed by sorting and summarizing coded transcript segments.

RESULTS

Women held a wide range of beliefs concerning the relationship between diet and breast cancer, particularly their own cancer occurrence. Actions were not always consistent with professed beliefs. Some women believed that diet contributes to breast cancer, even their own cancer, yet made no diet changes; others did not believe in such a relationship but did change their diets postdiagnosis. Family support, employment, financial resources, cultural food patterns, and other health concerns were strong influences.

CONCLUSIONS AND IMPLICATIONS

Although beliefs about diet-cancer connections affect actions concerning diet change, the relationship is not consistent. Diet change is also affected by social, cultural, and economic concerns that are at least as important as a woman's beliefs. Nutrient supplements appear to be a common, although perhaps temporary, response to diagnosis. Future research should explore the possibilities for nutrition professionals to help women think critically about the range of influences on their diets.

'Is this worth getting into a big fuss over?' Everyday racism in medical school

INTRODUCTION

Faced with an increasingly diverse student body, educators in the health professions struggle for ways to foster equality and understand racism. The concept of 'everyday racism' provides an important tool for examining subtle processes that construct a racialised climate in medical schools and other institutions.

OBJECTIVES

To examine the ways racism is understood and experienced within one medical school and investigate the micro level interactional processes that may perpetuate inequality.

METHODS

A survey (n = 72) and interviews (n = 25) were conducted with third year students at one Canadian medical school. A second class was surveyed (n = 61) 3 years later and 25 more students were interviewed.

RESULTS

Students identified the linguistic advantage enjoyed by some classmates from ethno-cultural minority groups, but were less likely to identify the advantages enjoyed by white students, who may be more readily granted student-doctor status. Students from racialised minority groups experienced marginalisation through segregation, and struggled to respond appropriately to racist jokes and comments from patients and staff. A third (29%) of those who identified as 'minority' group members did not feel they fitted in particularly well at medical school, compared with only 7% of 'non-minority' students (chi2 P = 0.006; t-test P = 0.004).

CONCLUSION

Medical students from racialised minority groups may experience 'everyday racism', mundane daily practices which intentionally or unintentionally convey disregard, disrespect or marginality. Such experiences are particularly difficult to deal with. Educators have a responsibility to counter with sustained antiracism, learning to acknowledge salient differences without reinforcing hierarchies of superiority and inferiority.

Teaching social and cultural awareness to medical students: "it's all very nice to talk about it in theory, but ultimately it makes no difference"

PURPOSE

To investigate the effect of exposure to a new course addressing social and cultural issues in medicine on third-year medical students' awareness and understanding of how these issues affect their lives as students, the lives of patients, the work of physicians, and patient-physician interaction. The course, Physicians, Patients & Society (PPS) was introduced at the time the school was moving to a PBL curriculum.

METHOD

In the late 1990s, a questionnaire was administered to third-year medical students at one Canadian medical school, prior to the curriculum change (Time 1). In-depth interviews were held with 25 of these students. A few years later, the same methods were repeated (Time 2) with a third-year class that had experienced the PPS course.

RESULTS

The response rate for Time 1 was 59% (n = 72), for Time 2, 51% (n = 61). Students in Time 2 did not demonstrate increased awareness of social and cultural issues. Most failed to recognize, or even denied, the effects of race, class, gender, culture, and sexual orientation. Those who acknowledged the effect of social differences tended to deny social inequality, or at best recognized disadvantages experienced by Others, but not the accompanying privileges enjoyed by their own social group.

CONCLUSIONS

In general, students concluded that learning about social and cultural issues made little or no difference when they did their clinical rotations. For a medical school to produce physicians who are sensitive to and competent working with diverse communities requires a balance between attention to "difference," attention to self, and attention to power relations.

Neutralizing differences: producing neutral doctors for (almost) neutral patients

Today 50% of medical students in Canada are women; they come from a wide range of racial, cultural, academic, and class backgrounds; they may openly identify as gay or lesbian. Yet to the extent that professional socialization produces uniformity of values, attitudes and future practice styles, the impact of increasing diversity is lessened. Based on a survey with undergraduate medical students, interviews with 25 students, and interviews with 23 faculty members and administrators at one Canadian medical school, this paper argues that there are impetuses within believe that the social class, 'race', ethnicity, gender, sexual orientation of a physician is not--and should not be--relevant during physician patient interactions. In short, intentional and unintentional homogenizing influences in their training work to neutralize the impact of increasing social differences among medical students.