1. Communication Between Cultures 7th ed. Larry A. Samovar San Diego State University, Emeritus Richard E. Porter California State University, Long Beach, Emeritus

2. Chapter 10 Overview Cultural influences on context: the health care setting • Cultural beliefs about health care • Intercultural health care competence • Health care communication strategies • Language diversity

3. Diverse health care belief systems Theories of health and disease/illness causation tied to worldviews Examples: Chinese believe health a state of spiritual and physical harmony with nature; value health care that helps to attain this ideal African Americans frequently view folk medicine as curative Fundamental understanding of relationships between health care, culture, and communication necessary for health care professionals

4. Health care belief systems Supernatural / magico / religious • Underlying premises - Supernatural forces predominate the world - Followers hold strong beliefs about existence of sorcery, magic, evil spirits • Causes of illness - Illness attributed to spiritual forces (example: belief in power of the evil eye, i.e. projected by gazing/staring) - Five belief categories 1) sorcery 2) breaching a taboo 3) intrusion of a disease object 4) intrusion of a disease-causing spirit 5) loss of the soul • Treatment of illness - Wellness achieved by positive association with spirits - Treatment carried out by healer-practitioners (examples: shamans, medicine men, curanderos, santeros, spirit healers) - Practices that vary culture to culture include cupping, hanyak, animal sacrifice, Santeria, botanicals)

5. Health care belief systems Holistic • Underlying premises - Based on natural law that whole is made up of interdependent, interacting parts - More than a view about health; actually an approach to life • Causes of illness - Assumption that a person’s health requires being in harmony with nature’s laws - Cultures possessing holistic health views: Chinese, Filipino, Korean, Japanese, Southeast Asian, Mexican, Puerto Rican, African, Haitian, Jamaican, American Indian • Treatment of illness - Chinese treatments include strict food regimens (also ingesting thousand-year-old eggs), acupuncture, moxibustion, herbal remedies, exercise - Mexican folk treatments include foods, herbs administered by curanderos, yerberos (herbalists), and sobadors (masseuses) - Categories of South African healers: destructive/evil, diagnosticians/diviners, therapeuticians, specialists

6. Health care belief systems Scientific • Underlying premises - Focused on objective diagnosis and scientific explanation of disease - Disavows metaphysical, ignores holistic approaches - Can result in Western biomedical ethnocentrism • Causes of illness - Illness caused by breakdown in patient’s physical, chemical processes - Interested in discovering abnormalities in body’s function; deviations suggest/ indicate disease • Treatment of illness - Physicians employ surgery, medicine (e.g. antibiotics), therapies to destroy/remove causative agents - Some co-cultures subscribe to combination of beliefs/treatments, respecting both scientific/biomedical approach together with culturally-accepted approach

7. Cultural diversity in prevention of illness • Many cultures combine supernatural, holistic, and scientific to prevent illness In U.S., physical exams, immunizations, exercise, good nutrition combined with stress-reducers (massage, meditation), ingestion of probiotics, alternative treatments (chiropractors, acupuncturists, etc.) • Other illness prevention examples - Muslim Afghanis’ rely on Koran for protection: ta’ wiz (Koranic verses literally worn or ingested to ward off evil) - Latino and Asian cultures maintain hot-cold balance through therapies, remedies - Mexican and Puerto Rican cultures use amulets, charms, candles, crystals; Chinese also use amulets and jade charms - Laotians engage in ceremonies, group prayers - American Indians avoid or counteract violations of cultural taboos

8. Intercultural health care competence • Intercultural competence defined The knowledge, motivation, and skills to interact effectively and appropriately with members of different cultures. • Five attributes of intercultural competence in health care settings 1) Culturally diverse staff reflecting cultures served 2) Providers/interpreters who speak patients’ language 3) Training for providers about patients’ language/culture 4) Signage, instructional literature in patients’ language and consistent with norms 5) Cultural skill

9. Developing intercultural competence 1) Know your own culture Awareness of host culture’s beliefs help practitioners to realize how they affect practice, lead to appreciation of other belief systems 2) Gain knowledge of co-cultures Respectfully explore patients’ beliefs within context of culture (may hold several viewpoints simultaneously Include family in concerns/decisions where consistent with norms Clinical situation best conceptualized as negotiation

10. Health care communication strategies: Do’s and don’ts to remove barriers to effective communication 1) Do not treat patient in the same manner as you want to be treated - Culture determines manner for polite, caring behavior 2) Begin interaction with formality 3) Allow patient to be open and honest: patient information helpful, in some cases vital 4) Do not discount effects of beliefs in the supernatural - Causation belief may posture patient’s acceptance of treatment 5) Inquire indirectly about patient’s belief/use re: nontraditional cures - Generalize the question in common culture-specific practice terms 6) Never try to force change or demand compliance: think negotiation 7) Employ empathy: address patients’ vulnerability, offer reassurance 8) Be restrained in relating bad news 9) Follow patient’s lead in communication style: match nonverbal communication 10) Make use of the LEARN model: L isten, E xplain, A cknowledge, R ecommend, N egotiate

11. Language and health care • Language diversity Complications/confusion from different metaphors for medical phenomena, medical jargon, words with different meanings within same basic language • Conducting interviews Primary practitioner technique for gathering information to diagnose, prescribe To-do’s for effective interviewing - Use interpreter unless fluent (same gender as patient, if possible) - Learn/use basic words/sentences; emphasize by repetition, speak slowly, be patient - Do not address patient’s direct commentary to or through interpreter - Return to issue if negative response does not quell suspicion of specific problem - Instruct in list format, have patients repeat - Avoid technical terminology, other language that may challenge interpretation - State concretely and confidently • Employing interpreters Three reasons for using: legal, quality of care, financial Trained, medical interpreters generally preferred over family members

12. Death and dying Diversity in cultural beliefs about death challenge health care communication • Western culture assumes patient best person to make health decisions • Non-western cultures vest in family/community decision-making authority • Bias in Western culture’s optimistic posturing when discussing end-of-life situations

13. Next … Chapter 11 Venturing into a new culture: becoming competent