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Learning Objectives
Introduction
Definitions
General Information
Examples of Potential Differences in Values
Gaining Accurate Information
General Information About Cultures
Minority Populations
Recently Immigrated Minorities
Non-Verbal Communication
Verbal Communication
For More Information
References
Self-Reflection Picture Exercises
Self-Reflection Exercises
Team Exercises
Case Histories
Working with Interpreters
At the conclusion of this section, participants will be able to:
There has been a dramatic increase in the ethnic and racial minority population in the United States in recent decades. As a result of these changes, clinicians are providing health care services in multicultural environments where patients and providers may be of different cultures, traditions, and even languages. These differences can serve as barriers to effective health care service delivery. Most patients prefer to be seen by a health care provider who shares his or her culture but this is not always possible. The challenge is to provide health care services across cultural boundaries in a competent and sensitive manner.
There are examples in the medical literature documenting that culturally insensitive care may have a profound negative impact on the health of minority populations. Likewise, studies have underlined the positive impact of culturally competent care. Knowledge of the history of the community and respect for cultural differences relevant to the community helps to gain access, develop cooperative alliances, and communicate more effectively. An absence of culturally sensitive and acceptable treatment models, along with poverty, has been identified as a major reason why some populations are underserved by traditional medicine and public health programs.
The Washington metropolitan area has a diverse multicultural population. For more information follow this link: WASHINGTON, DC
Many definitions of cultural competence are emerging in the literature yet none is accepted as the "gold standard". The term "cultural competence" embodies the knowledge, attitudes, skills, and protocols that allow an individual or system to render services across cultural lines in an optimal manner. Cultural competency permits individuals to respond with respect and empathy to people of all cultures, classes, races, religions and ethnic backgrounds in a manner that recognizes, affirms and values the worth of individuals, families, and communities. It has been characterized as a continuum that encompasses several stages which include:
Several culture-related terms used in the scientific literature include:
biculturalism
- the simultaneous identification with two cultures
cross cultural- interaction between individuals from different cultures
culture - the shared values, norms, traditions, customs, arts, history,
folklore and institutions of a group of people
cultural diversity - differences in race, ethnicity, language, nationality
or religion
ethnicity - belonging to a common group with shared heritage, often
linked by race, nationality and language
race - a socially defined population that is derived from distinguishable
physical characteristics that are genetically determined
Health professions
students involved in service-learning will need to become attuned to issues
of language, culture and ethnicity in the context of the communities they
serve. They will need to begin developing the key attitudes, skills, and knowledge
which will enhance their community-based activities. Cultures vary in their
beliefs of the cause, prevention, and treatment of illness. These beliefs
dictate the practices used to maintain health. The value of "good health"
is also variable. Too often we interpret the behavior of others as negative
because we don't understand the underlying value system of their culture.
The natural tendency is to assume that our own values or customs are more
sensible and right.
The following list provides a general comparison of traditional American values
with values commonly found in some other cultures.
| Traditional American Values | Other Cultures Values |
| Personal control over environment | Fate, Destiny, "God's will" |
| Change and variety | Tradition |
| Competition | Cooperation |
| Individualism | Group Welfare |
| Future orientation | Past orientation |
| Directness | Indirectness/"In Your Face"" |
| Informality | Formality |
| Time importance | Human interaction importance |
| Duration of life | Quality of life |
| Nuclear family | Extended family |
Participants
and health-care staff may differ on the value of time. Most of us are ruled
by time schedules. If "being on time" and "not wasting time"
are not familiar concepts to the participant, a 9 o'clock appointment may
not be kept until 10 or 11 o'clock. Many cultures mark time by major events-births,
deaths, marriages-that repeat themselves throughout the life cycle. Many Western
cultures mark time in a precise, linear system that is oriented toward work,
future, and money.
Decisions regarding medical screening and treatment might not be decided by
the individual, but by group or family agreement. Some cultures put a high
degree of trust in the personal physician regarding all health matters.
For some ethnic groups, respect for authority and politeness in public may
prevent a person from raising questions or participant may make an effort
to "please" us.
Many cultures accord great respect to the elderly. This can affect how one
is perceived and how well materials or programs are accepted in the community.
A participant also may be uncomfortable with your sex, educational level or
race.
For some cultures a person is not defined or named individually but in relation
to their parents or spouse. They do not have an individual identity.
Some cultures do not speak in positive terms about a spouse, children, or
possessions because they feel it brings attention which could cause bad luck.
Oral communication is frequently the most important mode of information transfer.
A participant may not be literate in English or his/her native language.
A participant may have different standards about the appropriateness of being
asked for certain types of information (e.g., income data, functional status
data, sexual information). Consider using teams, for example both a male and
a female, to question participant. Emphasize that while some questions may
not be appropriate to them, they have to be asked of everyone.
Direct questioning may be considered an inappropriate means of questioning.
Information may need to be gathered indirectly.
There are many reasons why a participant of a different culture may not provide you with accurate information.
Lack of trust
May be unfamiliar with standardized questions, multiple response options,
rating scales, or "skip to" item designations.
May be wary of researchers misusing information. Explain that sensitive information
will not be reported at the individual level; only group data will be reported.
May perceive research as a form of exploitation in which non-minority individuals
reap the benefits. Emphasize the importance and value to the community of
the data to be collected and how it will help.
May be concerned about being used as a "guinea pig" in research.
May believe that only minorities should study minority populations.
There is a tendency
to view groups, e.g., African-Americans, Hispanic, Asians, older patients,
and people with special needs as monolithic, and to focus on the limitations
rather than on the strengths of their culture and their community.
Precautions
General characterizations
may not apply to all minorities or all people from a minority group.
Published statistics and information on minority communities may not be accurate.
Check on:
Silence.
You may view silence as awkward, however, other cultures are quite comfortable
with periods of silence.
Distance.
The most comfortable physical distance between you and another person varies
from culture to culture. The typical American generally prefers to be about
an arm's length distance away form another person. Hispanics usually prefer
closer proximity than most Americans. Allow the other person to establish
the proper distance for the interaction.
Eye Contact.
The amount of eye contact that is comfortable varies with each culture. Many
Americans are brought up to look people straight in the eye. However, some
cultures have been taught not to make eye contact. Staring is considered impolite
in some groups. However, if you avoid eye contact, or break eye contact too
frequently it may be misinterpreted by the participant as disinterest. Sitting
next to someone, rather than directly across from them, will reduce eye contact.
Facial Expression. Expression of emotion between people of different cultures
varies from very expressive, as with Hispanics, to total non-expressiveness,
as with Asians. Many Americans have a tendency to regard people who are more
expressive as immature and those with less expression as unfeeling.
Body Language.
The position, gestures, and motion of the body can be interpreted differently
depending on the culture. The use of hands is a common vehicle for nonverbal
expression. A firm handshake may be a positive gesture of goodwill in the
Anglo-American culture, but some other cultures prefer only a light touch.
Many cultures use handshakes more frequently than do most Americans, some
even as a greeting between husband and wife. Standing with hands on hips may
imply anger to some participants. Pointing or beckoning with a finger may
appear disrespectful to some cultures. Conservative use of body language is
wise when you are uncertain as to what is appropriate within a cultural group.
Observing actions and interactions may give you direction. Being open with
participants and asking general questions about body language can also help.
How you speak is as important as what you say in cross-cultural interactions. Often we mistakenly assume that a louder voice is clearer and therefore more easily understood. Avoid slang and technical jargon.
Formality.
Anglo-Americans tend to be informal in their verbal communication, but
some other cultures prefer to keep a relationship more formal. Many other
cultures may view being addressed by their first name as too familiar and
may infer disrespect. Asking how someone prefers to be addressed is the easiest
solution, or assume formality when in doubt.
Follow this link for Community Toolbox whose mission is "Promoting community health and development by connecting people, ideas and resources." Has additional links.
Follow this link for Ethnic Medicine for information about cultural beliefs, medical issues and other related issues pertinent to the health care of recent immigrants to Seattle, many of whom are refugees fleeing war-torn parts of the world. Has some specific article links.
Follow this
link for Cultural
Information at Galaxy for information about different ethnic and religious
groups, immigration, world communities, resources for diversity and community
development. Has additional links.
Follow this link for Diversity RX,
promoting language and cultural competence to improve health care for minority,
immigrant and ethnically diverse communities. Has additional links.
Follow this link to The Implicit Association Test IAT to begin to understand how we respond unconsciously and automatically to someone based on appearance.
Campbell, F (ed) "Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Communities", Cultural Competence Series 1, US Dept. of Health and Human Services, 1995
Like R, et al.; "Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Care"; Family Medicine 1996:27:291-7
Women's Health Initiative
Manual: Volume 2-Procedures, pp20.1-20.14, 1994, adapted from: "Cross
Cultural Counseling: A guide for Nutrition and Health Counselors.", USDA,
US Department of HHS, FHN 250, 1986
Look at the following pictures. Before you read the information available at each link, ask yourself if you have already made assumptions about the person.
Picture 1
Picture 2
Picture 3
Picture 4
Define yourself
ethno-culturally (include race, culture, ethnicity)
In your culture, what factors determine illness? (pathogens, fate, lack of
balance...)
Who are considered the "healers" or health care providers in your
culture?
This exercise does not require you to send a response. It is to help you begin
thinking about the prejudices and assumptions you may have. Sometimes we start
an interaction with ideas already established as to a person's educational
level, employment status, beliefs, etc. Consider discussing your reactions
with your team.
Consider these exercises as you discuss cultural competencies with your team mates.
Define your
project community ethno-culturally.
What cultural similarities and differences have you identified between the
team and the community:
How was your project designed to incorporate these cultural factors?
You may want to consider these case histories as you discuss cultural competence with your team mates. Consider how cultural issues related to each of these case histories.
Complete the following exercises, regarding the impact of cultural issues on patients, using sample case scenarios.
Language
Assistance Resources
Clinics
may use a combination of resources to provide language assistance, including:
1.
Bilingual staff, which may not be sufficient if patients usually include
several language groups.
2.
Staff interpreters, especially where there is a very large presence in a
few major language groups.
3.
Volunteer staff or community interpreters. This is especially cost-effective but can be
disorganized. Community-based organizations also can review translated materials
to ensure that they are accurate and easily understood.
4.
Contract with an outside interpreter service. This may be an option for small clinics or offices,
where there is a small "limited English proficiency" (LEP) population or
there are some less common LEP language groups.
5.
Use a telephone interpreter service, such as the AT&T Language Line,
as a supplemental system for a language not usually encountered. These services may not always have readily available
interpreters who are familiar with the specialized medical terminology.
6.
Use of patient's family or friend. This is usually the least appropriate because
the person is untrained, may not understand specialized terminology, and
has no obligation to maintain confidentiality.
His or her presence, especially if it is a child, may obstruct the
flow of confidential, intimate, medical information or details of family
life to the provider or explicit explanations from a provider to the patient.
(http://www.hhs.gov/ocr/lep/guide.html)
The
Interpreter's role is seen as a flexible gradient, ranging from the least
intrusive and interactive "neutral" transmitter, to conduit or clarifier,
to culture broker and finally, to the most intrusive role of advocate.
The
"traditional neutral interpreter" role only provides accurate transmissions,
conversions from one language to another, without being active in the social
encounter.
The
more "active and engaged" roles of an interpreter are usually when the interpreter
is a part of the patient community, helping to "facilitate" the "intended
meaning" of the messages between two people. The interpreter potentially is an active member
of the social encounter with the provider and the patient.
"We
have to think of ourselves as being part of the community.
We have to think about the people that we are talking to (and our
relationship to them). There is a clan system. There are certain things
I can't interpret if it's for my husband's clan . . . or
(http://www.ncihc.org/HC_Interpret_Role.pdf
The
Role of the Health Care Interpreter, An Evolving Dialogue,
TECHNIQUES
FOR WORKING WITH AN INTERPRETER
There
are particular techniques that are important for working with an interpreter.
o
Arrange the seating to allow for easy communication: in a circle
or triangle or place the interpreter to the side and just behind you.
Sit facing and looking at the patient. Do not look back and forth
from the interpreter to the patient.
o
Talk directly to the patient, as you would with an English speaker,
not the interpreter. Always
use the first person eg "How are you feeling?" or "How are you sleeping"
not (to the interpreter) "Ask her how she is feeling" or "How is she sleeping?"
o
Be aware that it may take more words than you've spoken to convey
the message.
oRemember
to watch the patient's non-verbal cues (they are 60 percent of all communication).
oIf
the patient and interpreter start talking to each other, ask for a translation.
Do not let their conversation continue without you, but likewise,
avoid long conversations with the interpreter which would exclude the patient.
oAllow
for extra time.
oBrief
the interpreter, if possible.
oArrange
a discrete signal that the interpreter can give you if you are speaking
too fast.
oEncourage
the interpreter to inform you of any cultural differences that may lead
to misunderstandings or lack of compliance with the prescribed treatment. Respect the interpreter's suggestions but do
not allow him/her to take over.
MEETING
WITH THE PATIENT
o
Introduce yourself and the interpreter.
oConfirm
the issue of confidentiality with the interpreter and reassure the patient.
oSpeak
a little more slowly than usual, in your normal speaking tone. Speaking
louder doesn't help.
oUse
plain English where possible, do not use slang, jargon, or colloquial expressions.
Avoid jokes.
oAvoid
using the word 'GET' - it is difficult to translate in many languages.
oPause
after 2 or 3 sentences to allow the interpreter to relay the message.
oIf
you have a good understanding of the other language, you may spot some errors
in the translation. Be cautious of
embarrassing your interpreter.
oSummarize
periodically. If the patient does
not understand, it is your responsibility (not the interpreter's) to explain
more simply.
oSeek
the patient's permission if you need to obtain cultural information from
the interpreter.
oLong
numbers can be confusing. Be sure the interpreter has the right number of
zero's.
AFTER THE MEETING WITH THE PATIENT
oDebrief
the interpreter if the interview was emotional and clarify, out of sight
of the patient, any questions you have from the meeting.
oAsk
the interpreter for feedback as to how you could improve in future.
http://www.mywhatever.com/cifwriter/library/36/acc551.html)
(http://www.culturalsavvy.com/interpreters_2.htm
(http://www.intracen.org/servicexport/sehp_working_with_interpreters.htm)
(http://www.culturalsavvy.com/interpreters_2_a.htm
(http://www.barrettwells.co.uk/interpreters.htm)
ISCOPES Office:
The George Washington University, 900 23rd St, NW, Suite #6186, Washington,
DC 20037; 202-994-3089
Please send site and curriculum suggestions to
Sandy
Hoar, PA-C . (Last updated: 03/22/06)
