CULTURAL
ASPECTS
OF CARE
OBJECTIVES
Know and understand:
•  How culture influences health behavior and
preferences about provision of health care
•  Principles of respectful communication with
patients from a different cultural background
•  Questions to include in history-taking
•  Ways in which end-of-life care may need to be
adapted
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TOPICS COVERED (1 of 3)
•  Cultural Competence
•  No Culture Is Monolithic
•  Addressing the Patient
•  Language and Literacy
•  Respectful Nonverbal Communication
Slide 3
TOPICS COVERED (2 of 3)
•  “Elephants in the Room”
•  History of Traumatic Experiences
•  Immigration Issues
•  Acculturation
•  Tradition and Health Beliefs
Slide 4
TOPICS COVERED (3 of 3)
•  Attitudes toward Health Services
•  Culture-Specific Health Risks
•  Approaches to Decision-Making
•  Disclosure and Consent
•  Gender Issues
•  End-of-Life Care
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CULTURAL COMPETENCE
•  Not a form of “political correctness”
•  Most definitions emphasize a careful
coordination of individual behavior,
organizational policy, and system design to
facilitate mutually respectful and effective
cross-cultural interactions
•  Combines attitudes, knowledge base, acquired
skills, and behavior
•  An approach, not a technique
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NO CULTURE IS MONOLITHIC
•  The cultural information in this presentation is
accurately described in general
•  Beliefs, traditions, customs, and preferences of
the individuals in a cultural group vary widely
•  Clinicians must never assume that any
person’s cultural background dictates his or her
health choices or behavior
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ADDRESSING THE PATIENT
•  Determine the patient’s preferred term for
cultural identity and use it in conversation and
in health records
•  Use the patient’s title (eg, Dr, Reverend, Mr,
Mrs, Ms, Miss) and surname unless the patient
requests a more casual form of address
•  Ask how to pronounce the patient’s name
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LANGUAGE AND LITERACY
•  What language does the patient feel most
comfortable speaking? Will a medical
interpreter be needed?
•  Does the patient read and write English?
•  If the patient is not literate, can someone assist
at home with written instructions?
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RESPECTFUL NONVERBAL
COMMUNICATION (1 of 2)
•  Hand gestures, facial expression, physical contact,
and eye contact can hold different meanings for the
patient and clinician if their cultural back-grounds
differ
•  Watch for body language cues that appear to be
significant to the patient
•  Be alert to making negative judgments about a
patient based on cultural assumptions about the
meaning of body language
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RESPECTFUL NONVERBAL
COMMUNICATION (2 of 2)
•  Use conservative body language early in the clinical
relationship or when in doubt
  Assume a calm demeanor
  Avoid expressive extremes such as very vigorous
handshakes, a loud voice, excessive hand gestures,
and impassive facial expression
•  Determine what distance seems to be the most
comfortable for each patient
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“ELEPHANTS IN THE ROOM”
•  Lack of trust in health care providers and the
health care system
•  Fear of medical research and experimentation
•  Fear of medications or their side effects
•  Unfamiliarity or discomfort with the Western
biomedical belief system
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HISTORY OF
TRAUMATIC EXPERIENCES
Include relevant questions in history-taking:
•  Is the patient a refugee or survivor of
violence or genocide?
•  Are family members missing or dead?
•  Have the patient or family members been
tortured?
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IMMIGRATION ISSUES
Immigration status
•  Consider assuring each patient that information given will
be kept in confidence, especially since patients may not
have appropriate documents
History of immigration or migration
•  The history of a group can affect attitudes and behaviors of
many generations of its members
•  A person’s migration history often provides insight into the
key life transitions informing his or her outlook
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ACCULTURATION (1 of 2)
•  A process in which members of one cultural group
adopt the beliefs and behaviors of another group
•  May be evidenced by changes in language
preference, attitudes and values, and/or ethnic
identification
•  Can be an issue dividing families
•  May greatly affect a person’s health behavior and
preferences about end-of-life care
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ACCULTURATION (2 of 2)
•  Ask how long the patient has lived in North
America and whether he or she was born here
•  Remember that the degree to which a person is
acculturated to Western customs and attitudes
is the consequence of many factors, not just
length of time since immigration
•  It can be useful to ask patients directly about
their adherence to cultural traditions
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TRADITION AND HEALTH BELIEFS
•  Some non-Western paradigms about illness:
  Illnesses have spiritual causation
  Illnesses result from imbalance in essential physical
components or bodily humors
  Illnesses are caused by a person’s actions in past lives
•  Ask about use of alternative remedies and rituals
•  Negotiate a common understanding of causation,
diagnosis, and treatment
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ATTITUDES TOWARD NORTH
AMERICAN HEALTH SERVICES
Minority patients may be uncomfortable due to:
  Lack of familiarity with Western practices
  Dissatisfying previous encounters
  Belief that insensitivity or discrimination is inevitable
for anyone in the cultural or ethnic group
  Having been stereotyped or treated insensitively or
even unfairly by clinicians in the past
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CULTURE-SPECIFIC HEALTH RISKS
•  Epidemiologic and medical research has
identified numerous differences among ethnic
and cultural populations with regard to specific
health risks
•  Clinicians who treat many patients from a
specific group should stay abreast of the latest
findings in relevant areas
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APPROACHES TO DECISION-MAKING
•  In many non-Western cultures, decisionmaking about health care is family- or
community-centered
•  Autonomy principles allow competent persons
to involve others in their health decisions or to
cede those rights to a proxy decision maker
•  Ask patients if they would prefer to involve or
defer to others about decision-making
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DISCLOSURE AND CONSENT
•  Some cultures believe that patients should not
be informed of a terminal diagnosis, as this
may damage health or hasten death
•  It can be difficult to obtain informed consent
from these patients
•  Early in the clinical relationship, explore each
patient’s preferences regarding disclosure of
serious findings, and reconfirm these wishes
at intervals
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GENDER ISSUES
•  Cultural norms for men and women can
influence their expectations about interaction
with providers, and their health behavior,
decision-making, disclosure, and consent
•  Explore each patient’s decision-making
preferences and their attitudes toward their
autonomy early in the clinical relationship,
confirm these preferences at intervals, and
follow the patient’s wishes whenever possible
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END-OF-LIFE DECISION-MAKING
AND CARE INTENSITY
•  Listen carefully to the patient’s goals and
concerns and avoid making culture-based
assumptions
  The assumption that “no one would want to live in
that condition” or that “everyone would want
treatment in this situation” is likely to be faulty
•  Strive to understand the overall approach to life
and death, and as far as possible provide care
congruent with that approach
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ATTITUDES TOWARD
ADVANCE DIRECTIVES
•  Be sensitive to the possibility that some
minority older persons will prefer to:
  Use verbal directives
  Dictate directives to family members or others
  Avoid discussing directives so as to observe
proscriptions against talking about death
•  Allow patient to indicate the interventions they
do want as well as those they do not want
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SUMMARY
•  Cultural competence is a nuanced understanding
of the impact of culture on health care encounters
•  Culture influences health behavior and patient
preferences about treatment
•  Clinicians should remain alert to differences among
patients from a given culture
•  It is important to explore the patient’s attitudes
about such issues as disclosure, consent, and
decision-making early in the clinical relationship
Slide 25
QUESTION 1 (1 of 2)
Name 3 ways to demonstrate
respectful non-verbal communication
during an intercultural patient
encounter.
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QUESTION 1 DISCUSSION (2 of 2)
•  Determine what distance seems to be most
comfortable for the patient.
•  Use a calm voice.
•  Avoid vigorous handshakes.
•  Avoid excessive hand gestures.
•  Continually assess the patient for discomfort or
puzzlement.
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QUESTION 2 (1 of 2)
Name 2 questions that could be
included in the history of individuals
from outside the US.
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QUESTION 2 DISCUSSION (2 of 2)
•  How long have you lived in North America?
•  What traditions from your country of origin are
very important to you?
•  Do you and your children have different views
about health care?
•  Have you changed your views on any health
care matters since moving to North America?
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QUESTION 3 (1 of 2)
Name 2 approaches to end-of-life
care and/or advanced directives for
persons from non-Western cultures.
Slide 30
QUESTION 3 DISCUSSION (2 of 2)
•  Ask who makes health care decisions for the
patient.
•  Determine whether a patient would like to
know his or her diagnoses.
•  Ask about the patient’s goals irrespective of
the country of origin.
•  Try to learn the patient’s overall approach to
life and death.
Slide 31
ACKNOWLEDGEMENTS
GRS6 Chapter Author:
Reva N. Adler, MD
Consulting Slide Editors: Gwen Yeo, PhD
MD
Brangman, MD
Carmel Dyer,
Sharon A.
Medical Writers:
Beverly A. Caley, Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society
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