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In health care today, clinicians are providing services in multicultural environments where patients and providers may be of different cultures, traditions, and even languages. These differences can serve as barriers to effective health care service delivery. While many patients prefer to be seen by a health care provider who shares his or her culture, it is not always possible. Hence, the challenge is to provide health care services across cultural boundaries in a competent and sensitive manner.

The meaning of culture includes various theoretical and philosophical definitions. In general, culture includes the ‘customary beliefs, social forms and material traits of a racial, religious or social group,’ as well as an ‘integrated pattern of human knowledge, belief and behavior.’1 How we deal with these aspects when attempting to work with a person whose culture is one with which we are unfamiliar has to do with our level of cultural competence.

Central to cultural competence in health care is the understanding that cultures vary in their beliefs of the cause, prevention, and treatment of illness, as well as what “good health” means. These beliefs dictate the practices used to maintain health and to seek health care when needed. Too often we interpret the behavior of others as negative because we don't understand the underlying value system of their culture. The natural tendency is to assume that our own values or customs are more sensible and right. Yet, it is important to suspend our judgments in order to understand the patient and to identify the best way to provide care for the patient.

Another source of cultural misunderstanding stems from differences in communication styles, which can vary based on both the patient and the doctor’s cultural background. For example, communication can be linear or direct, attempting to ensure the listener will ‘get the point,’ or it can be circular and indirect, where the listener is expected to derive the meaning from the context. Communication can also have different styles such as personal and procedural. Personal communication attempts to understand issues on a case-by-case basis and is focused on the circumstances in the situation. On the other hand, procedural communication expects that procedure and policy can be used in resolving issues and may be more common in cultures that more closely follow the norms of society. Thus, procedural communication seeks to follow the rules rather than focus on the circumstances.3

It is also important to consider cultural differences in emotional expressions and body language, how they are used, or not used by different cultures and what these non-verbal cues mean. All of these differences in both verbal and non-verbal communication in the health care setting create the potential for misunderstanding. Hence, there is a need for culturally competent health care providers and leaders.

Cultural competence has been described by Bennet and Bennet as developing in stages denoting levels of intercultural sensitivity. The first three are incorporated into the term ‘ethnocentric stages’ and include denial, defense and minimization. The second three involve ‘ethnorelative stages’ and include acceptance, adaptation and integration.2  It is important to understand these stages and where one falls along the continuum. With this understanding, one can then work towards developing one’s cultural competence in order to provide the best care to each person served.

Various instruments can be used to measure an individual’s orientation toward cultural differences. ISCOPES participants will have the opportunity to take the Intercultural Development Inventory (IDI).4 The IDI is a paper and pencil exercise that allows the  respondent to assess their own understanding of intercultural issues and gives them a point from which to reflect on their own perceptions of culture. ISCOPES attempts to offer a more comfortable learning environment, in which participants can apply their knowledge and further their understanding of culture while engaging in the group service experience.

Self-reflection

How well do you know your biases? One way to measure subconsciously held bias and stereotyping is by taking the implicit association test (IAT). It has been used for many years now within the field of psychology and can help you to see some areas where society's prejudice has invaded your own psyche. You may wish to take one or two of the tests, perhaps to start with one that seems a little less daunting.

Subconsciously held attitudes are harder to change than the conscious ones, but not impossible. Methods that have shown some hope for helping to change subconscious attitudes include:
-- Positive role models: spending time with someone you respect that is of the group against which you showed some bias can help.
--Conscious effort: actually trying to think positively about someone of another group can reduce bias.
-- Putting yourself in another's shoes: as you engage with someone from another group try to consider things from their perspective.

Take the IAT by clicking here.


Additional Information

For additional information on topics discussed in the text above, please click on each of the following links:

Definitions
Values
Communication (Non-Verbal and Verbal)
Obtaining Accurate Information (especially in research context)
Recent Immigrants
Interpreters in health care (language assistance resources, interpreters’         roles, and working with a patient through an interpreter)
Scenario Case Histories
Web Resources

References

1Merriam Webster Collegiate Dictionary, Eleventh Edition.

2Bennet, MR; Bennett, MJ. (2004). Developing Intercultural Competence: A Reader. Portland, Oregon: Intercultural Communication Institute.

Campbell, F (ed) (1995). "Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic/Racial Communities", Cultural Competence Series 1, US Dept. of Health and Human Services.

4Hammer, MR; Bennett, MJ. (2001) The Intercultural Development Inventory [Instrument]. Portland, Oregon: Intercultural Communication Institute.

3Landis, D; Bennett, JM; Bennett, MJ. eds. (2004) Handbook of Intercultural Training, Third Edition. Thousand Oaks, California: Sage Publications.

Like R, et al. (1996). "Recommended Core Curriculum Guidelines on Culturally Sensitive and Competent Care"; Family Medicine 27:291-7.

Women's Health Initiative Manual: Volume 2-Procedures, pp20.1-20.14, 1994, adapted from: "Cross Cultural Counseling: A guide for Nutrition and Health Counselors", USDA, US Department of HHS, FHN 250, 1986.