Perspectives on Healthcare
From Amsterdam Wiki
Abstract
Recent studies have shown that migrant Muslim populations in Amsterdam have poorer health outcomes than the ethnic Dutch than can be explained by socioeconomic status alone. Contacts with ethnic minority patients are sometimes difficult for the provider and the patient due to language barriers and cultural differences, leading to lack of trust, non-compliance, and poorer health care received. Our study examined these barriers and the differences in beliefs about the barriers between the patients and their providers with the intent of highlighting the issues that could most easily improve the health care experience for both parties. A qualitative approach was taken: surveys of Muslim ethnic minority women and health care providers, interviews, site visits, and library research. The surveys of the women (n=4) showed that male doctors and language issues are their biggest barriers to care. The surveys of the doctors (n=5) indicated that language and the women's spouses were the greatest barriers. The interviews (n=3) gave a broader scope of the issues surrounding Muslims in Amsterdam and showed how culturally appropriate care could improve the care received. Overall, the main reported barriers to care were language and cultural differences and not enough time in appointments for explanation. Analysis showed that the barriers listed by the women and the providers were the same, but they were described differently, further demonstrating the cultural and communication differences. The cultural competence approach, which includes cultural background education for the providers, culturally appropriate and sensitive care methods, and adequate interpretation services, has shown promise in addressing these issues. A dialogue between the women and their doctors can illuminate the main issues and bring them together in a consensus. In particular, the implementation of migrant health specialists with interpretative communication ability would probably be the most efficient solution.
Although the Netherlands is known worldwide for its liberal social policies and tolerant attitudes, it still deals with the reality of a changing and diverse population (see right), one that brings new and challenging problems. From the 1960's through the early 1980's, globalization brought in migrant workers from Morocco and Turkey and decolonization brought in repatriates from the former Dutch colonies Indonesia and Suriname. Each of these countries have significant, if not majority, Muslim populations. They settled in urban areas, mainly Amsterdam, Rotterdam, the Hague and Utrecht. It was assumed in the Netherlands that these people were temporary guest workers, and that within a few years, they would be heading home. But it became apparent that many of these migrants were here to stay, as they began buying homes instead of renting, and their families came to live with them. Each of these and other ethnic groups have their own cultural beliefs and practices, which can lead to conflict both between them and the native Dutch population. These migrants became known as Allochtonen, a Dutch word that refers to immigrants and their children. It carries the sense of "outsider." One is considered an allochtoon if one or both parents were not born in the Netherlands. Ideological differences, like what happens between Islam and secular Western thought, can bring about the most stark conflicts and marginalizations. A group's position within a society can be measured in many ways, including education, income, and health outcomes. One can best study these effects when looking at the most marginalized within an already marginalized group of people. For this reason, we chose to study the Muslim female allochtonen population and their experiences with the conflicts that occur in the health care setting.
Contacts with ethic minority patients are sometimes difficult for the provider and patient due to several issues: not understandable or recognizable reasons for the encounter, lack of patient's compliance from the physician's point of view, impossibility of discussing psycho-social matters, and a high frequency of encounters. Language is not the only barrier - cultural background appears to play a greater role in complicating the encounters (Harmsen 10). The differences in ethnic and cultural background can lead to a lack of trust and mutual disrespect. Physicians consider their 'culturally different' patients as "problematic," while ethnic minority patients experience their relationship with their physician as "difficult" (Harmsen 10).
The root of these problems can be boiled down to a key issue: communication problems. Communication between patient and provider is affected by both language and culture. Kleinman's theory says that patient and physician have different views on health and illness and this is someone's 'clinical reality' (Harmsen 11). The differences in 'clinical reality' are more pronounced when the patient and the doctor come from different ethnic (including geographic and racial) and cultural backgrounds. In consultations with patients of a non-Western ethnic or cultural background, there is less mutual understanding between physician and patient than there is in consultations with patients of a Western background. These patients perceive less quality of care and are more dissatisfied and are less likely to comply with their physician's requests (Harmsen 134). Communication between patient and physician is "crucial."
Communication can be improved by and exchange of explanatory models between patient and physician. Agreement about the opinions or treatment is not necessarily required to achieve an improvement; rather, an increase in knowledge about cultural differences and mutual opinions between the patient and the provider can improve the quality of care (Harmsen 135). In Amsterdam in the year 2004, migrant health educators were placed in 22 practices serving over 55,000 patients. The migrant health educators served as intermediates between the patients and providers. This in turn proved to lower the burden of language and cultural barriers for general practitioners. These migrant health educators "improved the quality of health care for both patients and providers" (Johnston 2004). To prove that special care is needed to achieve appropriate health care for these allochtonen women one can look at the fertility and child maternal mortality rates. Immigrant women have higher fertility and child/maternal mortality than native Dutch (Nordbeckk 1985, nigz.nl)." These are indicators of lower health outcomes and health disparities, which indicate that health care for these non-native Dutch, or is affected by various barriers that are otherwise not apparent for native Dutch women.
Research Question:
What are the greatest barriers to health care for female Muslim allochtonen? What are the differences in beliefs about those barriers between patients and providers?
Conceptual Framework:
In order to ground our research in theory, we took two frameworks - cultural diversity and cultural competency - that would allow us to acknowledge both the cultural backgrounds of the women and the doctors and also provide a backbone for possible solutions and interventions.The first, cultural diversity, gives credibility to the experiences and opinions of the women and their doctors.
Culture is beliefs, values and traditions which form together in a person's mind the basis for shared social action and which are transmitted and reinforced within a group. People share distinctive social and recreational pursuits, language and customs, manners, sense of place and group identity (Vermeer 11).
In order to have a successful interaction, patients and providers need to understand each other. This understanding does not mandate agreement with the other's beliefs and practices, but it does require mutual knowledge and respect of each other. It is important that when working with ethnic, religious, or cultural minorities to not expect total assimilation.
Everyone experiences the need to belong: the need to feel that one's identity is rooted in a history, a place, a social group, and a culture. In an increasingly culturally diverse world, achieving and maintaining the sense of security which comes from a sound sense of belonging is difficult (Vermeer 8).
A good approach for doing providing a way for patients and providers to interact without losing their personal identities is by using cultural competence. Cultural competence is a process by which someone becomes more able to interact with others of different cultures. There are four components:
- An awareness of one's own culture and beliefs
- A positive attitude towards cultural differences
- Knowledge of different cultures, their practices, and their world views
- Cross-cultural skills
(Martin and Vaughn 2007)
Cultural competence in practice in the medical setting includes cultural background education and sensitivity training for providers, culturally appropriate care methods, and adequate language interpretation services. It has been shown to be useful in reducing the conflicts that arise because of the cultural and language differences.
Case Study: Miscommunication and Mistrust
Harun Yildirim, a young Muslim student activist we interviewed, has had a personal experience with cultural conflict. Last May, his mother, Güllü Yildirim, who had suffered from back pain for a long time, suddenly found it increasing to levels that really impeded her daily life. As is the practice in the Netherlands, she first saw her general practitioner, a woman, first. She was diagnosed with a hernia. She asked to see a specialist, but the doctor shrugged her off, saying that it didn't seem that serious. Several days later, Mrs. Yildirim was in such pain that she couldn't even leave her room on the upper floor of their building. After Harun realized that his mother needed immediate medical assistance, he called the general practitioner and ask her to come right away. Patients in the Netherlands need a form from their doctor before they can go to the hospital. The doctor was out doing house calls and informed Harun that she would not be able to assist his mother until late afternoon, more than four hours later. Harun explained that this would not be acceptable, and that his mother was in serious pain and needed to be seen immediately. After much persistence on Harun's part, the doctor agreed and told Harun she would be there in 15 minutes. When she finally arrived, she realized that Harun's mother needed to go to the hospital immediately. But to everyone's dismay, they realized that a gurney would not fit up the stairwell. They had to call the Fire Department, who had to remove the 3rd story window so that Mrs. Yildirim could be lifted out. She went to the hospital and had her hernia repaired surgically. After her release, the family did not trust that she had been treated completely. They sent her to one of the better hospitals in Turkey. The doctors there found and repaired a second hernia. When the family returned to the Netherlands, they confronted the doctors there with the second hernia. The Dutch doctors first responded that they had given the family this information. When the family denied that this was true, the doctors then said that it wouldn't have mattered if they had said it. The family was "really disturbed" by these events and attitudes. Harun commented that it was incidents like these that decreased the trust that the immigrant populations had in the Dutch health care system.
This personal anecdote illustrates many of problems that arise between native Dutch physicians and their allochtonen female patients. The first problem that came up was that Harun's mother did not receive an adequate diagnosis, because of the miscommunication between her and her doctor. Even with some Dutch, she was unable to fully convey the pain and other symptoms that she was experiencing, which led to her being sent home without the proper care. Ultimately, this brought about the medical emergency that occurred. If Harun had not called the doctor for his mother and pressured for her earlier arrival, Harun's mother would have waited until after 3'o'clock, several hours later, which could have had disastrous consequences for her health.
Research Methods:
There were two target populations for our research: Muslim women and their health care providers. Each group required a different set of questions because of their differing positions among each other and in society, one is a provider and one is a civilian. The data we tried to acquire addressed our research question: how do Muslim women perceive the barriers to their health care vs. how their providers perceive barriers to health care given to the Muslim women.
For Muslim women, our approach was to pass out a survey about their health care experiences. They could respond either in English or a Dutch version that we had specially translated. We made connections with these women through Harun Yildirim, a 22 year old Turkish Muslim who is the secretary of a Muslim student organization in the Netherlands. We also attempted to make connections through different immigrant organizations such as Zami, Mama Cash and Centrum Mimoza. After contacting these organizations numerous times, we found that their ability to help was limited due to most of their members being on vacation in August. We also contacted a nurse, Lilith Turk, who runs an alternative medicine and yoga clinic. She teaches immigrant women how to give birth at home and also does differing forms of therapy from physical to mental, specifically for pregnant women.
For the health care professionals, we took a more direct approach. We also passed out surveys to the physicians but instead of going through community members who knew doctors we traveled around the city to various locations asking physicians directly to fill out our surveys. We found that by going to the differing medical institutions we were able to get a better result among people who participated. Most physicians found the survey method acceptable instead of interviewing. The survey method was much easier than interviews because of how busy they were with patients. These surveys asked questions about their experiences with their Muslim women patients and the differing issues that they need to deal with on a regular basis because of cultural and language barriers. These questions were fairly general and did not make the doctors uncomfortable.
We did conduct three different interviews from three very different sources. One source was Harun Yildirim, mentioned above. We asked him questions regarding his experience living in the Turkish Muslim community, his insight helped us better understand the dual worlds between his community and the native-Dutch. We also talked to Lilith Turk who teaches homebirth almost exclusively to immigrant mothers. She gave us a professional provider's viewpoint. Our third interview was with Mirjam Schieveld, a native Dutch citizen and academic. She gave us insight to the Dutch culture and helped us edit our research project. All three of these subjects were important to further our understanding of how the health care system works, Dutch society, and immigrant life.
Finally we did library research, where we used online articles, print journal articles, research books, non-fiction biography, online data bases and librarians. We spent about three hours in the epidemiology library in the main Public Health building of Amsterdam and two in the IIAV (International Information Center and Archives for the Women's Movement) library where we collected other research projects information that would further explain our own project and answer questions that we were not able to receive through our survey and interviews.
Ethical Issues:
We realize the sensitivity and privacy issues of asking questions about health care. To help mediate this, we implemented several strategies to protect privacy and prevent exploitation. We tried to gather our “patient� pool from the general Muslim female population at random. Any woman who received health care in the Netherlands was eligible to answer our survey. All data collected was not tied to a name and no photos of the subjects were taken. When surveying health care professionals, we asked to see if recording name was acceptable, if it wasn’t, then they were allowed to omit that and anything else they did not want to answer for various reasons.
Biases and Assumptions:
Some major biases that we had before coming to Amsterdam had to do with the global perceptions and media presentations of the Muslim community in general. Some of our assumptions about Islam in the Netherlands were politicized based on sensationalized media accounts of the conflicts in America, the Van Gogh killing, Hirsi Ali's Submission, FITNA and the Iraq war. Prior to our personal experiences with this community, we had some knowledge that the information we had received via the media was one-sided and tried to come into the project with an open mind. We had though that Muslim women were culturally prohibited from using birth control, sex education, and abortion when in fact this is not the case. We also have been aware of our generalizing of Muslim female allochtonen as on singular group. Different ethnic backgrounds, such as Turkish vs. Moroccan, create different cultures and although the women may share similar religious beliefs, they cannot be put into the exact same category. Because of its liberal drug and prostitution policies and it's reputation for being socially progressive, we did not think that the Netherlands had the same sort of segregation and racist/religious issues that America has. Through our cultural studies we have discovered that this is not true. The Netherlands seems to have many difficulties dealing with its immigrant groups when it comes to assimilation into the native Dutch society. This segregation is shown through many forms for example, education level, socio-economic levels, infant mortality and religious segregation. This problem is far larger than most native Dutch seem to admit. We dealt with these assumptions by studying our subjects, learning from their personal experiences, and reading about Islam and the differing cultures.
Process/ Reflection:
Throughout this project we have learned a great deal about the process of creating a good research project and how oftentimes one's initial goal was ends up being distant from the ultimate ending. Starting out on this journey, we both had a strong idea on what area of interest we wanted to study. We both have a background in issues surrounding health care and cultural knowledge, and therefore choosing Muslim women and their perceptions of health care in comparison to those of their general practitioners was not a hard choice to make. What we didn’t realize at the time of creating this idea in our cozy University of Washington classroom, is that health care studies are quite difficult, and reaching Muslim women would be even more difficult than talking to doctors because their community was so separate from the mainstream Amsterdam/Dutch society. These issues aside, we also had a strict time constraint which in itself created problems not only for us but for the people we were asking to participate during their vacation month. With these realizations, the slow meticulous process with large numbers of survey responses we originally thought would take place ended up not being realistic, and we received much smaller numbers. Even with these constraints, we still learned a great deal not only about Dutch society in general, the Muslim population, and the health care system, but we learned that being able to adjust and to be flexible to change was in itself part of creating a research project. (For documentation of our process at UW, see our first preliminary project presentation, original project proposal and "final" presentation.)
When we arrived in Amsterdam the most important part of our project was to get acquainted with Dutch society. We needed to feel out cultural norms so that when we went on interviews we would receive favorable responses because of our appropriate behavior. At this point in time we also both realized that asking people who don’t speak native English, to participate in an “outsiders� study was going to be very uncomfortable for both of us, especially on such a private issues such as health care, and dealing with the issue of inequality which many native- Dutch don’t want to admit is present in Dutch society. The best approach we discovered was to feel out the situation by actually going to different locations including hospitals, general practitioners offices, therapist’s offices, mosques and differing immigrant women’s organizations. (Example of notes taken at the location here.) In each location we received differing responses. Some people were willing to help us and others were not. We realized that many of the people who didn’t help us may not have understood our intentions because of language barrier. Many who did help us, only did after we told them we were students studying at the University of Amsterdam for the summer. As time went on it never seemed to become any easier to ask people for help because each person's response and each institution's abilities were completely different. Even though we did not receive many responses from either side we did receive some which opened our eyes to the reality of the health care problems the Muslim female allochtonen face along with the challenges their doctors have when trying to treat them. This experience in itself allowed to us to realize how long it takes to receive large numbers of surveys from people. It also showed us that persistence and willingness to step outside of one’s comfort zone is the only way finding subjects gets done; in any case, they definitely did not fall into our laps. We continually had to call them, email them and basically nag them to fill out our forms. Many who said they would help, ended up not filling out the forms.
Another important part of our process occurred three times. This happened when two important people were willing to sit down with us, in interview form and help us not only with concepts surrounding our paper but also with actually data. These two people were Mirjam Schieveld and Harun Yildirim. Schieveld is a program director at the University of Amsterdam. She helped to open our eyes to her idea of Dutch culture. She also went though our project and helped revise it for any cultural differences in wording of which we were unaware. She also gave us ideas of places to find hard data. We ended up spending three hours in the epidemiology library, and two more in the IIAV library (women’s history). Yildirim who is a Turkish Muslim, took us to his headquarters where he is the president of the largest young Muslim society in the Netherlands. He spent about three hours with us explaining the cultural issues that he along with other Muslims face living in the Netherlands. (Find our interview notes here.) He also gave personal anecdotes about his family that opened our eyes to real situations where doctors and patients did not mesh because of cultural differences and language barriers. Yildirim was also a great contact because he new many Muslim women who filled out our forms. Yildirim also kindly said he would translate our surveys into Dutch so his community would be willing and more able to fill it out. Through both of these contacts we were able to further our research in quick strides. We learned that one person can and does often make the difference when it comes to the success of a research project.
After our initial research experience out in the field we found that it was necessary to see what other researches had done in the health and immigrant area. At the epidemiology library mentioned above, we were able to find many sources that helped in the completion and success of our research question and framework. Through this closed reading we were able to learn from other researchers who not only had more time but had varying ideas concerning the issue of immigrant women and health care. These differing opinions helped us to shape our own opinions because we learned that our data collection alone would not be sufficient in trying to answer our research question.
The process of creating and doing our research project has been hard but rewarding. We both have learned a great deal about how much time and effort it takes to complete a research project. We learned that time often means the difference between being able to collect a sufficient amount of data or not being able too. We also gained respect for the many researchers out there completing research projects that take years. As researchers ourselves, we discovered how to step outside of our comfort zones, how to get answers and how to open our eyes to reality which can ultimately change our biases towards people cultures in general. We both feel that the education we recieved was not just from the project findings but from the research process itself. (Here's our final presentation of findings.)
'Analysis/Discussion:'
The purpose of our research was to illuminate the barriers to health care that affect the female Muslim allochtonen. We also wanted to show the many faces of the issue: patient and provider, male and female, native Dutch and allochtonen. We have seen how the issues are the same, yet the perspectives are different (see right). The barriers that proved to be the most important were language and cultural differences. By looking at these two barriers one can explain why allochtonen women are not receiving the best health care possible. For example, women from our surveys would not even go to the doctor for serious illnesses unless they were assured a female doctor would be taking care of them. (Sample Response) Doctors on the other hand were understaffed and could not always insure that a female doctor would be available. In our interview with Harun Yildirim, he discussed with us the problem with child birth and male doctors. He explained that if a male doctor was the only doctor present when a Muslim man’s wife was giving birth then the husband would simply tell his wife that "the child cannot come.� Just as women saw male doctors as a significant issue from keeping them from appropriate care, doctors see spouses as the number one problem not allowing women to receive appropriate care. The second biggest barrier was language. Most women in our surveys felt that their doctors talked too quickly, got frustrated when they, the women, could not understand, and did not make sure that they understood what was wrong with them and what they needed to do to fix it. In the doctors’ surveys, (Sample Response) they also felt that language affected the care they could give to their patients. But they also discussed family members and translators being a big help. Many of the women in our surveys did not even know a translator was an option. With lack of communication and understanding, doctors and patients become frustrated, which leads to lack of trust and poor health outcomes.
In Amsterdam's ever-increasing diversity, it is crucial for doctors and patients to work together to understand each other. This is why we think through our literature reviews, surveys and interviews that a cultural competency approach would be helpful in reducing these barriers. Both cultural competency training for doctors and specialized cultural competency workers have been shown to reduce the distance between patient and provider, improving the health care experience for everyone. In our interview with Lilith Turk, we saw firsthand how cultural competence can really help the doctor and the patient. Ms. Turk was trained in cultural competency and helped immigrant women learn how to give birth at home without a doctor if only a male doctor was available at the time of birth. She also helped connect women with midwives which would provide care closer to what they might have received in their native countries. She explained that she tries to give appropriate care in all situations, taking the time to understand the problems the Muslim women are faced with, and being sensitive to their religion and culture. This in turn has created a balanced and healthy relationship between patient and provider.
This transparency can be achieved in all health care facilities by opening up a dialogue between the women and the health care professionals. Successful programs incorporate the opinions of the people they are trying to reach. In developing programs to improve the health of migrant women, the women themselves need to have a say about what issues are most important to them. This way the interventions can be targeted and efficient, really addressing the issues that matter.
Conclusion:
In one doctors survey, we asked the question, " Do you believe that you can provide all cultures and the differing immigrant populations with appropriate health care?" The doctor answered "No." Cultural competency training could provide the doctors in Amsterdam with the tools to increase health care and improve health outcomes of certain allochtonen populations that are otherwise being neglected. With cultural competency training, there would be a deeper understanding of cultural issues between doctor and patient. Doctors would better understand patient issues and patients would be more trusting and recieve better health care. We realize that there are deeper issues that affect the cultural distance between the women and the doctors that can't be solved by cultural competency training, including the increasing isolation of the neighborhoods in Amsterdam, and the increasing segregation of the schooling system. Starting at a young age, isolation and segregation have created these differing cultural barriers, and many barriers would be non-existent if schools and neighborhoods were better integrated. With many of our surveys, we saw that some of the younger generation with higher levels of education have been able to reduce the cultural gaps and have therefore had fewer problems with communication and culture in the health care setting. They seem much more integrated into the overall Dutch community than the older generations who go to, for example, Turkish barbers, Turkish grocery stores and restaurants, and only have Turkish friends. The Netherlands policy makers and the allochtonen need to take responsibility for integrating and making sure that the younger generations are able to continue being able to receive proper health care, education, and employment opportunities.
Further Questions/Research:
How would the following affect health outcomes?
Policy changes for desegragation of schools
Closing the gap on language and cultural barriers
Increasing training in cultural competency for doctors
Having an open forum where both women and doctors could speak about the issues that affect health care.
If we were to continue our research we would need more data. We would like to interview cultural competency educators from Amsterdam and from other parts of the world and look deeper into spousal issues. We would also like to interview more women from different ethnic backgrounds, and examine whether the main issues are cultural, religious, or based on language. With more data, we would be able to make stronger recommendations about what could improve the health care received by allochtonen here in Amsterdam.
Bibliography
- “Central Bureau of Statistics: Netherlands.�( 2008). http://www.cbs.nl/nl-NL/default.htm
- Doornbos, J.P, Nordbeck, H.J. Perinatal mortality: Obstetric risk factors in a community or mixed ethnic origin in Amsterdam. ICG Printing: B.V. Dordrecht, 1985.
- Harmsen, J.A.M. When Cultures Meet in Medical Practice. Erasmas Universiteit, 2003.
- Kocken, P.L. Health promotion in migrants and older generations. Universiteit Maastrich, 2000.
- “Mama Cash� (2008). http://www.mamacash.org/page.php?id=1
- Reijneveld, Sijmen, P. Caulford, Y. Vali, Andrade J. “Ethnicity & Health�. Studies in Migrant Health in Europe. 23-25 ( 2004): Volume 9 Supplement 1.
- Stronks K, Ravelli CJ, Reijneveld S A. “ Immigrants in the Netherlands: Equal access for equal needs?� Department of Social Medicine. (2001): 701-707
- Uitenbroek, Dann. “ Voorlichting Eigen Taal en Cultuur (VEFC) in de huisartsenpraktijk�. Jaarrapportage Volksgezondheid Amsterdam. GG&GD (2001): 45-46
- Uitenbroek Dann, Verhoeff, Arnoud. “ Life expectancy and mortality differences between migrant groups living in Amsterdam, the Netherlands�. Studies in Social Science& Medicine. 54 (2002): 1379-1388
- Van de Ven, Wynand, Schut, Frederik. “ Universal Mandatory Health Insurance in The Netherlands: A model For The United States?� Health Affairs. 27.3 (2008): 771-781
More Resources
- http://www.amsa.org/programs/gpit/cultural.cfm Lila Lee link
- http://www.4woman.gov/healthpro/cultural/: womens health.gov cultural competency for women.
- http://sis.nlm.nih.gov/outreach/multicultural.html Further resources US national library on cultural competence medicine.
Books to read for further research ISLAM general/ Islam women’s health:
- Infidel Ayaan Hirsi Ali: http://www.amazon.com/Infidel-Ayaan-Hirsi-Ali/dp/0743289692/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1219339812&sr=8-1
- Women and Gender in Islam: Historical Roots of a Modern Debate by Leila Ahmed (Paperback - Jul 28, 1993 http://www.amazon.com/Women-Gender-Islam-Historical-Modern/dp/0300055838/ref=sr_1_2?ie=UTF8&s=books&qid=1219339389&sr=8-2
- Women in Islam and the Middle East: A Reader (Paperback) by Ruth Roded (Author) http://www.amazon.com/Women-Islam-Middle-East-Reader/dp/1845113853/ref=sr_1_4?ie=UTF8&s=books&qid=1219339389&sr=8-4
- When Islam and Democracy Meet: Muslims in Europe and in the United States by Jocelyne Cesari (Paperback - Jan 19, 2006) http://www.amazon.com/When-Islam-Democracy-Meet-Muslims/dp/1403971463/ref=sr_1_7?ie=UTF8&s=books&qid=1219339615&sr=8-7
- When Ways of Life Collide: Multiculturalism and Its Discontents in the Netherlands by Paul M. Sniderman (Author), Louk Hagendoorn (Author) "THIS IS A BOOK about a vulnerability of liberal democracy..." http://www.amazon.com/When-Ways-Life-Collide-Multiculturalism/dp/0691129061/ref=sr_1_13?ie=UTF8&s=books&qid=1219339615&sr=8-13
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Cultural competency books:
- Cross-Cultural Medicine (Paperback)by Judyann Bigby: http://www.amazon.com/Cross-Cultural-Medicine-Judyann-Bigby/dp/193051302X/ref=sr_1_3?ie=UTF8&s=books&qid=1219339916&sr=1-3
- Cultural Competence in Health Care: A Practical Guide (Paperback) by Anne Rundle (Editor), Maria Carvalho (Editor), Mary Robinson (Editor): http://www.amazon.com/Cultural-Competence-Health-Care-Practical/dp/078796221X/ref=sr_1_4?ie=UTF8&s=books&qid=1219339916&sr=1-4
- Cultural Competency in Health, Social & Human Services: Directions for the 21st Century (Garland Reference Library of Social Science) (Hardcover) by Pedro J. Lecca : http://www.amazon.com/Cultural-Competency-Health-Social-Services/dp/0815322054/ref=sr_1_5?ie=UTF8&s=books&qid=1219339916&sr=1-5
