Historic events of the past 40 years have increased our awareness of our multicultural population. During the 1960's, our society focused on inequality. This was evidenced through the Civil Rights movement; student uprisings on college and university campuses; inner city riots in Watts, Detroit, and Washington D.C.; and Lyndon B. Johnson's War on Poverty which proposed health care for all, rich or poor, young or old. Also, the year 1965 marked the passage of Medicare and Medicaid.

The 1970's saw the end of the Viet Nam War. An influx of refugees from Viet Nam, Cambodia, and Laos occurred. These refugees brought traditional health and illness beliefs and practices with them which were unfamiliar to health care practitioners in this country.

The 1980's brought health care policy changes. We also experienced greater immigration from third world countries, emergence of the AIDS epidemic, increased number of cases of resistant tuberculosis, re-emergence of diseases once considered non-threatening, and increases in homelessness and drug addiction.

During the 1990's, social violence and social problems increased. Our health care system has seen the growth of managed care and a movement toward socialized medicine.

As health care providers, we must be made aware that our perceptions or culture may be very different from those of our clients. Because cultural differences exist, conflicts may occur between providers and clients. Health care providers may tend to minimize the conflict if they do not fully understand the client's cultural background and beliefs. Health care providers are mainly interested in the scientific "how's" and "why's" of treatment and sometimes tend to ignore the beliefs and feelings of their clients.

American health care providers have been socialized to blame the client for failing to comply with treatment. We have been taught to believe that modern medicine as taught and practiced in the Western world is the answer to everyone's needs and that alternative medicine is quackery. We also believe that good health practices are common knowledge and tend to forget that not everyone possesses this knowledge. Ignorance of clients' beliefs can negatively effect their course of treatment. We need to be more attentive to the cultural needs of our clients.

1. How does the client view life?
2. What are their beliefs, values, and norms?
3. What is their cultural background and how does it influence behavior?
4. How do such factors affect the meanings of "health" and "illness"?
5. What does health mean in terms of survival?
6. How does one person's socialization differ from that of another?

There are three models to analyze health beliefs: Health Belief Model; Holistic Concept of Health & Health Traditions; and Cultural Phenomenon. Each model is discussed below.

Health Belief Model is based on perceptions; how we perceive susceptibility, seriousness of the condition, and the benefit of taking action. Percevied susceptibility pertains to how susceptible to a certain condition to people consider themselves to be. Many people have the "That will never happen to me" attitude (denial) about illness and disease. An example is a young man of 35 saying, "I can't be having a heart attack, I'm too young." Family health history will influence perception to susceptibility.  If a certain condition, such as diabetes, is prevalent in a family, family members will perceive susceptibility as something likely to happen to them. Health care providers and clients usually agree on perceptions of susceptibility related to family health history.

Perceptions related to the seriousness of the condition will vary. The degree of seriousness of a condition is usually related to the amount of difficulty the client believes the condition will cause.  The health care provider usually knows how serious a problem or condition is due to their experience and training. Some clients experience fear and dread just by hearing the name of a problem or conditon such as cancer or AIDS.

Perceptions of the benefit of taking action to cure or relieve the condition or illness will vary. If a serious conditon occurs, some clients may seek immediate help from health care providers, while others may delay seeking or using help. These clients are in denial.  Several barriers exist to seeking and using health care such as cost, availability, and missing or taking time off from work. Health care providers believe they should be the ones to define who should be consulted, when help should be sought, and what therapy should be prescribed.

Holistic Concept of Health & Health Traditions
Holistic health is defined as the complex phenomenon which involves the balance of all facets of the person - body, mind, and spirit, and the person must be in a state of balance with the family, community, and forces of nature around them. Illness is the opposite, an imbalance of one or all parts of the person or with family, community, or nature.

The body includes all physical aspects such as genetic inheritance, body chemistry, gender, age, nutrition, and physical condition. The mind includes cognitive processes such as thoughts, memories, knowledge, and emotions. Spirit encompasses the positive and negative learned spiritual practices and teachings which include dreams, symbols, stories, gifts and intuition, and grace and protecting forces.

The traditional model is predicated on a person knowing health traditions of ethnocultural heritage. Families pass on and teach these traditions and methods to following generations. Ethnoreligious and ethnocultural communities usually have resources available to meet a person's health needs.

Health, in the traditional context, has nine facets:

1. Traditional methods of maintaining physical health
2. Traditional methods of maintaining mental health
3. Traditional methods of maintaining spiritual health
4. Traditional methods of protecting physical health
5. Traditional methods of protecting mental health
6. Traditional methods of protecting spiritual health
7. Traditional methods of restoring physical health
8. Traditional methods of restoring mental health
9. Traditional methods of restoring spiritual health

Traditional methods of health maintenance, protection, and restoration require knowledge and understanding of health-resources of one's heritage. These traditional methods are usually practiced along with or instead of modern health care methods.  Traditional methods are not considered as alternative health care because they are a part of a person's heritage.

Traditional ways of maintaining health are the active, everyday ways people go about living and staying well, basically their ordinary functioning within society. Traditional foods and diets and cleanliness of self and environment are other examples. Mental health in maintained by concentrating and using the mind in such activities as reading, crafts, art, music, and hobbies.  Spiritual health is maintained through family and community connections.

Traditional health protection is achieved by preventing harm, illness, and misfortune by looking after oneself, avoiding harmful circumstances and people, and avoiding harmful elements that cannot be seen or understood.  Many people see illness as punishment for bad behavior or from a curse. Physical protection is accomplished through special diets and symbolic clothing. For example, some cultures forbid eating pork or beef. Mental protection is achieved by avoiding people who can cause harm and by developing a strong sense of identity with family and community. Spiritual protection occurs through adherence to religious customs and rituals, following superstitions, and wearing amulets.

Once health is compromised, there are several traditional methods for restoring health. Restoration of physical health is accomplished by traditional remedies such as herbs, teas, liniments, special foods, and massage. The use of chicken soup as a cure-all comes to mind. Various techniques of mental health restoration include exorcism, use of traditional healers, teas, massage, and seeking family and community support. Spiritual restoration occurs through healing rituals or use of symbols, prayers, meditation, and exorcism.

Cultural Phenomena affecting health include environmental controls, biological variations, social organization, communication, space, and time orientation.

The environmental control of health involves the ability of members of a particular cultural group to plan activities that control nature or direct environmental factors. Examples would be the way a community tries to control air and water polution, making environments lead-free or asbestos-free to prevent lead poisoning and asbestosis, and the use of sunscreens and sunglasses to prevent damage from UV rays.

Biological variations are the ways in which one culture differs biologically from another either physically or genetically.  An example is body build and structure. Asians and Mayans have small statures. Other examples include skin color, tone, texture, healing abilities, hair follicles, enzymatic and genetic variations, susceptibility to disease, and nutritional variations (tolerance for hot & spicy foods, Kosher diets, lactose intolerance).

Social organization includes the social environment in which people grow up and live.  The socialization process is an inherent part of heritage. Individuals may be prevented from seeking health due to social barriers such as unemployment, underemployment, homelessness, and poverty.

Communication involves differences in language, verbal and non-verbal behaviors, and silence. Language differences is probably the biggest obstacle in providing multi-cultural health care.

Space is a cultural phenomena we rarely think about. Many people express certain behaviors and attitudes toward the space around them. Different ethnic groups have varying norms related to space. Territoriality describes the behavior and attitudes people exhibit about an area they have claimed. They defend or react emotionally when others encroach on it. Examples would be territories marked by inner-city gangs and the sanctity of houses of worship.

Time orientation is the way time is viewed, whether in the present, past, or future. Future-oriented individuals are concerned with long range goals and usually practice preventive health care measures.

Heritage consistency is defined as the degree to which one's lifestyle effects his or her respective tribal culture. It includes culture, ethnicity, and religion.

Culture may be defined in several ways. It is the non-physical socially inherited traits we possess which are handed down from generation to generation. It is the sum of beliefs, practices, habits, likes, dislikes, norms, customs, and rituals we learn from our families during years of socialization. And it also involves the metacommunication system of a society wherein not only spoken words have meaning, but everything else as well. Culture is learned and the capacity to learn is genetic but the subject matter is not genetic. It is the way we express our self. What we believe, think, and do, both consciously and unconsciously, are determined by our cultural background.

Ethnicity is the condition of belonging to a particular ethnic group. There are at least 106 ethnic groups and more than 170 American Indian groups in the United States today. Ethic groups share the following characteristics:

1. Common geographic origin
2. Migratory status
3. Race
4. Language and dialect
5. Religion
6. Ties that transcend kinship, neighborhood, and community boundaries
7. Shared traditions, values, and symbols
8. Literature, folklore, and music
9. Food preferences
10. Settlement and employment patterns
11. Special interest with regard to politics (homeland and U.S.)
12. Institutions that specifically serve and maintain the group
13. Internal sense of distinctiveness
14. External perception of distinctiveness

Religion is the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe; and a system of beliefs, practices, and ethical values.  Religion is a major reason for the development of ethnicity. Religion is related to health in that adherence to a religious code is conducive to spiritual harmony and health.

As health care providers, we belong to a "health care provider culture" which has definite views regarding health and illness. This culture usually involves a discipline specific professional socialization which teaches a student a set of beliefs, practices, habits, likes, dislikes, norms, and rituals. The more knowledgeable a student becomes about their profession, they tend to move farther away from their past belief system and farther from the population at large. Whether we like it or not, health care providers can be viewed as a "foreign" culture having its own language (i.e.; STAT, ICU, CBC, MRI, etc.) and a social and cultural system. Since we generally adhere rigidly to the Western system of health care delivery we tend to become xenophobic (fearful of strangers) when alternative, and sometimes traditional, methods of health care are introduced. Many health care providers believe they comprehend all facts of health and illness and have superior knowledge in these areas above the general population.

Following are some characteristics of our "health care provider culture":

• Beliefs - we have a standardized definition of health and illness and a reverence toward technology.
• Practices - we encourage annual physical exams, diagnostic procedures, immunization, and preventive medicine.
• Habits - charting, documentation, systematic approach, problem solving, constant use of jargon (language).
• Likes - we prefer promptness, neatness, organization, and compliance.
• Dislikes - tardiness, disorderliness, and disorganization.
• Customs - professional deference and adherence to the pecking order, hand washing, employment of certain procedures attending birth and death.
• Rituals - physical examinations, surgical procedures, limiting visitors, and visiting hours.

Epidemiology is the causation of illness.  It explores the relationship among host, agent, and the environment and attributes the cause of a disease to a specific agent (bacteria, virus, chemical, carcinogen, pollutant, etc.). The traditional theories of epidemiology involve spirit possession, spells, and loss of soul. Causative agents of disease may be another person practicing witchcraft or voodoo. Some cultures believe illnesses may be prevented by not provoking wrath in another person. Health care providers need to keep an open mind in order to provide useful care for individual with tradtional epidemiologic beliefs.

Pain is a culture-bound phenomenon. How pain, discomfort, and emotions are presented vary among cultures. Some cultures allow free and open expression of pain whereas others teach true feelings must never be revealed. Our expression "bite the bullet" is an example of our belief to tolerate pain. Also, males in Western society are not expected to cry to in public.

PREPARING

• Understand you own cultural values and biases.
• Acquire basic knowledge of cultural values and health beliefs and practices for client groups you serve.
• Be respectful of, interested in, and understanding of others cultures without being judgmental.

ENHANCING COMMUNICATION

• Determine the level of fluency in English and arrange for an interpreter, if needed.
• Ask how the client prefers to be addressed.
• Allow the client to choose seating for comfortable personal space and eye contact.
• Avoid body language that may be offensive or misunderstood.
• Speak directly to the client, whether an interpreter is present or not.
• Choose a speech rate and style that promotes understanding and demonstrates respect for the client.
• Avoid slang, technical jargon, and complex sentences.
• Use open-ended questions or questions phrased in several ways to obtain information.
• Determine the client's reading ability before using written materials in the teaching process.

PRMOTING POSITIVE CHANGE

• Build on cultural practices, reinforcing those that are positive, and promoting change only in those that are harmful.
• Check for client understanding and acceptance of recommendations.
• Remember: Not all seeds of knowledge fall into a fertile environment to produce change. Of those that do, some will take years to germinate. Be patient and provide health care in a culturally appropriate environment to promote positive health behavior.

Return to Syllabus

References:

Spector, Rachel. (1996). Cultural Diversity in Health and Illness. Stamford, CT: Appleton & Lange.

Schilling, B. and Brannon, E. (1986). Cross-Cultural Counseling - A Guide for Nutrition and Health Counselors. US Department of Agriculture, US Department of Health & Human Services, Nutrition & Technical Services Division.