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Negotiating Identity and Belonging

Exhibit and this TIP focus on main population groups as identified by the U. Census Bureau Humes et al. There are often many cultural groups within a given population or ethnic heritage. For simplicity, these groups are not represented on the actual model, and it is assumed that the reader acknowledges the vast inter- and intragroup variations that exist in all population, ethnic, and cultural groups. Refer to Chapters 5 and 6 to gain further clinical knowledge about specific racial, ethnic, and cultural groups.

This dimension includes cultural awareness, cultural knowledge, and cultural skill development. To provide culturally responsive treatment services, counselors, other clinical staff, and organizations need to become aware of their own attitudes, beliefs, biases, and assumptions about others. Providers need to invest in gaining cultural knowledge of the populations that they serve and obtaining specific cultural knowledge as it relates to help-seeking, treatment, and recovery. This dimension also involves competence in clinical skills that ensure delivery of culturally appropriate treatment interventions.

Several chapters capture the ingredients of this dimension. Chapter 1 provides an overview of cultural competence and concepts, Chapter 2 provides an indepth look at the role and effects of the counselor's cultural awareness and identity within the counseling process, Chapter 3 provides an overview of cultural considerations and essential clinical skills in the assessment and treatment planning process, and Chapter 5 specifically addresses the role of culture across specific treatment interventions.

This dimension targets key levels of treatment services: the individual staff member level, the clinical and programmatic level, and the organizational and administrative level. Interventions need to occur at each of these levels to endorse and provide culturally responsive treatment services, and such interventions are addressed in the following chapters.

Foremost, cultural competence provides clients with more opportunities to access services that reflect a cultural perspective on and alternative, culturally congruent approaches to their presenting problems. Culturally responsive services will likely provide a greater sense of safety from the client's perspective, supporting the belief that culture is essential to healing.

Even though not all clients identify with or desire to connect with their cultures, culturally responsive services offer clients a chance to explore the impact of culture including historical and generational events , acculturation , discrimination, and bias, and such services also allow them to examine how these impacts relate to or affect their mental and physical health. Culturally responsive practice recognizes the fundamental importance of language and the right to language accessibility, including translation and interpreter services.

For clients, culturally responsive services honor the beliefs that culture is embedded in the clients' language and their implicit and explicit communication styles and that language-accommodating services can have a positive effect on clients' responses to treatment and subsequent engagement in recovery services. The Affordable Care Act, along with growing recognition of racial and ethnic health disparities and implementation of national initiatives to reduce them HHS b , necessitates enhanced culturally responsive services and cultural competence among providers. Most behavioral health studies have found disparities in access, utilization, and quality in behavioral health services among diverse ethnic and racial groups in the United States Alegria et al.

The lack of cultural knowledge among providers, culturally responsive environments, and diversity in the workforce contribute to disparities in healthcare. Even limited cultural competence is a significant barrier that can translate to ineffective provider—consumer communication, delays in appropriate treatment and level of care, misdiagnosis, lower rates of consumer compliance with treatment, and poorer outcome Barr ; Carpenter-Song et al.

Increasing the cultural competence of the healthcare workforce and across healthcare settings is crucial to increasing behavioral health equity. Additionally, adopting and integrating culturally responsive policies and practices into behavioral health services provides many benefits not only for the client, but also for the organization and its staff.

Foremost, it increases the likelihood of sustainability. Cultural competence supports the viability of services by bringing to the forefront the value of diversity, flexibility, and responsiveness in organizations and among practitioners. For instance, implementing culturally responsive services is likely to increase access to care and improve assessment, treatment planning, and placement.

So too, it is likely to enhance effective communication between clients and treatment providers, thus decreasing risks associated with misunderstanding the clients' presenting problems or the needs of clients with regard to appropriate referrals for evaluation or treatment. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual or gender orientation; geographic location; or other characteristics historically tied to discrimination or exclusion.

Source: U. Organizational investment in improving cultural competence and increasing culturally responsive services will likely increase use and cost effectiveness because services are more appropriately matched to clients from the beginning. A key principle in culturally responsive practices is engagement of the community, clients, and staff. As organizations establish community involvement in the ongoing implementation of culturally responsive services, the community will be more aware of available treatment services and thus will become more likely to use them as its involvement with and trust for the organization grows.

Likewise, clients and staff are more apt to be empowered and invested if they are involved in the ongoing development and delivery of culturally responsive services. Client and staff satisfaction can increase if organizations provide culturally congruent treatment services and clinical supervision. An organization also benefits from culturally responsive practices through planning for, attracting, and retaining a diverse workforce that reflects the multiracial and multiethnic heritages and cultural groups of its client base and community.

Developing culturally responsive organizational policies includes hiring and promotional practices that support staff diversity at all levels of the organization, including board appointments. Increasing diversity does not guarantee culturally responsive practices, but it is more likely that doing so will lead to broader, varied treatment services to meet client and community needs.

Organizations are less able to ignore the roles of race , ethnicity , and culture in the delivery of behavioral health services if staff composition at each level of the organization reflects this diversity. Culturally responsive practice reinforces the counselor's need for self-exploration of cultural identity and awareness and the importance of acquiring knowledge and skills to meet clients' specific cultural needs.

Cultural competence requires an understanding of the client's worldview and the interactions between that worldview and the cultural identities of the counselor and the client in the therapeutic process. Culturally responsive practice reminds counselors that a client's worldview shapes his or her perspectives, beliefs, and behaviors surrounding substance use and dependence, illness and health, seeking help, treatment engagement, counseling expectations, communication, and so on.

Cultural competence includes addressing the client individually rather than applying general treatment approaches based on assumptions and biases. It also can counteract a potentially omnipotent stance on the part of counselors that they know what clients need more than the clients themselves do. Cultural competence highlights the need for counselors to take time to build a relationship with each of their clients, to understand their clients, and to assess for and access services that will meet each client's individual needs.

The importance and benefit of cultural competence does not end with changes in organizational policies and procedures, increases in program accessibility and tailored treatment services, or enhancement of staff training. In programs that prioritize and endorse cultural competence at all levels of service, clients, too, will have more exposure to psychoeducational and clinical experiences that explore the roles of race , ethnicity , culture , and diversity in the treatment process.

Treatment will help clients address their own biases, which can affect their perspectives and subsequent relationships with other clients, staff members, and individuals outside of the program, including other people in recovery. Culturally responsive services prepare clients not only to embrace their own cultural groups and life experiences, but to acknowledge and respect the experiences, perspectives, and diversity of others. Cultural groups are diverse and continuously evolving, defying precise definitions. Cultural competence is not acquired merely by learning a given set of facts about specific populations, changing an organization's mission statement, or attending a training on cultural competence.

Becoming culturally competent is a developmental process that begins with awareness and commitment and evolves into skill building and culturally responsive behavior within organizations and among providers. Cultural competence is the ability to recognize the importance of race , ethnicity , and culture in the provision of behavioral health services. Specifically, it is awareness and acknowledgment that people from other cultural groups do not necessarily share the same beliefs and practices or perceive, interpret, or encounter similar experiences in the same way.

Thus, cultural competence is more than speaking another language or being able to recognize the basic features of a cultural group. Cultural competence means recognizing that each of us, by virtue of our culture, has at least some ethnocentric views that are provided by that culture and shaped by our individual interpretation of it. Cultural competence is rooted in respect, validation, and openness toward someone whose social and cultural background is different from one's own Center for Substance Abuse Treatment [CSAT] b. Nonetheless, cultural competence literature highlights how difficult it is to appreciate cultural differences and to address these differences effectively, because many people tend to see things solely from their own culture -bound perspectives.

For counselors, specific cognitions, attitudes, and behaviors characterize the path to culturally competent counseling and culturally responsive services. Exhibit depicts the continuum of thoughts and behaviors that lead to cultural competence in the provision of treatment. For most people, the process of becoming culturally competent is complex, with movement back and forth along the continuum and with feelings and thoughts from more than one stage sometimes existing concurrently. The Continuum of Cultural Competence. Organizational Level: At best, the behavioral health organization negates the relevance of culture in the delivery of behavioral health services.

Agencies expect individuals from diverse ethnic and cultural backgrounds more Culture is defined by a community or society. It structures the way people view the world. It involves the particular set of beliefs, norms, and values concerning the nature of relationships, the way people live their lives, and the way people organize their environments. Culture is a complex and rich concept. Understanding it requires a willingness to examine and grasp its many elements and to comprehend how they come together.

Castro identified the elements generally agreed to constitute a culture as:. Although these criteria cannot be strictly applied to every cultural group, they do sufficiently define cultures so that groups are distinguishable to their members and to others Castro Note that these criteria apply more or less equally well to cultural groups based on nationality, ethnicity , region e.

Common Characteristics of Culture. The following list provides examples of common elements that distinguish one culture from another. Not every cultural group will define or endorse every item on this list, but most cultural groups will uphold the most more However, culture is not a definable entity to which people belong or do not belong. Within a nation, race , or community, people belong to multiple cultural groups, each with its own set of cultural norms i.

In this TIP, with the exception of the drug culture, the focus is on cultural groups that are shaped by a dynamic interplay among specific factors that shape a person's identity, including race , ethnicity , religion, socioeconomic status, and others. Race is often thought to be based on genetic traits e. Thus, what we perceive as diverse races based largely on selective physical characteristics, such as skin color are much more genetically similar than they are different. Moreover, physical characteristics ascribed to a particular racial group can also appear in people who are not in that group.

Asians , for example, often have an epicanthic eye fold, but this characteristic is also shared by the Kung San bushmen, an African nomadic Tribe HHS Although it lacks a genetic basis, the concept of race is important in discussing cultural competence. Race is a social construct that describes people with shared physical characteristics. It can have tremendous social significance in terms of behavioral health services, social opportunities, status, wealth, and so on.

The perception that people who share physical characteristics also share beliefs, values, attitudes, and ways of being can have a profound impact on people's lives regardless of whether they identify with the race to which they are ascribed by themselves or others. The major racial groupings designated by the U. The U. Racial labels do not always have clear meaning in other parts of the world; how one's race is defined can change according to one's current environment or society.

Racial categories also do not easily account for the complexity of multiracial identities. An estimated 3 percent of United States residents 9 million individuals indicated in the Census that they are of more than one race Humes et al. The percentage of the total United States population who identify as being of mixed race is expected to grow significantly in coming years, and some estimate that it will rise as high as one in five individuals by Lee and Bean White Americans constitute the largest racial group in the United States. In the Census, 72 percent of the United States population consisted of non-Hispanic Whites, a classification that has been used by the Census Bureau and others to refer to non-Hispanic people of European, North African, or Middle Eastern descent Humes et al.

Census Bureau predicts, however, that White Americans will be outnumbered by persons of color sometime between the years and The primary reasons for the decreasing proportion of White Americans are immigration patterns and lower birth rates among Whites relative to Americans of other racial backgrounds Sue and Sue b. Whites are often referred to collectively as Caucasians, although technically, the term refers to a subgroup of White people from the Caucasus region of Eastern Europe and West Asia. To complicate matters, some Caucasian people—notably some Asian Indians—are typically counted as Asian U.

Census Bureau a. African Americans, or Blacks, are the second largest racial group in the United States, making up about 13 percent of the United States population in Humes et al. Although most African Americans trace their roots to Africans brought to the Americas as slaves centuries ago, an increasing number are new immigrants from Africa and the Caribbean.

The terms African American and Black are used synonymously at times in literature and research, but some recent immigrants do not consider themselves to be African Americans, assuming that the designation only applies to people of African descent born in the United States. The racial designation Black, however, encompasses a multitude of cultural and ethnic variations and identities e.

The history and experience of African Americans has varied considerably in different parts of the United States, and the experience of Black people in this country varies even more when the culture and history of more recent immigrants is considered. The racial category of Asian is defined by the U. In the census, Asian Americans accounted for 4. For those who identified with only one Asian group, 23 percent of Asian Americans were Chinese; 19 percent, Asian Indian; 17 percent, Filipino; 11 percent, Vietnamese; 10 percent, Korean; and 5 percent, Japanese. Asian Americans comprised about 43 ethnic subgroups, speaking more than languages and dialects HHS The tremendous cultural differences among these groups make generalizations difficult.

Beginning with the Census, however, the Federal Government recognized Pacific Islanders as a distinct racial group. Nonetheless, remnants of the old classification system are evident in research based on the API grouping. Where possible, the TIP uses data solely for Asians; however, in some cases, the only research available is for the combined API grouping. Racially, Native Americans are related to Asian peoples notably, those from Siberia in Russia , but they are considered a distinct racial category by the U. Census Bureau a , p. Department of the Interior, Indian Affairs a , but there are numerous other Tribes recognized only by States and still others that go unrecognized by any government agency.

These Tribes, despite sharing a racial background, represent a widely diverse group of cultures with diverse languages, religions, histories, beliefs, and practices. According to Yang , ethnicity refers to the social identity and mutual sense of belonging that defines a group of people through common historical or family origins, beliefs, and standards of behavior i. In some cases, ethnicity also refers to identification with a clan or group whose identity can be based on race as well as culture.

Some Latinos , for example, self-identify in terms of both their ethnicity e. Because Latinos can belong to a number of races, the Census Bureau defines them as an ethnic group rather than a race. In , Latinos comprised 16 percent of the United States population Ennis et al. They are the fastest growing ethnic group in the United States; between and , the number of Latinos in the country increased 43 percent, a rate nearly four times higher than that for the total population Ennis et al.

By , Latinos are expected to make up 29 percent of the total population Passel and Cohn Nearly 60 percent of Latino Americans were born in the United States, but Latinos also account for more than half of the nation's foreign-born population Larsen ; Ramirez and de la Cruz Foreign-born Latinos include legal immigrants, some of whom have succeeded in becoming naturalized American citizens, as well as undocumented or illegal immigrants to the United States. Approximately three-quarters 74 percent of the Nation's unauthorized immigrant population are Hispanics, mostly from Mexico Passel and Cohn Ethnicity differs from race in that groups of people can share a common racial ancestry yet have very different ethnic identities.

Thus, by definition, ethnicity—unlike race—is an explicitly cultural phenomenon. It is based on a shared cultural or family heritage as well as shared values and beliefs rather than shared physical characteristics. Regional and political differences exist among various groups as to whether they prefer one term over the other. The literature currently uses both terms interchangeably, as both terms are widely used and refer generally to the same Latin-heritage population of the United States.

That said, a distinction can technically be drawn between Hispanic literally meaning people from Spain or its former colonies and Latino which refers to persons whose origins lie in countries ranging from Mexico to Central and South America and the Caribbean, which were colonized by Spain, and including Portugal and its former colonies as well.

For that reason, this TIP uses the more inclusive term Latino, except when research specifically indicates the other. The term Latinas is used to refer specifically to women who are a part of this cultural group. Within a racial group e. The White Anglo-Saxon Protestant peoples of England and Northern Europe have, for example, many differing cultural attributes and a very different history in the United States than the Mediterranean peoples of Southern Europe e. Cultural identity describes an individual's affiliation or identification with a particular group or groups.

Cultural identity arises through the interaction of individuals and culture s over the life cycle. Cultural identities are not static; they develop and change across stages of the life cycle. People reevaluate their cultural identities and sometimes resist, rebel, or reformulate them over time. All people, regardless of race or ethnicity , develop a cultural identity Helms Cultural identity is not consistent even among people who identify with the same culture. Two Korean immigrants could both identify strongly with Korean culture but embrace or reject different elements of that culture based on their particular life experiences e.

Cultural groups may also place different levels of importance on various aspects of cultural identities. In addition, individuals can hold two or more cultural identities simultaneously. Some of the factors that are likely to vary among members of the same culture include socioeconomic status, geographic location, gender, education level, occupational status, sexuality, and political and religious affiliation. For individuals whose families are highly acculturated, some of these characteristics e. The section that follows provides more detailed information on the most important cross-cutting factors involved in the creation of a person's cultural identity.

Language is a key element of culture , but speaking the same language does not necessarily mean that people share the same cultural beliefs. Even within the United States, people from different regions can have diverse cultural identities even though they speak the same language. Conversely, those who share an ethnicity do not automatically share a language.

Families who immigrated to this country several generations earlier may identify with their culture of origin but no longer be able to speak its language. English is the most common language in the United States, but 18 percent of the total population report speaking a language other than English at home Shin and Bruno Styles of communication and nonverbal methods of communication are also important aspects of cultural groups. Issues such as the use of direct versus indirect communication, appropriate personal space, social parameters for and displays of physical contact, use of silence, preferred ways of moving, meaning of gestures, degree to which arguments and verbal confrontations are acceptable, degree of formality expected in communication, and amount of eye contact expected are all culturally defined and reflect very basic ethnic and cultural differences Comas-Diaz ; Franks ; Sue More specifically, the relative importance of nonverbal messages varies greatly from culture to culture; high-context cultural groups place greater importance on nonverbal cues and the context of verbal messages than do low-context cultural groups Hall For example, most Asian Americans come from high-context cultural groups in which sensitive messages are encoded carefully to avoid giving offense.

A behavioral health service provider who listens only to the literal meaning of words can miss clients' actual messages. What is left unsaid, or the way in which something is said, can be more important than the words used to convey the message. African Americans have a relatively high-context culture compared with White Americans but a somewhat lower-context culture compared with Asian Americans Franks Thus, African Americans typically rely to a greater degree than White Americans on nonverbal cues in communicating.

Conversely, White American culture is low context as are some European cultural groups, such as German and British ; communication is expected to be explicit, and formal information is conveyed primarily through the literal content of spoken or written messages. Cultural groups form within communities and among people who interact meaningfully with each other. Although one can speak of a national culture , the fact is that any culture is subject to local adaptations. Local norms or community rules can significantly affect a culture.

Thus, it is important for providers to be familiar with the local cultural groups they encounter—to not think, f o r example, in terms of a homogeneous Mexican culture so much as the Mexican culture of Los Angeles, CA, or the Mexican culture of El Paso, TX. The following examples provide broad descriptions that do not necessarily fit all cultural groups from a specific racial or ethnic group.

Counselors should avoid assuming that a client has a particular expectation or expression of nonverbal and verbal communication based solely on race , ethnicity , or cultural heritage. For example, a counselor could make an assumption during an interview that a Native American client prefers a nondirective counseling style coupled with long periods of silence, whereas the client expects a more direct, active, goal-oriented approach. Counselors should be knowledgeable and remain open to differences in communication patterns that can be present when counseling others from diverse backgrounds.

The following are some examples of general differences among cultural groups:. Geographical factors can also have a significant effect on a client's culture. For example, clients coming from a rural area—even if they come from different ethnicities—can have a great deal in common, whereas individuals from the same ethnicity who were raised in different geographic locales can have very different experiences and, consequently, attitudes. For example, although the vast majority of Asian Americans live in urban areas 95 percent in ; Reeves and Bennett , a particular Asian American client may have been born in a rural community or come from a culture e.

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Other clients who currently live in cities may still consider a rural locale as their home and regularly return to it. Many Native Americans who live in urban areas or in communities adjacent to reservations, for example, travel regularly back to their home reservations Cornell and Kalt ; Lobo In addition to its potential influence upon culture , geography can strongly affect substance use and abuse, mental health and well-being, and access to and use of health services Baicker et al.

In very rural or remote areas, illicit drug use is likely to be even less common than in rural areas Schoeneberger et al. Even among members of the same culture, less substance use is observed in those who live in more rural regions. For example, O'Connell and associates found that alcohol consumption was lower for American Indians living on reservations than for those who were geographically dispersed and typically living in urban areas.

Likewise, individuals born or living in urban areas may be at greater risk for serious mental illness. In one systematic study, higher distribution rates of schizophrenia were found in urban areas, particularly among people who were born in metropolitan areas McGrath et al. There are many ways of conceptualizing how culture influences an individual. Culture can be seen as a frame through which one looks at the world, as a repertoire of beliefs and practices that can be used as needed, as a narrative or story explaining who people are and why they do what they do, as a set of institutions defining different aspects of values and traditions, as a series of boundaries that use values and traditions to delineate one group of people from another, and so on.

According to Lamont and Small , such schemata recognize that culture shapes what people believe i. Thus, it is impossible to review and summarize the variety of cultural values, traditions, and worldviews found in the United States in this publication. Providers are encouraged to speak with their clients to learn about their worldviews, values, and traditions and to seek training and consultation to gain specific knowledge about clients' cultural beliefs and practices. Although families are important in all cultural groups, concepts of and attitudes toward family are culturally defined and can vary in a number of ways, including the relative importance of particular family ties, the family's inclusiveness, how hierarchical the family is, and how family roles and behaviors are defined McGoldrick et al.

In some cultural groups e. Some cultural groups clearly define roles for different family members and carefully prescribe methods of behaving toward one another based on specific relationships. For example, in Korean culture , wives are expected to defer to their in-laws about many decisions Kim and Ryu Even in cultural groups with carefully defined roles and rules for family members, family dynamics may change as the result of internal or external forces.

The process of acculturation , for instance, can significantly affect family roles and dynamics among immigrant families, causing the dissolution of longstanding cultural hierarchies and traditions within the family and resulting in conflict between spouses or different generations of the family Hernandez ; Juang et al. Gender roles are largely cultural constructs; diverse cultural groups have different understandings of the proper roles, attitudes, and behaviors for men and women. Even within modern American society, there are variations in how cultural groups respond to gender norms.

For example, after controlling for income and education, African American women are less accepting than White American women of traditional American gender stereotypes regarding public behavior but more accepting of traditional domestic gender roles Dugger ; Haynes Culturally defined gender roles also appear to have a strong effect on substance use and abuse. This can perhaps be seen most clearly in international research indicating that, in societies with more egalitarian relationships between men and women, women typically consume more alcohol and have drinking patterns more closely resembling those of men in the society Bloomfield et al.

A similar effect can be seen in research conducted in the United States with Latino men and women with varying levels of acculturation to mainstream American society Markides et al. The terms for and definitions of gender roles can also vary. For example, in Latino cultural groups, importance is placed on machismo the belief that men must be strong and protect their families , caballerismo men's emotional connectedness , and marianismo the idea that women should be self-sacrificing, endure suffering for the sake of their families, and defer to their husbands Arciniega et al.

These strong gender roles have benefits in Latino culture , such as simplifying and clarifying roles and responsibilities, but they are also sources of potential problems, such as limiting help-seeking behavior or the identification of difficulties. For example, because of the need to appear in control, a Latino man can have difficulty admitting that his substance use is out of control or that he is experiencing psychological distress Castro et al. Negotiating gender roles in a treatment setting is often difficult; providers should not assume that a client's traditional culture -based gender roles are best for him or her or that mainstream American ideas about gender are most appropriate.

The client's degree of acculturation and adherence to traditional values must be taken into consideration and respected. Sociologists often discuss social class as an important aspect in defining an individual's cultural background. In this TIP, socioeconomic status SES is used as a category similar to class—the difference being that socioeconomic status is a more flexible and less hierarchically defined concept. SES in the United States is related to many factors, including occupational prestige and education, yet it is primarily associated with income level.

Thus, SES affects culture in several ways, namely through a person's ability to accumulate material wealth, access opportunities, and use resources. Discrimination and historical racism have led to lasting inequalities in SES Weller et al. SES affects mental health and substance use. From to , adults 45 through 64 years of age were five times more likely to have depression if they were poor National Center for Health Statistics Serious mental illness among adults living in poverty has a prevalence rate of 9.

Some research demonstrates higher risk for schizophrenia from lower socioeconomic levels, but other studies draw no definite conclusion Murali and Oyebode Most literature suggests that poverty and its consequences, including limited access to resources, increase stress and vulnerability among individuals who may already be predisposed to mental illness. An Institute of Medicine report on disparities Smedly et al.

However, the most persistent and prominent cause appears to be disparities in SES, which affect insurance coverage and access to quality care Russell These economic disparities account for significantly higher death rates, particularly among African Americans compared with non-Hispanic Whites Arias , as well as greater lack of insurance coverage or worse coverage for people of color Smedly et al. Evidence-based interventions to reduce health disparities are limited Beach et al.

Current strategies generally focus on reducing risk factors that affect groups who experience a greater burden from poor health Murray et al. The Federal Government has recognized the need to address health disparities and has made this issue a priority for agencies that deal with health care HHS b. More specific information on mental health and substance abuse treatment disparities is provided in Chapter 5 of this TIP.

Studies have had conflicting results as to whether people with high or low SES are more likely to abuse substances Jones-Webb et al. In international studies, increases in wealth on a societal level have been associated with increases in alcohol consumption Bergmark and Kuendig ; Kuntsche et al. However, other factors, such as the availability of social support systems and education, as well as the individual's acculturation level, can also play a role.

Karriker-Jaffe and Zemore found that, in immigrants, a greater level of acculturation was associated with increased heavy drinking for those with above-average SES but not for those with lower SES. Education is also an important factor related to SES Exhibit Research in the United States has found that problems with alcohol are often associated with lower SES and lower levels of education Crum ; Mulia et al. However, other studies have shown that greater frequency of drinking and number of drinks consumed are generally associated with higher levels of education and higher SES Casswell et al.

For example, the NSDUH showed that adult rates of past-month alcohol use increased with increasing levels of education; among those with less than a high school education, Education can also affect substance use independently of SES. For example, lower education levels seem to relate to heavy drinking independently of socioeconomic status Kuntsche et al. Education and Culture. Culture has an effect on an individual's attitudes toward education; for instance, a lack of cultural understanding on the part of educational institutions affects student goals and achievements Sue A number of factors besides more The desperation associated with poverty and a lack of opportunity—as well as the increased exposure to illicit drugs that comes from living in a more impoverished environment—can also increase drug use Bourgois Lower SES and the concurrent lack of either money or insurance to pay for treatment are associated with less access to substance abuse treatment and mental health services Chow et al.

For example, compared with Medicare coverage, private insurance coverage increases the odds twofold that someone who has a substance use disorder will enter treatment Schmidt and Weisner Thus, lower SES can have a dramatic effect on recovery. Often, they encounter a difficult process of acculturation as discussed throughout this chapter.

They can also share concerns surrounding the renewal of visas, obtainment of citizenship, or fears of possible deportation depending on their legal status. Immigration itself is stressful for immigrants, though the reasons for migrating and the legal status of the immigrant affect the degree of stress. For documented residents, the process of adaptation tends to be smoother than for those who are undocumented. Undocumented persons may be wary of deportation, are less likely to seek social services, and frequently encounter hostility Padilla and Salgado de Snyder Nonetheless, there are numerous variables that contribute to or influence well-being, quality of life, cultural adaptation, and the development of resilience e.

Research suggests that immigrants may not experience higher rates of mental illness than nonimmigrants Alegria et al. Department of State's Bureau of Population, Refugees, and Migration, is a useful resource for clinicians to gain information about topics including culture , resettlement experiences, and historical and refugee background information. This site is also quite useful for refugees. It provides refugee orientation materials and guidance in establishing housing, language , transportation, education, and community services, among other pressing refugee concerns.

Immigrants who are refugees from war, famine, oppression, and other dangerous environments are more vulnerable to psychological distress APA They are likely to have left behind painful and often life-threatening situations in their countries of origin and can still bear the scars of these experiences. Some refugees come to the United States with high expectations for improved living conditions, only to find significant barriers to their full participation in American society e. Behavioral health services must assess the needs of refugee populations, as the clinical issues for these populations may be considerably different than for immigrant groups Kaczorowski et al.

For immigrant families, disruption of roles and norms often occurs upon arrival in the United States for review, see Falicov Generally, youth adopt American customs, values, and behaviors much more easily and at higher rates than their parents or older members of the extended family. Parental frustration may occur if traditional standards of behavior conflict with mainstream norms acquired by their children. The differences in parents' values and expectations and adolescents' behavior can lead to distress in close-knit immigrant families.

This disruption, known as the acculturation gap, can result in increased parent-child conflicts APA ; Falicov ; Telzer Research shows that family cohesion and adaptability decrease with time spent in the United States, regardless of the amount of involvement in mainstream culture. This suggests that other factors may confound the relationship between family conflict and increased exposure to American culture Smokowski et al. When working with clients who are recent immigrants or have immigrated to United States during their lifetime, the APA recommends exploring:.

Clients who are migrants e. In the United States, migrant workers are considered one of most marginalized and underserved populations Bail et al. Migrants face many logistical obstacles to treatment-seeking, such as lack of childcare, insurance, access to regular health care, and transportation Hovey ; Rosenbaum and Shin Current data are limited but suggest high rates of alcohol use, alcohol use disorders, and binge drinking, often occurring as a response to stress or boredom associated with the migrant lifestyle Hovey ; Worby and Organista In addition, limited data on migrant mental health reflect mixed findings regarding increased risk for mental illness or psychological distress Alderete et al.

One factor associated with mental health status is the set of circumstances leading up to the migrant worker's decision to migrate for employment Grzywacz et al. Many factors contribute to an individual's cultural identity, and that identity is not a static attribute. As a result, people may feel conflicted about their identities—wanting to fit in with the mainstream culture while also wanting to retain the values of their culture of origin. For clients, sorting through these conflicting cultural expectations and forging a comfortable identity can be an important part of the recovery process.

Some of the more commonly used terms related to cultural identity are defined in Exhibit Cultural Identification and Cultural Change Terminology. Acculturation is the process whereby an individual from one cultural group learns and adopts elements of another cultural group, integrating them into his or her original culture.

Although it can more All immigrants undergo some acculturation over time, but the rate of change varies from group to group, among individuals, and across different periods of history. Since the end of the last glacial period , Canada has consisted of eight distinct forest regions , including extensive boreal forest on the Canadian Shield.

Canada is geologically active, having many earthquakes and potentially active volcanoes, notably Mount Meager massif , Mount Garibaldi , Mount Cayley massif , and the Mount Edziza volcanic complex. Average winter and summer high temperatures across Canada vary from region to region. Coastal British Columbia has a temperate climate, with a mild and rainy winter. Canada is described as a " full democracy ", [] with a tradition of liberalism , [] and an egalitarian , [] moderate political ideology. At the federal level, Canada has been dominated by two relatively centrist parties practicing "brokerage politics", [b] [] [] [] [] the centre-left Liberal Party of Canada and the centre-right Conservative Party of Canada or its predecessors.

Canada has a parliamentary system within the context of a constitutional monarchy —the monarchy of Canada being the foundation of the executive, legislative , and judicial branches. The person who is the Canadian monarch is the same as the British monarch , although the two institutions are separate.

The direct participation of the monarch and the governor general in areas of governance is limited. The governor general or monarch may, though, in certain crisis situations exercise their power without ministerial advice. Each of the members of parliament in the House of Commons is elected by simple plurality in an electoral district or riding. General elections must be called by the governor general, either on the advice of the prime minister or if the government loses a confidence vote in the House. The members of the Senate, whose seats are apportioned on a regional basis, serve until age Canada's federal structure divides government responsibilities between the federal government and the ten provinces.

Provincial legislatures are unicameral and operate in parliamentary fashion similar to the House of Commons. The Bank of Canada is the central bank of the country. In addition, the minister of finance and minister of industry utilize the Statistics Canada agency for financial planning and economic policy development. The Constitution of Canada is the supreme law of the country, and consists of written text and unwritten conventions.

The Indian Act , various treaties and case laws were established to mediate relations between Europeans and native peoples. The role of the treaties and the rights they support were reaffirmed by Section Thirty-five of the Constitution Act, Canada's judiciary plays an important role in interpreting laws and has the power to strike down Acts of Parliament that violate the constitution. All judges at the superior and appellate levels are appointed after consultation with non-governmental legal bodies.

The federal Cabinet also appoints justices to superior courts in the provincial and territorial jurisdictions. Common law prevails everywhere except in Quebec, where civil law predominates. Criminal law is solely a federal responsibility and is uniform throughout Canada. Canada is recognized as a middle power for its role in international affairs with a tendency to pursue multilateral solutions. Canada and the United States share the world's longest undefended border, co-operate on military campaigns and exercises, and are each other's largest trading partner.

Pearson eased tensions by proposing the inception of the United Nations Peacekeeping Force , for which he was awarded the Nobel Peace Prize. In , Canada deployed troops to Afghanistan as part of the U. The nation employs a professional, volunteer military force of approximately 79, active personnel and 32, reserve personnel. The Canadian Forces will acquire 88 fighter planes and 15 naval surface combatants, the latter as part of the National Shipbuilding Procurement Strategy. Canada is a federation composed of ten provinces and three territories. Using its spending powers, the federal government can initiate national policies in provincial areas, such as the Canada Health Act ; the provinces can opt out of these, but rarely do so in practice.

Equalization payments are made by the federal government to ensure reasonably uniform standards of services and taxation are kept between the richer and poorer provinces. Since the early 20th century, the growth of Canada's manufacturing, mining, and service sectors has transformed the nation from a largely rural economy to an urbanized, industrial one.

Canada is one of the few developed nations that are net exporters of energy. Canada also has a sizeable manufacturing sector centred in southern Ontario and Quebec, with automobiles and aeronautics representing particularly important industries. Canada has a strong cooperative banking sector, with the world's highest per capita membership in credit unions. The Canadian Space Agency operates a highly active space program, conducting deep-space, planetary, and aviation research, and developing rockets and satellites.

The Canadian Census enumerated a total population of 35,,, an increase of around 5. Canada has one of the highest per-capita immigration rates in the world, [] driven mainly by economic policy and, to a lesser extent, family reunification. Canada's population density, at 3. The majority of Canadians Healthcare in Canada is delivered through the provincial and territorial systems of publicly funded health care , informally called Medicare. In common with many other developed countries, Canada is experiencing a cost increase due to a demographic shift towards an older population, with more retirees and fewer people of working age.

In , the average age was According to a report by the OECD, Canada is one of the most educated countries in the world; [] the country ranks first worldwide in the number of adults having tertiary education , with over 56 percent of Canadian adults having attained at least an undergraduate college or university degree. Since the adoption of section 23 of the Constitution Act, , education in both English and French has been available in most places across Canada.

Self-reported ethnic origins of Canadians based on geographic region Census [2]. Another Canada is religiously diverse, encompassing a wide range of beliefs and customs. Canada has no official church, and the government is officially committed to religious pluralism. Some of the most common non-official first languages include Chinese 1,, first-language speakers , Punjabi , , Spanish , , Tagalog , , Arabic , , German , , and Italian , Citizens have the right, where there is sufficient demand, to receive federal government services in either English or French and official- language minorities are guaranteed their own schools in all provinces and territories.

Other provinces have no official languages as such, but French is used as a language of instruction, in courts, and for other government services, in addition to English. Manitoba, Ontario, and Quebec allow for both English and French to be spoken in the provincial legislatures, and laws are enacted in both languages. In Ontario, French has some legal status, but is not fully co-official. Additionally, Canada is home to many sign languages , some of which are Indigenous. Canada's culture draws influences from its broad range of constituent nationalities, and policies that promote a " just society " are constitutionally protected.

Canada's approach to governance emphasizing multiculturalism, which is based on selective immigration , social integration , and suppression of far-right politics, has wide public support. Historically, Canada has been influenced by British , French , and Indigenous cultures and traditions. Through their language, art and music , Indigenous peoples continue to influence the Canadian identity. The primary characteristics of Canadian humour are irony, parody, and satire. Canada has a well-developed media sector , but its cultural output; particularly in English films , television shows , and magazines , is often overshadowed by imports from the United States.

Canada's national symbols are influenced by natural, historical, and Indigenous sources. The use of the maple leaf as a Canadian symbol dates to the early 18th century. The maple leaf is depicted on Canada's current and previous flags , and on the Arms of Canada.

Canadian literature is often divided into French- and English-language literatures, which are rooted in the literary traditions of France and Britain, respectively. Canadian visual art has been dominated by figures such as Tom Thomson — the country's most famous painter — and by the Group of Seven. Though referred to as having seven members, five artists— Lawren Harris , A. Jackson , Arthur Lismer , J. MacDonald , and Frederick Varley —were responsible for articulating the Group's ideas.

They were joined briefly by Frank Johnston , and by commercial artist Franklin Carmichael.

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Casson became part of the Group in The Canadian music industry is the sixth-largest in the world producing internationally renowned composers , musicians and ensembles. The earliest, The Bold Canadian , was written in Jean-Baptiste Day ceremony, and was officially adopted in The text was originally only in French before it was adapted into English in The roots of organized sports in Canada date back to the s. Canada shares several major professional sports leagues with the United States. Other popular professional sports in Canada include Canadian football , which is played in the Canadian Football League , National Lacrosse League lacrosse, and curling.

From Wikipedia, the free encyclopedia. For other uses, see Canada disambiguation. Country in North America. Coat of arms. English French. List of ethnicities. List of religions. Main article: Name of Canada. Main article: History of Canada. See also: Timeline of Canadian history and List of years in Canada. Further information: Historiography of Canada. Main articles: Geography of Canada and Climate of Canada. Main articles: Government of Canada and Politics of Canada.

Elizabeth II Monarch. Julie Payette Governor General. Justin Trudeau Prime Minister. Main article: Law of Canada. Main articles: Foreign relations of Canada and Military history of Canada. Main article: Provinces and territories of Canada. See also: Canadian federalism. Main articles: Economy of Canada and Economic history of Canada.

Main articles: Science and technology in Canada and Telecommunications in Canada. Main article: Demographics of Canada. Largest census metropolitan areas in Canada by population census view talk edit. Main article: Healthcare in Canada. Main article: Education in Canada. Main article: Canadians. Other North American [c] Europe Caribbean and Central and South America 3. Africa 2. Asia Oceania 0. Main article: Religion in Canada. Main article: Languages of Canada. English — English and French — French — Main article: Culture of Canada.

Main article: National symbols of Canada. Main article: Canadian literature. Main article: Canadian art. Main article: Music of Canada. Main article: Sports in Canada. Canada portal North America portal. Additionally, its first three lines are also included within the "Viceregal Salute", which is accorded to the governor general and provincial lieutenant governors.

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However, it has never been adopted as an official symbol of the country. However, "Canadian" as an ethnic group has since been added to census questionnaires for possible ancestral origin or descent. Respondents generally are visibly European Anglophones and Francophones , however no-longer self-identify with their ethnic ancestral origins. This response is attributed to a multitude or generational distance from ancestral lineage. Encyclopedia of Music in Canada.

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