cultural diversity and health care. we all have it! we all have it! obvious manifestations: obvious...

Cultural Diversity and Health Cultural Diversity and Health CareCare


We All Have It!We All Have It! Obvious Manifestations:Obvious Manifestations:

ReligionReligion Ethnicity (Race?)Ethnicity (Race?) National Origin (language)National Origin (language) GenderGender


Less Obvious Manifestations:Less Obvious Manifestations: AgeAge EducationEducation Educational StatusEducational Status Mobility (including handicaps)Mobility (including handicaps)


What is Culture?What is Culture? Definition: the sum total of the way of Definition: the sum total of the way of

living; includes values, beliefs, living; includes values, beliefs, standards, language, thinking standards, language, thinking patterns, behavioral norms, patterns, behavioral norms, communications styles, etc. Guides communications styles, etc. Guides decisions and actions of a group decisions and actions of a group through time.through time.


Expressions of Culture in Health CareExpressions of Culture in Health Care

Health Belief SystemsHealth Belief Systems

Define and categorize health and illnessDefine and categorize health and illness Offer explanatory models for illnessOffer explanatory models for illness Based upon theories of the relationship between Based upon theories of the relationship between

cause and the nature of illness and treatmentscause and the nature of illness and treatments Defines the specific “scope” of practice for healersDefines the specific “scope” of practice for healers


The Culture of Western MedicineThe Culture of Western Medicine Meliorism – make it betterMeliorism – make it better Dominance over nature – take controlDominance over nature – take control Activism – do somethingActivism – do something Timeliness – sooner than laterTimeliness – sooner than later Therapeutic aggressiveness – Therapeutic aggressiveness –

stronger=betterstronger=better Future orientation – plan, newer=betterFuture orientation – plan, newer=better Standardization – treat similar the sameStandardization – treat similar the same


““Ours”Ours” Make it BetterMake it Better Control Over NatureControl Over Nature Do SomethingDo Something Intervene NowIntervene Now Strong MeasuresStrong Measures Plan Ahead – Plan Ahead –

Recent is BestRecent is Best Standardize – Treat Standardize – Treat

Everyone the SameEveryone the Same

““Others”Others” Accept With GraceAccept With Grace Balance/Harmony Balance/Harmony

with Naturewith Nature Wait and SeeWait and See Cautious DeliberationCautious Deliberation Gentle ApproachGentle Approach Take Life As It Comes Take Life As It Comes

– “Time Honored”– “Time Honored” Individualize – Individualize –

Recognize DifferencesRecognize Differences


Cultural Competence – DefinitionCultural Competence – Definition

A set of congruent A set of congruent behaviors, practices, behaviors, practices, attitudes and policiesattitudes and policies that come that come together in a system or agency or together in a system or agency or among professionals, enabling among professionals, enabling effective work to be done in cross-effective work to be done in cross-cultural situationscultural situations


The Cultural Competence The Cultural Competence ContinuumContinuum

Where Am I Now?Where Am I Now? Where Could I Be?Where Could I Be?

The Cultural Competence The Cultural Competence ContinuumContinuum


Cultural Competence DefinitionsCultural Competence Definitions Cultural DestructivenessCultural Destructiveness: forced : forced

assimilation, subjugation, rights and assimilation, subjugation, rights and privileges for dominant groups onlyprivileges for dominant groups only

Cultural IncapacityCultural Incapacity: racism, maintain : racism, maintain stereotypes, unfair hiring practicesstereotypes, unfair hiring practices

Cultural BlindnessCultural Blindness: differences : differences ignored, “treat everyone the same”, ignored, “treat everyone the same”, only meet needs of dominant groupsonly meet needs of dominant groups


Cultural Competence DefinitionsCultural Competence DefinitionsCultural Pre-competenceCultural Pre-competence: explore cultural : explore cultural

issues, are committed, assess needs of issues, are committed, assess needs of organization and individualsorganization and individuals

Cultural CompetenceCultural Competence: recognize individual : recognize individual and cultural differences, seek advice from and cultural differences, seek advice from diverse groups, hire culturally unbiased staffdiverse groups, hire culturally unbiased staff

Cultural proficiencyCultural proficiency: implement changes to : implement changes to improve services based upon cultural improve services based upon cultural needs, do research and teachneeds, do research and teach


Acquiring Cultural CompetenceAcquiring Cultural Competence

Starts with AwarenessStarts with Awareness Grows with KnowledgeGrows with Knowledge Enhanced with Specific SkillsEnhanced with Specific Skills Polished through Cross-Cultural Polished through Cross-Cultural

EncountersEncounters

The Explanatory Model The Explanatory Model Arthur Kleinman, Ph.D.Arthur Kleinman, Ph.D.

Culturally sensitive approach to asking Culturally sensitive approach to asking inquiring about a health probleminquiring about a health problem

What do you call your problem?What do you call your problem? What do you think caused your problem?What do you think caused your problem? Why do you think it started when it did?Why do you think it started when it did? What does your sickness do to you? How What does your sickness do to you? How

does it work?does it work? How severe is it? How long do you think you How severe is it? How long do you think you

will have it?will have it?(continued next page)(continued next page)

The Explanatory Model The Explanatory Model Arthur Kleinman, Ph.D.Arthur Kleinman, Ph.D.

Culturally sensitive approach to Culturally sensitive approach to asking about a health problemasking about a health problem What do you fear most about your illness?What do you fear most about your illness? What are the chief problems your sickness What are the chief problems your sickness

has caused you?has caused you? Anyone else with the same problem?Anyone else with the same problem? What have you done so far to treat your What have you done so far to treat your

illness: What treatments do you think you illness: What treatments do you think you should receive? What important results do should receive? What important results do you hope to receive from the treatment?you hope to receive from the treatment?

Who else can help you?Who else can help you?

The The LEARNLEARN Model ModelBerlin and FowkesBerlin and Fowkes

LListenisten to the patient’s perception of to the patient’s perception of the problemthe problem

EExplainxplain your perception of the your perception of the problemproblem

AAcknowledge cknowledge and discuss and discuss differences/similaritiesdifferences/similarities

RRecommendecommend treatment treatment

NNegotiateegotiate treatment treatment

Working with InterpretersWorking with Interpreters

QualificationsQualifications Bilingual, bicultural, understands Bilingual, bicultural, understands

English medical vocabularyEnglish medical vocabulary Comfort in the medical setting, Comfort in the medical setting,

understands significance of the health understands significance of the health problemproblem

Preserves confidentialityPreserves confidentiality


Multiple Roles:Multiple Roles:

Translator of LanguageTranslator of Language Culture BrokerCulture Broker Patient Advocate: Convey Patient Advocate: Convey

expectations, concernsexpectations, concerns


Use language to identify the Use language to identify the interpreter as the go-between, not interpreter as the go-between, not as the person to be blamed, e.g., as the person to be blamed, e.g., the interpreter might say, “The the interpreter might say, “The doctor has ordered tests and this is doctor has ordered tests and this is what he says”what he says”


Translation factorsTranslation factors Language: how are new words created?Language: how are new words created?

Navajo: Penicillin = “the strong white medicine shot Navajo: Penicillin = “the strong white medicine shot you get for a cold”you get for a cold”

Minimize jargon, e.g., “machine to look at Minimize jargon, e.g., “machine to look at your heart” instead of “EKG”your heart” instead of “EKG”

Nonverbal communication = 60% of all Nonverbal communication = 60% of all communicationcommunication

Nodding may indicate politeness, not Nodding may indicate politeness, not comprehensioncomprehension

Bilingual interviewing takes at least twice as Bilingual interviewing takes at least twice as long as monolingual interviews!long as monolingual interviews!

Caretakers’ Caretakers’ ResponsibilitiesResponsibilities

Learn and use a few phrases of greeting Learn and use a few phrases of greeting and introduction in the patient’s native and introduction in the patient’s native language. This conveys respect and language. This conveys respect and demonstrates your willingness to learn demonstrates your willingness to learn about their culture.about their culture.

Tell the patient that the interpreter will Tell the patient that the interpreter will translate everything that is said, so they translate everything that is said, so they must stop after every few sentences.must stop after every few sentences.


When speaking or listening, watch the When speaking or listening, watch the patient, not the interpreter. Add your patient, not the interpreter. Add your gestures, etc. while the interpreter is gestures, etc. while the interpreter is translating your message.translating your message.

Reinforce verbal interaction with visual Reinforce verbal interaction with visual aids and materials written in the client’s aids and materials written in the client’s language.language.

Repeat important information more than Repeat important information more than once.once.

(continued on next page)(continued on next page)


Always give the reason or purpose for a Always give the reason or purpose for a treatment or prescription.treatment or prescription.

Make sure the patient understands by Make sure the patient understands by having them explain it themselves.having them explain it themselves.

Ask the interpreter to repeat exactly what Ask the interpreter to repeat exactly what was said.was said.

Personal information may be closely Personal information may be closely guarded and difficult to obtain.guarded and difficult to obtain.

Patient often request or bring a specific Patient often request or bring a specific interpreter to the clinic.interpreter to the clinic.

(continued on next page)(continued on next page)


In some cultures it may not be In some cultures it may not be appropriate to suggest making a will for appropriate to suggest making a will for dying patients or patients with terminal dying patients or patients with terminal illnesses; this is the cultural equivalent illnesses; this is the cultural equivalent of wishing death on a patient.of wishing death on a patient.

Avoid saying “you must... Instead teach Avoid saying “you must... Instead teach patients their options and let them patients their options and let them decide, e.g., “some people in this decide, e.g., “some people in this situation would...”situation would...”


It is because we are different It is because we are different that each of us is special.that each of us is special.

ReferencesReferences

Putsch III RW. Cross-cultural Putsch III RW. Cross-cultural communication: The special case communication: The special case of interpreters in health care. JAMA of interpreters in health care. JAMA 1985;254(23):3344-481985;254(23):3344-48

Sockalingum adapted from Hayes, Sockalingum adapted from Hayes, Cultural Competence Continuum, Cultural Competence Continuum, 1993 and Terry Cross Cultural 1993 and Terry Cross Cultural Competency Continuum.Competency Continuum.

cultural diversity and health care. we all have it! we all have it! obvious manifestations: obvious...

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