Barriers to providing good health care for adolescents parallel those facing minority groups such as the Maori. Indigenous peoples often feel disenfranchised and dominated by a “foreign” culture. They feel pressure to assimilate into the majority culture, yet the dominant culture shows little respect for or comprehension of their lifestyle. Adolescents experience similar stresses, which manifest as health problems that are classically displayed among oppressed groups: mental health problems, lifestyle disorders (such as obesity), and self harm.
In the late 1980s Maori nurses conceived the idea of “cultural safety” to improve nurses' delivery of health care. The study of its principles is now part of the registration requirement for nurses and midwives. Cultural safety requires healthcare providers to reflect on their own cultural background and the nature of power relations in the provision of services to a minority culture by a dominant culture, so that the providers can work in a culturally “safe” manner. Nurses must acknowledge the beliefs and practices of people who differ from them in age, occupation or social class, ethnic background, sex, sexuality, religious belief, and disability. Providers do not need to research and understand other groups' beliefs and cultural practices; rather, they acknowledge their own culture as different from those of the people they serve, to ensure that they do not impose their beliefs on the minority communities. Cultural safety requires providers from the majority culture to challenge their own stereotyped views of a minority culture. It promotes positive recognition of diversity.
Cultural safety promotes positive recognition of diversity
A feature of health services for Maori people before the advent of cultural safety was how Maori culture could be “protected”—an attitude that reinforced the dominance and paternalism of the majority culture. This issue applies equally to adolescents. Problems in service provision for both these minority cultures result from the majority culture's guilt and frustration about its failure to engage and help the minority effectively.
Lifestyles of minority cultures must be acknowledged and respected if appropriate services are to be offered and used. To the Maori, health, or hauora, has four cornerstones: the physical (taha tinana), the mental (taha hinengaro), the spiritual (taha wairua), and the extended family (taha whanau). Adolescents' beliefs concerning health are generally broader than those of adults and emphasise “wellness” rather than illness. Adolescents define health through family, peers, education, employment, and leisure (including consumption of material and media products).
How can the concept of cultural safety improve relations between adolescents and healthcare providers from the majority adult culture? A major step would be recognition of adolescents' distinct lifestyles and beliefs. As adolescents develop and become part of the dominant adult culture they leave behind much of their former exploration of identity, but it would be wrong to see them as a precursor of the dominant culture. Cultural safety requires professionals to accept that they might not understand adolescents' lifestyles, which change from one generation to the next and are not homogeneous even across one age group. Reflecting on one's own youth—or one's own adolescent children—is inappropriate.
Cultural safety provides a framework within which the minority culture can devise and deliver its own health services. Such a concept is used in pioneering centres in California funded by the California Wellness Foundation. Adolescent health workers are involved in counselling, treatment, and outreach. Adolescents were recruited who reflected the general community, and a teen advisory committee guides their work. Adolescent staff members undergo training as medical assistants, gaining a basic health worker qualification. Early evaluation of the sites showed an increased enrolment of adolescents, including elusive male teens.
Cultural safety demands that minority groups face no additional barriers when using mainstream health services. Some adolescents worry about being seen in the surgery by adult friends of their parents, who might reveal their visit, so the teen health clinics in California do not allow adults in the waiting room at the same time as the adolescents. Many adolescents have come to rely on text messaging and email to communicate with friends, retailers, and service providers. Adolescents should be able to interact with and gain access to our health systems through these means.
The Treaty of Waitangi guarantees Maori people “protection, partnership and participation.” Adolescents have no equivalent treaty. We hope that the children's national service framework will acknowledge that the needs of adolescents differ greatly from those of younger children and will give adolescents opportunities to be partners in developing their own health services.