Article from the Boston Globe’s On Call Magazine, August 1999
By Helen Osborne, MEd., OTR/L
President of Health Literacy Consulting
Cultural values, beliefs, and assumptions influence healthcare. In every clinical encounter, providers decide what to say and what not to say, who to include in important discussions, how to provide patient teaching, and when to schedule follow-up care. When providers are working with someone from another culture, these decisions may be influenced by assumptions and stereotypes about what people from that culture are like. If the assumptions are wrong, a person’s health can be seriously jeopardized.
The Egyptian woman who has breast cancer does not speak English well. While she’s getting the needed tests, medication, and treatment, you realize she might be eligible to participate in a clinical research trial. Do you talk with her about it? Or do you choose not to, assuming that this conversation would take too much time, that she wouldn’t understand, and that it’s highly unlikely she would follow through anyway?
An elderly Asian man has high blood pressure but shows no overt symptoms. You know that his potentially serious disease can be managed with routine monitoring, and proper diet. “We need to watch this,” you say, and the patient nods. But he doesn’t show up for follow-up appointments, and test results indicate he did not modify his diet. You wonder if you should have recommended medication instead.
In the hurried clinical environment, healthcare providers may make assumptions about how the cultural values and beliefs of people they treat affect their understanding of health information. These assumptions are often based on a person’s birthplace, command of the language, color of skin, age, or appearance. “This tendency is not malicious,” says Grace Clark, Coordinator of Diversity Initiatives at the Dana-Farber Cancer Institute in Boston, “but happens unconsciously. Inadvertently, the provider may make assumptions that language and culture will prohibit understanding.” But the assumptions are not always right. In fact, Clark adds, “We might be right only about half of the time.”
The Need for Order vs. the Need to Be Effective
Judy A. Baker, president of Global Visions in Boston, points out that making assumptions, or stereotyping, is something we do to “make order by categorizing and grouping. It is a natural human tendency,” she says. “This happens when you’re an outsider to a group. The first people you meet either reinforce the stereotype, or they shatter it. Then you have to guard against replacing the old stereotype with a new one.”
When healthcare providers see only stereotypes and not the individuals, the result can be miscommunication that will have a major impact on treatment and care decisions.
Here are tips about how to talk with people who come from cultures other than your own. Use these tips when you need to communicate important health information to someone whose experiences and understanding of life are likely to be considerably different from your own.
Start by Examining Your Own Beliefs
To treat the individual and not the stereotype, you need to understand your own cultural beliefs about health. You need to know your own and your family’s rituals, traditions, and biases. “Be aware,” Clark says, “that some things you do or recommend may come from your own values.” When they do, she adds, they may not match the values of the person you are providing care for. “You can’t understand someone else’s cultural complexities,” she says, “without knowing yourself first.”
Learn What You Can About Other Cultures
Actively participate in cultural-competency programs at your facility. Whether they employ terms such as “cultural awareness,” “cultural competency,” “anti-racism,” or “diversity training,” these programs offer practical strategies about ways to treat people from a variety of cultural backgrounds. You can also increase your awareness of other cultures by getting information from the Internet or the library and by talking with others.
As you learn about other cultures, however, stay aware of the fact that there are groups within groups. The people you meet from another culture may not match even what you’ve learned from careful study. Individual differences within a culture can lead to many confusing contradictions. These contradictions can get in the way of effective care unless you make a conscious effort to genuinely understand a patient’s background.
Use Professional Resources
Use a trained medical interpreter. A professional interpreter not only knows the patient’s language, but is also fluent in medical terminology. A trained medical interpreter is also unbiased when presenting information. “Family members edit what they interpret, and may decide to withhold bad news or leave out information about cultural beliefs and practices. Avoid this situation whenever possible,” Baker advises.
Look for Ways to See the Situation Through the Patient’s Eyes
Arthur Kleinman, MD, Harvard Medical School, developed a set of questions that are useful in understanding a patient’s values and beliefs toward illness. These questions include:
- How do you hope I can help you today?
- What do you think caused this problem?
- Why do you think it started?
- What kind of treatment do you think you should receive?
- Have you tried any herbal medicines, home remedies, or anything else to treat your problem?
- What are the most important results you hope to get from treatment?
When you provide patient education materials, make an effort to choose material that is appropriate to the person’s experience and background. Pay close attention to whether or not the material is easy to read. Does it provide concrete, specific, and relevant information? Does it show models and use pictures that the patient can identify with to demonstrate treatment procedures? Will checklists for self-care tasks make sense to the patient? Do food and behavioral recommendations seem consistent with a person’s lifestyle, environment, and cultural habits?
Work with the Decision-Maker
Remember that the patient may or may not be the primary decision-maker with regard to treatment. Find out whether decisions are made solely by the patient, by the entire family, or by a designated family member. Identify the decision-maker, and include this person when important information is being discussed or when treatment decisions are being made.
Find ways to compromise and work together. Be open to considering, for example, a treatment plan that includes both antibiotics and a spiritual advisor. By working together, providers and patients can find common ground for respectful treatment and care.
Where to Find Out More
- Lipson W., Dibble S., and Minarik P., editors. (1996) Culture and Nursing Care: A Pocket Guide. UCSF Nursing Press, San Francisco.
- Kleinman A. (1988) The illness narratives: suffering, healing and the human condition. Basic Books, New York.
- Fadiman A. (1997) The Spirit Catches You and You Fall Down. Noonday Press, New York.
- Judy A. Baker, MA, MEd, is the president of Global Visions, Inc., a Boston-based human-resources and diversity consulting firm. She can be reached at (617) 436-9009.
- Grace Clark, RN, is the Coordinator of Diversity Initiatives at the Dana-Farber Cancer Institute in Boston. She can be reached at: firstname.lastname@example.org.