- Respect patients’ and families’ behaviors and values
- Be aware of the influence of sociocultural factors on patients, providers, the clinical encounter and interpersonal relationships
- Appreciate the heterogeniety that exists within and across all cultural groups and the need to avoid overgeneralization and negative stereotyping
- Be aware of own cultural beliefs, values, and practices that influence self as a cultural person.
Useful Concepts and Techniques for Providing Cultural Competent Health Care
Professional, Popular, and Folk Health Care Sectors
It is estimated that the majority of self-recognized illness episodes are managed outside of the formal health care sector,2 or the professional health sector.3 The professional health sector is the organized, regulated, legally sanctioned health profession, such as allopathic and osteopathic medicine in the United States. Other societies may have professional medical systems in addition to western, allopathic/osteopathic medicine included in their professional health sectors, such as Chinese or Oriental medicine in China, and Ayurvedic medicine, in India.
The popular health care sector is the largest part of any health care system and consists of the lay, non-professional, non-specialist arena in which illness is initially defined for an individual and treatment is initiated.3 The popular health care sector can be conceptualized to contain many levels, including individual, family, social network, and community. An individual may use one or more of these levels for assistance during an illness episode to define symptoms, decide where to seek treatment, engage in treatment, and evaluate treatment outcomes. Self-treatment is generally the first resort when an individual becomes ill and self-treatment practices are grounded in popular health care beliefs and practices. After treatment is received, regardless of whether given by the popular, professional or folk sectors, patients rely on the popular sector to evaluate treatment, and if necessary, decide upon the next course of action.
The folk health care sector is the non-professional, non-bureaucratic, specialist sector that may overlap with the professional and popular sectors.3 Folk medicine practitioners include the herbalist, curandero, shaman, etc. In some societies where professional medicine is absent, the folk and popular health care sectors are the health care system. Folk health beliefs and practices may be secular or sacred, or a combination of both.
Health care providers’awareness of these three sectors in a particular health care system is important for the provider to understand that patients rely on multiple sources during their illness experience in addition to the professional health care provider from whom they have sought assistance (as is illustrated in the case study above). Popular, folk and practitioners of other professional medicine can all, or in part, impact on a patient’s health care beliefs and behaviors.
Disease and Illness
Medical anthropologists developed the distinction between the concepts of disease and illness to better understand the dynamic relationship between culture, medicine, and physician-patient communication. Disease refers to the malfunctioning of the physiological and/or psychological processes in an individual. Illness refers to the psychosocial experience and meaning of the perceived disease for the individual (and those associated with the individual, i.e., family members).4 Illness behavior includes the perception, cognition, affective response to, and valuation of the symptoms of the disease. The distinction between disease and illness is more readily understood with the example of a patient diagnosed with hypertension (a disease), but who has no experience with symptoms, and thus does not perceive the existence of an illness. Similarly, a patient may complain of chronic pain (illness), but on exam and testing, does not have any physical findings, and thus no apparent "disease."The majority of physicians’ training focuses on diagnosing and treating diseases, the physiological pathologies that affect individuals. However, patients arrive at the physician’s office because of their experience and interpretation of ill-feeling bodily symptoms, or illness. Individuals evaluate their health care outcomes based on their illness experience, and thus it is important for health care providers to recognize that patients’ experience with illness may vary from their professional interpretation of the disease.
Another key medical anthropological concept useful for developing cultural competency is the explanatory model. Kleinman3 writes that "explanatory models are the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process." Explanatory models conceptually include 5 major questions about an illness episode:
Not all explanatory models may include these five questions. Health care professional explanatory models typically answer most or all of these questions, and the explanatory model is generally disease-based. Patient and family models, which focus on illness, often do not answer all of these questions. Explanatory models differ from popular health care beliefs in that the individual forms them in response to a particular illness episode. They frequently incorporate concepts from popular health care beliefs, but it is important not to equate the two.
- Time and mode of onset of symptoms
- Course of sickness, including both degree of severity and type of sick role – acute, chronic, impaired, etc.
Recognition of explanatory models and attempts to access a patient’s and family members’ explanatory models about a particular illness episode is the most fruitful means to: 1) practice culturally competent medicine and 2) improve patient outcomes. Learning about a patient’s and family members’ explanatory models will generally provide information about any cultural health beliefs and practices relevant to the individual’s illness episode. Furthermore, with the knowledge of the patient’s and family members’ explanatory models about the illness, the health care practitioner can provide appropriate patient education about the disease and illness, and effectively negotiate with the patient a treatment regimen that will be acceptable and effective for the patient to follow. In this manner, patient outcomes are positively effected.
Eliciting an Explanatory Model
Eliciting an explanatory model is not necessary for all patient illness episodes (i.e, an acute condition such as a sore throat), but there will be many occasions when it is judged that further probing about the patient’s conceptions of the illness will further enhance the physician-patient relationship and treatment outcomes (i.e., recurrent and chronic conditions). Imperative for eliciting an explanatory model is a genuine, non-judgemental interest in the patient’s beliefs and communication to the patient that this interest is based on the knowledge that eliciting this information is important for planning an effective treatment regimen with the patient.Kleinman3 suggests the following questions to elicit an explanatory model:
- What do you think caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to you?
- How severe is your sickness? Do you think it will last a long time, or will it be better soon in your opinion?
- What are the chief problems your sickness has caused for you?
- What do you fear most about your sickness?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to get from treatment?
Steps Toward Practicing Culturally Competent Health Care
Several steps can be taken to begin to incorporate the knowledge, skills and attitudes necessary for practicing culturally competent health care.
|1.||Examine Your Own Cultural Attitudes and Knowledge|
|An important step is to examine your own comfort interacting with individuals from cultural backgrounds different than your own and to assess your own cultural beliefs, assumptions, preferences and biases.|
|2.||Use of Culturally Sensitive Interviewing Tools|
|In addition to the Kleinman’s explanatory model questions, there are other tools for interviewing patients and family members in a culturally sensitive manner. These include:|
|a.||Eliciting illness prototypes and patient requests5|
|Individual or family illness prototypes:|
|1.||What are your ideas or concerns about your illness based on your previous personal experience?|
|2.||What are your ideas or concerns about your illness based on the experiences of other family members or friends?|
|Individual or family patient requests:|
|1.||What type of help would you (your family member) like (hope, wish, want) to receive form the practitioner?|
|b.||Cultural Status Exam (Pfifflering6)|
|1.||How would you describe the problem that has brought you to me?|
|a.||Is there anyone else with you that I can talk to about your problem? (If yes, to significant other: Can you describe X’s problem?)|
|b.||Has anyone else in your family/friend network helped you with this problem?|
|2.||How long have you had this (these) problem(s)?|
|a.||Does anyone else have this problem that you know? If yes, describe them, how old they are, and their different presentations/symptoms.|
|3.||What do you think is wrong, out of balance, or causing your problem?|
|a.||Who else do you know who has, or gets this kind of problem?|
|b.||Who, or what kind of people don’t get this problem?|
|4.||Why has this problem happened to you, and why now?|
|a.||Why has it happed to (the involved part)?|
|b.||Why did you get sick and not someone else?|
|5.||What do you think will help to clear up your problem?|
|a.||If they suggest specific tests, procedures, or drugs, ask them to further define what they are and how they will help.|
|6.||Apart from me, who else do you think can help you get better?|
|a.||Are there things that make you feel better, or give you relief, that doctors don’t know about?|
|3.||Foster an Open, Sensitive Approach to Patient Health Care Beliefs|
|Remember that your attitude, conveyed verbally and non-verbally, has a tremendous impact on the physician-patient relationship. If the patient perceives that you disapprove or ridicule his or her belief system, he or she may not share important information with you and may not return for follow-up care.|
Popular and Folk Health Care Beliefs Held by Cultural Groups in South Carolina
All cultural and ethnic groups hold concepts related to health and illness and associated practices for maintaining well-being or providing treatment when it is indicated. For an individual, socioeconomic, educational, geographic, religious and other factors will mediate and shape cultural and ethnic health beliefs. For this reason, a health care practitioner should never assume that an individual from one ethnic group holds the same beliefs as another individual from the same ethnic group. Caution is needed to avoid stereotyping. However, there are common elements of belief that may be shared among members of cultural and ethnic groups and a general familiarity with these can be very helpful in further understanding a patient’s particular perspective. Members of a cultural or ethnic group who are younger, more educated, more affluent members, and more acculturated into mainstream American society may not adhere to popular and folk medical beliefs. However, it is likely that others in their social network will rely upon these concepts when such an individual becomes ill in order to identify the illness, suggest treatment and evaluate prescribed treatment.
Health beliefs among African-Americans will vary across sub-cultural groups related to urban or rural residence, geographic location in the U.S. (north versus south), class, and age. In addition, and pertinent to South Carolina, are African-American cultural sub-groups based upon geographic origin and historical experience in the U.S.
Sea Islands People or Gullah
An important cultural sub-group in the Southern U.S. is the population of the Sea Islands, sometimes referred to as the Gullah. The islands that begin off the North Carolina coast and continue along the coasts of South Carolina and Georgia to the Florida border are known as the Sea Islands or Gullah Area. They range in size from very small and uninhabitable to the largest of these islands, Johns Island here in South Carolina. The Sea Islands were accessible only by boat until the beginning of the 1930s.7 Before the Civil War, the islands’ economy was upon plantations, and in many areas, enslaved blacks outnumbered the white inhabitants. On many islands, the only white individuals in residence were the plantation owner or overseer.
A unique culture developed on the islands for several reasons.7,8 First, the influence of American white culture was minimal because the islands were isolated and populated by a large number of enslaved blacks. Second, in the early 18th century, a more favorable duty was placed in South Carolina on slaves brought directly from Africa. This practice continued even after the 1808 Slave Trade Act, and as late as 1858, enslaved Africans were brought to the Sea Islands. The large number of slaves arriving from Africa and remaining in relative isolation on the Sea Islands meant that several features of African culture were retained in the area, and subsequently modified into a distinctive African-American culture. Although contemporary changes in the last few decades have dramatically reduced the isolation of the Sea Islands people, a syncretism of African, American, and slave patterns, plus contemporary American life styles does exist.
Key features of the Gullah culture are the oral heritage or stories and songs (used as the basis for Uncle Remus stories, for example), and the distinctive Gullah dialect, formerly known as Geechee. Research has demonstrated that the characteristic elements of Gullah reflect both African roots and English dialects of colonial Carolina.7
With respect to health beliefs and medical care, historically, the enslaved population of the Sea Islands maintained their own medical practices for each other, especially those used to cure common illnesses; assistance was sought from the planter or plantation doctor if the slaves found their own remedies were not successful for a particular illness episode. African knowledge of plant and animal pharmacopoeia was handed down from generation to generation. In addition, local Indians shared their knowledge of plant and animal life vis a vis health remedies. Given the isolation of the Sea Islands, a black folk medicine relying upon herbal substances flourished during the antebellum period.7
Traditional African-American Folk Health Beliefs
Natural and Unnatural Illnesses
Illness is conceptually divided into natural and unnatural forms.7,9,10,12 Natural events have to do with the world as God has made it and as He intends it to be. Natural illness results when an individual fails to maintain harmony in the physical or natural world. Dietary or lifestyle excesses are the most frequent causes of illness. Natural phenomena, such as the phases of the moon and signs of the zodiac are also thought to affect the human body and its processes. The following are believed to be important for maintaining health and well-being:
Unnatural illness occurs when the individual is the victim of a hex, curse or spell. With such illness, the plan of God has been disrupted, thus making the illness unnatural. The decision that an illness is unnatural is generally reached after the patient has seen a physician and a specific diagnosis has not been immediately offered or the prescribed treatment has failed. (Treatment failure may be the result of inappropriate patient use of the medication because of misunderstanding.) Symptoms of unnatural illness are often gastrointestinal or behavioral in nature.
- Knowledge of how the body functions. These beliefs are based upon a concept of humoral pathology in which it is important for all body functions to be in proper balance.
- Knowledge of when the body is vulnerable. Age (i.e., very young, very old) and weather (i.e., very cold) are important elements that make the body vulnerable.
- Having a proper relationship with God. In some cases, illness may be viewed as punishment from God.
- "Acting right" by eating proper foods and keeping the body clean.
- Knowing roots, herbs, potions, oils and lucky charms that cure or ward off illness.
Rootwork is one term to describe the traditional medical system practiced by many African-Americans, particularly those in inner city areas and southern rural areas. 7,9,10,12 The term rootwork is derived from the belief that herbs and other natural substances can cure illness. Natural illnesses are cured with roots, herbs, barks and teas by an individual knowledgeable in their use, an herbalist. The term rootwork is also derived from the belief that plant roots can be used to cast spells, and the terms voodoo, hoodoo, witchcraft and black magic are alternative references for rootwork because of the related belief that magic can induce illness.
Hoodoo, conjure, or ju-ju are Sea Islands terms for the techniques used to produce unnatural or supernatural illnesses.7 The conjurer uses his or her own powers and those found in certain materials, objects, and words to create an illness in a specific person. A hoodoo amulet or hand is thought to protect the wearer from hoodoo. Only a conjurer can cure someone who has been hexed. A person who is both herbalist and conjurer is frequently called a root doctor.
Phrases and Terms Used to Describe Illness Symptoms
Particular phrases used by some African-Americans and other Southerners have distinctive health-related meanings.12 These include:
Bad blood – equated with venereal disease, and may also simply refer to an individual who is promiscuous
Falling out – means fainting or loss of consciousness
Falling off – means weight loss
Sugar – diabetes
Low blood – anemia
High blood – hypertension and/or polycythemia
The Concept of Blood
Blood is a key concept in the African-American traditional health belief system.7,9-12 New blood is constantly formed and used blood is eliminated from the body. Women eliminate the used blood in their bodies through menses; men eliminate it through sweat. Blood loss is weakening, and thus women’s monthly blood loss through menses makes them more weak than men. Impurities in the blood are manifested cutaneously. Skin eruptions such as urticaria, measles, diaper rash, chicken pox or syphilitic lesions represent impurities that are trying to come out and therefore, interference is not necessary. Blood viscosity is also thought to be affected by age, gender, diet and outside temperatures. The blood thickens in cold weather to keep the body warm; thin blood is associated with lowered resistance to the onslaught of cold damp air upon the body. To thin out the blood for warmer weather and the summer months, drinking sassafras or other types of tea is recommended. Food and drink are thought to build up the blood volume, for example beets, grape juice, liver and red meat.
The Role of God in Illness
Any health problem may be viewed as being sent by God as punishment for sin, even if the patient accepts the physician’s biomedical explanation.10-12 It is wise for the health care provider to allow the patient to express spiritual concerns, real or imagined. If the health care provider is uncomfortable with this type of discussion, particularly if it may become involved, he or she may suggest that the patient meet with the appropriate religious figure. Allowing the patient to express his or her fears may alleviate symptoms and the discussion may be healing in itself. The health care provider must recognize that patient education will not remove the fear of a witch, the belief in a punitive God, and or the anxiety about the actions of loved ones.
High and Low Blood Pressure
The prevalence of hypertension among African-Americans is significantly higher than other ethnic groups in the United States, with higher rates for men. Research suggests that race and socioeconomic class interact to increase the likelihood of hypertension occurring among African-Americans who are in lower socioeconomic positions.13
High and low blood pressures are interpreted in traditional folk health beliefs as high or low blood.10-12 Low blood is viewed as anemia, whereas in clinical terms, high blood would be polycythemia. It is believed that diet can manage both low and high blood problems, because both are generally caused by dietary factors. Low blood results from ingesting too many acid or astringent foods (i.e., lemon juice, vinegar, pickles, etc.) These foods "cut" the blood and "bring it down" or "dry it up." Symptoms associated with low blood are fatigue, weakness and not having the energy to get and go. High blood is from ingesting too many rich foods, especially red meat. The symptoms of high blood are dizziness, palpitations, headache and vision difficulties. Remedies include the ingestion of acid or astringent foods, such as lemon juice, vinegar, sour oranges, or brine from pickles or olives, to bring the blood down. It is believed that if left untreated, high blood will cause excess blood to back up in the brain, causing the individual to have a stroke.
For the patient diagnosed with high blood pressure by a health care provider, taking medication for a long period time may be viewed with some wariness. The patient may think that prolonged use of the medication will result in low blood pressure, because it is the blood volume that is understood to be the source of the problem. Patients may be inclined to use home or folk remedies to address the problem, such as drinking the appropriate substance. Health care practitioners need to ask questions about diet with patients because the patient may also be using a home remedy such as olive or pickle brine.
Insulin and non-insulin dependent forms of diabetes have higher morbidity and mortality rates in African-Americans when compared to non-Hispanic whites. The African-American population also has high rates of end-stage renal disease, blindness, lower-extremity amputation, perinatal mortality, and major congenital malformations due in large part to diabetes.14
Diabetes, or "sugar" runs in families and is conceptualized as the result of excessive consumption of starchy, greasy foods, excessive worry about family and work-related stresses.9 For symptoms of weight loss, thirst and frequent urination, dietary changes, use of appropriate herbs, and reestablishment of harmony with family, friends and coworkers are initially recommended in the popular health beliefs. If the person is unable to make sufficient changes in these areas or the herbs do not appear to remedy the symptoms, then a visit to the physician is warranted.
A diagnosis of diabetes is generally well-accepted when the patient is told that the blood sugar is elevated. With this explanation, insulin and oral hypoglycemic medications are more easily accepted because they are thought of as "bittering" agents used to lower the sugar content. Home remedies such as herbal teas, garlic and lemon juice may also be used to bitter the blood. Insulin may be viewed by some patients (generally older patients) as too powerful a substance, promoting addiction or dependence. This fear may be exacerbated when the patient is told that they will need therapy forever.
Traditional Health Beliefs of Mexican-Americans and other Latin Cultures
The migrant worker population from Mexico and other parts of Central and South America is increasing in South Carolina. These individuals tend to be young and may be more acculturated to American mainstream society than are members of their own cultures still residing in their native lands. Generational, regional, socioeconomic, and educational differences mediate how individuals from these cultures conceptualize health, illness and associated practices. Younger members may not subscribe to these beliefs as strongly, if at all, as may members of older generations. However, it would be inappropriate not to explore cultural conceptions of illness when it appears necessary. An additional element related to cultural competency is that Spanish is spoken by these individuals; it is not an uncommon for the need for an interpreter during a health care consultation, unless the health care provider speaks Spanish.
Illness Beliefs – The Role of God and "Hot" and "Cold"
Among Mexican-Americans, health is traditionally viewed as the absence of pain, and thus if a person is not in pain, he or she is healthy.9,10 An external locus of control is a prominent belief, and good health is seen as a matter of fortune or reward from God for good behavior. Maintaining harmony and balance with God is linked to the concept of good health, and warding off evil influences is important to maintain this balance. Evil thoughts or actions may provoke illness, or illness may simply be the result of bad luck. Natural illnesses may be viewed as God’s will, and if God is thought to have afflicted the individual with an illness, then penance, promises and prayers are offered. Preventive health concepts may not readily accepted because of the external locus of control in that one has little control over what happens.
Causes of illness may be physical or supernatural. 9,10 Balance of the forces of nature, such as hot and cold, wet and dry, is a key concept in traditional health beliefs. Physical illness may be due to an imbalance of hot and cold, and thus restoring this balance is imperative. A hot illness requires a cold treatment, and vice versa. However, there is no universal agreement about which illnesses, foods, and treatment are hot or cold. Heat is generally associated with blood (which keeps a person warm during cold weather) and with fevers and rashes. Cold is associated with water, damp air, and phlegm. Families hold their own specific beliefs about these issues and have passed this knowledge on from one generation to another. Health care provider awareness that illnesses are hot or cold is important because if a "hot" treatment is prescribed for a "hot" illness (i.e., penicillin for a strep throat), the patient may not want to follow medical advice because health beliefs are that a "cold" treatment is appropriate for the "hot" illness. To elicit a patient and family’s particular beliefs about hot and cold illness and treatments, the use of explanatory models or the other questions listed above is recommended.
Supernatural illnesses are commonly associated with emotional and psychological illnesses. Home remedies are often the first line of treatment for all types of illness. These include herbal teas, massaging the body with oils, poultices, and eating the appropriate "hot" or "cold" food. If the patient does not improve with any of these therapies, then a physician is consulted.
Curanderismo is the most common form of Mexican-American folk medicine.9 Because illness is conceptualized in a religious and social context, the healer’s or curandero’s (male)curandera’s (female) ability to heal in God’s name, is viewed as a gift from God. Religious belief systems, including those of Catholicism, are incorporated into their practice. Several influences are present in the practice of curandismo, including Native American plant and herbal knowledge, medieval Spanish medicine, witchcraft, modern spiritualism and psychic phenomena, and scientific medicine.
Curanderas are consulted for natural illnesses as well, and frequently patients will visit a curandero even if they have had a consultation with a physician. Herbs, oils, and religious symbols are used during treatment, and when necessary, the curandero will go into a trance to communicate with or manipulate spiritual forces.
Specific Folk Illnesses
Below is a listing of common folk illnesses in the Mexican-American community.9 Other Latin American cultures may share beliefs in these illnesses, or have their own variations.
Caida de Mollera, or fallen fontanelle:
This affects babies and symptoms include crying, failure to suckle, irritability, sunken eyes, vomiting and diarrhea. It is caused by pulling a baby away too quickly from the breast or bottle, if a baby falls on the floor, or carrying the baby incorrectly.Empacho
This affects all age groups and symptoms include anorexia, vomiting, diarrhea, indigestion, bloating and constipation. It is caused by a bolus of undigested or uncooked food that has stuck to the wall of the stomach or intestine.Susto, or "fright sickness"
This affects all age groups and symptoms include extreme lethargy, anxiety, depression, insomnia, and irritability. It is caused by a frightening or traumatic experience. A severe form of the illness is when the spirit leaves the body because of the fright.Mal Puesto
This can affect all age groups and the most frequent symptoms include sudden attacks of screaming, crying or singing, convulsions and uncontrolled urination. This is an evil illness intentionally put on the individual by a hex.Mal Ojo, or evil eye
This affects primarily children, all of whom are susceptible. Symptoms include crying, restlessness, fever, and occasionally vomiting. It is caused by someone with a "strong eye" who looks at or admires a child.
Additional Sources for Information about Cultural Competence:
- Culhane-Pera KA, Reif C, Egli E, Bake NJ, Kassekert R. A curriculum for multicultural education in family medicine. Family Medicine 1997;29(10):719-723.
- Zola IK. Studying the decision to see a doctor. In:Lipowski Z, eds. Advances in Psychosomatic Medicine Vol.8. Basel:Karger, 1972.
- Kleinman A. Patients and Healers in the Context of Culture. Berkeley, California: Univeristy of California Press, 1980.
- Kleinman A, Eisenberg L, Good B. Culture, illness, and care. Annals of Internal Medicine. 1978;88:251-258.
- Like RC, Steiner RP, Rubel AJ. Recommended core curriculum guidelines on culturally sensitive and competent health care. Family Medicine 1996;27:291-297.
- Pfifferling JH. A cultural prescription for mediocentrism. In: Eisenberg L, Kleinman A., eds. The Relevance of Social Science for Medicine. Dordrecht, Holland: D. Reidel, 1981, 207.
- Mitchell MF. Hoodoo Medicine Gullah Herbal Remedies. Columbia South Carolina: Summerhouse Press, 1999.
- Jackson J, Slaughter S, Blake HJ. The Sea Islands as cultural resource. The Black Scholar. 1974;March:32-39.
- Fishman BM, Bobo L, Kosub K, Womeodu RJ. Cultural issues in serving minority populations: emphasis on Mexican Americans and African Americans. The American Journal of the Medical Sciences 1993;306:160-166.
- Snow LF. Folk beliefs and their implications for care of patients. Annals of Internal Medicine 1974;81:82-96.
- Snow LF. "High blood" is not high blood pressure. Urban Health 1976:June:54-55.
- Snow LF. Ethnicity and clinical care: American Blacks. Physician Assistant & Health Practitioner 1980;July:50-54;58.
- Lillie-Blanton M, Parsons PE, Gayle H, Dievler A. Racial differences in health: not just black and white, but shades of gray. Annual Review of Public Health 1996;17:411-448.
- Millar J, Etches DJ, DipObs, Diaz, S. Ethnic groups. Primary Care 1995:22:713-730.
Minnesota Public Health Association’s Immigrant Health Task Force. Six Steps Toward Cultural Competence. Minneapolis, MN: Minnesota Department of Health, 1996.
University of Washington Family Medicine Clerkship. Family Medicine and Cultural Competency Website. http://www.fammed.washington.edu/pr…oral/clerkship/student/comptoc.html