When+cultures+collide+in+the+healthcare+setting+-++The+relevance+of+culture+to+the+effective+delivery+of+health+services

Student Name: Mickaela Gray Student number: 8101345 Tutor Name: Jacinda Wilson

(as cited in Harrison, 2005, mins 24-26)

**Cultural Artefact: “Crossing the Line” Australian Documentary**

“Crossing the Line” is an emotional two part documentary series that was screened in 2005 by the Australian Broadcasting Corporation’s program, Message Stick. The documentary shadowed two Caucasian city-dwelling university medical students, Amy and Paul whilst they undertook an eight week placement in the remote North-Western Queensland indigenous community of Mornington Island. The young interns are confronted by the different approaches that the indigenous residents have towards their health, especially in regards to lifestyle related factors. During the placement, Amy and Paul’s academic supervisors become concerned that the student’s have become too emotionally invested and that by losing their professionalism they risk causing themselves and the community residents emotional harm. The students do not share this view which eventually leads to the students being unexpectedly withdrawn from the community. Nine months after the internship, the students reflect on their experiences and the ways that it has shaped their practice in regards to culture and care.

Amy and Paul working in the Mornington Community (Harrison, 2005) **How is this artefact relevant to Public Health Issues?**

This artefact represents three key issues that are very relevant to the current study of Public Health. Firstly, the contrast between the students and the island residents highlights the extent that health inequities can exist between different cultural groups in society. Secondly, Amy and Paul’s struggle with patient compliance demonstrates the negative health outcomes that can result from intercultural doctor-patient relationships. Thirdly, the specific manner in which the students were expected to interact with their patients creates an opportunity to discuss and evaluate the benefits and relevance of the concepts of culturally appropriate or safe care.

**Literature Review**

Since the 1950s, researchers have investigated the effect of culture on healthcare (Capell, Veenstra, & Dean, 2007, p. 31). Hruschka (2008) refers to the popular definition of culture as a “shared system of learned norms, beliefs, values and behaviours that differ across populations”. The American based Office of Minority Health concisely described the pivotal role that culture plays in the healthcare context. They stated that cultural factors “determine how people “define health, wellness and illness”, “shape health-seeking behaviours” and “defines the roles and expectations of patients and healthcare providers” (as cited in Capel et al. 2007, p. 31). The specific scopes and foci of research on this topic has transformed and evolved through time (Allotey, Manderson, & Reidpath. 2007). However, research has consistently found that cultural factors are a key determinant of the effectiveness of health care services (Schouten & Meeuwesen. 2006., Johnstone, & Kanitsaki, 2007., & Dogra, 2010) . This literature review will take an evidence based and analytical approach these findings to examine the, how cultural factors actually impact on health, the population health impacts of this topic as well as a consideration of current theoretical models that have been designed to redress this issue.

The “clinical reality” described by Kleinman, Eisenberg and Good in 2006 (p. 142) described how the differing beliefs, views and models of health between health providers and patients affect health by impacting the ability of healthcare to be effective. Alegria, Atkins, Farmer, Slaton, & Stelk (2010) supplemented this research by stating that the patient’s health status has the potential to be adversely affected when their cultural beliefs do not match the “prevailing paradigms” of their health care system or practitioner (Alegria, 2010, p.50). Schouten & Meeuwesen also underlined the fact that each patient and health care provider brings their own unique cultural understandings and assumptions to any medical interaction (2006). The vast majority of studies examined for this review underlined the fact that both patients and providers are culturally influenced and that their respective health seeking or solving behaviours have the potential to impact on the type and quality of care received (Williamson & Harrison, 2010 ). However, the more simplistic study designs tend to focus more on the patient’s culture versus that of the practitioner culture as the primary determinant of health outcomes (Kleinman et al. 2006). This traditional and more basic approach will be discussed later as a contributing factor to the large amount of research that is carried out on this topic.

Research findings have unanimously concluded that cultural factors impact on health (Allotey et al., 2007, Alegria et al., 2010 &  Williamson &  Harrison, 2010 ). However, what the studies do not as comprehensively agree upon is the specific way that culture can be a negative health outcome mechanism (Capell et al. 2007). Schouten & Meeuwesen conducted a review of the current research and found that when cultures clash between a patient and their healthcare environment it does so in three key ways (2006). Firstly, there is reduced patient compliance in healthcare interactions. This means that patients are less likely to trust, value, agree with and thus adhere to medical advice or instructions provided by their health care provider due to difference in cultural backgrounds. Secondly there is reduced patient satisfaction, which has been concluded by Kleinman et al. (2006) to actually affect subjective patient experiences of symptoms of illness or disease especially in regards to pain and chronic disease management (Padela & Punekar, 2009). Thirdly, the underpinning factor of poor intercultural care is the increased misunderstandings between patient and healthcare provider. The difficulties of language barriers (Harmsen, Meeuwesen, Wieringen, Bernsen, & Bruijnzeels. 2003), the contrast in communication styles between high and low context cultures (Roberts, Moss, Wass, Sarangi, & Jones, 2005) as well as different cultural care expectations can contribute to these misunderstandings and lead to poor health outcomes.

<span style="font-family: 'Arial','sans-serif';">As demonstrated by Schouten and Meeuwesen’s research (2006), supported by the works of Harmsen, Wachtler, Brorsson and Troein (2006) as well as <span style="color: #000000; font-family: 'Arial','sans-serif';">Johnstone & Kanitsaki (2007), <span style="font-family: 'Arial','sans-serif';"> the identified cultural factors that can impact upon health outcomes are mostly focused on the way that the doctor-patient intercultural relationships are managed. Roberts et al (2005) quantified the misunderstandings that can occur within doctor patient relationship by finding that cultural differences caused misunderstandings in twenty percent of intercultural consultations and that the communication style of a health provider is a statistically “more important factor than their own personal culturally specific health beliefs” (Roberts et al 2005, p. 467).

<span style="font-family: 'Arial','sans-serif';">These research findings have allowed contemporary theorists to develop and amend existing culturally appropriate care frameworks and strategies to attempt to ensure that different cultural groups in society have equitable healthcare access and outcomes. The predominant theoretical frameworks that exist are the interrelated and sometimes interdependent concepts of Cultural Competence, Transcultural Care and Cultural Safety (Alegria et al., 2010). Cultural competence and Transcultural care theories originated from the United States in 1978 and the 1950s respectively (Capell et al., 2007). Cultural safety was developed in New Zealand in the early 1990s and is unique in that it was created from an indigenous post-colonialist perspective. These theories are similar in that they all acknowledge a patient’s cultural backgrounds as a key health determinant. Where they diverge is that concepts of competence and safety recognize the provider’s own cultural ‘baggage’ and how it impacts on care relationships. According to <span style="color: #000000; font-family: 'Arial','sans-serif';">Johnstone and Kanitsaki <span style="font-family: 'Arial','sans-serif';">, Cultural Safety was considered be revolutionary when it was first introduced due to two factors (2007). Firstly it incorporated the power relationship that exists between marginalised and dominant cultural groups in society into its structure. Secondly it stipulated that the evaluation of whether a care interaction was culturally appropriate or ‘safe’ was to be completed by the end service user, not the practitioner or the health system.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">It is clear that there exists a considerable volume of current research on the importance of culture in health, and the ways that this impacts the effectiveness of health care services. This research focus and energy is validated by the “abundance” of evidence that surrounds the health inequities experienced by specific marginalised cultural groups in society (Roberts et al. 2005). For example, according to the Australian Institute of Health and Welfare the average indigenous life expectancy for males is 11.5 and 9.7 years for females, lower than those from a non-indigenous background (AIHW, 2011). Non-Australian born residents and are far less likely to access health services relative to health need (AIHW, 2011) and are more likely to suffer from chronic health conditions and illnesses (CSDH, 2008). This marginalised cultural experience in health is mirrored in many other countries and settings.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">The World Health Organisation specifically outlined cultural factors as a key health determinant in their 2008 report entitled “Closing the gap in a generation” (CSDH, 2008). Specific case examples of intercultural health care inequities were documented by Harmsen et al. where the Dutch qualitative questionnaire based research indicated that misunderstandings between patients and their health care providers were increasing the rates of reported illness within specific Turkish migrant groups (2003).

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Furler et al. observed that in relation to mental health issues, healthcare practitioners were able to theoretically understand the different conceptions of depression in different cultural groups (2010). However in clinical practice, symptoms of mental illness for specific groups would more likely be attributed to the historical and social backgrounds of the patients rather than any cultural constructs of mental health (Furler et al. 2010).

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">There exist several specific methodological limitations to the type and quality of research and data upon which this review is based. First and foremost, the identification as belonging to a specific cultural group is a self-disclosed fact (Kleinman et al. 2006). Therefore any correlations between culture and health rely very heavily on patients themselves nominating a specific cultural identity. Regarding specific intercultural health communication research there are very few observational studies that examine this topic. Most of this research is conducted as a questionnaire style studies which raises the risk of participant bias The validity of this research does come into question when considering the cultural framework concepts with which many of the results are assessed against. Although modernised culturally appropriate care frameworks take into account the inherent bias of the patient and practitioner, the bias of the researcher in how they have chosen to define the conceptual terms is not openly discussed within the literature. This is a fundamental dilemma which faces this topic as just as the concepts and structure of culture and good health are social constructs, so too in fact are the concepts of cultural competence or safety (Capell et al. 2007). Despite existing limitations, the evidence that supports the need for culturally appropriate care is compelling motivator for further research studies.

<span style="font-family: 'Arial Black',Gadget,sans-serif; font-size: 20.6667px;">**Cultural and Social Analysis**

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">As discussed previously in this article, concepts of society and culture are intrinsically linked to the effectiveness of healthcare services. Social constructionist theory can be used to support this by reiterating that 'we are culture' and therefore it is natural and to be expected that the dominant cultural paradigms are reflected in our health institutions and practices (González, Biever, & Gardner, 2004, p 314). According to the theories of socialist Karl Marx, cultural inequities in health are actually to be expected as the interplay of social power dynamics, market forces and economics naturally give preferential treatment to the majority interests of society. Broad philosophical theories acknowledge the current health dilemma facing society in how to provide care for sections of the community that are most in need. These general theories tend to consider global concepts of human nature and the way that society behaves and structures itself.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">By placing this topic within a more specific geo-political context it is possible to gain an understanding of not just the broad inclinations of society but also the specific contributing factors that have led to this topic being considered a key current determinant of health.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Globalisation is extensively referred to in current research as a contributing factor for the increase in amount of intercultural care situations (Hruschka, 2008). As immigration and rates of regional and international travel increases (Hruschka, 2008) the likelihood of either a patient or a healthcare provider being from a different cultural background also increases ( <span class="wiki_link_ext">Ellen Rosenber ga et al., 2007). According to Allotley, Australia has the "second highest proportion of immigrants of any country” (2008, p.145). Coupled with more recent ethnically diverse migration patterns, Australia is being faced with increased cultural divides between it's care providers and patients.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Internal policy changes in Australia have also contributed to highlighting the relevance of culturally appropriate healthcare. Over time, culturally diverse groups in Australia have had a “mixed” healthcare experience as policy and legislation has evolved and changed <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> (Johnstone & Kanitsaki, 2007, p 233) <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">. In the Australian context this has contributed to discussions as to why effective culturally appropriate care is so important and remains a key research focus. The negative care experiences that several ethnically and culturally diverse groups in society experienced through policies such as Assimilation, the White Australia Policy and the disbandment of specialist ethnic specific health services in the 1970s and 1980s led to a noticeable decrease in their overall health status (Allotey et al., 2007).

<span style="font-family: 'Arial','sans-serif';">Cultural health inequities primarily affect the health status of marginalized cultural groups within society ( <span class="citationauthor" style="font-family: 'Arial','sans-serif';">Rosenberg, Kirmayer, Xenocostas, Dao & Loignon, 2007 <span style="font-family: 'Arial','sans-serif';">). However there exists a global movement towards patient centric care modeling which indicates a shift towards a wider population impact. This is due an increase in understanding that the effectiveness and efficiency of a health system can actually be partly measured and evaluated by its ability to cater for community sectors that are most in need ( <span class="citationauthor" style="font-family: 'Arial','sans-serif';">Dogra, <span class="citationdate" style="font-family: 'Arial','sans-serif';">2010 <span style="font-family: 'Arial','sans-serif';">). This is from a socio-ethical duty-of-care perspective as well as from an economic standpoint which accounts for the large chronic public health care costs typically associated with marginalized societal groups ( <span class="citationauthor" style="font-family: 'Arial','sans-serif';">Dogra, <span class="citationdate" style="font-family: 'Arial','sans-serif';">2010 <span style="font-family: 'Arial','sans-serif';">).

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">The recommendations for further research that have resulted from this literature review centre around the need for further study into practical application of conceptual care models as well as research into the effective ways that health care professionals can be trained to deliver culturally appropriate care. These recommendations have been made on the basis that intercultural provider training is currently not sufficient to deal with specific patient needs (Schouten & Meeuwesen, 2006) as well as the fact that communication methods of healthcare providers have only been “theoretically associated with clinical outcomes” and this has yet to be fully substantiated (Capell et al. 2007). Cultural safety and competency frameworks have drawn much positive attention for their conceptual clarity. However they have also several negative criticisms due to the fact they have not been rigorously tested and therefore do not have a sound evidence base from which to reorient health services. These recommendations for further research are designed to increase the effectiveness of intercultural care delivery in specific areas so as to enable “genuine empowerment and self-determination” for culturally diverse stakeholders (Australian Human Rights Commission, 2003).

**References**

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Allotey, P., Manderson, L., & Reidpath, D. (2007). Addressing cultural diversity in Australian health services //Health// <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> //Promotion Journal of Australia//, 13(2), 29-33. Retrieved from <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> [|http://search.informit.com.au.ezp01.library.qut.edu.au/documentSummary;res=APAFT; issn=1036-1073; py=2002;vol=13;iss=2;spage=29]

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Alegria, M., Atkins, M., Farmer, E., Slaton, E., & Stelk, W. (2010). One size does not fit all: Taking diversity, culture <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> and context seriously. //Administration and Policy in Mental Health and Mental Health Services// <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> //Research, 37//(1-2), 48-60. doi:10.1007/s10488-010-0283-2

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Australian Human Rights Commission, Office of the Human Rights and Equal Opportunity Commission (2003). <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> Submission to the Northern Territory Law Reform Committee.Retrieved from Australian Human Rights <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> Commission website []

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Australian Institute of Health and Welfare, Office of Australian Institute of Health and Welfare (2011) The health and welfare of Australia’s Aboriginal and Torres Strait Islander people: an overview. Retrieved from the Australian Institute of Health and Welfare website []

<span style="color: #000000; font-family: 'Arial','sans-serif';">Capell, J., Veenstra, G., & Dean, E. (2007). Cultural competence in healthcare: critical analysis of the construct, its assessment and implications. //Journal Of Theory Construction & Testing, 11//(1), 30-37. Retrieved from <span style="font-family: 'Arial','sans-serif';">: @http://findarticles.com/p/articles/mi_hb1449/is_200704/ai_n32232706/

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Commission on Social Determinants of Health, World Health Organization (2008). //Closing the gap in a generation: health equity through action on the social determinants of health.// Retrieved from World Health Organization website //[]//

<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Cook, C. (2004). 'Who cares about Marx, Weber and Durkheim?': social theory and the changing face of medicine. //Health Sociology Review//, 13(1), 87-96. Retrieved from []

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<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">González, R., Biever, J.L., & Gardner, G. T. (2004). The multicultural perspective in therapy: A social constructionist approach. //Psychotherapy: Theory, Research, Practice, Training,// //31//(3), 515-524. doi: 10.1037/0033-3204.31.3.515

Harrison, K. (Writer, Director & Co-Producer), Freedman, R. (Co-Producer). (2005). //Crossing the Line// [DVD]. Canberra, ACT: Australian Film Commission.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Harmsen, H., Meeuwesen, L., Wieringen,J., Bernsen, R., & Bruijnzeels,M. (2003). When cultures meet in general practice: intercultural differences between GPs and parents of child patients. //Patient Education and Counseling//, //51//(2),99-106, doi: 10.1016/S0738- 3991(02)00195-7. <span style="font-family: 'Arial','sans-serif';">Hruschka, D. J. <span class="citationdate" style="font-family: 'Arial','sans-serif';">(2008) <span style="font-family: 'Arial','sans-serif';">. <span class="citationarticleorsectiontitle" style="font-family: 'Arial','sans-serif';">A glossary of culture in epidemiology. <span class="citationsource" style="font-family: 'Arial','sans-serif';">//Journal of epidemiology and community health// <span style="font-family: 'Arial','sans-serif';">, <span class="citationvolume" style="font-family: 'Arial','sans-serif';">//62// <span class="citationissue" style="font-family: 'Arial','sans-serif';">(11) <span style="font-family: 'Arial','sans-serif';">, <span class="citationspagevalue" style="font-family: 'Arial','sans-serif';">94-98. <span class="slug-doi" style="font-family: 'Arial','sans-serif';">//doi: 10.1136/jech.2008.076729//

<span style="color: #000000; font-family: 'Arial','sans-serif';">Johnstone, M., & Kanitsaki, O. (2007). An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context. //Journal of Transcultural Nursing//, 18(3), 247-256. <span style="font-family: 'Arial','sans-serif';">doi: <span class="slug-doi" style="font-family: 'Arial','sans-serif';">10.1177/1043659607301304 <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Kleinman, A., Eisenberg, L.,& Good, B.(2006). Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. //<span style="font-family: 'Arial','sans-serif';">Annals of Internal Medicine //<span style="font-family: 'Arial','sans-serif';">, //4//(1). 140-145. Retrieved from []

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<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Roberts, C., Moss, B., Wass, V., Sarangi, S., Jones, R. (2005) Misunderstandings: a qualitative study of primary care consultations in multilingual settings and educational implications. //Medical Education.// 39, 465–75. Doi: 10.1111/j.1365-2929.2005.02121.x

<span style="font-family: 'Arial','sans-serif';">Rosenberg, E., Kirmayer, L., Xenocostas, S., Dao, M.M., & Loignon, C. ( <span class="citationdate" style="font-family: 'Arial','sans-serif';">2007) <span style="font-family: 'Arial','sans-serif';">. <span class="citationarticleorsectiontitle" style="font-family: 'Arial','sans-serif';">GPs' strategies <span style="font-family: 'Arial','sans-serif';"> in intercultural clinical encounters. //<span style="font-family: 'Arial','sans-serif';">Family practice // <span class="citationissn" style="font-family: 'Arial','sans-serif';">, <span class="citationvolume" style="font-family: 'Arial','sans-serif';">//24// <span class="citationissue" style="font-family: 'Arial','sans-serif';">(2) <span style="font-family: 'Arial','sans-serif';">, <span class="citationspagevalue" style="font-family: 'Arial','sans-serif';">145-151. <span class="slug-doi-wrapper" style="font-family: 'Arial','sans-serif';">//doi:// <span class="slug-doi" style="font-family: 'Arial','sans-serif';">//10.1093/fampra/cmm004//

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> Schouten, B., & Meeuwesen’s (2006), Cultural differences in medical communication: A review <span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;"> of the literature, //Patient Education and Counseling//, //64//( 3), 21-34, doi: 10.1016/j.pec.2005.11.014.

<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Wachtler, C., Brorsson, A., Troein, M. Meeting and treating cultural difference in primary care: a qualitative interview study. //Family Practice// (2006) 23: p. 111–15

<span style="font-family: 'Arial','sans-serif';">Williamson, M. & Harrison, L. <span class="citationdate" style="font-family: 'Arial','sans-serif';">(2010) <span style="font-family: 'Arial','sans-serif';">. <span class="citationarticleorsectiontitle" style="font-family: 'Arial','sans-serif';">Providing culturally appropriate care: A literature review. <span class="citationsource" style="font-family: 'Arial','sans-serif';">//International journal of nursing studies// <span style="font-family: 'Arial','sans-serif';">, <span class="citationvolume" style="font-family: 'Arial','sans-serif';">//47// <span class="citationissue" style="font-family: 'Arial','sans-serif';">(6) <span style="font-family: 'Arial','sans-serif';">, <span class="citationspagevalue" style="font-family: 'Arial','sans-serif';">761-766. doi: <span style="color: #000066; font-family: 'Arial','sans-serif';">10.1016/j.ijnurstu.2009.12.012 <span style="font-family: 'Arial','sans-serif';">.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">include component="comments" page="When cultures collide in the healthcare setting - The relevance of culture to the effective delivery of health services" limit="10" include component="pageList" hideInternal="true" tag="Commented on by Mickaela Gray" limit="10"

<span style="font-family: 'Arial','sans-serif'; font-size: 20.6667px;"> **<span style="font-family: 'Arial','sans-serif';">"Crossing the Line": my own personal reflection and worldview **

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">The cultural artefact really prompted my thinking about cultural safety and the actual practical applications of the concept. So much theoretical, philosophical and almost promotional literature exists about this topic; however there is a dearth of tangible scientific evidence. Therefore it can be easy to ‘forget’ the reasons why so much energy has been put into developing this framework. This cultural artefact served to remind me that cultural health inequities are very real. I believe this artefact is a very good example of the contention, controversy and difficulty that characterises Australia’s current challenges with adopting a viable cultural appropriate care model. “Crossing the line” is actually is used in many clinical practice courses and theoretical based courses in several New South Wales and Victorian universities as a learning resource because of its recognised relevance to this topic. The aspect of this artefact that I most appreciate is that it brings up the three core issues of culturally appropriate care. Specifically these are the health inequities can exist between different cultural groups in society the negative health outcomes that can result from intercultural doctor-patient relationships and the potential the benefits and application of the concepts of culturally appropriate or safe care. I feel that these topics have been approached in a manner that is able to stimulate and engage the audience to question the current health model status quo.

<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">I found this artefact to have quite a fair bit of personal significance due to my own and my father’s professional experiences. I spent a period of time working in an indigenous community in the located in the Canadian Arctic Circle several years ago and my father has worked extensively through the remote indigenous Northern Territory Tiwi Islands. Through this personal exposure, I found that I could relate to the culture shock and confrontational experiences that Amy and Paul went through. I feel that although some reviews have been critical of the ways in which Amy and Paul approached their internship, I have a different sense of appreciation of the personal challenges that they would have encountered.

**<span style="font-family: 'Arial','sans-serif';"> My Comments on other student's Wiki pages: **

Is generation Y ‘real’ or a creation of the media? Has the media created the ideal body image and what impact is it having on generation Y’s health?
 * My Comments on James Calligeros's article: **

**<span style="font-family: 'Times New Roman','serif';"><span style="font-family: Arial,Helvetica,sans-serif;">My Response: Zyzz- body dismorphia and men, do you think there is a double standard ? **

My first though when I saw your artefact was “wow, is this guy for real?”, and although (thankfully!) the credits identied the video as a ‘spoof’ actor-clip that are so common on the internet these days I cannot help but wonder:

Is this somebody having a laugh at the man-body beautiful image? OR Is this a truthful lifestyle depiction masquerading as a parody?

The reason why I lean towards the latter is that the character“Zyzz” had an obviously chemically enhanced physique. He clearly had the capacity to take some humour in his own body-beautiful image, yet (if the news reports are to believed) he participated in dangerous steriod use that led to his death ([] I actually had to research the news reports as the rumours that I had heard prior to reading your article was that his death was also an internet scam). I was really interested in the historical perspective on body image that was presented in this article, especially the section referring to 77% of girls believing that they were overweight and the evolvement of the GI Joe figurines. The thoughts that I had running through my head as I was reading your interesting article were threefold:

1. It seems like we this expression of male body dismorphia is not taken as seriously than their male or female anorexic or bulimic counterparts- Although the research that I looked at after reading your article suggests that the health impacts have the potential to be just as serious.

2. I wonder if the 120,000+ ‘Zyzz’ fans mentioned in this article would openly confess to being avid fans of a bulimic/anorexic youtube star- Does his percieved attractiveness affect fandom status? If so, what does this say about the broader conception of a body healthy image?

3. After looking further on Youtube it seems that the character of ‘Zyzz’ is still openly celebrated in body-building and so-called ‘aestheics’ circles. As a young woman I often wondered and feared the idea of eventually raising a teenage daughter as I myself have experienced the perils ofmedia and the bombardment dangerously unhealthy body depictions. After reading your article, and seeing your cultural artefact firsthand I am scared now scared for future generations of girls AND boys….

P.S. Great choice of artefact, really thought provoking and I liked your summary of data from a variety of sources- it showed good rese arch.

Cultural Wealth is healthy
 * My Comments on Louise Elvin-Walsh's article: **


 * My response: Cultural Wealth, an interesting read **

I was really interested to reading your summary of Dockery’s (2010) ‘caring for country’ idea, how providing decision making in land decisions can actually positively affect health outcomes. This had never really occurred to me yet it makes sense in terms of community and societal empowerment and I like the way that it was clearly expressed within your article. I selected you article for discussion for two reasons, Firstly I liked the symbolic meaning behind your image especially as you talk about your own journey in realizing the plight of Australian indigenous people. Secondly, I appreciated the different slant or aspect that you took to cultural aspects in health. My topic was of a similar theme and I am interested in seeing how two people can interpret the topic very differently. The use of first person patient statements helped in the persuasiveness of your topic and the visual aids helped to demonstrate and outline your points. I think by reading through your article I have learnt how I can take different perspectives on a topic; I have enjoyed critically appraising yours and my own work. The questions that your article has really brought to mind are:
 * 1) Do you think self determination is possible in the Australian context? Research on the current situation in the Nunavut states in Northern Canada is experimenting with self- healthcare governance without as much success as they would hope. I think this is really going to be the place to watch as to whether this is a successful model.
 * 2) I love trying to understand the conceptual frameworks of what is considered culturally ‘safe’, ‘competent’ or ‘aware’. Researchers adore talking about this topic. I would be interested to hear if you found many succinct measures of these terms. Descriptions are in abundance, which is why my article was trying to look at the evaluation of framework methods.

So your article definitely provoked my thinking! Congratulations on a clear and concise article. I think yours is a important topic that will remain very much a public focus for years to come (and your article has definitely outlined the reasons why this is so- nice work)