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CHAPTER NINE Cultural Influences on Context: The Health Care Setting If you are not in tune with the

unive,se there is sickness in the heart and mind. NAVAJO SAYING He who has health, has hope; and he who ba.c hope, has everything. ARA8IAN PROVERB I Los Angeles, a young women from Mexico, who speaks no English, returns to the emergency ward and tries to explain that the liquid drops she put into her babys mouth (which the doctors intended for the babys ears) have made her child worse. In Taiwan, ninetyfour rare turtles are seized from the cargo comparrnicnt ofan airplane heading for the United States. Taiwanese residents living in the United States wanted the long hairs that grow from die turtles. They believe these hairs can be a cure tot cancer. In Fresno, California, the courts must decide if a young boy from Southeast Asia should be forced to have surgery on his club foot. His parents arc from one of the eighteen Hmong clans from Laos that have settled in the United States. They believe that the surgery will arouse angry spirits who have punished the boy for a wrong deed committed by an ancestor. North American mothers, because thei believe that germs cause disease, become uncomfortable when people get too close to their infants. In contrast, tvl:xican mothers become upset when people adinie theli hahics wuhotit touching them. A compliment that is unaccompanied by a touch can bring on the evil eye and harm the child. Interestingly, the very act that is believed to protect a child from illness in one culture is thought to cause illness in another,t A young Japanese woman on her way to surgery began to cry when she noticed she was being wheeled into operating room number four. In contrast, Navaho patients take theit medications more consistentLy when they are administered or required four times a day. For the Japanese, the character for the number four is almost identical to the word death, For the Navaho, much of the world is viewed in terms of four. Phraset are repeated four times in their ritual chants, pollen is thrown to the four directions iii many of their ceremonies, and they revere four sacred mountains.2 Something a simple as a number can stimulate negative connotations in one culture and have th exact opposite impact in another. Although the goal of a medical system may be to provide optimal care for all of in patients, this may be a difficult task in a multicultural society. As indicated through. our this book, cultural diversity has become a leading topic in virtually all sectors o our society. This is true for the context of health care as well, for we bring our cultura experiences to the health care setting. As children grow up, they learn about appropri ate health care behaviors from their parents, family, and schools; from medical workers; and from many others with whom they interact. Culture teaches children what makes people sick or causes injury, the language or words they should use to describe body pam and illness sensations, how they should behave when they are ill or injured, and what they need to do or say to feel better. People who have grown up in different societies have acquired very different sets of knowledge, beliefs, values, and attitude,s concerning health. It is important to examine the health care setting for many reasons. First, the promotion of health and the prevention of disease constitute an usgent need for studying this context. Thousands of people die daily from lack of immunization and From disease,s tnd VruSe,c such as AIDS, tuberculosis, cholera, and dyscntary,4 In addition, many of

these diseases are highly contagious, and if immigrants with these disorders are not brought into the health care system, they can transmit these diseases to other people. Second, misunderstandings from ineffective communication cause many people to suffer needlessly. Misdiagnosis, risky procedures, and unnecessary treatments are the rest,Ii of ntis tltiseoflhlntinicatiot,S Finally, in one way or anothet; you may be parr of an inrer;ulrural health care interaction. The health care industry is one of rise fastestgrowing industries in the United States, and as such, you may someday become a health care professional. ERctive communication is necessary to resolve health issues. This chapter explores Sornp of those issues. We begin by considering cultural wriations in explanations of ilss, how illness is rrcatcd, and how it can be prevented. Second, we explore some .cfccific issues concerning gender roles and health care. Third, we examine comrnuni patterns in the multicultural health care setting of the United States. And, lnally, we offer some suggestions for improving cross-cultural health care encounters,. Explanations, Treatment, and Prevention of illness Cultures differ in the way they explain, treat, and prevent illness. Despite these differences, all health belief systems can be divided into three categories: biomedical, personalistic, and naturalistic,6 The biomedical system is the dominant belief sytern in the United States, In this view, illness is the result of abnormalities in the bodys functioning or structure. These are generally caused by agents such as bacteria and viruses, or ph)sial conditioti audi as an iuitiry or aging. Treatment destroys or removes the LtttS,IIiVC agent, lepaiis the aftected body parr, or controls the affected body system. Prevention of disease involves .ivoidin Pathogen,, agents. or iCtiVtiC,c kn0 to ,I:se lii llte/ts:sOflh,/ir,,,,,, according toAngelucci: Disease is the result of active intervention by a supernatural being (deity or god), a nonhuman being (ghost or evil spirit) or a human (witch or sorcerer. The person is a victim of punishment and is rendered ill by the agent. Treatment involves .155(11 ing positive 2ssocIStiofl wirh spirits, erc. Our earlier example for the Hmong culture is a vivid illustration of the personalistic system. In tliar Ce tIle family believed tlsar the evil pirit could be appeased only if the boy suffered for the entire family. (1) Many people from Cuba, Puerto Rico, and Brazil believe in Snteria (a type of religion). Whenever someone becomes sick, a santero is contacted who consults an Orisha (saintlike deity) to assist in the cure.18 It is not uncommon for Haitians to consult voodoo priests and priestesses for treatment that can involve candles, baths, charms, and spirit visits. Within the United States, some groups, particularly African Americans, rely on picaa craving for nonfood ubatancesto treat illness. For example, an individual may eat laundry starch to build up the blood after an auto accident.9 Although some of these treatments may seem unusual, medical practitioners in other cultures have been using them as treatments for centuries. Cultural Variations in the Prevention oflilness Cultures also vary in their belief of what can be done to prevent illness. In the United States and other highly technological cultures, good health is based on annual physicals, immunizations at specified times, exercise, and good nutrition. In sharp contrast, many Muslim Afhanis rely on the Koran to protect them from illness. In a practice called

tawiz, Koran verses are written on paper, wrapped in doth, and worn by babies and the sickly. S/mist are Koran verses written on paper, then soaked in water that is drunk. Dudi are Koran verses written on paper and burned with rue close to the patient so the smoke will kill germs and ward off evil spirits.20 Mexican and Puerto Rican cultures depend on a variety of items for protection. Amulets or charms, often inscribed with a magic symbol or saying, are common to protect the wearer from disease or evil. Candles, herbs, crystals, statues of saints, shells, and teas also provide protection. Baci is a common practice in many Asian cultures. During pregnancy birth, marriage, a change of location, illness, or surgety, the family hosts a ceremony. Family members, including a community elder, gather around an alter of candles, incense, rice, holy water, flowers, and strings.2 Because some Asians believe that the spirit might depart from the body on these occasions, the body spirits are contacted by the chanting of the elder, and then strings are tied around the patients wrist to bind the spirits to the body. These strings ate usually worn for three days. Many other cultures avoid violating cultural taboos for protection from illness or in an attempt to avoid exacerbating the illness. For example, several Native American cultures believe it is taboo to cut a childs hair because the child will become sicker and die. This belief can even extend to procedures on the childs head, such as stitches that require removal of the hajr. The only way to avoid the death of the child is to counteract the violation of the taboo by attaching a medicine bundle to the childs chest.22 Although many cultures practice preventive measures, for others, prevention is a totally new concept. Many Haitians, for example, do not believe in preventive strategies and rarely engage in immunization. They may bring their ailing to the hospital only when death is imminent. Some cultures believe that the cure for our illnesses often can be found within ourselves. A Yugoslavian proverb says, Good thoughts are half of health. Our examination of explanations, treatments, and prevention of illness clearly indicates that what a patient believes can profoundly affect the treatment process. Cultural Influences on Context: The Health Care Setting 227 Thjoughout this discussion, we have alluded to the impact of religion and spiritualir ca(Isc dccp strlIctL,ral issUes have such a profound effect on health carc, they warrant further consideration Religion, Spiritual ity and Health Care Religion, spirituality, and health care are often intertwined For many cultures, religiori provides Solutions and solace when one is in ill health. It [religionj dictates social, moral, and dietaryptactices that are designed to keep a person in balance and healthy and plays a vital role in a persons perception of the prevention of illness.23 In many Eastern religions, people are portrayed as spiritual, and a sense of weflness or good health influences a persons spiritual journey.24 In these cases, health and spirituality arc rccirocal. llliayana highlights this balance: Quiet acceptance olones Fare, also pervasive in some Eastern philosophies, is difcult to reconcile with a commitment to preventive methods. Symptoms may be ignored because the fear of dying is lessened. Extraordinary efforts to preserve life may be hard to accept when a deep-rooted belief in reincarnation exists.25 Buddhism and Hinduism both offer examples of how religion influences health care pracrice,s. Although it is not common, some Buddhists do not accept responsibility for illness because they believe that illness is caused by spirits.26 There are also some

Hindus sects that are not concerned about ill health because they believe that it is a result of misdeeds committed in a past life. They also belive that praying for health is the lowest form of prayer because medical treatment, although useful, is transirory2? For many cultures, religion and prayer often provide solutions and solice in ill health. (2) Chapter Nine Cultural Influences on Context: The Health Care Setting 229 Most Western religions are accepting of modern medicine, although there is a great deal of diversity in religious practice. As evidenced elsewhere in this chapter, Judaism advocates adherence to strict rabbinical laws. In addition, kosher laws incorporate dietary restrictions. Despite diversity and divisions in beliefs and practices of Judaism, there is no contradiction between Jewish beliefs and health care. Christian beliefs are very much in line with modern medical practices, and as in Judaism, good health is highly valued. In Mexico, which is predominantly Catholic, fatalism saturates Mexicans existence. They even have a saying that illustrates this view perfectly: We submit to pain because it is inevitable, to bereavement because it is irreparable. and to death because it is our destiny. By now, it should be obvious that religion and spirituality have a strong influence on the way people define illness and choose to prevent it. In the United States, modern medicine and technology have often outweighed spiritual fuith and alternative- healing methods. However, as the world quickly becomes the global village described in Chapter 1, and medical practices in other cultures become known, some health care personnel are becoming more open to the influence of spiritual healing and acknowledging it as an effective form of recovery and prevention. Recently, the Harvard Medical School conducted a course entitled Spirituality and Healing Medicine att&nded by 800 scholars, doctors, clinicians, chaplains, and nurses from around the United States. The course consisted of presentations about the healing traditions of various faiths, including Islam, Roman Catholicism, Christian Science, Seventh Day Adventist, and Hinduism.28 What has been long known in several cultures around the world is now becoming recognized in Western societiesa persons mental attitude and spirituality can help in healing. Naturally, Western medical practitioners are requiring research data and experience before wholeheartedly advocating this position. Evidence supporting the healthspirituality connection is fairly straightforward. For example, In 212 clinical studies conducted since the mid-i 980s, 160 showed positive effects of religious commitment on health, while only 15 showed negative effects.29 The spiritual mindbody connection is a fundamental part of non-Western medicine and thus is a major issue for health care professionals. In Eastern India, for example, this mindbody approach to medicine is called Ayurvedic. In this system, the mind, body, and soul are interconnected components of a system in which malfunctioning in one component. . . disturbs the harmony of the whole system. This disequilibrium causes sickness.3 This interrelated system of mind, body, and universe is seen in various forms in Native American, African, and Chinese medical 31 Today, many medical institutions have incorporated mindbody components into their programs, and mindbody medicine spans many cultures. For example, Deepak Chopra, a world-renowned leader in the field of mindbody medicine, has published work that combines physics, philosophy, Eastern spiritual wisdom, and Western science

to facilitate healing.32 In another example of the growing interest in mindbody medicine, a Public Television Broadcast series by journalist Bill Moyers explored the healing connection between mind and body. Part of the series focused on the Peoples Republic of China and their fusion of Western practices and traditional Chinese medicine, including acupuncture, massage, and herbal potions.33 Gender Roles and Health Care As we indicated earlier, societies hold different expectations for boys and girls. Culture also contributes guidelines that tell males and kmales how to perceive and act regarding health care issues. In this section, we examine some of those guidelines as they apply to the health care setting. Male dominance, female purity and modesty and cultural differences in pregnancy and childbirth are considered. Male Dominance in the Health Care Setting As we have noted elsewhere, in much of the world male and female roles are not as fluid as they are in the United States. That is, many cultures make sharp distinctions between what is proper behavior for men and for women. For example, in the Middle East, Asia, Latin America, Mexico, and Africa, men are in positions of authority both in and out of the home. The importance of male dominance in these cultures may become the source of misunderstanding and conflict in th health care setting. At one extreme, routine procedures may be delayed, and at the other extreme, the life of the pat:eiit may be endangered because men in these cultures hold the authority. The case of Rosa Gutierrez and her two-month-old son demonstrates this. Rosa had brought her son to the emergency room because he was having diarrhea and had not been nursing. The staff discovered that he was also suffering from sepsis, dehydration, and high ) Fever. The physician wanted to perform a routine spinal tap, but Rosa refused to allow it. When asked why, she said she needed her husbands permission before anything could be done to the baby. The staff tried to convince her that this was a routine procedure, but Rosa was adamant. Nothing could be done until her htisband arrived.t4 In most traditional Mexican households, the man makes all the major decisions. Rosa could have legally signed the spinal tap consent form, but from her cultural perspective, she did not hold the authority to do so. Another issue is that men from cultures with strong traditional values often give little credibility to female physidans and nurses; on some occasions, they refuse to be treated or have their family treated by them. In the S.iiidi Arabian culture, men bcliev it is their duty to act as an intermediary between the world and their wives. When men from this country and others like it bring in their wives for emergency room or doctor visits, they usually answer all the (lLIe.%tions diiecied to their wives. Even if the wife can speak English, the Saudi male will speak for her. litis value of male dominance also extends to male children who are patients. In maledominated cultures, males, particularly first-born males, have very high status. As a result, when male children are ill, they often receive preferential treatment from the family. Henry i5 One such example. Henry was a fifteen-year-old Taiwanese boy who was dying from liver cancer. His devoted parents stayed by his bedside throughout his one-year hospital stay and communicated their love and support in many ways. They catered to his frequent demands, brouglt all his meals from home, and even flew ro Chinatown to acquire herbs that might help his condition. After witnessing such (3)

Health Care Setting 231 family devotion, the nurses were shocked to hear Henrys parents tate several times in the presence of his sisters that it would be better if one of the daughters had cancer and died rather than Henry35 Not only do male children receive preferential treatment from the family when they aie ill, but they are often allowed to engage in what North Americans would consider unruly behavior. Male children may be allowed to completely dominate their mothers and even hitthem.36 Female Purity and Modesty The English essayist Joseph Addison wrote, Modesty is not only an ornament, but also a guard to virtue. Female chastity is yet another issue that can affect the health care setting. In many male-dominated cultures, female purity and modesty are of paramount importance. Males are charged with protecting female honor. Females are expected to be virgins until they are married. Only their husbands are allowed to ;ce them naked. If these rules are broken, it brings dishonor to the family. The only way honor can be restored to a family in which a females purity and modesty have been compromised is to punish the girl. A female from such a culture may be reluctant to seek medical attention, follow medical advice, or undress for a medical examination because of these values. Western practitioners often dont understand the possible consequences of violating one of these cultural norms, particularly if the woman is from an ultraconservative traditional background. Galanti, a medical anthropologist, reported a story that clearly illustrates the importance of female purity and family honor. Fatima was an eighteen-year-old Saudi Arabian who had been brought to an Air Force hospital with a gunshot wound in her pelvis. She had been shot by her cousin to whom she was bethrothcd. As was customary, her parents had arranged the marriage. Fatima, however, was in love with someone else and did not wish to mart) her cousin. An argument followed in which her drunk cousin shot her, paralyzing her from the waist down. At the hospital, x-rays to txamine the bullet revealed that Fatima was pregnant. One of the doctors in the case had lived in the Middle East for ten years anU realizedthe potentially explosive situation facing him and the girl. Girls with out-of-wedlock pregnancies typically were stoned to death. The doctor swore the x-ray technician to secrecy and arranged to have Fatima flown to London for a secret abortion and to remove the bullet. The internist involved was reluctant to go along with the plan, but finally agreed. Unfor:unarely, as Fatima was being wheeled to the waiting plane, the internist could not live with his conscience and cold Fatimas father about the pregnancy. Galanti continues the story: The father did not say a word. He simply grabbed his daughter off the gurney, threw her into the car, and drove away. Two weeks later, the obstetrician saw one of Fatimas brothers. He asked him how Fatima was. The boy looked down at the ground and mumbled, She died. Family honor had been restored.37 Pregnancy and Childbirth Much of the world embraces the Irish saying Bricks and mortar make a house, but children make a home. We can say with some degree of accuracy that in every cul ture, childbearing and the gift of life are treated with celebration. All cultures have specific arittidcs, practices, gender-related roles, and normative behaviors with regard to pregnancy and childbirth8 For these reasons, childbearing is another crucial issue in the health care setting. Although childbearing is a deeply felt emotional experience, the meaning and signiflcan of the experience are often dictated by culture, Childbearing is valued for distinct reasons in different cultures. In the Mexican culture, a womanti

status is often derived from the number of children she has borne. In Asian cultures, children, especially males, are valued because they carry on the family name and care for their parents in old age. For Orthodox Jews, childbirth is valued because it is in obedience to biblical law to multiply and replenish the earth. In some cultures, children are valued because of the labor and support they can contribute to the family. Whereas birth might be a private experience in one culture, it is a societal event in another. For North Americans, the birth experience is normally a private affair involving only the nucler family. In many non-Anglo cultures, the birth experience is anticipated and shared by a large extended fmily. Often, Asian, Mexican, and Gypsy families crowd outside delivery rooms awaiting the event. Aendance of the actual birth itself varies from culture to culture as well. In North America, it is standard for the womans husband to assist her in the labor and delivery of their chlld, but for many cultures this is not the case. Orthodox Jewish men rarely participate in childbirth because a man is forbidden tt touch a woman during unclean times__when blood is present during menstruation or childbirth. Many Arab men feel that birthing is a female job. Many Mexicans feel this way as well, so the womans mother usually accojnpanies her during birth, and the husband does not see his wife or child until dery is over and they have both been cleaned and dressed. In Asian families, b&ause couples generally reside with the husbands parents, the mother-in_law is often the birth attendant.3) In some cultures, the pain of childbirth is responded to with self-restraint and silence; yet in other cultures, pain is openly and freely expressed. As we noted eadier m this book, culture dictates the expression of emotion. In many Asian cultures, pain and discomfort are expected to be a part of labor and delivery, but to express the pain brings shame. As a result, many Asian women are stoic, and pain is evidenced only by white knuckles and looks of intense concentration40 In Middle Eastern and Mexican cultures, women are not exp&ted to be inhibited in their expression of pain. In the Iranian culture, women are compensated for their suffering during childbirth with gifts. Larger, more expensive gifts are given for greater suffering.4 Postpartum periods and practices are different fiom culture to culture as well. In the North American cusrom, women are encouraged to be active immediatefy after delivery. This includes a bath or shower right away. In contrast, many cultures have taboos against bathing for several days after birth. This is true in many Asian cultures. In the Japanese culture, washing or showering ones hair is taboo for a week or more after delivery.42 North American mothers have the shortesr hospital stay24 to 36 hoursof any ihdusrrialized nation. In -France, the stay is up to two weeks with a fiveday minimum; in Germany; seven days; in Japan, up to seven days; in Ireland, six days; and in Sweden, three days and midwife home visirs.for a week.43 The practice of avoiding exercise and bathing is often referred to as doing the month bynianyAsian and Mexican cultures and usually lasts between 0 and 40 days.44 The lying-in period is designed to give the new mother rest between childbirth and returning to work. ,During this rime, the mother usually stays in bed and is taken care of by female (4) family members or nurse artendant. Types of flied that can be eaten arc also affected by this lying-in period. For example, in Asia: Giving birth causes the s4dden loss of yang, or heat, which must be restored. The most effective way to do this is to eat yang foods, such as chicken. Cold liquids should be avoided lest the system receive too great a shock.4

As this discussion shows, gender and culture have a profound impact in the health care setting. Communication, assessment, and identification of the various attitudes, behaviors, values, and belief held by patients are essential to optimal health care. With our recognition of the impact various health care beliefs can have, we now examine health care in the diverse population of the United States. The United States: Health Care in a Diverse Patient Population As should be evident by the preceding examples, miscommunication is a frequent problem in the health care setting. If optimal health care is to be a goal in the multicultural United States, then health care providers must be aware of potential problems related to cultural differences. In this next section, we focus on problems related to self-disclosure, language, nonverbal messages, and formality Se/f-Disclosr re Proptr l;.z.. h care demands that the patient trust the health care professionai so that essential medical information can he exchanged by both parties. However, cuitura norr ut openness and self-disclosure can often impede the communication process. .. kough Anericans tend to have few qualms about disclosing personal information, in other cultures information of a personal nature is less forthcoming. We have already mentioned that some women from Latin America may feel embarrassed or shy when talking about female problems. For the Chinese culture, the problems associated with self-disclosure are somewhat different. For many Chinese, too much talk about personal matters is often considered in poor taste. In this collective cult4re, self-importance is a violation of a cultural norm. The Germans, because they value proper decorum, are also reluctant to disclose highly personal information in most settings. The German proverb A friend to everyone is a friend to no one clearly underscores their view of superficial relationships. This reticent and reserved attitude often transfers to the health care context. The above examples demonstrate that not all patients are willing to talk to doctors and nurses with the same degree of openness. Knowing these cultural variations regarding self-disclosure can help the professional extricate important and valuable information concerning the patients health. Language Barriers Many of the problems we discuss in Chapter 5 concerning language apply to the health care context as well. Obvious problems such as language diversity and the use of interpreters complicate medical interactions. As noted earlier, literal translations Chapter Nine Cultural Influences on Context: The Health Care Setting 233 often do not convey the true meaning of a communicated message. Think for a moment about the potential for confusion if a Western doctor speaks of a womans period to someone whose culture does not use this euphemism Also, a literal translariori of the phrase have your tubes tied may render an understanding that they can just as easily be untied. Medical implicatiojss resulting from such miscommunica non can be detrimental to the patient. Subtle forms of communication behavior can have just as great an impact. From the following example, we can see how the use of idioms can cause misunderstandings. A Chinese-born physician called the night nurse one evening to check on a patient scheduled for surgery the next day. The nurse advised the physician that she noticed a new hesitancy in the patients attitude. To tell you the truth, doctor, I think Mrs. Colby is getting cold feet. The physician was nor familiar with this idiom, suspected circulation problems, and ordered vaular tests.46

The use of medical jargon may als0 complicate the health care interaction. For example, the use of words like rhinitis rather than hayfezier, anosmia instead of a loss of taste, and dementia rather than memory loss can be confusingto native language speakers and even more so for individuals who speak a different language. In addition, It is sometimes diflicult for members of diverse cultures to articulate their symptoms and feelings in the nonnative language.7 As a result, vague symptoms and generalized descriptions of health may be conveyed. Finally, members of some cultures may be reluctant to reveal personal or private problems, particularly if their children are used a.sjflcrpr(.rcrs For instance, a Mexican Woman whose son usually interpreted for her sflered a great deal before the doctor discovered her actual problem__a fistula in her rectum. She was so embarrassed about her condition that she was reluctant to reveal her symptoms through her son. Only when a cultural interpreter was called did she reveal her true symptonis.48 Nonverbal Messages Nonverbal communication can e equally problematic in health care. Although many of the issues arc discussed inChaprer 6, a brief reiteration will mike the point that iiOlive hal hel iavi )is a llcr health care corn in ii nica don. As noted earlier, the okay gesture (thumb and forefinger forming a circle) that is so commonly used in North America is tlerogatory in many other cultures. In Brazil, it is a crude sexual invitation Imagine a North American doctor responding with the okay sign to an inquiry about test results from a female patient who is from Brazil. Eye contact can also be a source ofconhisjo, because many cultures avoid direct cye contact as a sign of respect. This is parricul:irly true when conversing.wirh an authority figure, which many doctors and medical Professionals are perceived to be. Interaction distances bctwccn health care professionals and patients can also be compounded by cultural influences Whereas Greek, African, Italian, and Arab patients may prefer to engage at Close range, patients from Asia and much of Europe may desire extra interpersonal distance As a result, Greeks, Africans, Italians, and Arabs mayview North American health care professionals as cold and tincaring, whereas Asians and Europeans may believe that Greeks, Africans, Italians, and Arabs are pishy and aggressive, Touch is another nonverbal VII able that can cause problems in rlic health care .ccrring. The usc of (5) touch is viewed as warm and friendly in some cultures, and as intiusive and inappror nate in others.49 Finally, a patients orientation to dine may affect wiwn he on she shows up for appointments and how consistently he or she follows medical advice. Differences in time orientaridns can also influence the amount of time the health care professional spends with the patient. As we note in Chapter 6, members of P-time cultures would expect the doctor or nurse totake a great deal of time establishing rapport and explaining both the causes and cures for the illness. Forma1iy Degrees of formality and informality in communication can affect the health care environment. Members from Asian, Mexican, and European cultures, as well as others who value formality in language use, may be shocked at the North American practice of addressing each other by first names. A physician who addresses an Asian by his or her first name rather than by title and first and last name may inadvertently diminish his or her credibility. Formality can also be reflected in varying degrees of politeness. For example, Chinese politeness calls for three refusals before one accepts an offer.5 Bat

in North America, no means no the first time. Imagine a Chinese patient declining the pain medication offered by a North American nurse and politely suffering while waiting for the second and third offer, which are not Forthcoming. This fornsal politeness is also reflected in face-saving communication. In many cultures, authority figures are not to be disagreed with or challenged. Even if the patient does not concur or understand the physicians advice, he or she may agree to comply because of politeness norms. For example, many Mexican Americans believe that directly contradicting a physician is rude and disrespectful. They may itidicine cootpliance in order not to embarrass the physician. but in actuality, they have no intention of following the instructions. The physician who perceives agreement then erroneously believes that a plan of action has been reached.51 Finally, relational eitpccl.ltiuns can be rellcctcd iii pliteiics. Iiidivi(ltIals Frutii lll.llly 111,11 cslvlll LIII tures expect their physicians to develop personal relationships with them. For the Mexican patient, this means establishing confianza (confidence) before medical progress can be made. For the Middle Easterner, this means a relationship should evolve before medical issues are discussed. As these examples suggest, many misunderstandings in the health care setting can be traced to miscommunications in language or nonverbal patterns. Although being sensitive to cultural differences is important, health care professionals also need to have excellent intercultural communication skills to be able to handle cultural issues. This need for sensitivity and effective communication skills is clearly evident, for instance, when a folk illness represents a real medical emergency. In the Mexican culture, caida de mofiera is a folk illness in which a baby has a fever, irritability; vomiting, and diarrhea. This illness is often treated with folk remedies, but these symptoms indicate serious illness in an infant and medical attention is promptly needed.52 In situations like this, the health care provider needs to be sensitive to the patients beliefs while educating him or her (or the parents in this case) about the negative consequences of relying on folk remedies. Conveying this information in a respectful manner requires excellent communication skills so that the patient is not humiliated or insulted, preventing compliance with the medical advice. This often is not as easy The Health Care Setting 235 as it miht sound. Many health care professionals as well as researchers have sought SI r.itcpts (It facilitate tie unique interactions necessary in the medical environment. In the final section of this chapter, we share some tactics for improving the multiculrural health care interaction Improving the Multicultural Health Care Interaction Often it is nota lack of shared cultural knowledge that causes the breakdown of cornlii l ittil ilimital licaJh cals illlcracliiin; rafter, ili ltiltirc to Use that hiowl<111: llI,l% ((1 (ant problems. When awareness, acknowledgment, and action cllal,mcftr.e tIte Immtllltctilturaj health care Context, greater empathy is achieved. Health care professionals can better understand the problem from the patients perspective, arid ilitt OtiS tii:tt ate satisfactory to all can be the result, in this way, optimal health care for ti! ta ellIs can he accomplished. Ii n irtijiot 1,1111 III,IL >5)11 .1(1 11(11 prc5(Itm that tIme stmggcsrilitls t;llcred here are niutu.t ly xcltpsivr ill rXli:1IiSIIVC. likewise, we recommend that you do nor .lssutne that the in!i)rIlt.lI loll Li )lli2lIiccI ill I his chapter applies to all people associated with a parriciihir culture, tot rums notion tails to acknowledge individuality Additionally, acculturation and assinmilaticii levels will atlect a patients response to

illness and treatment. Despite these caveats, the suggestions provided should be helpfimi in facilitating communication in the cross-cultural health care encounter. First, it is important to recognize that many cultures may have several medical systems on which they rely. Even in the United States, many1ternatiye medical systems exist, including the mindbody and spiritual connections discussed earlier. Chiropractic, Health care professionals need excellent intercultural communication skills to be abic to handle cultural issues, (6) naturopathy, herbalism, and the laying on of hands can also be considered alternative medical systems.53 In many instances, Western biomedicine is combined with an alternative method with great success. Second, even in cases Where Western scientific medicine is superior, if the patient believes it is insufficient for treating the probkm, it probably will be.54 As a result, to treat patients successfully, their beliefs concerning what caused the illness, how the illness should be treated, and how it can be prevented next time must be acknowledged. This concept is clearly illustrated in the following story: An eighty-three-year-old Cherokee Indian woman was brought to a hospital emergency room after she passed out at home. X-rays revealed a bowel obstruction that required surgery: The woman refused to sign the consent form because she wanted to see the medicine man on the reservation. At the request of the social worker, the womans grandson drove to the reservation and returned with the medicine man in full traditional dress. He conducted a healing ceremony complete with bells, rattles, chanting, and singing for forty-five minutes. At the end of the ceremony, the medicine man indicated that the woman was ready to sign the consent form. She did, and her immediate surgery was uneventful and without complications.55 Recognizing various medical systems and being sensitive to patients beliefs require a great deal of information. In addition to cultural knowledge and an awareness of ommunication patterns, particular knowledge of the individual is necessary: Fitzgerald offers a series of questions that may provide basic information about an individuals health care belief. These questions have cultural implications in that they illuminate cultural variations in how the questions are answered. 1. What do you think has caused your problem? 2. Why do you think it started when it did? 3. What do you think your sickness (or injury) does to you? How does it work? 4. How severe is your sickness (or injury)? Will it have a long or short course? 5. What kind of treatment do you think you should receive? 6. What are the most important results you hope to achieve from this treatment? 7. What are the chief problems your sickness (or injury) has caused for you? 8. What do you fear most about your sickness or injury?56 As we conclude, we again remind you of the primary motivation behind this chapter. Simply stated, an understanding of different cultural medical systems. communication patterns, and individual beliefs should assist health care providers in becoming more attuned to the culturally based health care expectations held by people whose cultural background is different from their own. SUMMAI.Y Explanations, Treatment, and Prevention of Illness Cultures differ in the way they explain, treat, and prevent illness.

Health Care Setting 237 All health belief systems can be divided into three categories: biomedical, personalistic, and naturalistic. There are cultural variations in the cause of illness. There are cultural variations in the treatment of illness. There are cultural variations in the prevention of illness. Religion, Spirituality: and Health Care Religion, spirituality, and health care are often intertwined. For maiiy cultures, religion and prayer often provide solutions and solace when one is in ill health. Gender Roles and Health Care Cultures divide the social world into male and female categories. This division affects the health care setting. In much of the world, the North American concept of equality among the sexes does not exist. In many cultures, women hold traditional roles that are subservient to men. These subservient roles are evident in the health care setting. In many cultures, female purity and modesty are of paramount importance. In all cultures of the world, childbearing and the gift of life are treated with celebj tion. The United States: Health Care in a Diverse Patient Population If optimal health care is to be provided in a muItierhtic society stich as the United Stares, an awareness of culturally diverse patterns olcommtlnicaiion is essentiaL Language barriers, nonverbal messages, and formality and politeness can cause miscommunication in the health care setting. Improving the Multicultural Ha1th Care Interaction Olien it is nn a lack of shared cuhural knowledge that causes the breakdown of communication in the multicultural health care interaction. Instead, failure to act on that knowledge tends to cause problems. ACTlVlfl IS i. In a small group, discuss the various cross-cultural beliefs in the explanation, treatment, and prevention of illness. 2. In a small group, discuss the impact of gender and spirituality on the health care setting. 3. In a small group, discuss challenges in providing optimal health care to all patients in a multiethnic society: (7) DISCUSSION IDEA$ 1. Discuss how effective intercultural communication is crucial in the multiethnic health care setting. 2. Discuss how nonverbal behaviors can complicate the multiethnic health care setting. 3. Discuss how more than one medical belief system can be incorporated to treat patients. (8)