This document discusses cultural diversity and its impact on health care. It notes that culture includes factors like religion, ethnicity, language, gender, age, education, and socioeconomic class. Culture shapes a group's values, beliefs, behaviors and decision-making over time. A patient's cultural background influences their health beliefs, perspectives on illness and treatments. The document emphasizes the importance of cultural competence in health care, including understanding different cultural perspectives, using interpreters effectively, and employing models to understand a patient's experience of their illness.

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Cultural Diversity and HealthCultural Diversity and Health
CareCare

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Cultural DiversityCultural Diversity
 We all have it!We all have it!
 Obvious manifestations include:Obvious manifestations include:
 religionreligion
 ethnicity (race)ethnicity (race)
 national origin (language)national origin (language)
 gendergender

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Cultural DiversityCultural Diversity
Less obvious manifestations include:Less obvious manifestations include:
 ageage
 educationeducation
 socioeconomic classsocioeconomic class
 mobility (including handicaps)mobility (including handicaps)

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What is Culture?What is Culture?
Culture is the sum total of the way ofCulture is the sum total of the way of
living; includes values, beliefs, standards,living; includes values, beliefs, standards,
language, thinking patterns, behaviorallanguage, thinking patterns, behavioral
norms, communications styles, etc.norms, communications styles, etc.
Culture guides decisions andCulture guides decisions and
actions of a group through time.actions of a group through time.

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Expressions of Culture inExpressions of Culture in
Health CareHealth 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
 are based upon theories of the relationshipare based upon theories of the relationship
between cause and the nature of illnessbetween cause and the nature of illness
and treatmentsand treatments
 define the specific “scope” of practice fordefine the specific “scope” of practice for
healershealers

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The Culture of WesternThe Culture of Western
MedicineMedicine
Common Practices in Western MedicineCommon Practices in 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

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Comparing Our Beliefs to OthersComparing Our Beliefs to Others
 ““Western”Western”
 Make it betterMake it better
 Control over natureControl over nature
 Do somethingDo something
 Intervene nowIntervene now
 Strong measuresStrong measures
 Plan ahead – recentPlan ahead – recent
is bestis best
 Standardize – treatStandardize – treat
everyone the sameeveryone the same
 ““Others”Others”
 Accept with graceAccept with grace
 Balance/HarmonyBalance/Harmony
with naturewith nature
 Wait and seeWait and see
 Cautious deliberationCautious deliberation
 Gentle approachGentle approach
 Take life as it comesTake life as it comes
– “time honored”– “time honored”
 Individualize –Individualize –
recognizerecognize
differencesdifferences

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Cultural CompetenceCultural Competence
Cultural competence is defined as a setCultural competence is defined as a set
of congruentof congruent behaviors, practices,behaviors, practices,
attitudes and policiesattitudes and policies that come together in athat come together in a
system or agency or among professionals,system or agency or among professionals,
enabling effective work to beenabling effective work to be
done in cross-cultural situations.done in cross-cultural situations.

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The Cultural CompetenceThe Cultural Competence
ContinuumContinuum
Requires Self ReflectionRequires Self Reflection
 Where am I now?Where am I now?
 Where could I be?Where could I be?

10. The Cultural Competence ContinuumThe Cultural Competence Continuum

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Cultural CompetenceCultural Competence
DefinitionsDefinitions
 Cultural DestructivenessCultural Destructiveness:: forcedforced
assimilation, subjugation, rights andassimilation, subjugation, rights and
privileges for dominant groups onlyprivileges for dominant groups only
 Cultural IncapacityCultural Incapacity:: racism, maintainracism, maintain
stereotypes, unfair hiring practicesstereotypes, unfair hiring practices
 Cultural BlindnessCultural Blindness:: differences ignored,differences ignored,
“treat everyone the same”, only meet“treat everyone the same”, only meet
needs of dominant groupsneeds of dominant groups

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Cultural CompetenceCultural Competence
DefinitionsDefinitions
 Cultural Pre-competenceCultural Pre-competence:: explore culturalexplore cultural
issues, are committed, assess needs ofissues, are committed, assess needs of
organization and individualsorganization and individuals
 Cultural CompetenceCultural Competence:: recognize individualrecognize individual
and cultural differences, seek advice fromand cultural differences, seek advice from
diverse groups, hire culturally unbiased staffdiverse groups, hire culturally unbiased staff
 Cultural ProficiencyCultural Proficiency:: implement changes toimplement changes to
improve services based upon cultural needs,improve services based upon cultural needs,
do research and teachdo research and teach

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Acquiring CulturalAcquiring Cultural
CompetenceCompetence
 Begins with awarenessBegins with awareness
 Grows with knowledgeGrows with knowledge
 Enhanced with specific skillsEnhanced with specific skills
 Polished through cross-culturalPolished through cross-cultural
encountersencounters

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The Explanatory ModelThe Explanatory Model
Arthur Kleinman, Ph.D.Arthur Kleinman, Ph.D.
Use a culturally sensitive approach toUse a culturally sensitive approach to
inquiring about a health problem.inquiring about a health problem.
Ask your patient:Ask your patient:
 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? HowWhat does your sickness do to you? How
does it work?does it work?
 How severe is it? How long do you think youHow severe is it? How long do you think you
will have it?will have it?

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Ask Your PatientAsk Your Patient
 What do you fear most about your illness?What do you fear most about your illness?
 What are the chief problems your sickness has causedWhat are the chief problems your sickness has caused
you?you?
 Do you know anyone else with the same problem?Do you know anyone else with the same problem?
 What have you done so far to treat your illness?What have you done so far to treat your illness?
 What treatments do you think you should receive?What treatments do you think you should receive?
 What important results do you hope to receive from theWhat important results do you hope to receive from the
treatment?treatment?
 Who else can help you?Who else can help you?

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TheThe LEARNLEARN ModelModel
Berlin and FowkesBerlin and Fowkes
 LListenisten to the patient’s perception of theto the patient’s perception of the
problem.problem.
 EExplainxplain your perception of the problem.your perception of the problem.
 AAcknowledgecknowledge and discussand discuss
differences/similarities.differences/similarities.
 RRecommendecommend treatment.treatment.
 NNegotiateegotiate treatment.treatment.

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InterpretersInterpreters
Qualifications:Qualifications:
 Bilingual, bicultural,Bilingual, bicultural,
 Understands English medicalUnderstands English medical
vocabularyvocabulary
 Comfort in the medical setting,Comfort in the medical setting,
understands significance of theunderstands significance of the
health problemhealth problem
 Preserves confidentialityPreserves confidentiality

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Multiple Roles of InterpretersMultiple Roles of Interpreters
Interpreters have multiple roles including:Interpreters have multiple roles including:
 translator of languagetranslator of language
 culture brokerculture broker
 patient advocate: convey expectations,patient advocate: convey expectations,
concernsconcerns

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

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Working with LanguageWorking with Language
Translation ConsiderationsTranslation Considerations
 Language: consider meaningful descriptionLanguage: consider meaningful description
 Navajo: Explain Penicillin as “the strong white medicineNavajo: Explain Penicillin as “the strong white medicine
shot you get for a cold”shot you get for a cold”
 Minimize jargon, e.g., “machine to look at yourMinimize jargon, e.g., “machine to look at your
heart” instead of “EKG”heart” instead of “EKG”
 Nonverbal communication comprises 60% of allNonverbal communication comprises 60% of all
communicationcommunication
 Nodding may indicate politeness, notNodding may indicate politeness, not
comprehensioncomprehension
 Bilingual interviewing takes at least twice as longBilingual interviewing takes at least twice as long
as monolingual interviews!as monolingual interviews!

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Responsibilities of HealthResponsibilities of Health
Care ProvidersCare Providers
 Learn and use a few phrases of greeting andLearn and use a few phrases of greeting and
introduction in the patient’s native language.introduction in the patient’s native language.
This conveys respect and demonstrates yourThis conveys respect and demonstrates your
willingness to learn about his/her culture.willingness to learn about his/her culture.
 Tell the patient that the interpreter willTell the patient that the interpreter will
translate everything that is said, so they musttranslate everything that is said, so they must
stop after every few sentences.stop after every few sentences.

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Responsibility of Health CareResponsibility of Health Care
ProvidersProviders
 When speaking or listening, watch theWhen speaking or listening, watch the
patient, not the interpreter. Add yourpatient, not the interpreter. Add your
gestures, etc. while the interpreter isgestures, etc. while the interpreter is
translating your message.translating your message.
 Reinforce verbal interaction with visual aidsReinforce verbal interaction with visual aids
and materials written in the client’s language.and materials written in the client’s language.
 Repeat important information more thanRepeat important information more than
once.once.

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Your ResponsibilitiesYour Responsibilities
 Always give the reason or purpose for aAlways give the reason or purpose for a
treatment or prescription.treatment or prescription.
 Make sure the patient understands by havingMake sure the patient understands by having
them explain it themselves.them explain it themselves.
 Ask the interpreter to repeat exactly what wasAsk the interpreter to repeat exactly what was
said.said.
 Personal information may be closely guardedPersonal information may be closely guarded
and difficult to obtain.and difficult to obtain.
 Patient may request or may bring a specificPatient may request or may bring a specific
interpreter to the clinic.interpreter to the clinic.

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ConsiderationsConsiderations
 In some cultures it may not be appropriate toIn some cultures it may not be appropriate to
suggest making a will for dying patients orsuggest making a will for dying patients or
patients with terminal illnesses; this is thepatients with terminal illnesses; this is the
cultural equivalent of wishing death on acultural equivalent of wishing death on a
patient.patient.
 Avoid saying “you must”, instead teachAvoid saying “you must”, instead teach
patients their options and let them decide,patients their options and let them decide,
e.g., “some people in this situation would...”e.g., “some people in this situation would...”

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Additional InformationAdditional Information
 JCAHO requires education for all health careJCAHO requires education for all health care
providers regarding cultural diversity.providers regarding cultural diversity.
 Visit these sites for more information:Visit these sites for more information:
www.ggalanti.com/articles.htmlwww.ggalanti.com/articles.html
www.ggalanti.com/concepts.htmlwww.ggalanti.com/concepts.html
www.ggalanti.com/cultural_profiles.htmlwww.ggalanti.com/cultural_profiles.html
www.nursingworld.org/ojin/topic20/tpc20_2.htmwww.nursingworld.org/ojin/topic20/tpc20_2.htm
www.diversityrx.org/www.diversityrx.org/
www.health.qld.gov.au/multicultural/cultdiv/default.aspwww.health.qld.gov.au/multicultural/cultdiv/default.asp

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Cultural Diversity and HealthCultural Diversity and Health
CareCare
It is because we are different that each of us is special.It is because we are different that each of us is special.