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
Slide 2
TOPICS COVERED (1 of 3)
•
Cultural Competence
•
No Culture Is Monolithic
•
Addressing the Patient
•
Language and Literacy
•
Respectful Nonverbal Communication
•
Unspoken Challenging Medical Issues
Slide 3
TOPICS COVERED (2 of 3)
•
History of Traumatic Experiences
•
Immigration Issues
•
Acculturation
•
Tradition and Health Beliefs
•
Attitudes toward Health Services
•
Culture-Specific Health Risks
Slide 4
TOPICS COVERED (3 of 3)
•
Culture and Religion
•
Approaches to Decision Making
•
Disclosure and Consent
•
Gender Issues
•
End-of-Life Care
•
ETHNICS Mnemonic
Slide 5
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
Slide 6
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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Percent of adults 65 yr
EDUCATION & LITERACY (1 of 2)
80
73
70
60
50
40
30
24
20
10
19
5
0
1965
2004
Completed
high school
Bachelor's
degree
EDUCATION & LITERACY (2 of 2)
Despite gains in education level, older adults
still rank below working-age adults:
• Far lower education and literacy levels
• Half as likely to have a personal computer
and use the Internet
• Lower average levels of health literacy
RESPECTFUL NONVERBAL
COMMUNICATION (1 of 2)
• Hand gestures, facial expression, physical contact,
and eye contact can hold different meanings for
people from different cultural backgrounds
• 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
Slide 12
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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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?
Slide 14
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
Slide 15
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
Slide 16
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
Slide 17
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
Slide 18
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
Slide 19
UNSPOKEN CHALLENGING
MEDICAL ISSUES
• 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
Slide 20
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
Slide 21
INTERFACE BETWEEN
CULTURE AND RELIGION
• Impact of religion on culture and health behavior
and decision making can be subtle and complex
• Most patients prefer or accept clinicians asking
about their spiritual beliefs and their impact on
world view, health behavior, and decision making
• Questions regarding religion and spirituality
should be incorporated sensitively and early in
the patient-physician relationship
APPROACHES TO DECISION MAKING
• In many non-Western cultures, decision
making about health care is family-centered
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
Slide 23
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
Slide 24
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
Slide 25
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
Slide 26
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
Slide 27
THE ETHNICS MNEMONIC
• Practical interviewing tool to facilitate effective
health interviews and care planning in crosscultural settings, described by Kobylarz in 2002
 Kobylarz FA, Heath JM, Like RC. J Am Geriatr Soc.
2002;50:1582-1589.
• Designed to be integrated into a 15-minute visit in
multiple settings
• ETHNICS: Explanation, Treatments, Healers,
Negotiate, Intervene, Collaborate, Spirituality
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 29
CASE 1 (1 of 3)
• An 81-year-old woman is brought to the office by her
family because of increasing abdominal distension,
nausea, and vomiting. She recently immigrated to the
US from India after the death of her husband.
• Thorough evaluation confirms a diagnosis of
pancreatic cancer with liver metastases. The family
believes she will not be able to tolerate this news
because she has just lost her husband, and requests
that the diagnosis be withheld from her.
• She is anxious and wants to know what is wrong.
Slide 30
CASE 1 (2 of 3)
Which of the following is the most appropriate
course of action?
(A) Inform the patient of the diagnosis.
(B) Tell the patient she has a minor illness that will
soon resolve.
(C) Meet with the patient and the family together to
explore their concerns.
(D) Seek advice from the legal department of the
local hospital.
Slide 31
CASE 1 (3 of 3)
Which of the following is the most appropriate
course of action?
(A) Inform the patient of the diagnosis.
(B) Tell the patient she has a minor illness that will
soon resolve.
(C) Meet with the patient and the family together to
explore their concerns.
(D) Seek advice from the legal department of the
local hospital.
Slide 32
QUESTION 2 (1 of 2)
Which of the following is meant by culturally
competent care?
(A) Allocation of resources in proportion to the cultural
composition of the community
(B) Delivery of health services according to the cultural
practices of the caregiver
(C) Delivery of health services that acknowledges
cultural diversity in the clinical setting
(D) Characterizing patients based on their cultural
backgrounds rather than their individual preferences
Slide 33
QUESTION 2 (2 of 2)
Which of the following is meant by culturally
competent care?
(A) Allocation of resources in proportion to the cultural
composition of the community
(B) Delivery of health services according to the cultural
practices of the caregiver
(C) Delivery of health services that acknowledges
cultural diversity in the clinical setting
(D) Characterizing patients based on their cultural
backgrounds rather than their individual preferences
Slide 34
QUESTION 3 (1 of 2)
Which of the following is true about health literacy?
(A) Health literacy is the degree to which a person can
obtain, process, and understand information to make
appropriate health decisions.
(B) People with limited health literacy are more likely to
ask questions about care during physician visits.
(C) Health status, rate of hospitalization, and health care
costs of people with limited health literacy are similar
to those of people with adequate literacy.
(D) In the United States, 12% of the population lacks
health literacy.
Slide 35
QUESTION 3 (2 of 2)
Which of the following is true about health literacy?
(A) Health literacy is the degree to which a person can
obtain, process, and understand information to make
appropriate health decisions.
(B) People with limited health literacy are more likely to
ask questions about care during physician visits.
(C) Health status, rate of hospitalization, and health care
costs of people with limited health literacy are similar
to those of people with adequate literacy.
(D) In the United States, 12% of the population lacks
health literacy.
Slide 36
ACKNOWLEDGMENTS
Editor:
Annette Medina-Walpole, MD
GRS Chapter Author:
Reva N. Adler, MD
GRS Question Writer:
Pushpendra Sharma, MD
Medical Writers:
Beverly A. Caley
Faith Reidenbach
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2010 American Geriatrics Society
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