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http://www.musc.edu/cultural/ A resource developed by Dr. Amy Blue and the MUSC College of Medicine The
Provision
of Culturally Competent Health Care
by Amy V. Blue, Ph.D.
Associate Dean for Curriculum and Evaluation, MUSC College of Medicine Assistant Professor, Department of Family Medicine "Arnella L., age 64, woke up one morning unable to see or use her right arm. An ambulance was called and she was taken to the emergency room. Her problem was diagnosed as a "light stroke," and, as the hospital was overcrowded, she was sent home in the care of relatives. The attending clinician gave her a bottle of pills; medication, she was told, that she would have to take for the rest of her life. She, however, felt that "that don’t make no sense," and discarded the medication. She believed her blood had "boiled up" in her brains - her own fault for eating too much rich food. She then embarked on her own combination of healing strategies. The first of these was to sleep propped up on pillows, as postural change to allow some of the excess blood to drain back into the body. She then began a course of vinegar and honey in hot water (taken daily for nine days) to bring the excess blood down to a safe level. Finally, she called in her minister to pray for her; she later reported that she "felt the stroke leave" her body when he laid his hand on her head. In any case, a niece stated bitterly, "The doctors didn’t do nothin’ for her, that’s for sure." From: Snow LF. Ethnicity and Clinical Care: American Blacks. Physician Assistant and Health Practitioner, July 1980, p. 52. This case illustrates the significant role health beliefs, based on culturally-grounded health and illness concepts, have in patient treatment and outcomes. A culturally competent physician would have recognized that the patient might hold health beliefs about this illness episode that differ from a physician’s. The culturally competent physician would have asked the patient a few, brief open-ended questions to learn the patient’s health beliefs, or explanatory model about the illness episode. This information would have then been used to negotiate with the patient a treatment plan that was mutually satisfactory and most likely for the patient to use.What is Cultural Competency Culture consists of a body of learned beliefs, traditions, and guides for behaving and interpreting behavior that are shared among members of a particular group. It includes values, beliefs, customs, communication styles, behaviors, practices, and institutions. The visible aspects of a culture include clothing, art, buildings, food; the less visible aspects of culture include values, norms, worldviews, and expectations. Culture influences an individual’s health beliefs, behaviors, activities and medical treatment outcomes. Because of the significant influence of culture upon health and related outcomes, health care professionals should be culturally competent in order to provide optimum health care to patients. Cultural competency in the context of health care provision consists of:Culhane-Perea et al1, describe five levels of cultural competence with respect to health care. They are: Associated with the acceptance of the role of cultural beliefs, values, and behaviors on health disease, and treatment (Level 3) are the knowledge, attitudes and skills objectives listed below (adapted from Culhane-Perea, et al1) Knowledge:
Attitudes:
Useful Concepts and Techniques for Providing Cultural Competent Health Care Professional, Popular, and Folk Health Care Sectors
It is estimated that the majority of self-recognized illness episodes are managed outside of the formal health care sector,2 or the professional health sector.3 The professional health sector is the organized, regulated, legally sanctioned health profession, such as allopathic and osteopathic medicine in the United States. Other societies may have professional medical systems in addition to western, allopathic/osteopathic medicine included in their professional health sectors, such as Chinese or Oriental medicine in China, and Ayurvedic medicine, in India. The popular health care sector is the largest part of any health care system and consists of the lay, non-professional, non-specialist arena in which illness is initially defined for an individual and treatment is initiated.3 The popular health care sector can be conceptualized to contain many levels, including individual, family, social network, and community. An individual may use one or more of these levels for assistance during an illness episode to define symptoms, decide where to seek treatment, engage in treatment, and evaluate treatment outcomes. Self-treatment is generally the first resort when an individual becomes ill and self-treatment practices are grounded in popular health care beliefs and practices. After treatment is received, regardless of whether given by the popular, professional or folk sectors, patients rely on the popular sector to evaluate treatment, and if necessary, decide upon the next course of action. The folk health care sector is the non-professional, non-bureaucratic, specialist sector that may overlap with the professional and popular sectors.3 Folk medicine practitioners include the herbalist, curandero, shaman, etc. In some societies where professional medicine is absent, the folk and popular health care sectors are the health care system. Folk health beliefs and practices may be secular or sacred, or a combination of both. Health care providers’awareness of these three sectors in a
particular health care system is important for the provider to
understand that patients rely on multiple sources during their illness
experience in addition to the professional health care provider from
whom they have sought assistance (as is illustrated in the case study
above). Popular, folk and practitioners of other professional medicine
can all, or in part, impact on a patient’s health care beliefs and
behaviors. Disease and Illness Medical anthropologists developed the distinction between the concepts of disease and illness to better understand the dynamic relationship between culture, medicine, and physician-patient communication. Disease refers to the malfunctioning of the physiological and/or psychological processes in an individual. Illness refers to the psychosocial experience and meaning of the perceived disease for the individual (and those associated with the individual, i.e., family members).4 Illness behavior includes the perception, cognition, affective response to, and valuation of the symptoms of the disease. The distinction between disease and illness is more readily understood with the example of a patient diagnosed with hypertension (a disease), but who has no experience with symptoms, and thus does not perceive the existence of an illness. Similarly, a patient may complain of chronic pain (illness), but on exam and testing, does not have any physical findings, and thus no apparent "disease." The majority of physicians’ training focuses on diagnosing and treating diseases, the physiological pathologies that affect individuals. However, patients arrive at the physician’s office because of their experience and interpretation of ill-feeling bodily symptoms, or illness. Individuals evaluate their health care outcomes based on their illness experience, and thus it is important for health care providers to recognize that patients’ experience with illness may vary from their professional interpretation of the disease.Explanatory Models Another key medical anthropological concept useful for developing cultural competency is the explanatory model. Kleinman3 writes that "explanatory models are the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process." Explanatory models conceptually include 5 major questions about an illness episode: Not all explanatory models may include these five questions. Health care professional explanatory models typically answer most or all of these questions, and the explanatory model is generally disease-based. Patient and family models, which focus on illness, often do not answer all of these questions. Explanatory models differ from popular health care beliefs in that the individual forms them in response to a particular illness episode. They frequently incorporate concepts from popular health care beliefs, but it is important not to equate the two. Recognition of explanatory models and attempts to access a
patient’s and family members’ explanatory models about a particular
illness episode is the most fruitful means to: 1) practice culturally
competent medicine and 2) improve patient outcomes. Learning about a
patient’s and family members’ explanatory models will generally provide
information about any cultural health beliefs and practices relevant to
the individual’s illness episode. Furthermore, with the knowledge of
the patient’s and family members’ explanatory models about the illness,
the health care practitioner can provide appropriate patient education
about the disease and illness, and effectively negotiate with the
patient a treatment regimen that will be acceptable and effective for
the patient to follow. In this manner, patient outcomes are positively
effected. Eliciting an Explanatory Model Eliciting an explanatory model is not necessary for all patient illness episodes (i.e, an acute condition such as a sore throat), but there will be many occasions when it is judged that further probing about the patient’s conceptions of the illness will further enhance the physician-patient relationship and treatment outcomes (i.e., recurrent and chronic conditions). Imperative for eliciting an explanatory model is a genuine, non-judgemental interest in the patient’s beliefs and communication to the patient that this interest is based on the knowledge that eliciting this information is important for planning an effective treatment regimen with the patient. Kleinman3 suggests the following questions to elicit an explanatory model:
Several steps can be taken to begin to incorporate the knowledge, skills and attitudes necessary for practicing culturally competent health care.
Popular and Folk Health Care Beliefs Held by Cultural Groups in South Carolina All cultural and ethnic groups hold concepts related to health
and illness and associated practices for maintaining well-being or
providing treatment when it is indicated. For an individual,
socioeconomic, educational, geographic, religious and other factors
will mediate and shape cultural and ethnic
health beliefs. For this reason, a health care practitioner should
never
assume that an individual from one ethnic group holds the same beliefs
as
another individual from the same ethnic group. Caution is needed to
avoid
stereotyping. However, there are common elements of belief that may be
shared
among members of cultural and ethnic groups and a general familiarity
with
these can be very helpful in further understanding a patient’s
particular
perspective. Members of a cultural or ethnic group who are younger,
more
educated, more affluent members, and more acculturated into mainstream
American
society may not adhere to popular and folk medical beliefs. However, it
is
likely that others in their social network will rely upon these
concepts
when such an individual becomes ill in order to identify the illness,
suggest
treatment and evaluate prescribed treatment. African-Americans Health beliefs among African-Americans will vary across sub-cultural groups related to urban or rural residence, geographic location in the U.S. (north versus south), class, and age. In addition, and pertinent to South Carolina, are African-American cultural sub-groups based upon geographic origin and historical experience in the U.S. Sea Islands People or Gullah An important cultural sub-group in the Southern U.S. is the population of the Sea Islands, sometimes referred to as the Gullah. The islands that begin off the North Carolina coast and continue along the coasts of South Carolina and Georgia to the Florida border are known as the Sea Islands or Gullah Area. They range in size from very small and uninhabitable to the largest of these islands, Johns Island here in South Carolina. The Sea Islands were accessible only by boat until the beginning of the 1930s.7 Before the Civil War, the islands’ economy was upon plantations, and in many areas, enslaved blacks outnumbered the white inhabitants. On many islands, the only white individuals in residence were the plantation owner or overseer. A unique culture developed on the islands for several reasons.7,8 First, the influence of American white culture was minimal because the islands were isolated and populated by a large number of enslaved blacks. Second, in the early 18th century, a more favorable duty was placed in South Carolina on slaves brought directly from Africa. This practice continued even after the 1808 Slave Trade Act, and as late as 1858, enslaved Africans were brought to the Sea Islands. The large number of slaves arriving from Africa and remaining in relative isolation on the Sea Islands meant that several features of African culture were retained in the area, and subsequently modified into a distinctive African-American culture. Although contemporary changes in the last few decades have dramatically reduced the isolation of the Sea Islands people, a syncretism of African, American, and slave patterns, plus contemporary American life styles does exist. Key features of the Gullah culture are the oral heritage or stories and songs (used as the basis for Uncle Remus stories, for example), and the distinctive Gullah dialect, formerly known as Geechee. Research has demonstrated that the characteristic elements of Gullah reflect both African roots and English dialects of colonial Carolina.7 With respect to health beliefs and medical care, historically, the enslaved population of the Sea Islands maintained their own medical practices for each other, especially those used to cure common illnesses; assistance was sought from the planter or plantation doctor if the slaves found their own remedies were not successful for a particular illness episode. African knowledge of plant and animal pharmacopoeia was handed down from generation to generation. In addition, local Indians shared their knowledge of plant and animal life vis a vis health remedies. Given the isolation of the Sea Islands, a black folk medicine relying upon herbal substances flourished during the antebellum period.7 Traditional African-American Folk Health Beliefs Natural and Unnatural Illnesses Unnatural illness occurs when the individual is the victim of a hex, curse or spell. With such illness, the plan of God has been disrupted, thus making the illness unnatural. The decision that an illness is unnatural is generally reached after the patient has seen a physician and a specific diagnosis has not been immediately offered or the prescribed treatment has failed. (Treatment failure may be the result of inappropriate patient use of the medication because of misunderstanding.) Symptoms of unnatural illness are often gastrointestinal or behavioral in nature. Traditional Medicine Hoodoo, conjure, or ju-ju are Sea Islands terms for the techniques used to produce unnatural or supernatural illnesses.7 The conjurer uses his or her own powers and those found in certain materials, objects, and words to create an illness in a specific person. A hoodoo amulet or hand is thought to protect the wearer from hoodoo. Only a conjurer can cure someone who has been hexed. A person who is both herbalist and conjurer is frequently called a root doctor. Phrases and Terms Used to Describe Illness Symptoms The Concept of Blood The Role of God in Illness High and Low Blood Pressure High and low blood pressures are interpreted in traditional folk health beliefs as high or low blood.10-12 Low blood is viewed as anemia, whereas in clinical terms, high blood would be polycythemia. It is believed that diet can manage both low and high blood problems, because both are generally caused by dietary factors. Low blood results from ingesting too many acid or astringent foods (i.e., lemon juice, vinegar, pickles, etc.) These foods "cut" the blood and "bring it down" or "dry it up." Symptoms associated with low blood are fatigue, weakness and not having the energy to get and go. High blood is from ingesting too many rich foods, especially red meat. The symptoms of high blood are dizziness, palpitations, headache and vision difficulties. Remedies include the ingestion of acid or astringent foods, such as lemon juice, vinegar, sour oranges, or brine from pickles or olives, to bring the blood down. It is believed that if left untreated, high blood will cause excess blood to back up in the brain, causing the individual to have a stroke. For the patient diagnosed with high blood pressure by a health care provider, taking medication for a long period time may be viewed with some wariness. The patient may think that prolonged use of the medication will result in low blood pressure, because it is the blood volume that is understood to be the source of the problem. Patients may be inclined to use home or folk remedies to address the problem, such as drinking the appropriate substance. Health care practitioners need to ask questions about diet with patients because the patient may also be using a home remedy such as olive or pickle brine. Diabetes Diabetes, or "sugar" runs in families and is conceptualized as the result of excessive consumption of starchy, greasy foods, excessive worry about family and work-related stresses.9 For symptoms of weight loss, thirst and frequent urination, dietary changes, use of appropriate herbs, and reestablishment of harmony with family, friends and coworkers are initially recommended in the popular health beliefs. If the person is unable to make sufficient changes in these areas or the herbs do not appear to remedy the symptoms, then a visit to the physician is warranted. A diagnosis of diabetes is generally well-accepted when the
patient is told that the blood sugar is elevated. With this
explanation, insulin and oral hypoglycemic medications are more easily
accepted because they are thought of as "bittering" agents used to
lower the sugar content. Home remedies such as herbal teas, garlic and
lemon juice may also be used to bitter the blood. Insulin may be viewed
by some patients (generally older patients) as too powerful a
substance, promoting addiction or dependence. This fear may be
exacerbated when the patient is told that they will need therapy
forever. Traditional Health Beliefs of Mexican-Americans and other Latin Cultures The migrant worker population from Mexico and other parts of Central and South America is increasing in South Carolina. These individuals tend to be young and may be more acculturated to American mainstream society than are members of their own cultures still residing in their native lands. Generational, regional, socioeconomic, and educational differences mediate how individuals from these cultures conceptualize health, illness and associated practices. Younger members may not subscribe to these beliefs as strongly, if at all, as may members of older generations. However, it would be inappropriate not to explore cultural conceptions of illness when it appears necessary. An additional element related to cultural competency is that Spanish is spoken by these individuals; it is not an uncommon for the need for an interpreter during a health care consultation, unless the health care provider speaks Spanish. Illness Beliefs - The Role of God and "Hot" and "Cold" Causes of illness may be physical or supernatural. 9,10 Balance of the forces of nature, such as hot and cold, wet and dry, is a key concept in traditional health beliefs. Physical illness may be due to an imbalance of hot and cold, and thus restoring this balance is imperative. A hot illness requires a cold treatment, and vice versa. However, there is no universal agreement about which illnesses, foods, and treatment are hot or cold. Heat is generally associated with blood (which keeps a person warm during cold weather) and with fevers and rashes. Cold is associated with water, damp air, and phlegm. Families hold their own specific beliefs about these issues and have passed this knowledge on from one generation to another. Health care provider awareness that illnesses are hot or cold is important because if a "hot" treatment is prescribed for a "hot" illness (i.e., penicillin for a strep throat), the patient may not want to follow medical advice because health beliefs are that a "cold" treatment is appropriate for the "hot" illness. To elicit a patient and family’s particular beliefs about hot and cold illness and treatments, the use of explanatory models or the other questions listed above is recommended. Supernatural illnesses are commonly associated with emotional and psychological illnesses. Home remedies are often the first line of treatment for all types of illness. These include herbal teas, massaging the body with oils, poultices, and eating the appropriate "hot" or "cold" food. If the patient does not improve with any of these therapies, then a physician is consulted. Curanderismo Curanderas are consulted for natural illnesses as well, and frequently patients will visit a curandero even if they have had a consultation with a physician. Herbs, oils, and religious symbols are used during treatment, and when necessary, the curandero will go into a trance to communicate with or manipulate spiritual forces. Specific Folk Illnesses
Minnesota Public Health Association’s Immigrant Health Task Force. Six Steps Toward Cultural Competence. Minneapolis, MN: Minnesota Department of Health, 1996. University of Washington Family Medicine Clerkship. Family Medicine and Cultural Competency Website. http://www.fammed.washington.edu/pr…oral/clerkship/student/comptoc.html
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