assessment discussion wk 1

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CHAPTER

2 Cultural Competency

Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowl-

edge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective patient- centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ from his or her own. This adaptability, coupled with a genuine curiosity about a patient’s beliefs and values, lay the foundation for a trusting patient-provider relationship.

A Definition of Culture Culture, in its broadest sense, reflects the whole of human behavior, including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination. Language is a part of culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups. Each group is identified by a particular body of shared traits (e.g., a particular art, ethos, or belief; or a particular behavioral pattern) and is rather dynamic in its evolving accommodations with internal and external influences. Any individual may belong to more than one group or subgroup, such as ethnic origin, religion, gender, sexual orientation, occupation, and profession.

Distinguishing Physical Characteristics The use of physical characteristics (e.g., gender or skin color) to distinguish a cultural group or subgroup is inap- propriate. There is a significant difference between distin- guishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group leads to misunderstandings about the individual. The stereotype, a fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. People can and do respond differently to the same stimuli. Stereotyping occurs through two cognitive phases. In the first phase, a stereotype becomes activated when an individual is categorized into

a social group. When this occurs, the beliefs and feelings (prejudices) come to mind about what members of that particular group are like. Over time, this first phase occurs without effort or awareness. In the second phase, people use these activated beliefs and feelings when they interact with the individual, even when they explicitly deny these stereotypes. Multiple studies have shown that healthcare providers activate these implicit stereotypes, or unconscious biases, when communicating with and providing care to minority patients (Stone and Moskowitz, 2011). With this in mind, you can begin learning cultural competence by acknowledging your implicit, or unconscious, biases toward patients based on physical characteristics.

At the same time, this does not minimize the value of understanding the cultural characteristics of groups, nor does this deny the interdependence of the physical with the cultural. Genotype, for example, precedes the develop- ment of the intellect, sensitivity, and imagination that leads to unique cultural achievements, such as the creation of classical or jazz music. Similarly, a person’s phenotype, like skin color, precedes most of the experience of life and the subsequent interweaving of that phenotype with cultural experience. Although commonly used in clinical practice, the use of phenotypic traits to classify an individual’s race is problematic. The term race has been used to categorize individuals based on their continent or subcontinent of origin (e.g., Asian, Southeast Asian). However, there is ongoing debate about the usefulness of race, considering the degree of phenotypic and genetic variation of individuals from the same geographic region (Relethford, 2009). In addition, the origins of race date back to the 17th century, long before scientists identified genetic similarities. Over time, beliefs about particular racial groups were shaped by economic and political factors, and many believe race has become a social construct (Harawa and Ford, 2009).

Genomics and Personalized Medicine A growing body of research examines genetic markers associated with racial and ethnic groups and potential interactions with environmental determinants in predicting disease susceptibility and response to medical treatment. An explosion of genome-wide association studies (GWAS) are attempting to link genomic loci, or single-nucleotide polymorphisms (SNPs) with common diseases such as

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with core aspects of the patient-centered care model (Fig. 2.1). Seeleman et al (2009) have proposed a framework for teaching cultural competence that emphasizes an awareness of the social context in which specific ethnic groups live. For ethnic minority individuals, assessing the social context includes inquiring about stressors and support networks, sense of life control, and literacy. In doing so, healthcare providers will need to be flexible and creative in working with patients. Campinha-Bacote’s (2011) Process of Cultural Competence Model is another approach and includes five cultural constructs: encounters, desire, awareness, knowl- edge, and skill. Box 2.1 defines these five constructs.

Cultural Humility Cultural humility involves the ability to recognize one’s limitations in knowledge and cultural perspective and be open to new perspectives. Rather than assuming all patients of a particular culture fit a certain stereotype, healthcare providers should view patients as individuals. In doing so, cultural humility helps equalize the imbalance in the patient-provider relationship. (Borkan et al, 2008). A provider may know many specific details about a patient’s particular culture, yet not show cultural humility. Cultural humility involves self-reflection and self-critique with the goal of having a more balanced, mutually beneficial relationship. It involves meeting patients “where they are” without judgment to avoid the development of stereotypes. Attaining cultural humility is an ongoing process shaped by every

rheumatoid arthritis, type 1 and type 2 diabetes mellitus, and Crohn disease (Visscher et al, 2012). Personalized medicine, as defined by the National Cancer Institute, is “a form of healthcare that considers information about a person’s genes, proteins and environment to prevent, diagnose and treat disease” (Su, 2013). Direct-to-consumer genetic testing is rapidly evolving and will likely become more affordable and accessible to our patients. Healthcare providers in all disciplines will need to become fluent in the language of genomics and learn how to discuss risks and benefits of gene testing with their patients and families (Calzone et al, 2013; Demmer and Waggoner, 2014). With this new emphasis, it will be perhaps even more important to acknowledge unconscious biases and seek to understand the patient’s unique cultural and personal health beliefs and expectations.

Cultural Competence Culturally competent care requires that healthcare providers be sensitive to patient’s heritage, sexual orientation, socio- economic situation, ethnicity, and cultural background (Cuellar et al, 2008). Many models have been proposed to teach cultural competence. Most include the domains of acquiring knowledge (e.g., understanding the meaning of culture), shaping attitudes (e.g., respecting differences of individuals from other cultures), and developing skills (e.g., eliciting patient’s cultural beliefs about health and illness) (Saha et al, 2008). Some of these domains overlap

Patient-Centered Care • Curbs hindering

behavior such as technical language, frequent interruptions, or false reassurance

• Understands transference/ countertransference

• Understands the stages and functions of a medical interview

• Attends to health promotion/disease prevention

• Attends to physical comfort

Cultural Competence • Understands the meaning of culture • Is knowledgeable about different cultures • Appreciates diversity • Is aware of health

disparities and discrimination affecting minority groups

• Effectively uses interpreter services when needed

• Understands and is interested in the patient as unique person

• Uses a biopsychosocial model • Explores and respects patient

beliefs, values, meaning of illness, preferences, and needs

• Builds rapport and trust • Finds common ground • Is aware of own biases/

assumptions • Maintains and is able to convey

unconditional positive regard • Allows involvement of friends/

family when desired • Provides information and

education tailored to patient’s level of understanding

FIG. 2.1 Overlapping concepts of patient-centered care and cultural competence. (From Saha S et al, 2008.)

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healthcare professionals as well. Allopathic providers often demonstrate skepticism regarding the use of complementary and alternative medicine (CAM) without considering the possibility of potential benefit to patients.

The Blurring of Cultural Distinctions Some cultural differences may be malleable in a way that physical characteristics are not. For example, one group of people can be distinguished from another by language (see Clinical Pearl, “Language Is Not All”). However, globaliza- tion, the growing diversity of the U.S. population, and evidence of healthcare disparities mandate more and more that we learn one another’s languages. Although modern technology and economics may eventually lead to universal- ity in language, we can begin by acknowledging and

patient encounter that involves openness, partnership, and genuine interest in understanding our patients’ belief systems and lives (Fahlberg et al, 2016).

The Impact of Culture The information in Box 2.2 suggests that racial and ethnic differences, as well as social and economic conditions, may affect the provision of specific healthcare services to certain groups and subgroups in the United States. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups. Although death rates have declined overall in the United States over the past 50 years, the poorly educated and those in poverty still die at higher rates from the same conditions than those who are better educated and economically advantaged. Morbidity, too, is greater among the poor. Data from the 2013 Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report reveal a variety of healthcare disparities. A significantly higher rate of Hispanic and non-Hispanic blacks were uninsured compared with Asian/Pacific Islanders and non-Hispanic whites. The infant mortality rate among infants born to non-Hispanic black women is more than double the rate for infants born to non-Hispanic white women. Compared with white women, a much higher percentage of black women die from coronary heart disease before age 75 (37.9% versus 19.4%). This same difference was observed between black and white men (61.5% versus 41.5%) (CDC, 2013). These rather stark facts are sufficient to underscore the need for cultural awareness in health and medical care professionals. Cultural and practice differences exist among

Data from Bukutu et al, 2008; Flores, 2010; Shao et al, 2016.

BoX 2.2 The Influence of Age, Race, Ethnicity, Socioeconomic Status, and Culture

Age, gender, race, ethnic group, and, with these variables, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care. Consider, for example, the ethnic and racial differences in the treatment of depression in the United States. The prevalence of major depressive disorders is similar across groups; however, compared with white Americans, black and Latino patients are less likely to receive treatment. Although some of the disparity is related to differing patient attitudes and perceptions of counseling and medication, there is growing evidence suggesting clinician communication style and treatment recommendations differ on the basis of patient race and ethnicity (Shao et al, 2016). Similarly, in the pediatric population, black and Latino children in the United States also experience health disparities, including lower overall health status and lower receipt of routine medical care and dental care compared with white children. Flores and colleagues (2010), in a systematic literature review, demonstrated that, compared with white children, black children have lower rates of preventive and population health care (e.g., breast-feeding and immunization coverage), higher adolescent health risk behaviors (e.g., sexually transmitted infections), higher rates of asthma emergency visits, and lower mental health service use. There is a clear need to better understand why these differences exist more globally, but removing cultural blindness at the individual patient level is an important first step.

Furthermore, the possible beneficial and harmful effects of many culturally important herbal medicines, which are used but not always acknowledged, must be understood and, in trusting relationships, reported to us if we are to guide their appropriate use. Crossing the cultural divide helps, but skepticism is a barrier. For example, many allopathic medical providers question the notion that complementary and alternative medicine might be a helpful adjuvant therapy for the prevention and treatment of acute otitis media. However, in several randomized controlled studies, xylitol, probiotics, herbal ear drops, and homeopathic treatments have been shown, compared with placebo, to have a greater effect in reducing pain duration and decreasing the use of antibiotics. Although skepticism can be put aside, evidence-driven guidance is still essential. Cultural competence is entirely consistent with that.

From Campinha-Bacote, 2011.

BoX 2.1 Dimensions of Cultural Competence

CULTURAL ENCOUNTERS—The continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge.

CULTURAL DESIRE—The motivation of the healthcare professional to “want to” engage in the process of becoming culturally competent, not “have to.”

CULTURAL AWARENESS—The deliberate self-examination and in-depth exploration of one’s biases, stereotypes, prejudices, assumptions, and “isms” that one holds about individuals and groups who are different from them.

CULTURAL KNOWLEDGE—The process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups.

CULTURAL SKILL—The ability to collect culturally relevant data regarding the patient’s presenting problem, as well as accurately performing a culturally based physical assessment in a culturally sensitive manner.

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Box 2.4 offers a guide to help understand the patient’s beliefs and practices that can lead to individualized, culturally competent care. Particular attention should be paid to caring for patients who self-identify as being lesbian, gay, bisexual, and transgender (LGBT). Unfortunately, these individuals face discrimination and disrespect in the healthcare setting. Thus, it is imperative that healthcare providers invest time in becoming culturally competent and develop cultural humility to work effectively with LGBT patients. Specific responsibilities include providing a welcoming and safe environment, gathering a history with sensitivity and compassion, and performing a physical examination using a “gender-affirming” approach (i.e., using the correct name and pronouns). Box 2.5 provides useful terminology (Center for Excellence for Transgender Health, 2016).

Interprofessional Care—A Culture Shift in the Health Professions There is a harmony—a unity—in the care of patients that is not constricted by the cultural and administrative boundar- ies of the individual health professions. To the extent that we stake out territories of care by allowing individual profes- sional cultures and needs to take precedence over patient needs, we may impede the achievement of harmony. In 2010, the World Health Organization (WHO) published

overcoming our individual biases and cultural stereotypes. Because it is impossible to learn the native languages of all of our patients, when language barriers arise, we must become aware of our resources and know how to effectively use interpreters (Seeleman et al, 2009). Use of medical interpreters has a positive impact on healthcare quality, but we continue to use suboptimal methods of communica- tion (e.g., family members). Although greater adoption of medical interpreter use involves policy and system-level changes, healthcare provider training and encouragement remain critically important (DeCamp et al, 2013).

ClInICal pearl

Language Is Not All A patient who knows the English language, however well, cannot be assumed to know the culture. Consider the diversity of the populations in Britain, India, American Samoa, and South Africa who are English speaking. The absence of a language barrier does not preclude a cultural barrier. You will likely still need to achieve a “cultural translation.”

The Primacy of the Individual in Health Care The individual patient may be visualized at the center of an indefinite number of concentric circles. The outermost circles represent constraining universal experiences (e.g., death). The circles closest to the center represent the various cultural groups or subgroups to which anyone must, of necessity, belong. The constancy of change forces adaptation and acculturation. The circles are constantly interweaving and overlapping. For example, a common experience in the United States has been the economic gain at the root of the assimilation of many ethnic groups. Although this results in greater homogeneity among the population, an individual’s gender, ethnic behaviors, or sexual orientation and identity will likely be unique. Predicting the individual’s character merely on the basis of the common cultural behavior, or stereotype, is not appropriate. Based on the Joint Commission 2010 report, “Checklist to Improve Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Across the Care Con- tinuum,” White and Stubblefield-Tave (2016) remind us that unconscious bias, stereotyping, racism, gender bias, and limited English proficiency underlie healthcare inequali- ties. They offer their own checklist of recommendations for healthcare providers to address these issues with the goal of reducing disparities in care (Box 2.3).

Ethical issues often arise when the care of an individual comes into conflict with the utilitarian needs of the larger community, particularly with the recognition of limited resources and, in the United States, rising healthcare costs. Cultural attitudes of our patients, at times vague and poorly understood, may constrain our professional behavior and confuse the context in which we serve the individual.

Modified from White & Stubblefield-Tave, 2016.

BoX 2.3 Provider Role in Reducing Disparities in Health Care

This modified “culturally competent checklist” is provided as a guide to help providers partner with patients and families to provide high- quality care. Although some items are simple, others are quite complicated and difficult to achieve. On our path to achieving cultural humility, we should strive to incorporate as many of these recom- mendations as possible into our routine clinical practice.

1. Humanize your patient. 2. Identify and monitor conscious and unconscious biases. 3. Do a teach-back. 4. Help the patient to learn about his or her disease or condition. 5. Welcome a patient’s friend, partner, and/or family members. 6. Learn a few key words and phrases in the most common languages

in your area. 7. Use a qualified medical interpreter as appropriate. 8. Be aware of the potential for “false fluency” (clinician language

skill should be tested and certified). 9. Seek training in working with an interpreter.

10. Consider the health literacy of one’s patients. 11. Respond thoughtfully to patient complaints. 12. Hold one’s institutions accountable for providing culturally and

linguistically competent care. 13. Advocate that the affiliated institution’s analyses of patient satisfac-

tion and outcome include cultural group data and that the results lead to concrete action.

14. Encourage patients to complete patient satisfaction and demo- graphics forms.

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“The Framework for Action on Interprofessional Education and Collaborative Practice.” In this publication, interprofes- sional education is described as training in which “students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.” The WHO believes this type of training can lead to “interprofessional collaborative practice,” in which health team members from different professional backgrounds work together to deliver high-quality care. In recent years, there has been a surge in published curricula on interprofessional education and team-based training for students and faculty. Although most curricula for nursing and medical students focus on improving communication skills, training programs need to evolve to address cultural humility and valuing diversity in patient populations (Foronda et al, 2016).

The Impact of Culture on Illness Disease is shaped by illness, and illness—the full expression of the impact of disease on the patient—is shaped by the

Modified from Stulc, 1991.

BoX 2.4 Cultural Assessment Guide: The Many Aspects of Understanding

Health Beliefs and Practices • How does the patient define health and illness? How are feelings

concerning pain, illness in general, or death expressed? • Are there particular methods used to help maintain health, such as

hygiene and self-care practices? • Are there particular methods being used for treatment of illness? • What is the attitude toward preventive health measures such as

immunizations? • Are there health topics that the patient may be particularly sensitive

to or consider taboo? • Are there restrictions imposed by modesty that must be respected;

for example, are there constraints related to exposure of parts of the body, discussion of sexual health, and attitudes toward various procedures such as termination of pregnancy or vasectomy?

• What are the attitudes toward mental illness, pain, chronic disease, death, and dying? Are there constraints in the way these issues are discussed with the patient or with reference to relatives and friends?

• Is there a person in the family responsible for various health-related decisions such as where to go, whom to see, and what advice to follow?

• Does the patient prefer a health professional of the same gender, age, and ethnic and racial background?

Faith-Based Influences and Special Rituals • Is there a religion or faith to which the patient adheres? • Is there a significant person to whom the patient looks for guidance

and support? • Are there any faith-based special practices or beliefs that may affect

health care when the patient is ill or dying?

Language and Communication • What language is spoken in the home? • How well does the patient understand English, both spoken and

written?

• Are there special signs of demonstrating respect or disrespect? • Is touch involved in communication? • Is an interpreter needed? (If so, this person ideally should be a

trained professional and not a family member.)

Parenting Styles and Role of Family • Who makes the decisions in the family? • What is the composition of the family? How many generations are

considered to be a single family, and which relatives compose the family unit?

• What is the role of and attitude toward children in the family? • Do family members demonstrate physical affection toward their

children and each other? • Are there special beliefs and practices surrounding conception,

pregnancy, childbirth, lactation, and childrearing? Is co-sleeping practiced? (If so, further inquiry is necessary regarding safe sleep practices for infants 12 months and younger.)

Sources of Support Beyond the Family • Are there ethnic or cultural organizations that may have an influence

on the patient’s approach to health care? • Are there individuals in the patient’s social network that can influence

perception of health and illness? • Is there a particular cultural group with which the patient identifies?

Can this be clarified by where the patient was born and has lived?

Dietary Practices • Who is responsible for food preparation? • Are any foods forbidden by the culture, or are some foods a cultural

requirement in observance of a rite or ceremony? • How is food prepared and consumed? • Are there specific beliefs or preferences concerning food, such as

those believed to cause or to cure an illness? • Are there periods of required fasting? What are they?

From Center for Excellence for Transgender Health, 2016.

BoX 2.5 Gender, Transgender, and Sexuality Terminology

Gender/gender identity: People’s internal sense of self and how they fit into the world from the perspective of gender.

Sex: Historically referred to the sex assigned at birth, based on external genitalia; often used interchangeably with gender, although there are differences, especially when considering the transgender population.

Transgender: Person whose gender identity differs from sex assigned at birth; a transgender man is someone with a male gender identity and a female birth assigned sex; a transgender woman is someone with a female gender identity and a male birth assigned sex.

Gender nonconforming: Person whose gender identity differs from that sex assigned at birth but may be more complex, fluid, less clearly defined than a transgender person.

They/Them/Their: Neutral pronouns used by some who have noncon- forming gender identity.

Sexual orientation: Term describing a person’s sexual attraction; sexual orientation of transgender people should be defined by the individual.

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In Japan, for example, the family is generally considered the legitimate decision-making authority for competent and incompetent patients. Persons of some cultures (e.g., Middle Eastern and Navajo Native American) believe that a patient should not be told of a diagnosis of a metastatic cancer or a terminal prognosis for any reason, but this attitude is not likely to be shared by Americans with European or African traditions. Traditionally, the members of the Navajo culture believe that thought and language have the power to shape reality. Talking about a possible outcome is thought to ensure the outcome. It is important, then, to avoid thinking or speaking in a negative way. The situation can be dealt with by talking in terms of a third person or an abstract possibility. You might even refer to an experience you have had in your own family. Obviously, the conflicts that may arise from differing views of autonomy, religion, and information sharing require an effort that is dominated by a clear understanding of the patient’s goals. However, it is important to remember that a patient may not typify the attitudes of the group of origin.

Modes of Communication Communication and culture are interrelated, particularly in the way feelings are expressed verbally and nonverbally. The same word may have different meanings for different people. For example, in the United States, a “practicing physician” is an experienced, trained person. “Practicing,” however, suggests inexperience and the status of a student to an Alaskan Native or to some Western Europeans. Similarly, touch, facial expressions, eye movement, and body posture all have varying significance.

In the United States, for example, people may tend to talk more loudly and to worry less about being overheard than others do. The English, on the other hand, tend to worry more about being overheard and speak in modulated voices. In the United States, people may be direct in conversation and eager to be thought logical, preferring to avoid the subjective and to come to the point quickly. The Japanese tend to do the opposite, using indirection, talking around points, and emphasizing attitudes and feelings. Silence, although sometimes uncomfortable for many of us, affords patients who are Native American time to think; the response should not be forced and the quiet time should be allowed.

Many groups use firm eye contact. The Spanish meet one another’s eyes and look for the impact of what is being said. The French, too, have a firm gaze and often stare openly at others. This, however, might be thought rude or immodest in some Asian or Middle Eastern cultures. Americans are more apt to let the eyes wander and to grunt, nod the head, or say, “I see,” or “uh huh,” to indicate understanding. Americans also tend to avoid touch and are less apt to pat you on the arm in a reassuring way than are, for example, Italians.

These are but a few examples of cultural variation in communication. They do, however, suggest a variety of behaviors within groups. As with any example we might

totality of the patient’s experience. Cancer is a disease. The patient dealing with, reacting to, and trying to live with cancer is having an illness—is “ill” or “sick.” The definition of “ill” or “sick” is based on the individual’s belief system and is determined in large part by his or her enculturation. This is so for a brief, essentially mild episode or for a chronic, debilitating, life-altering condition. If we do not consider the substance of illness—the biologic, emotional, and cultural aspects—we will too often fail to offer complete care. To make the point, imagine that while taking a shower you have conducted a self-examination and, still young, still looking ahead to your career, you have discovered an unexpected mass in a breast or a testicle. How will you respond? How might other individuals respond?

evidence-Based practice in physical examination

Cultural Adaptations for Screening We often use a variety of screening tools to identify health concerns and help our patients stay well. These screening tools are based on norms that may not be consistent across cultures. Screening tools may contain cultural biases and result in misleading information. Whenever possible, we should use instruments that have been adapted for and tested with individuals from our patients’ specific cultural groups. Screening, brief intervention, and referral to treatment (SBIRT) is an approach to identify and care for patients affected by alcohol and drug use. Using SBIRT involves the use of validated screening tools. Fortunately, a recent literature review indicates a variety of instruments have been validated in racial and ethnic subgroups (Manuel et al, 2015). Before implementing a screening tool, it is our responsibility to ensure the instrument is valid and at an appropriate literacy level for our specific patient populations.

The Components of a Cultural Response When cultural differences exist, be certain that you fully understand what the patient means and know exactly what he or she thinks you mean in words and actions. Asking the patient if you are unsure demonstrates curiosity and is far better than making an assumption, which could result in a damaging mistake. Avoid assumptions about cultural beliefs and behaviors made without validation from the patient.

Beliefs and behaviors that will have an impact on patient assessment include the following: • Modes of communication: the use of speech, body

language, and space • Health beliefs and practices that may vary from your

own or those of other patients you care for • Diet and nutritional practices • The nature of relationships within a family and

community A variety of ethnic attitudes toward autonomy may exist.

The patient-centered care model, still firmly respected in the United States, could be at odds with a more family- centered model that is more likely dominant elsewhere.

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be comfortable with Western approaches to health and medical care. However, the scientific view is reductionist and looks to a very narrow, specific cause and effect. A more naturalistic or “holistic” approach broadens the context. It views our lives as part of a much greater whole (the entire cosmos) that must be in harmony. If the balance is disturbed, illness can result. The goal, then, is to achieve balance and harmony. Aspects of this concept are evident among the beliefs of many Hispanics, Native Americans, Asians, and Middle Eastern groups, and they are increasingly evident in people of all ethnic groups in the United States today (Box 2.6). Other groups believe in the supernatural or forces of good and evil that determine individual fate. In such a context, illness may be thought of as a punishment for wrongdoing.

Clearly, there can be a confusing ambivalence in many of us, patient and healthcare provider alike, because our genuine faith-based or naturalistic beliefs may conflict with the options available for the treatment of illness. Consider, for example, a child with a broken bone, the result of an unintentional injury that occurred while the child was under the supervision of a babysitter. The first need is to tend to the fracture. That done, there is a need to talk with the parents about the guilt they may feel because they were away working. They might think this injury must be God’s punishment. It is important to be aware of, to respect, and to discuss without belittlement a belief that may vary from yours in a manner that may still allow you to offer your point of view. This can apply to the guilt of a parent and to the use of herbs, rituals, and religious artifacts. After all, the pharmacopoeia of Western medicine is replete with plants and herbs that we now call drugs (see Clinical Pearl, “Complementary and Alternative Treatments for the Common Cold”). Our difficulty in understanding the belief of another does not invalidate its substance, nor does a patient’s adherence to a particular belief preclude concurrent reliance on allopathic or osteopathic health practitioners.

use, they are not to be thought of as rigidly characteristic of the indicated groups. Still, the questions suggested in Box 2.4 can at times provide insight to particular situations and can help avoid misunderstanding and miscommunication.

The cultural and physical characteristics of both patient and healthcare provider may significantly influence com- munication (Fig. 2.2). Social class, race, age, and gender are variables that characterize everyone; they can intrude on successful communication if there is no effort for mutual knowledge and understanding (see Clinical Pearl, “The Impact of Gender”). The young student or healthcare provider and the older adult patient may have to work harder to develop a meaningful relationship. Recognizing these differences and talking about them, evoking feelings sooner rather than later, can result in a more positive encounter for both patient and provider. It is permissible to ask whether the patient is uncomfortable with you or your background and whether they are willing to talk about it.

FIG. 2.2 Being sensitive to cultural differences that may exist between you and the patient can help avoid miscommunication.

ClInICal pearl

The Impact of Gender In a qualitative study examining videotapes of primary care visits, compared with male physicians, female physicians were more “patient- centered” in their communication skills. The greatest amount of patient-centeredness was observed when female physicians interacted with female patients. Elderly hospitalized patients treated by female internists had lower mortality and readmissions compared with those cared for by male internists. On the flip side, compared with a female physician, obese men seen by a male physician were more likely to receive diet and exercise counseling.

From Bertakis and Azari, 2012; Pickett-Blakely et al, 2011; Tsugawa et al, 2017.

Health Beliefs and Practices The patient may have a view of health and illness and an approach to cure that are shaped by a particular cultural and/or faith belief or paradigm. If that view is “scientific,” in the sense that a cause can be determined for every problem in a very precise way, the patient is more apt to

ClInICal pearl

Complementary and Alternative Treatments for the Common Cold Home-based remedies for common colds are widely used. In children, the following therapies may be effective: buckwheat honey, vapor rub, geranium, and zinc sulfate. In adults, Echinacea purpurea, geranium extract, and zinc gluconate may be effective. When asking about medications, always remember to ask about use of complementary and alternative therapies. Using a nonjudgmental approach, you may wish to start with the question, “What else have you tried?”

From Fashner et al, 2012.

Family Relationships Family structure and the social organizations to which a patient belongs (e.g., faith-based organizations, clubs, and

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One type of already-known behavior may predict another type of behavior. For example, low-income urban mothers who take advantage of appropriate prenatal care generally take advantage of appropriate infant care, regardless of educational level (Van Berckelaer et al, 2011). Adolescents who are not monitored by their parents are more likely to smoke, use alcohol and marijuana, be depressed, and initiate sexual activity than are those who are monitored (Dittus et al, 2015; Pesola et al, 2015). Being aware of this sequence of related behaviors is especially important because it may be unrelated to the integrity of the family structure, gender, or background. Parenting style and childrearing practices such as setting boundaries and expectations may be cultur- ally driven. Many adolescents and young adults find comfort in their families’ cultural traditions and practices and benefit from their connectedness. In a large study of U.S. college students from immigrant families, compared with their peers, students who retained their heritage practices reported fewer health risk behaviors such as substance use, unsafe sex, and impaired driving (Schwartz et al, 2011). These examples remind us that one individual may belong to many subgroups and that the behaviors and attitudes of a subgroup—for example, a young man who remains con- nected to his cultural heritage—can override the impact of the cultural values of the larger group (e.g., youth whose peers are engaged in risk-taking behaviors).

Diet and Nutritional Practices Beliefs and practices related to food, as well as the social significance of food, play an obvious vital role in everyday life. Some of these beliefs of cultural and/or faith-based significance may have an impact on the care you provide to patients. An Orthodox Jewish patient will not take some medicines, particularly during a holiday period like Passover, because the preparation of a drug does not meet the religious rules for food during that time. A patient who is Muslim must respect Halal (prescribed diet), even throughout pregnancy. A Chinese person with hypertension and a salt-restricted diet may need to consider a limited use of monosodium glutamate (MSG) and soy sauce. Attitudes toward vitamins vary greatly, with or without scientific proof, in many of the subgroups in the United States. It is still possible to work out a mutually agreed-on management plan if the issues are recognized and freely discussed. This is also possible with attitudes toward home, herbal, and natural—complementary or alternative—therapies. Many will have benefit; others may be dangerous. For example, some herbal medications containing cassia senna may cause liver damage, and other herbal preparations interact with prescribed medications (Posadzki et al, 2013).

Summing Up As healthcare providers, we face a compelling need to meet each patient on his or her own terms and to resist forming a sense of the patient based on prior knowledge of the race, religion, gender, ethnicity, sexual identity and orientation, or

schools) are among the many imprinting and constraining cultural forces. The expectations of children and how they grow and develop are key in this regard and often culturally distinct. Determining these family and social structures needs emphasis in the United States today, with its shift toward dual-income families, single-parent families, and a significant number of teenage parents. The prevalence of divorce (nearly one for every two marriages) and the increasing involvement of both parents in child care in two-parent families suggest cultural shifts that need to be recognized.

Modified from Purnell, 2013.

BoX 2.6 The Balance of Life: The “Hot” and the “Cold”

A naturalistic or holistic approach often assumes that there are external factors—some good, some bad—that must be kept in balance if we are to remain well. The balance of “hot” and “cold” is a part of the belief system in many cultural groups (e.g., Middle Eastern, Asian, Southeast Asian, and Hispanic). To restore a disturbed balance, that is, to treat, requires the use of opposites (e.g., a “hot” remedy for a “cold” problem and vice versa). Different cultures may define “hot” and “cold” differently. It is not a matter of temperature, and the words used might vary: for example, the Chinese have named the forces yin (cold) and yang (hot). The bottom line: We cannot ignore the natu- ralistic view if many of our patients are to have appropriate care.

Hot and Cold Conditions and Their Corresponding Treatments

COLD CONDITIONS

HOT TREATMENTS

HOT CONDITIONS

COLD TREATMENTS

CONDITIONS FOODS CONDITIONS FOODS

Cancer Cold Earaches Headaches Joint pain Malaria Menses Pneumonia Stomach

cramps Teething Tuberculosis

Beef Cereals Chili peppers Chocolate Eggs Goat’s milk Liquor Onions Peas

Constipation Diarrhea Fever Infection Kidney

problems Rash Sore throat

Barley water Chicken Dairy products Fresh vegetables Fruits Honey Goat meat Raisins

MEDICINES AND HERBS

MEDICINES AND HERBS

Anise Aspirin Castor oil Cinnamon Cod liver oil Garlic Ginger root Iron Tobacco Penicillin Vitamins

Bicarbonate of soda

Milk of Magnesia Orange flower

water Sage

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patients and display genuine curiosity about their beliefs and values, you will be making strides toward cultural competence. The U.S. Department of Health and Human Services Office of Minority Health provides continuing education, resources, and tools through the “Think Cultural Health” initiative (https://www.thinkculturalhealth.hhs.gov). The RESPECT model is one useful tool to bridge the cultural divide between patients and healthcare providers (Fig. 2.3).

It is not unusual to find tables of information about healthcare–related cultural attitudes for a variety of religious and ethnic groups in reference materials. Although this provides quick access to information about various

culture(s) from which that patient comes. That knowledge should not be formative in arriving at conclusions; rather, we must draw on it to help make the questions we ask more constructively probing to avoid viewing the patient as a stereotype (Box 2.7). You need to understand yourself well. Your involvement with any patient gives that interaction a unique quality, and your contribution to that interaction, to some extent, makes it different from what it might have been with anyone else. Remember that your attitudes and prejudices, which are largely culturally derived, may interfere with your understanding of the patient and increase the probability of unconscious bias and stereotypic judgment. When you’re able to adapt to the unique needs of your

BoX 2.7 Communication

This list of questions, derived over the years from our experience and multiple resources, illustrates the variation in human responses. Try not to be intimidated by the mass of “need to know” cultural issues, but begin reflecting on them as you work with patients to raise your cultural awareness and develop a greater sense of cultural humility. • How important are nonverbal clues? • Are moments of silence valued? • Is touching to be avoided? • Are handshakes, or even embracing, avoided or desired at meeting

and parting? • What is the attitude toward eye contact? • Is there a greater than expected need for “personal space”? • What is the verbal or nonverbal response if your suggestions are

not understood? • Is there candor in admitting lack of understanding? • What are the attitudes concerning respect for self and for authority

figures? • What are the attitudes toward persons in other groups, such as

minorities, majorities? • What are the language preferences? • What is the need for “chit-chat” before getting down to the primary

concern? • Is there a relaxed or rigid sense of time? • What is the degree of trust of healthcare professionals? • How easily are personal matters discussed? • Is there, even with you, a wish to avoid discussing income and other

family affairs?

Health Customs/Health Practices • What is the degree of dependence on the healthcare system, for

illness alone or also for preventive and health maintenance needs? • What is generally expected of a health professional and what defines

a “good one?” • What defines health? • Are there particularly common folk practices? • Is there a greater (or lesser) inclination to invoke self-care and use

home remedies? • Is there a particular suspicion or fear of hospitals? • What is the tendency to use alternative care approaches and/or

herbal remedies exclusively or as a complement? • What are the tendencies to invoke the magical or metaphysical? • Who is ultimately responsible for outcomes, you or the patient?

• Who is ultimately responsible for maintaining health, you or the patient?

• Is there a particular fear of painful or intrusive testing? • Is there a tendency toward stoicism? • What is the dependence on prayer? • Is illness thought of as punishment and a means of penance? • Is there “shame” attached to illness? • What is the belief about the origins of illness? • Is illness thought to be preventable and, if so, how? • What is the attitude toward autopsy? • Does a belief in reincarnation mandate that the body be left intact? • Are there particular cultural cooking habits that can influence diagnosis

or management? • Is the degree of modesty in both men and women more than you

would generally expect? • Do women, considering modesty, need a much more cautious and

protected approach than usual—for example, during the examination?

Family, Friends, and the Workplace • How tightly organized (and multigenerational) is the family

hierarchy? • How tight is the family? • Is social life extended beyond the family and, if so, to what degree? • Does the family tend to be matriarchal or patriarchal? • What are the relative roles of women and men? • Are there particular tasks assigned to individual genders—for example,

who does the laundry, family finances, grocery shopping? • To what extent are older adults and other authority figures given

deference, and how? • Who makes decisions for the family? • To what extent is power shared? • Who makes decisions for the children and adolescents? • How strongly are children valued? • Is there a greater value placed on one of the genders? • How much are self-reliance and personal discipline valued? • What is the work ethic? • What is the sense of obligation to the community? • How is education sought, that is, from school, reading, and/or

experience? • What is the emphasis on tradition and ritual practice?

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to meet your patients. Patient by patient, your insights will develop as you avoid stereotypes, consider the individual, and become increasingly culturally competent. View cultural competence as a lifelong journey and not a destination or endpoint in and of itself.

population groups, our experience suggests that the rigid superficiality in this information often does not adequately describe the beliefs and attitudes of a particular individual. Our purpose in this chapter is to review many of the ques- tions and frameworks that might be relevant as you prepare

Guide to Providing Effective Communication and Language Assistance Services www.ThinkCulturalHealth.hhs.gov

The RESPECT Model

What is most important in considering the effectiveness of your cross-cultural communication, whether it is verbal, nonverbal, or written, is that you remain open and maintain a sense of respect for your patients. The RESPECT Model1 can help you remain effective and patient- centered in all of your communication with patients.

apport • Connect on a social level • See the patient’s point of view • Consciously suspend judgment

Recognize and avoid making assumptions

mpathy • Remember the patient has come to you for help • Seek out and understand the patient’s rationale for his/her behaviors and

illness • Verbally acknowledge and legitimize the patient’s feelings

upport • Ask about and understand the barriers to care and compliance • Help the patient overcome barriers; Involve family members if appropriate • Reassure the patient you are and will be available to help

artnership • Be flexible • Negotiate roles when necessary • Stress that you are working together to address health problems

xplanations • Check often for understanding • Use verbal clarification techniques

ultural

competence

• Respect the patient’s cultural beliefs • Understand that the patient’s views of you may be defined by ethnic and

cultural stereotypes • Be aware of your own cultural biases and preconceptions • Know your limitations in addressing health issues across cultures • Understand your personal style and recognize when it may not be working

with a given patient

rust • Recognize that self-disclosure may be difficult for some patients; Consciously

work to establish trust

FIG. 2.3 The RESPECT Model.