Transcultural Considerations
in Health Assessment
What is culture?
• The sum total of socially inherited characteristics
of a human group that comprises everything
which one generation can tell, convey, or hand
down to the next
• The sum of beliefs, practices, habits, likes,
dislikes, norms, customs, rituals, and so forth
that we learned from our families during the
years of socialization (Spector, 2009)
Characteristics of culture
Culture is:
• Learned from birth through the process of
language acquisition and socialization
• Shared by all the members of the same cultural
group
• Adapted to specific conditions related to
environmental and technical factors and the
availability of resources
• Dynamic and ever-changing
Cultural competence
• The complex integration of
knowledge, attitudes and skills which
enhance cross-cultural
communication, and promote
meaningful interactions with patients
• Enables you to provide culturally
appropriate, congruent and relevant
health care that affirms the worth
and dignity of your patients
• Is NOT assuming what a person’s
culture is based on their race,
ethnicity, or national origin
Challenges
• Ethnocentrism: the tendency to view your own way of
life as the most desirable, acceptable or best, and to
act in a superior manner toward other cultures’
lifeways.
• Cultural imposition: the tendency to impose your
beliefs, values and patterns of behavior on individuals
from another culture
• Xenophobia: Fear or contempt of strangers or
foreigners, especially as reflected in one’s political or
cultural views
Cultural humility
• Starts with examining your own assumptions and
beliefs—what worldview and goals do YOU bring to
the clinical encounter?
• The biggest barrier is NOT lack of knowledge of the
details of different cultures’ beliefs but lack of selfawareness and respect for other points of view
• Developing the skills to examine the differences will
help you in any clinical encounter!
Cultural diversity
• Traditional focus is on: How are
others different from me?
• Consider instead: How am I
different from the other person?
“These other cultures are not failed
attempts to be us; they are unique
manifestations of the spirit”
—Wade Davis
Cultural blindness
• The belief that race, ethnicity, and culture make no
difference in how health care services are provided
• Ignores the assets and strengths of cultures
different from one’s own
• May place blame on the individual receiving care
for bad outcomes
“We treat all of our patients the same.”
Cultural Health Assessment
• A systematic examination of
health-related cultural beliefs,
values, and practices of
individuals, families, groups,
and communities
• Can be comprehensive or
focused depending on the
circumstances
Health-related beliefs and practices
In order to understand the health care needs of
others:
• One needs to confront one’s own biases,
preconceptions and prejudices about specific racial,
ethnic, religious or socioeconomic groups
• One must identify the meaning of health to the
client, remembering that concepts are derived in
part from the way in which members of their
cultural group define health
Levels of cultural competency
• Destructiveness
• Incapacity
• Blindness
• Pre-Competence
• Competence
• Proficiency
Let’s play Jeopardy!
The answer is:
The Land of the Free
&
The Home of the Brave
Now… think!
Why it’s important
• The US is becoming more and more culturally
diverse
• It goes beyond respect for the patient’s beliefs
and lifeways
• Culturally incompetent care affects outcomes
• People of non-dominant cultures are more likely
to delay care and to receive substandard care
• Misunderstandings can be fatal!
What does this
image evoke?
Immigrants to Ellis Island
Language barriers
•
•
•
•
Fluent provider
Competent in-person translation services
Telephone translation
Family members should not be used—especially
children!
English Only
Asian/Pacific Islander
Other Indo-European
Spanish
Other
12.2
0.8
3.7
3.0
80.3
Percent of US population age 5 and older by language
spoken at home
Language translation
• Mandated by law for agencies using federal/state
funding as well as by JCAHO
• This funding includes Medicaid and Medicare, so it
applies to just about every health care agency!
• Remember that this is only the beginning of
culturally appropriate care!
Subculture
Used for fairly large
aggregates of people
who have shared
characteristics that are
not common to all
members of the
culture and that
enable them to be
thought of as a
distinguishable group
Examples of subculture: these
can be based on:
• Ethnicity
• Blacks
• Latinos
• Native Americans
• Religion
•
•
•
•
•
Jews
Buddhists
Catholics
Mormons
Muslims
Subculture continued
• Occupation
• Nurses
• Doctors
• Military
• Health care characteristic
• The Blind
• The Deaf Community
• Age (adolescents, older adults)
• Gender or sexual preference (women, men,
gay men, lesbians, and transgender individuals)
Basic human problems culture
attempts to address:
• Innate nature of people
• Relationship to nature: destiny,
harmony, mastery
• Time dimension: past, present or
future oriented
• Purpose of existence: being, being in
becoming, doing
• Relationship with others: lineal,
lateral, individual
Time orientation: monochronic
• Prefer to complete one task
at a time
• Task-oriented time (work) is
separate from socioemotional time (play)
• Value punctuality, completing
tasks, keeping to schedules
• Ex: United States, Israel,
Germany, Switzerland
Time orientation: polychronic
• More flexible about
schedules and deadlines
• Integrate task-oriented and
socio-emotional activities
• Maintaining relationships is
more important than
accomplishing tasks
• Ex: Latin America, Middle
East, Africa
High vs. low context
High context
• Little meaning without
surrounding context
• Indirect, embellished
• Process-oriented
• Disagreement is
personalized, consensus
is valued
• Effectiveness
Low context
• Focus is on what is
explicitly written or said
• Direct, economical
• Task-oriented
• Disagreement is
depersonalized
• Efficiency
Definitions
• Values: refers to a desirable or
undesirable state of affairs
(Leininger, 1995)
• Norms:
• Rules by which human
behavior is governed
• Result from the cultural values
held by the group
• Individuals are rewarded or
punished as they conform to or
deviate from the established
norms.
Definitions
• Religion refers to an organized
system of beliefs concerning the
cause, nature and purpose of the
universe, especially belief in or
the worship of God or gods
• Spirituality is born of each
person’s unique life experience
and his or her personal effort to
find purpose and meaning in life
Types of families
• Nuclear: husband, wife and children
• Extended: nuclear plus blood relations and
others
• Blended: husband, wife and children from
previous relationships
• Single parent
• Communal: group of men, women and children
• Cohabitation: unmarried man and woman
• Gay/lesbian
“The family is who they say they are”
Cause of illness
• Biomedical: based on the assumption that all
events in life have a cause and effect and that all
of reality can be defined and measured
• Naturalistic: human life is only one aspect of
nature and that the forces of nature must be
kept in natural balance or harmony
• Magico-religious: the world is seen as an arena
in which supernatural forces dominate. The fate
of the world and those in it depends on the
actions of supernatural forces for good and evil
Sources of healing
• Self-treatment
• Lay or folk healing systems
• Spiritual or religious healing
• Scientific biomedicine
• Transcultural expression of illness: pain, sadness,
somaticization
• Examples of traditional health and illness beliefs
and practices (Jarvis, p. 49)
• Culture-Bound Syndromes (review Jarvis, p. 50)
Religious groups and death beliefs
Religious
Group
Heaven
Resurrection Cremation
Assembly of
God
Real place
Of the body
Baptists
Where the
Physical
redeemed go
Buddhists
No
independent
existence
Not
encouraged
Allowed but
not
encouraged
No future
Preferred
foreseen-belief
in reincarnation
Religious groups and death beliefs
Religious
Group
Heaven
Resurrection Cremation
Muslims
Several
layers
usually seen
Afterlife as
physical pains
and pleasures
Not practiced
Roman
Catholics
A condition:
eternal
fullness of
life
Physical
Disposal of
the body does
not affect
afterlife
Seventh-day
Adventists
Heaven
exists
Body and spirit
Yes
The Kleinman Model
1.
2.
3.
4.
5.
What do you call the problem?
What do you think has caused the problem?
Why do you think it started as it did?
What do you think the sickness does? How does it work?
How severe is the sickness? Will it have a short or a long
course?
6. What kind of treatment do you think you should receive?
What are the most important results you hope to receive
from the treatment?
7. What are the chief problems the sickness has caused?
8. What do you fear most about the sickness?
References
• Andrews, M. A., Bolye, J. S (2008). Transcultural Concepts in Nursing
Care (5th ed.). Philadelphia: Lippincott Williams & Wilkins
• Divi C, Koss RG, Schmaltz SP, Loeb JM. Language proficiency and
adverse events in US hospitals: a pilot study. International Journal of
Quality in Health Care. 2007 Apr;19 (2): 60-67. Epub2007 Feb 2
• Fadiman, A. (1997). The spirit catches you and you fall down: A
Hmong child, her American doctors, and the collision of two cultures.
New York: Farrar, Straus, and Giroux.
• O’Hara-Devereaux, M., Johansen, R. Transcending cultural barriers:
Context, relationships, and time. Retrieved January 28, 2012, from
http://www.csub.edu/TLC/options/resources/handouts/fac_dev/cul
turalbarries.html
• Rankin, S. H., Stallings, K. D., & London, F. (2004). Patient Education
in Health and Illness (5th ed.). Philadelphia: Lippincott Williams &
Wilkins
• Spector, R. E. (2009). Cultural diversity in health & illness. (7th ed.).
Upper Saddle River: Prentice Hall.