Culture as a Determinant of Health (Shared with the Health Determinants theme)
Inhtroduction: basic concepts
Definitions: Cultural awareness, competency & safety
Learning Cultural Competency
Communicating Across Cultures
The LEARN model
Issues in cultural communication
Types of Cultures
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In a country as profoundly influenced by immigration as Canada, physicians daily treat patients with widely differing approaches to health, illness, healing and life in general. This can lead to confusion, even conflict. Why?
Humans have a strong needs for a sense of personal identity and group membership. As a result, we all perceive others through the filter of our own cultural upbringing, experienced in myriad ways. Some of these are unconscious, and this is normal, but a physician who is unaware of his or her reactions to others can have difficulty in communicating with others, especially in understanding why communication has gone wrong.
Here are some basic terms and concepts:
Culture: the knowledge, beliefs and values shared by members of a society. Often shown in its traditions, language, literature, art, music, sports, etc. Culture is learned and is conveyed from generation to generation through the process of socialization. While culture mainly comprises ideas, some sociologists also argue that it can also cover artifacts: the so-called ‘material culture’.
Ethnicity: An ethnic group shares a common cultural identity, separating them from other groups around them. It differs from race in that the shared characteristics are values, norms and ideas rather than physical characteristics. Ethnic groups are generally sub-groups within a culture and within a racial grouping. Ethnicity may refer to how a person sees themselves in terms of ancestry, history and culture.
Race: A socially defined classification of people based on shared genetically transmitted physical characteristics: "A division of humankind possessing traits that are transmissible by descent and sufficient to characterize it as a distinctive human type." Many approaches have been used to classify people, based on characteristics such as skin colour, head shape, eye colour and shape, nose size and shape etc. But race is not scientifically rigorous, in that there is a huge amount of mixing among races; the defining characteristics do not appear in all individuals, and genetically there may be more differences within a race than between races. A 1999 Institute of Medicine report declares that race is a socially defined "construct of human variability based on perceived differences in biology, physical appearance, and behavior."
Prejudice: The holding of unfounded ideas (generally negative, but can also be positive) about a group (e.g., a race, class or ethnic group). These ideas are resistant to change and rarely open to logical discussion.
Multiculturalism is the recognition of racial and cultural diversity, respect for the customs and beliefs of others. It includes the right to equal opportunity and recognition, regardless of race, colour or religion.
Cultural broker: a person who can bridge or mediate between cultural groups to reduce conflict, enhance education and produce change. Cultural broker programs are becoming common within the health care system, and can greatly enhance outcomes of, and satisfaction with, care.
There is a hierarchy of levels of cultural awareness and skills in working with people from different cultures:
Cultural awareness: observing and being conscious of similarities and contrasts between cultural groups. In medicine, we are especially interested in the way in which culture may affect different people's approach to health, illness and healing.
Cultural sensitivity: being aware of, and understanding, a deeper level of emotions that attach to your own culture and the way your culture may be perceived by others. For example, is your culture perceived as being 'dominant'? Is there historical baggage linked to it from the perspective of someone from another culture? And how may cultural differences shape your approach to patients from other cultures?
Cultural competence builds on sensitivity and refers to the attitudes, knowledge, and skills of practitioners necessary to become effective health care providers to patients from diverse backgrounds. Cultural competence is more than just being aware of differences; it refers to demonstrating attitudes and an approach that allows you to work effectively cross-culturally. It implies valuing and adapting to diversity; being aware of your own identity and cultural biases; and being able to manage the dynamics of treating people who are different.
"People don't care how much you know until they know how much you care" (J. Camphina-Bacote, J Nursing Education, 1999; 38: 204)
Competence = knowledge + conviction + capacity for action.
“Culturally competent communication leaves our patients feeling that their concerns were understood, a trusting relationship was formed and, above all, that they were treated with respect.” (Nadine Caron. Royal College Outlook Fall 2006;3(2):19-23)
Cultural competency in medical practice is part of acknowledging the benefits of diversity in society. It helps to ensure the best and most appropriate care for each patient; ultimately, it helps encourage self-determination for all consumers. It holds us all accountable for meeting the needs of the communities we serve. Nonetheless, the Indigenous Physicians Association of Canada (IPAC) has pointed out some potential hazards of the notion of cultural competence:
- reducing culture to technical skills for which clinicians can be trained to develop expertise;
- offering a series of “do’s and don’ts” that define how to treat a patient of a given cultural and or ethnic background;
- portraying cultural communities as isolated societies with shared, homogenous cultural meanings; and,
- the fact that cultural factors are not always central to medical care.
Because of these concerns, the notion of cultural safety has come to be promoted as an extension of cultural competence. Other terms include "cultural humility" and "cultural responsiveness". [See Anne Fadiman's novel The spirit catches you and you fall down for numerous examples.]
In response, cultural safety is an approach to medicine that goes beyond cultural sensitivity and competence to include several additional layers of commitment:
- Self-reflection on the part of the practitioner, which is fundamental to understanding the power differentials inherent in health service delivery. It acknowledges that we are all bearers of culture and that our actions can easily damage culture, just as a callous remark can cause emotional harm.
- Taking a cultural safety approach implies a health advocacy role – working to improve health care access; exposing the social, political, and historical context of health care, and interrupting unequal power relations.
- It also implies awareness that the patient exists simultaneously within several cultural and also health care systems, experiencing influences from their family, community, education and traditions. These will interact with, and possibly conflict with, your interventions. (Spence, D. (2001). Hermeneutic notions illuminate cross cultural nursing experiences. Journal of Advanced Nursing 35(4): 624-630).
Cultural humility redefines cultural competency as an ongoing process, involving a life-long commitment to self-evaluation and self-critique: we must be willing to learn and to maintain humility in our approach to patients. Cultural humility also implies a desire to fix power imbalances: recognizing and addressing the possibly divergent perspectives at play in a physician-patient encounter.
Cultural responsiveness: encourages doctors to respond to people both as members of their culture, but also as unstereotyped individuals.
Culturally sensitive care responds to, and is compatible with, the patient's cultural beliefs and practices. Various authors have proposed steps in achieving cultural competency:
Mary Narayan wrote a "clinician's guide" to achieving culturally competent care in six steps:
- Promote a caring attitude: Respect the patient; Be patient and perceive the patient's perspective. Be open to their ideas and approaches. Be flexible and do not impose your perspective
- Awareness of culture: In every encounter there is an interaction of two cultures: the patient's and the physician's. Be aware of different feelings about eye contact, about body space and of what is is appropriate to talk about. Be attuned to possible differences in gender roles, in how decisions are made; in orientation to time and to fate.
- Obtain background information: Try to find out about the patient's culture. Consider social etiquette; nonverbal communication; beliefs and values; typical health issues and concerns of the culture
- History taking: Pay particular attention to nutrition, attitudes to medications, pain perceptions, and type of care preferred.
- Preserve, accommodate, restructure: Aim to preserve cultural practices that support recovery; accommodate your management to practices that are neutral. If you feel that some of the patient's cultural practices are harmful (e.g. refusal to take the medication) try to restructure these. Try to explain your recommendations using the patient's perspective
- Don’t be defensive! Mistakes will occur. Apologize, express regret, and be willing to learn and, if necessary, refer to another clinician.
You can never understand all relevant aspects of every culture you will encounter. Therefore, you must find ways to encourage your patients to tell you how their culture affects their health - and their perception is the important issue.
As with all good medicine, communication is key. Rather than make assumptions based on your own perception of the patient's situation, ask them.
Using the Disease-Illness-Sickness Model
A useful starting point is the Disease - Illness - Sickness model
- From the perspective of the doctor, it is a ‘disease’ that has an underlying biological pathology.
- From the patient’s perspective, it is an ‘illness’ that is experienced subjectively by each patient.
- Finally, society and culture’s perception of the illness is one of a ‘sickness’ that tends to breed specific emotions around the illness, especially for the patient.
(The following paragraphs are adapted from the University of Toronto notes: Cross-Cultural Interviewing: A Guide for Teaching and Evaluation. Toronto, ON, 1996).
Viewed from this three-part model, the doctor-patient encounter is an interaction between different perspectives. This is true even if they are from the same culture, for intra-cultural differences in how sickness and health care systems are viewed can be as great as inter-cultural differences. To avoid any misunderstanding, the physician must be aware of his or her own belief system, and take care not to stereotype or make assumptions about the patient's system.
The physician's perspective is usually disease-oriented, seeking to identify the biologic or pathologic cause, in order to execute a cure of that disease process. But while you may assume that biomedicine, as a reductionist science, is objective and neutral, dealing only with truth or facts, it is also grounded in a cultural belief system that is only one alternative approach to thinking about disease. Therefore, the physician should be aware of his own beliefs about medicine, yet recognize that other belief systems may be equally valid for others.
The patient's perspective will be illness-oriented, molded by their upbringing, education and culture (the overlapping sickness orientation). This formulates the meaning of the sickness for them, how they decide they are ill and perhaps why, and how they should cope with it. While explanatory models are culturally determined, they may vary in the same individual for different illnesses, or at different stages of an illness. Therefore, the physician must determine the model for each illness episode for each patient. For instance, a patient may have a relatively biomedical approach to a sickness episode until the stress of end of life issues results in a reversion to their original cultural values and traditions.
Arthur Kleinman proposed some questions that may help you identify the patient's understanding of their illness. These questions cover the major issues of concern to the physician: etiology, pathophysiology, course, and treatment:
- What do you think has caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to you? How does it work?
- How severe is your sickness? Will it have a short or a long course? What are the chief problems your sickness has caused for you? What do you fear most about it?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to receive from this treatment?
(Kleinman A, et al. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 1978; 88(2): 251-8. Also, see Anne Fadiman's "The spirit catches you and you fall down" for examples of incorporating this approach - page 260 in the 2012 edition)
Neither the physician's nor the patient's model is sufficient by itself. Both are needed for culturally sensitive, patient-centered care.
Having gained some knowledge of the patient's model, the physician can determine if treatments used by the patient are beneficial, harmful, or neutral. The physician's model can be explained to the patient, and negotiation on a shared understanding of the illness and treatment plan is begun.
Another easy model to follow for cross-cultural communication is the L.E.A.R.N. model:
Here is a short video that applies the LEARN model step by step.
Here are some videos contrasting poor and good cross-cultural communication styles (for dentistry students, but relevant for MDs also):
• Poor cross-cultural communication:
• Good cross-cultural communication:
• Several examples:
• Eliciting information on cultural health remedies:
Four reports from the California Endowment institute:
• "Improving cultural competency in Pediatric Care" (pdf report)
• "In the Right Words" describes the impact of language barriers on health and health care, and describes strategies for addressing this problem
• "Principles and Recommended Standards" for training clinicians in cultural competency
• "Resources in Cultural Competence Education" gives an extensive list of training resources.
Several concepts refer to issues that may arise in cultural communication:
Ethnocentrism: the sense that one's own beliefs, values and ways of life are superior to, and more desirable than the lifestyle of others. For example, patient autonomy may appear the ideal to you, but you patient may wish to let her spouse decide on whether or not she has the operation.
Empathy: Brian Goldman defined empathy as “The ability to use your imagination to see things from the point of view of another person, and to use that perspective to guide your behaviour” and noted that “providing care means showing care.”
Cultural Blindness:the tendency to teat all people as the same and to believe that race, ethnicity, etc. do not matter. This can make other people feel that their identity is being ignored, and can lead one to avoid addressing ways of behaving in another culture that one finds unacceptable or disturbing. This may arise in tackling issues such as infanticide, or female circumcision (“It’s a cultural matter so we will not go there.”)
Culture Shock: being stunned by what one sees in another culture. A common experience in those who have visited a slum in a developing country!
Cultural Conflict: feelings of stress when the rules of one's own culture are contradicted by the rules of another. For example, in some cultures it is normal when a person is dying to invite extended family members to sing songs and undertake rituals at the bedside to help the person's soul on its journey; this can easily frustrate other dying patients who seek peace and quiet.
Cultural Imposition: the tendency to impose the views and values of your own culture without consideration of the beliefs of others. The history of residential schools is an extreme example, but physicians need to be careful not to impose their values.
How to become aware of how your own identity affects how you approach others?
- Here is a short check-list for judging a physician's services to patients in a culturally diverse practice. It was developed by the American Academy of Family Physicians
- The Georgetown University National Center for Cultural Competence has collected several self-assessment instruments designed to increase awareness of our own personal cultural biases. Here is a link to their Cultural Competence assessment for health practitioners. After you complete the form (long!) it provides a long list of resources that may be helpful.
- Harvard psychologists have developed a free-access test to identify biases in perception of various groups of people (by race, gender, education, etc). Take a test!
Link to U Toronto program on end of life care -- module on how culture influences our thinking about dying.
Culture and clinical care Pachter LM. (JAMA 1994; 271(9)). This article offers a gateway to a literature on the topic of how culture can affect how patients respond to care.
Here is an example of clinical care for Latino patients
Maya Angelou's poem "Equality"
Here is a Youtube video describing cultural humility: https://www.youtube.com/watch?v=_Mbu8bvKb_U
Several authors have proposed ways to classify cultures, highlighting the contrasts between them. A general awareness of these may help you in communicating with people from different cultures.
Hofstede’s Cultural Dimensions Theory: A well-known approach was initially proposed by Gerd Hofstede in 1991 in which he arranged cultural values along four dimensions. In the last twenty years, these dimensions have been re-visited and 2 more dimensions added, bringing the total to six cultural dimensions
In some cultures, “power distance” is high. Subordinates tend to respect and accept their boss merely because of his position ("everyone has his place"). Examples include Arab countries, Mexico and India.
Relevance to Medicine: This tends to lead to unquestioning acceptance of a doctor’s orders. Patients from societies with lower power distance may not automatically respect a doctor's opinion and may tend to question your reason for saying what you do.
Countries such as Japan, France or Greece tend to avoid uncertainty; they prefer predictability and so develop strict hierarchies, laws and procedures. Deviant ideas are discouraged and consensus is important, so there is typically a strong sense of nationalism.
In Nordic and Anglophone countries, people seem more tolerant of uncertainty; they dislike structure; there is less nationalism.
Relevance to Medicine: People from cultures that avoid uncertainty may wish their doctor to provide clear guidance on what they must do. People from cultures that tolerate uncertainty may accept that there are always alternative approaches; a therapy may be tried and if it works, great, but if it does not, another one may.
Individualism vs. collectivism
In individualistic countries (Australia, US), people are responsible for themselves and initiative is valued; people have relatively weak ties to their organization.
In collectivist countries such as China or Japan, a person’s identity is based on their group membership, so they value tight social frameworks and a feeling of belonging to a community or organization.
Relevance to Medicine: People from individualistic cultures may expect to make their own decisions regarding their health.
It is common for people from collectivist cultures to take therapeutic decisions as a member of a group; social pressures may strongly influence the individual, who may fear a sense of humiliation if he does not comply. Collectivist societies value harmony whereas individualistic societies value self-respect and autonomy.
Masculinity vs. femininity
Countries such as Mexico, Germany or Japan espouse traditionally masculine values such as assertiveness, materialism and lack of concern for others. People work long hours and their job is of central importance. Gender roles are clearly distinguished; often the husband will make decisions for the wife.
By contrast, other cultures (Sweden, Denmark) may have low masculinity and high femininity. These countries value quality of life and concern for others. However, universal trends such as dual-career families are eroding the gap between high and low masculinity cultures.
Relevance to Medicine: Masculine values tend to coincide with a clear distinction between gender roles, with the man often perceived as superior; often the husband will make health-related decisions for the wife.
Long-term orientation vs. short-term orientation
Western societies typically have a short-term focus and view time as a valuable resource. There is an emphasis on focusing on one thing at a time. For other societies (African; Caribbean; some Indian groups) time urgency is much less important. They may be polychronic (lots of things can happen at once and things can be put off to later: mañana). Expect patients from such cultures to be late ("Eight o'clock Jamaica time" means any time after around nine or nine-thirty. Roughly). In some Arabic cultures, deadlines may even be viewed as an insult: important things take a long time and cannot be rushed.
Indulgence vs. restraint
Added in 2010, this dimension looks at whether simple joys are fulfilled. Indulgence is defined as “a society that allows relatively free gratification of basic and natural human desires related to enjoying life and having fun”. Conversely, a society with high restraint is “a society that controls gratification of needs and regulates it by means of strict social norms” (Scholar works).
Due to its newness, there is less data regarding this dimension. Latin America, parts of Africa, Nordic and Anglophone countries are found to have higher indulgence scores while East Asia, Eastern Europe and Arab countries have higher restraint.
A nice comparison of Aboriginal and Western values was provided by the Aboriginal Human Resource Council
Updated November 21, 2018