Transcultural Considerations in Health Assessment

What is culture?

• The sum total of socially inherited characteristics of a human group that comprises everything which one generation can tell, convey, or hand down to the next

• The sum of beliefs, practices, habits, likes, dislikes, norms, customs, rituals, and so forth that we learned from our families during the years of socialization (Spector, 2009)

Characteristics of culture

Culture is:• Learned from birth through the process of

language acquisition and socialization• Shared by all the members of the same cultural

group• Adapted to specific conditions related to

environmental and technical factors and the availability of resources

• Dynamic and ever-changing

Cultural competence• The complex integration of

knowledge, attitudes and skills which enhance cross-cultural communication, and promote meaningful interactions with patients

• Enables you to provide culturally appropriate, congruent and relevant health care that affirms the worth and dignity of your patients

• Is NOT assuming what a person’s culture is based on their race, ethnicity, or national origin

Challenges• Ethnocentrism: the tendency to view your own way of

life as the most desirable, acceptable or best, and to act in a superior manner toward other cultures’ lifeways.

• Cultural imposition: the tendency to impose your beliefs, values and patterns of behavior on individuals from another culture

• Xenophobia: Fear or contempt of strangers or foreigners, especially as reflected in one’s political or cultural views

Cultural humility

• Starts with examining your own assumptions and beliefs—what worldview and goals do YOU bring to the clinical encounter?

• The biggest barrier is NOT lack of knowledge of the details of different cultures’ beliefs but lack of self-awareness and respect for other points of view

• Developing the skills to examine the differences will help you in any clinical encounter!

Cultural diversity

• Traditional focus is on: How are others different from me?

• Consider instead: How am I different from the other person?

“These other cultures are not failed attempts to be us; they are unique manifestations of the spirit”—Wade Davis

Cultural blindness

• The belief that race, ethnicity, and culture make no difference in how health care services are provided

• Ignores the assets and strengths of cultures different from one’s own

• May place blame on the individual receiving care for bad outcomes

“We treat all of our patients the same.”

Cultural Health Assessment

• A systematic examination of health-related cultural beliefs, values, and practices of individuals, families, groups, and communities

• Can be comprehensive or focused depending on the circumstances

Health-related beliefs and practices

In order to understand the health care needs of others:• One needs to confront one’s own biases,

preconceptions and prejudices about specific racial, ethnic, religious or socioeconomic groups

• One must identify the meaning of health to the client, remembering that concepts are derived in part from the way in which members of their cultural group define health

Levels of cultural competency

• Destructiveness• Incapacity• Blindness• Pre-Competence• Competence• Proficiency

Let’s play Jeopardy!

The answer is:

The Land of the Free&

The Home of the Brave

Now… think!

Why it’s important

• The US is becoming more and more culturally diverse

• It goes beyond respect for the patient’s beliefs and lifeways

• Culturally incompetent care affects outcomes• People of non-dominant cultures are more likely

to delay care and to receive substandard care• Misunderstandings can be fatal!

What does this image evoke?

Immigrants to Ellis Island

Language barriers

• Fluent provider• Competent in-person translation services• Telephone translation• Family members should not be used—especially

children!

80.3

3.0

3.7

12.2 0.8

English Only Asian/Pacific Islander

Other Indo-European Spanish

Other

Percent of US population age 5 and older by language spoken at home

Language translation

• Mandated by law for agencies using federal/state funding as well as by JCAHO

• This funding includes Medicaid and Medicare, so it applies to just about every health care agency!

• Remember that this is only the beginning of culturally appropriate care!

Subculture

Used for fairly large aggregates of people who have shared characteristics that are not common to all members of the culture and that enable them to be thought of as a distinguishable group

Examples of subculture: these can be based on:• Ethnicity

• Blacks• Latinos• Native Americans

• Religion• Jews• Buddhists• Catholics• Mormons• Muslims

Subculture continued• Occupation

• Nurses• Doctors• Military

• Health care characteristic• The Blind• The Deaf Community

• Age (adolescents, older adults)• Gender or sexual preference (women, men,

gay men, lesbians, and transgender individuals)

Basic human problems culture attempts to address:• Innate nature of people• Relationship to nature: destiny,

harmony, mastery• Time dimension: past, present or

future oriented• Purpose of existence: being, being in

becoming, doing• Relationship with others: lineal,

lateral, individual

Time orientation: monochronic• Prefer to complete one task

at a time• Task-oriented time (work) is

separate from socio-emotional time (play)

• Value punctuality, completing tasks, keeping to schedules

• Ex: United States, Israel, Germany, Switzerland

Time orientation: polychronic

• More flexible about schedules and deadlines

• Integrate task-oriented and socio-emotional activities

• Maintaining relationships is more important than accomplishing tasks

• Ex: Latin America, Middle East, Africa

High vs. low context

High context• Little meaning without

surrounding context• Indirect, embellished• Process-oriented• Disagreement is

personalized, consensus is valued

• Effectiveness

Low context• Focus is on what is

explicitly written or said• Direct, economical• Task-oriented• Disagreement is

depersonalized• Efficiency

Definitions• Values: refers to a desirable or

undesirable state of affairs (Leininger, 1995)

• Norms: • Rules by which human

behavior is governed • Result from the cultural values

held by the group• Individuals are rewarded or

punished as they conform to or deviate from the established norms.

Definitions

• Religion refers to an organized system of beliefs concerning the cause, nature and purpose of the universe, especially belief in or the worship of God or gods

• Spirituality is born of each person’s unique life experience and his or her personal effort to find purpose and meaning in life

Types of families

• Nuclear: husband, wife and children• Extended: nuclear plus blood relations and

others• Blended: husband, wife and children from

previous relationships• Single parent• Communal: group of men, women and children• Cohabitation: unmarried man and woman• Gay/lesbian“The family is who they say they are”

Cause of illness• Biomedical: based on the assumption that all

events in life have a cause and effect and that all of reality can be defined and measured

• Naturalistic: human life is only one aspect of nature and that the forces of nature must be kept in natural balance or harmony

• Magico-religious: the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good and evil

Sources of healing

• Self-treatment• Lay or folk healing systems• Spiritual or religious healing• Scientific biomedicine• Transcultural expression of illness: pain, sadness,

somaticization• Examples of traditional health and illness beliefs

and practices (Jarvis, p. 49)• Culture-Bound Syndromes (review Jarvis, p. 50)

Religious groups and death beliefs

Religious Group

Heaven Resurrection Cremation

Assembly of God

Real place Of the body Not encouraged

Baptists Where the redeemed go

Physical Allowed but not encouraged

Buddhists No independent existence

No future foreseen-belief in reincarnation

Preferred

Religious groups and death beliefs

Religious Group

Heaven Resurrection Cremation

Muslims Several layers usually seen

Afterlife as physical pains and pleasures

Not practiced

Roman Catholics

A condition: eternal fullness of life

Physical Disposal of the body does not affect afterlife

Seventh-day Adventists

Heaven exists

Body and spirit Yes

The Kleinman Model

1. What do you call the problem?2. What do you think has caused the problem?3. Why do you think it started as it did?4. What do you think the sickness does? How does it work?5. How severe is the sickness? Will it have a short or a long

course?6. What kind of treatment do you think you should receive?

What are the most important results you hope to receive from the treatment?

7. What are the chief problems the sickness has caused?8. What do you fear most about the sickness?

References• Andrews, M. A., Bolye, J. S (2008). Transcultural Concepts in Nursing Care

(5th ed.). Philadelphia: Lippincott Williams & Wilkins• Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and adverse

events in US hospitals: a pilot study. International Journal of Quality in Health Care. 2007 Apr;19 (2): 60-67. Epub2007 Feb 2

• Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus, and Giroux.

• O’Hara-Devereaux, M., Johansen, R. Transcending cultural barriers: Context, relationships, and time. Retrieved January 28, 2012, from http://www.csub.edu/TLC/options/resources/handouts/fac_dev/culturalbarries.html

• Rankin, S. H., Stallings, K. D., & London, F. (2004). Patient Education in Health and Illness (5th ed.). Philadelphia: Lippincott Williams & Wilkins

• Spector, R. E. (2009). Cultural diversity in health & illness. (7th ed.). Upper Saddle River: Prentice Hall.