Shifting Paradigms: Taking a whole campus approach to move from cultural competency toward cultural safety in supporting international student mental health and wellbeing

INTRODUCTION 

It is well documented that the overall mental health and wellbeing of international students ​​is well below that of their domestic counterparts1. While many campuses across Ontario are taking this issue seriously and being proactive in their approaches, this work is vast, diverse, and complex. Compared to domestic students,​ international students​ have reported higher levels of suicide ideation, academic stress, and feeling less connected within their post-secondary community1, 2. Additionally, compared to domestic students,​ international students​ are less likely to report symptoms of mental health concerns, have lower mental health literacy, and have low help-seeking behaviours3. These trends tend to occur due to stigma, fear of judgement, difficulty with acculturation, communication barriers, and social disconnection. These challenges can particularly be prominent during the first ​half of a post-secondary degree​ as they are navigating their sense of belonging4. Additionally, post-secondary institutions do not always adequately recognize that the institutional environment was built for domestic students and therefore may be harder to navigate for newcomers. 

Campuses are already grappling with ensuring ​international students​ have adequate supports to adjust to life in Canada such as having safe, secure, and affordable housing; having access to culturally appropriate and nutritious food; and creating spaces for community building and connection. It is also crucial for schools to consider the cultural safety of their campuses (including, but not limited to, student support services) and how this might be impacting the mental health and wellbeing of international students. 

Embedding culturally inclusive services has been a common recommendation to address the various mental health and service accessibility challenges faced by ​international students​5. Culturally safe practices may retain students who sought help initially, improve therapeutic alliances, and encourage continuous support seeking5. This approach is especially important to international student populations who are racialized due to the rampant xenophobic and racist rhetoric they face in Canadian society and on their campuses. 

In this article, we will argue that embedding cultural safety in post-secondary institutions is crucial to improving the mental health and wellbeing of ​international students​. We will first discuss the context in which the theory of cultural safety arose and what preceded it. Next, we will discuss how this approach can be embedded at both the individual and systemic level on campus. We will end with a discussion of this approach’s limitations and highlighting some work in this area and its impacts. 

Ever Evolving: Awareness, Humility, Competence, and Safety 

The term “cultural safety’ was first proposed by Dr. Irihapeti Ramsden and Māori nurses in New Zealand ​in ​the 1990s. At the outset, the goal of bringing awareness to this issue was to improve the health outcomes of historically and presently marginalized populations; essentially, to reduce the effects of the social determinants of health. As a result, the concept of cultural safety is mainly tied to health & wellness settings, specifically for health and helping professions6.   

To understand cultural safety in its full context, we must look to the past to see the “cultural” concepts that both preceded and influenced it. Below is a brief explanation of a few key terms. Please note, the definitions for these terms are wide and vary across discipline, location, and author. For the purposes of this article, we will use the following definitions6: 

• Cultural Awareness: there are more cultures other than my own  

• Cultural Humility: my culture is not the most valuable/ true nor more valuable/ true than other cultures  

• Cultural Competency: if I know enough about another’s culture and its practices, I won’t ​cause​ harm, or I will cause less harm  

• Cultural Safety: I must always consider the power dynamics and systemic factors (e.g. colonialism) inherent in cross-cultural interactions if I intend to not cause harm or cause less harm 

 Below is a quotation from the International Journal for Equity in Health that further describes cultural safety for the context of our article: 

Cultural safety…rejects the notion that health providers should focus on learning cultural customs of different ethnic groups. Instead, cultural safety seeks to achieve better care through being aware of difference, decolonizing, considering power relationships, implementing reflective practice, and by allowing the patient to determine whether a clinical encounter is safe6.  

​Core Tenets 

 Further, the core tenets of cultural safety can be summarized as6: 

• A focus on critical self-reflection and awareness of social location 

• Relationship building between client and practitioner 

• Using a social justice lens to consider power imbalances 

• The client or service user is the one that determines if the care was culturally safe 

• This is an active and ongoing process 

SHIFTING PARADIGMS 

A Whole Campus Approach 

A key question of embedding cultural safety on campuses is the “where”. Where do these practices, procedures, and values go? To improve mental health outcomes and overall international student wellbeing, a whole​–​campus approach is recommended. In a whole-campus approach, all members of the campus community are involved in supporting student mental health. Ideally, practices that promote mental health are woven into all aspects of campus, from policies and programs/services to the learning environment (i.e the classroom). A whole-campus approach also involves breaking down silos between departments/campus areas and ensuring that everyone has the appropriate information and resources they need to support student mental health based on their role on campus. While this task can be daunting and is perpetually ongoing, it is hugely crucial to the betterment of overall student mental health and wellbeing. 

Taking Action: Individual Level 

To move towards a whole campus approach, each of us can start individually to examine how we can play a part in cultivating cultural safety. As mentioned above, one of the key actions is engaging in ongoing critical self-reflection. Critical self-reflection is when we “…question [our] own biases, attitudes, assumptions, stereotypes and prejudices…”6. And further, work to eliminate them from our day-to-day interactions, work, and practice. It is hard to look inward and acknowledge these pieces of ourselves, but it is integral to this work and our success in delivering equitable and effective supports to ​international students​​.​ 

Critical self-reflection is important because our individual actions can support and maintain the status quo of our institutions, which are based in colonialism. By engaging in critical self-reflection, we can identify ways in which we may be upholding ​harmful​ norms and begin to work on reformulating our practices so that they can instead help dismantle barriers to mental health on campus. 

Within one-on-one services, culturally safe practices can be encouraged through training and continuous learning both about diverse cultures and how to investigate our own complicity in doing harm and upholding harmful systems. According to Hechanova and Waedle, assessing how one navigates or understands emotional expression; shame related to mental health concerns; power between the service provider and service user; collectivism; and spirituality may be a good place to begin7.   

Taking Action: Systems Level 

Taking action on a systemic level looks like embedding and requiring robust and nuanced training on cultural safety, anti-oppressive practice, and anti-racism, to name a few. Delivering these trainings to all staff and faculty, regardless of department or role, does a lot to create an environment in which equity and power imbalances are top of mind. 

A common pitfall in large-scale training is that the curriculum remains static over time. It is important that the content and delivery of this education remain dynamic and are reassessed and improved regularly​​. As we’ve seen earlier in this article, discourses around culturally appropriate care have changed enormously in the last 20 years and they will continue to shift as we open our eyes to the ongoing harms of colonialism, racism, xenophobia, and other forms of discrimination. 

Further, it may be important for institutions to intentionally collect information to gain a better understanding of what factors impact help-seeking among ​international students​. For example, post-secondary institutions could look at how ​international ​students’ level of trust in mental health practitioners ​may​ be impacted by experiences of ​​​​oppression and colonization8 as historically, medical practices and research have violated and oppressed people of colour in the name scientific advancement9. Additionally, Western medicine has been regarded as the “standard”, while other understandings of wellness (Traditional Chinese medicine, Ayurvedic medicine) may not be considered valid forms of healing9. 

That being said, ease of access is also important in supporting international student’s mental health and wellbeing. Incorporating mental health services into primary care spaces may provide a way for ​international students to​ explore mental health services more discretely as we work to fully dismantle the stigma8.  

Embedding cultural safety into policy is also important. For example, HR policies and procedures should be designed and/or refined so that post-secondary institutions can attract and retain diverse mental health staff. These policies can also mandate an introduction to cultural safety during orientation for new staff/ faculty.  

Limitations 

The cultural safety framework has limitations and concerns. In our research for this article, we have found that cultural safety and its related tools and approaches have been mainly studied as they relate to Indigenous populations. The articles referenced in this piece mainly focused on research done in Canada, Australia, and New Zealand where Indigenous populations have been historically and presently subjected to the complex and violent processes of ​​​settler-​colonialism. To that end, with the acknowledgement that the current research on cultural safety and its impact on mental health exists largely in the context of indigeneity & ​settler-​colonialism, specific research must be done to see if cultural safety is effective in ​​improving the mental health and wellbeing outcomes for ​international students ​studying in Canada.  

However, cultural safety developed as a response to settler-colonialism is not entirely separate from the context of international students as many who come to Canada to study have come from places that have been impacted by settler-colonialism. In some cases, this has directly or indirectly created a situation in which they must go abroad to seek education and opportunities. This leaves some international students doubly impacted by colonialism both in their home country and in Canada.  

Further, a whole campus approach involves acknowledging and perhaps dismantling deeply entrenched power structures. This process is hard and will require buy-in from those who directly and indirectly receive privilege from these systems. It also involves the uncomfortable and at times painful process of acknowledging our personal role in causing harm. 

Cultural Safety Spotlights 

The following are examples of how bringing cultural safety into the community can lead to improved health and mental health outcomes for service users. 

 Mindfully Muslim – Dr. Yusra Ahmad10 

Dr. Yusra Ahmad, an academic psychiatrist from the University of Toronto and founder of the Mindfully Muslim group program, took a unique approach to support newcomers. While most therapeutic programs are secular and do not embed religion or spirituality, Dr. Ahmad created a program that offers mindfulness-based interventions that intertwine Islamic wisdom, teachings, and imagery. Offered at a mosque, this program recognizes the participant’s identity as part of the recovery process. Dr​.​ Ahmad has made ​a ​great impact ​in the​​ Muslim​ newcomer​ community ​through this program. 

Community Health Fair – Black Medical Students’ Association11 

When the Black Medical Students’ Association (BMSA) at the University of Alberta noticed that underserved communities weren’t actively seeking health supports, they began hosting community health fairs that brought health care to the community, and in a more relaxed, non-clinical setting. The Community Health Fairs included bringing cancer screening services, dentistry booths, and various types of doctors. The results were that community members were able to access crucial health care and information. By recognizing that service users will not always seek the support they need due to a variety of concerns, including how culturally safe and inclusive healthcare settings are, BMSA was able to deliver care to service users ​who​ would otherwise have remained underserved. 

Cultural Safety: The Professional Portfolio – Schulich Medicine & Dentistry, Western University12 

Students enrolled in the undergraduate medical program at Western University have the opportunity to engage with mentors through a yearlong mentorship program in their first three years of school. The mentorship is rooted in cultural safety with the specific aim to help students gain a better understanding of their “underlying assumptions and facilitate awareness of alternative perspectives”12. The program also helps students to learn the principles of culturally competent care, the importance of meeting the health care needs of underserved populations, and recognize the pervasiveness healthcare disparities. 

CONCLUSION 

International students are a vulnerable population that needs our continuous support, especially given the turbulent and challenging nature of this phase of their lives. Supporting their mental health by embedding cultural safety is a fundamental and important way to acknowledge the inherent power dynamics in mental health care and international students’ overall experiences within post-secondary spaces. A focus on cultural safety will not only benefit ​international students ​by ​fully ​supporting them and making services accessible to them, but it can also benefit the whole campus as the needs of diverse students and staff evolve.