Culture and Health
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
As cultural representations of the human body, time, life, death and disease vary, so do people's approaches to action, prevention and treatment. Procreation, childbirth, weaning, sexuality, death, disease and suffering are not just private experiences but all have an intrinsic social dimension. The health conditions in which they take place are often determined as much by cultural practices as by biological and environmental factors. For example, traditional practices such as female genital mutation, or food taboos during pregnancy and childbirth can have serious consequences for people's health. Similarly, until recently, though highly addictive and harmful to health, smoking was generally accepted as part of social life. The current increase in non-communicable diseases such as cancer, diabetes and cardiovascular diseases can only be understood in connection with the worldwide spread of new lifestyles and diet. To reduce sickness and death among mothers and children, to promote family planning, to prevent sexually transmitted diseases, to foster the rational use of health services or the social integration of the disabled, to improve nutrition or to control violence, we must be able to influence behaviors, cultural attitudes and lifestyles. From that point of view, Women's Health and Education Center (WHEC)'s community and family health approaches are particularly important for achieving social and cultural relevance in health work.
The purpose of this document to ensure community participation, and help to build health development on what people know and what they want and are therefore prepared to support in the long run. As health workers and educators we have a twofold responsibility: firstly, to provide equitable access to safe and effective health care and services; and secondly, to provide the necessary knowledge, information and infrastructure that will enable people to take care of themselves and promote their own health and that of their families.
The Culture of Medicine:
Medicine has a culture of its own, with traditional codes of conduct that have been passed on from generation to generation. This culture is pervasive within the medical profession, and it often supersedes the individual culture of the healthcare provider (1). Medical practice is a system designed to offer diagnosis and treatment options to an individual patient, who in turn, is expected to make decisions and follow through on treatments. Furthermore, it is underpinned by the assumption that those seeking care will understand how the system works and are able and willing to comply with its stipulations. This system and the values that shape it, however, may compromise access to care for patients from other cultures. Efforts can be made to value appropriately the effect of the quality of interpersonal relationships between patients and health care providers rather than an exclusive focus on adherence and healthcare outcomes. More credence can be given to such cultural factors as the role of the extended family in treatment decisions, the role of spiritual or religious beliefs in health care decisions, or the role or traditional remedies for cures and relief from symptoms. In some cultures, health and healing cannot be separated from religious beliefs. In fact, many women seek help from a religious-based practitioner before seeing a physician. Patients may seek traditional practices from their home country or try traditional remedies before or along with the treatments prescribed by their physicians. These remedies may augment, interfere, or have no interaction with the physician's management plan.
The physical structure of the health care system also can be improved to reduce unintended cultural barriers for patients and their families. Hospitals, for example, often have detailed and complex requirements surrounding admissions, visiting hours, and meal times that may not have to be so rigid. Additionally, the size of many hospitals and outpatient complexes, the volume of paperwork, and the constant use of professional jargon can intimidate new immigrants, minorities, and those with little exposure to the health care system. A culturally competent health care system values diversity, has the capacity for cultural self-assessment, is conscious of the dynamics inherent in any multicultural encounter, and has developed the necessary adaptations to service delivery that reflect an understanding and appreciation of cultural diversity (2). Achieving cultural competency may be difficult given wide exposure to multiple cultures. However, it may be easier and more practical for health care providers at the individual, group, and institutional levels to achieve a level of cultural proficiency that includes awareness of differences and sensitivity to the needs of patients whom they may not totally understand. The first step in this process is to develop an understanding of the cultures represented in the communities served.
Culture and Health Care:
The racial and ethnic composition of the population of the United States has changed significantly during the past decade. Between 1995 and 2005, there was a 75% increase in the Asian population, a 60% increase in individuals of Hispanic or Latino origin, a 92% increase in American Indians and Alaskan Natives, and a 25% increase in the African-American population. The white non-Hispanic population, however, increased by only 5%. According to U.S. Census 2005, there are more than 350 million inhabitants in the United States. Asian represents 3.6% of the population; Hispanics (of any race) represented 12.5%; Indians, Alaskan Natives, Native Hawaiians, and other Pacific Islanders represented 1% of total U.S. population (3). Behind these figures are countless cultural differences that define and distinguish an increasingly diverse populace. Culture is a broad term encompassing ideas, concepts, beliefs, and common goals and can include ethnicity. Hofstede defines culture as, "the collective programming of the human mind that distinguishes the members of one human group from those of another. Culture is a system of collectively held values" (4). Culture is not static. It is newly defined as the shared experiences and commonalities that evolve under changing social and political environments. This is especially evident when groups are compared with dominant culture or society. Therefore, culture is not limited to race or ethnicity, and includes age, gender, faith, class, activity, profession, sexual orientation, tastes, or any group characteristic that individual share.
Culture is dynamic and multidimensional context of many aspects of the life of an individual. Individuals from similar racial and ethnic groups, countries of origin, and socioeconomic levels all may have distinct cultures. Similarly, each age group, such as adolescents or baby boomers, also has a separate distinct culture. Culture encompasses rural versus urban identities as well. The shared systems and values of a given culture serve to facilitate interactions among its members. Conversely, interactions between members of different cultures can be complicated by a lack of cultural awareness. During every health care encounter, the culture of the patient, the culture of the health care provider, and the culture of medicine as seen in medical facilities and institutions converge and may affect patterns of health care utilization, adherence with recommended interventions, and eventually, health outcomes. Often, health care providers may not appreciate the effect of culture on their own lives, their professional conduct, and the lives of their patients. When an individual's culture is at odds with that of the prevailing medical establishment, the patient's culture generally will prevail, often straining physician-patient relationships (5).
Building on Local Health Culture:
The community health worker (CHW) makes a practical and proven contribution to the core of the primary health care approach, which is the involvement of people. It is absolutely essential of the health sector to promote good health rather than just control disease. Health personnel tend to assume that people do not know anything. They often see communities as empty vessels into with scientific knowledge have to be poured. But in reality, of course, there are no empty vessels; they are filled with popular health culture. Perhaps those who know their communities and their health culture best are the traditional healers. These are available in significant numbers in many parts of the world and are unlikely to disappear, despite the spread of modern health services. They have been found to be willing, effective and sustainable CHWs once they are given the necessary training and support (6). Traditional healers include people who may be known as herbalists, diviners, spiritual or faith healers, traditional birth attendants, curanderos, shamans, bone-setters and by many other names. Using available potential is essential. There is often strong opposition to traditional healers on the grounds that they are those who argue that whether they are "scientific". On the other hand there are those who argue that whether they are "scientific" or not, they are effective. Furthermore, many people trust them, they are accessible and affordable, and they are the only health services available to millions of people. In practice, arguments for and against traditional healers are not productive. It is more useful to start from the fact that they exist, they are accepted and used by their communities, and that in many cases they have the potential to be excellent CHWs. When a survey was made of projects that trained and used traditional healers as community health workers, the findings were summaries as follows (7):
On the other hand, there are also a number of difficulties to be overcome in using traditional healers as CHWs. The most important of these were found to be the following:
There are many Projects in Bangladesh, Ghana and Mexico organized by the World Health Organization (WHO) and the guidelines are produced. The aim is to assist individuals and organizations to develop the right kind of training programs. These will enable traditional healers to play a significant role in improving the health of their communities because they know the local traditions and culture, and can therefore build on them with the help of the modern health sector. CHWs play a unique role because they belong both to the community and to the health sector. They make a practical and proven contribution to the core of the primary health care approach, which is the involvement of people.
Lessons from the Community:
In addition to valuing diversity, physicians should be sensitive to the unique needs of women in the communities they serve. Communication barriers should be examined and addressed. For those who do not speak English, efforts should be made to provide assistance, such as appropriately trained interpreters and written translations of forms and patient education materials. In some circumstances, federal and state laws and regulations impose responsibilities on health care providers to accommodate individuals with "limited English proficiency" (eg, Department of Health and Human Services, Title VI of the Civil Rights Act of 1964; Policy Guidance on the Prohibition Against National Origin Discrimination as it Affects Persons with Limited English Proficiency, 65 Fed. Reg. 52762-74). Appropriate measures for overcoming communication barriers will depend on the circumstances of the individual practice and patient population. Various options may be available, including hiring interpreters as office staff, using appropriate community resources, or using translation telephone services.
Physicians or their staff should consider meeting with the representatives from the community to discuss how the delivery of services can be modified. Health education programs jointly sponsored with community organizations and located at appropriate sites can help to demystify the health care system and familiarize women with preventive health care measures in a non-threatening environment. Because patients interact with many individuals in the office and hospital, it is important for staff to receive training in cultural awareness and sensitivity (preferably provided by a member of the community being served) or appropriate resources for self education (8). Every health care encounter provides an opportunity to have a positive effect on patient health. Health care providers can maximize this potential by learning more about their patients' cultures.
Importance of Health Communication in Public Health:
In medicine, the quality of information transfer, understanding, and the development of rapport are critical in an effective physician-patient relationship and ongoing patient health and psychosocial status. Effective communication between physicians and their patients facilitates a more complete understanding of health and illness and ultimately affects the outcome of disease and patient encounters. Furthermore, a partnership model significantly decreases the likelihood of medical liability litigation. Communication with patients that indicates sensitivity and empathy is particularly important in obstetrics and gynecology, where patients may be more reluctant to discuss problems related to sexuality and intimacy. Patients with special issues or risk factors often do not have their needs addressed because of communication barriers. A physician who encourages open communication often will obtain more complete information that enables an accurate diagnosis and appropriate counseling. Many reviews of physician communication show striking absence of efforts to engage in discussions of treatment options. These reviews also reveal both a failure to consider differing cultural backgrounds and minimal attempts to communicate at the level of patient's knowledge. The following four qualities can be important in "caring communication skills": 1) comfort, 2) acceptance, 3) responsiveness, and 4) empathy. Often practitioners are not aware that their own cultural and social backgrounds affect the way they communicate. Regardless of the discordance between a patient's and practitioner's backgrounds and cultural beliefs, increased sensitivity by providers to patient's behaviors, feelings, and attitudes can result in increased patient and provider satisfaction.
Communication is at the heart of who we are as human beings. It is our way of exchanging information; it also signifies our symbolic capability. These two functions reflect what is characterized as the transmission and ritual views of communication, respectively (9). Thus, communication can be defined as the symbolic exchange of shared meaning, and all communication acts have both a transmission and a ritualistic component. Healthy People 2010 objectives illustrate its growing importance. The United States Department of Health and Human Services, stresses health communication is seen to have relevance for virtually every aspect of health and well-being, including disease prevention, health promotion and quality of life. This increase in the prominence of field, externally, is happening contemporaneously with important developments taking place, internally, one of which is the focus on the study of environmental, social and psychological influences on behavior and health. Health communication has much to celebrate and communicate. The field is gaining recognition in part because of its emphasis on combining theory and practice in understanding communication processes and changing human behavior. This approach is pertinent at a time when many of the threats to global public health (through diseases and environmental calamities) are rooted in human behavior (10). By bringing together researchers and practitioners from diverse disciplines and adopting multilevel theoretical approaches, health communicators have a unique opportunity to provide meaningful input in improving and saving lives.
Components of effective physician communication are:
Responsiveness and empathy refer to the quality of reacting to indirect messages expressed by a patient. Recognizing when emotions are present but not directly expressed is important and can lead to an exploration of the patient's feelings. Empathy involves both cognitive and behavioral processes and responses. An accurate understanding is gained and then followed by effective communication of that understanding to patient. Simple acknowledgment of a patient's emotions and needs facilitates open communication. A technique that encourages dialogue and helps to avoid misunderstanding is to restate a patient's concerns. To make a good decision, women need to be supported and sense of empathy and understanding from their physicians and feel cared for.
As the health system changes and increasingly focuses on primary care and prevention, it is critical that health care providers develop ongoing and trusting relationships with their patients. Cultural sensitivity and awareness is particularly relevant to maternity care. The birth of a child initiates another generation into a family and affords a new opportunity for cultural traditions to be solidified, thus strengthening the bond between parents and child and serving to unify family members. As such, pregnancy and childbirth often are entangled in complex cultural beliefs and traditions that may be less obvious in other settings. Additionally, the perinatal period often may be and immigrant family's first significant contact with the healthcare system. The sensitivity and understanding with which a pregnant woman and her family are treated can have a long-term effect on the family's future patterns of health care utilization.
Perhaps the greatest contemporary challenge in implementing the principles of effective communication lies in the current environment that demands increasing physician productivity and less time with each patient. Improving communication in the physician-patient relationship will help, as will using more non-physician health care providers and computer-based interactive health communication . Communication with patients that indicates sensitivity and empathy is particularly important in obstetrics and gynecology, where patients may be more reluctant to discuss problems related to sexuality and intimacy. Survivors of sexual abuse, and sexual assault may be particularly difficult to assess and examine, the provision of their care may require special skills. Regardless of their own and their patient's cultural backgrounds, sexual orientation, or lifestyles, practitioners must focus objectively on the medical or health promotion and maintenance issues presented by their patients.