Cultural Barriers to Treatment and CompliancePosted by Marcia Carteret, M. Ed. in Cultural Health Beliefs + Behaviors, Immigrant and Refugee Health, Patient Compliance
Because many health beliefs and behaviors are culturally-based, it follows that when two different cultures come together in a health care setting, a collision of expectations often occurs. Thus, when working with diverse populations in the United States, health practitioners often view their patients’ cultures as a barrier to care. Having very different beliefs about illness causation and treatment from those of Western health care professionals, patients/families often rely on traditional healing methods that are part of their cultural heritage first, seeking the help of a Western doctor only when symptoms worsen significantly. Many recent immigrants and refugees to the U.S. have misperceptions about Western medical treatments and their reluctance to discuss their understanding and/or their preference for cultural practices with Western doctors can lead to delayed or inaccurate diagnosis and poor treatment outcomes. So it is important for health care professionals to anticipate communication needs around these tendencies.
In this article we present cases to illustrate how culture can create barriers to care. Related links are provided for further reading. Key cross-cultural communication skills/concepts are presented in summary.
Misperceptions of Western Medicines
At a recent noon conference for medical residents at the University Of Colorado Health Sciences Center, Dr. Rosanna Fiallo-Scharer presented a case study involving a Mexican immigrant child with diabetes mellitus type 2. During office visits with Dr. Fiallo-Scharer, the girl’s mother accepted the diabetes diagnosis and the use of insulin in treatment. However, the child was not responding to treatment as expected. As Dr. Fiallo-Scharer is herself Latino and fluent in Spanish, the challenge in this case was not one of language, but there was definitely miscommunication happening between cultures – the Mexican immigrant culture and the Western medical culture. Eventually, the mother admitted that she was not adhering to the recommended course of insulin injections at home because the grandmother believed that insulin was addictive and refused to allow the required insulin injections. She preferred instead to rely upon the traditional remedies she herself trusted. This is a clear example of how a misperception about Western medicine became a significant barrier to treatment. It also highlights the importance of understanding culturally-based family dynamics which can have a dramatic impact on treatment and compliance. See related article in archives.
Another example of how Western medicine is misunderstood involves oral birth control. The use of oral birth control, so common in American culture, is very much misunderstood and often rejected in many parts of the world. In some cultures there are concerns about the side effects of oral contraceptives such as weight loss, fever and infection. (One study involving Cambodian refugees indicated this may correlate in some way to these same reactions in women taking the traditional herbs for birth control.)1 In a case involving a Hmong family, a child was admitted to an intensive care unit with a diagnosis of respiratory distress. The parents did not mention to the emergency room doctor that another one of their children had been admitted and died in the same unit. It turned out that the family carried an inherited muscular wasting disease known as Werdnig Hoffman Syndrome. However, when questioned, the father insisted his babies got this disease from the birth control pills his wife was taking. He had not allowed her to take them since the death of the first baby. Since then, she had given birth to eleven children; five others had died.
Problems Associated with Traditional Medicine Use
A 2001 survey of 745 members of the American Academy of Pediatrics found that 87 percent of pediatricians had been asked about complementary and alternative medicines by a patient or a parent in the 3 months prior to the survey. The pediatricians were asked most often about herbs and dietary supplements. Given these statistics among Americans, why is the use of traditional remedies such a cause for concern when treating patients from different cultural backgrounds? The answer lies largely in communication gaps that are more likely to occur in cross-cultural encounters. Most Americans are comfortable asking their doctors questions and will comfortably engage in dialogue about using alternative medicines. Recent immigrants and refugees who are unfamiliar with Western health care are far less likely to share such information. They may feel Western doctors will not understand or approve of their culturally-based remedies and they fear being judged for their “foreign” beliefs. In general, they will be less inclined to ask questions and negotiate their treatment with a doctor who they see as an authority figure. More common in their experience, perhaps, is having a doctor tell them what to do. They may not be aware that preventing adverse drug interactions depends on discussing all the medicines they take with their doctor. Similarly, it may not occur to them that giving medications prescribed for adults to children can be dangerous and that ALL medications, including herbal remedies, should be kept out of children’s reach. In multi-generational households, older children are often put in charge of younger ones. However, adults should be in charge of administering medicines of any kind. (A useful link to information about using alternative medicines with children can be found at http://nccam.nih.gov/health/children.)
Misunderstanding of Chronic Disease
Many cultures have specific treatments for acute illness, but have no concept of asymptomatic chronic diseases. Therefore, “it hurts you go to the doctor, if not, you don’t.” Without an understanding of how to manage chronic diseases, patients/parents may think that medications should be discontinued once symptoms have abated. Also, each exacerbation of symptoms may be seen as a separate illness unrelated to previous episodes, especially if there are variety of symptoms. It is also likely that remission will be seen as a cure. A common challenge for pediatricians around this barrier to successful treatment is seen in the use of controller medicines for children with asthma. Health care professionals become educators working to raise health literacy each time they help a patient/family understand their role in managing a chronic disease. This is incredibly important to reducing health disparities among populations that typically have the poorer health outcomes related to conditions like asthma.
Summary and Key Cross-Cultural Communication Concepts/Skills
Cultural barriers to treatment and compliance aren’t always easy to ascertain and, as we’ve seen in the above cases, create gaps in effective communication that impede the success of treatment. There is no way for health care professionals to predict specific cultural barriers with certainty in every situation, so cross-cultural communication skills become extremely important in uncovering misperceptions that will impede treatment. It is easy to understand why health care professionals often view their patients’ cultures as a barrier to care, but miscommunication happens between two – people, cultures, etc. To maximize understanding in the context of health care settings providers need to be cognizant of some basics:
- Taking a little extra time to build rapport before discussing the medical issue at hand.
- Demonstrating an awareness of culturally-based family dynamics – never turn your back on grandma!
- Recognizing how different cultures perceive the status of doctors and nurses and how this affects open communication
- Being emphatic about encouraging questions and giving silence a chance (if the patient is slow in arriving at an answer to your question, this may be a gesture of respect.)
- Expressing awareness of traditional remedy use by many patients from ALL cultures as well as genuine interest in patient use of these remedies and cures without judgment.
Related Links and Resources
1.Study referenced involving Cambodian refugees https://www.guttmacher.org/pubs/journals/2618800.html
2. Case Study involving Hmong family and misperceptions about birth control pills
3. Culture and Family Dynamics Newsletter
4. Information on use of alternative medicines for children at the National Institutes of Health National Center for Complementary and Alternative Medicinehttp://nccam.nih.gov/health/children