CULTURAL AWARENESS

Due to an increased exposure to different cultures through work, travel, community, it is necessary for us to develop a respect and appreciation for cultures different from our own. Health care workers must learn to communicate with cultural sensitivity to work effectively with clients, families, colleagues, and support personnel.

WHAT IS "CULTURE" ?

Margaret Mead described culture in the following way:

Abstractions from the body of learned behavior, which groups of people who share the same traditions transmit to their children and, in part, to adult immigrants who become members of the society. It covers the arts and sciences, religion and philosophies to which the world culture has historically applied, but also the system of technology. The political practice, the small intimate habits of daily life, such as the way of preparing and eating food, or of hushing a child to sleep as well as the method of electing a prime minister or changing the constitution.

This definition is quite inclusive and illustrates the impact a client’s culture will impact their response to illness or disability. Complex concepts do not have the same meaning in all cultures. 

Good health to someone in the US means the absence of bacteria or viruses. In China, good health means harmony between yin and yang. 

People learn to express symptoms of distress in ways that are acceptable to others in the same culture. 

In India, stress related disorders are often suspected when a client’s primary complaint is an upset stomach. In the US, stress is often associated with headaches and a great deal of advertising money is spent each year on headache relief medication.

As part of socialization, one learns that certain complaints about distress are acceptable and elicit understanding and others are unacceptable. Understanding the cultural basis for the client’s symptoms becomes more critical for accurate evaluation of the presenting problem leading to an accurate clinical diagnosis.

Individuals can experience cultural challenges in a number of situations, even when in their own country or environment. Some examples include:

• Traveling to another country 
• Meeting people of different sexual orientation 
• Talking to people of a different generation 
• Meeting others with different political views 
• Talking with people who practice a religion 

Cultural differences pose a challenge in daily life and are magnified when the individual becomes a “patient”. The health care environment is challenging, often viewed as overstimulating and fast paced. All features which can create anxiety in the best of times. The challenge is considerable when there exists a language difference between the client and the health care providers. The purpose of procedures and interventions many not be understood. Education provide to prevent recurrence may not be clear to the client. The ability to communicate symptoms or symptom relief may not be expressed by the client.

The concept of touch can be challenging for some cultures. There is a great deal of touch required to perform many therapy interventions and medical procedures. Most direct care is provided by women. This can create issues with a client whose culture perceives the role of women differently. Even the expression of pain or a lack of ability related to a condition can be perceived as weakness in some cultures and therefore the health care provider may not have all the information they need to proceed. It is obviously a complex situation to navigate and understand. 

The US began acknowledging cultural differences in 1975 with PL 94-142 and the 1986 its revision of PL 94-457 mandating public schools provide education to children from the ages of 3-21 regardless of handicap. It specified that ancillary health services (OT, PT, etc.) be provided in a “culturally competent” manner. When a majority of these health care providers are Caucasian and not bilingual, challenges exist in meeting this mandate. The lack of diversity will likely worsen as entry-level educational requirements continue to increase for these professions.

The size of the personal space or “bubble” varies by culture and situation. Many sources identify personal space is about 24” on either side, 27” in front and 16” behind for an average westerner. Americans typically have larger personal space boundaries than those from other cultures.

Under certain circumstances people can accept having their personal space entered without experiencing discomfort (i.e. crowded subways, public events, romantic encounters). In business settings people typically maintain more personal space between them in vs. in social situations. Personal space boundaries between a man and a woman usually remain larger than those between two women. People who live in highly populated areas often have a smaller area of personal space than those who live in less populated areas. People of higher status or wealth usually have a larger area of personal space.

What does this all mean to the health care provider? It illustrates the need to assess the client on a number of levels in order to be able to establish rapport and provide care. It is simply not enough to know what country the client is from and what their diagnosis is. Each client will respond differently to you, your touch and your personality. It is up to you to assess the best approach with each client by looking at them holistically and as individuals with unique needs.

UNIVERSAL ASPECTS OF HEALTHCARE

1. The health care provider applies a name to a problem.
2. The qualities of the health care provider are important.
3. The health care provider must establish credibility through the use of symbols and trappings of status that are familiar to the culture.
4. The health care provider places the client’s problems in a familiar framework.
5. The health care provider relies on a set of techniques meant to bring relief.
6. Interactions between the client and the practitioners occur at a special time and place.

CULTURE SHOCK

This is a common term used frequently when someone is “out of their element”. More seriously, it is the stress experienced when individuals cannot meet their everyday needs in a new culture as they could in their native culture. Familiar patterns of behavior learned through socialization of a culture no longer work in the new culture. The individual must observe others to learn new behaviors to become more effective in the new environment or context.

Elements of Culture  

CULTURAL COMPETENCE

This refers to the attitudes, behaviors, and policies of a system or organization in a cross-cultural situation. It is critical to recognize the importance of culture, assessment of cross-cultural relations, and understand the dynamics of cultural differences. There is a great deal of information about cultural features which can help health care providers modify the delivery of services to meet culturally unique needs.

Health professionals must be sensitive to clients’ beliefs, attitudes and behaviors regarding their illness, injury, or disability. In order for optimal healing to occur, there must be a fit between the expectations, beliefs, behaviors and evaluation of the outcome between the client and professional.

Beliefs: What people think is true

Attitudes: How people feel about something

Behavior: What people do

THE CONCEPT OF PERSONAL SPACE

We define personal space as the area surrounding an individual. Crossing or entering someone else’s personal space creates discomfort when the physical intimacy exceeds the relational intimacy. Too much space can cause discomfort and indicate rudeness as well.

NON-VERBAL COMMUNICATION

This refers to the exchange of information which does not require verbal or written forms of language. This includes gestures, facial expressions, and posturing. There are few cultural universals regarding non-verbal signals, however, all cultures have them. The therapist must avoid drawing conclusions regarding nonverbal behaviors without having more knowledge. For example, in the US, men will generally stand away from a woman when they first meet. Should the distance decrease, it will be interpreted as a sign of interest. In Latin cultures, this distance between a man and a woman when speaking does not convey a special interest.

SHARE YOUR EXPERIENCE

Think about a time when you treated a client of a different culture than yours.

• Describe ways you altered your behavior or approach in some way to make the situation more comfortable or effective.
• Describe how the session was more challenging. 
• What did you do to address these challenges.
• Discuss the effectiveness of your strategies.
• Describe what you learned about the client's culture from this encounter.