A Cross-Cultural Perspective

Remember that people’s sense of time and time management is very much culturally based. A minute is a minute anywhere in the world, but not all people manage their time in quite the same way Americans do. When it comes to strict time management, the health care profession in the U.S. is appointment driven to an extreme – time is money. In America, you can be inconsiderate of another person’s time. In many cultures, this concept would not make much sense to people.

People who are new to our health care system will operate based on what they know – very possibly a system that works without set appointments. In many places in the world, if you need to visit a doctor, you try to show up at the community clinic when the line of patients will be the shortest. Maybe early in the morning is a good time to arrive so your name will be first on the list. Perhaps late in the day is a good time because there won’t be as many people waiting.

Adapt Your Care

It is a good idea to use the term clocktime when scheduling appointments with patients and families who are new to this country, who may not speak English fluently, and/or may be habitually late to appointments. Also, it is important to explain and emphasize that showing up late may mean a wasted trip for them. Practices should explain their cancellation and no-show policies clearly. Posting these policies may be helpful for patients and families who can read and understand the signs, but many people won’t be able to. Realistically, how many languages, other than English and Spanish, can you use to post important messages about these policies? Depending on your patient population, two language just won’t be enough.

Related Article: Check out the  article titled “Culturally-based Attitudes About Health Care Contribute to No-Show Rates” 

Contributing Factor 1: Preventive Medicine is an Unfamiliar Concept.

In many societies around the world, there are immediate treatments for acute illness and injury, but little concept of preventive medicine in the way the American medical establishment conceives of it. In many cultures, if you are sick you go to the doctor, but if you aren’t sick there is no reason to go. Why would you seek out a doctor or traditional healer just to be sure you aren’t sick? For example, imagine a mother originally from Mexico who is recently immigrated to the U.S. She keeps missing her well-child check-ups even though she goes through the process of scheduling each follow-up appointment before leaving the doctor’s office. She might never call to say she won’t be there at the appointed time. Why? Well, perhaps this woman does not see any reason for going to the doctor because the doctor has already told her that her son is “well”. Why would she take her child to the doctor when she knows the child is healthy? Why make all the arrangements and pay a co-pay? If her child screamed and cried after getting shots at the doctor’s office during the previous visit, she may not want to put him through more of the same if he isn’t even sick. This mother demonstrates a common cross-cultural communication challenge; she does not understand the concept of preventive medicine, well-child checks, or the importance of keeping her appointments. There’s a much better chance the mother will show up for her appointments if this misunderstanding is cleared up. When people know the reason for something, and if it makes sense to them, they are more likely to comply.

Contributing Factor 2: Who Controls Our Well-Being?

It is also important to remember the dimension of culture “control over destiny.” For people who have a strong belief in fate and karma, what happens to them in life—good or bad luck, health or illness—is in the hands of their higher power. Therefore, self-management of one’s health for a better future outcome won’t drive behavior in significant ways. (Notice that even U.S. Americans who, by comparison, may believe that control over destiny is in their own hands, are slow to make appointments for routine physical exams. And how many keep putting off that visit to the dentist for teeth cleaning?) Some appointments seem obviously more important than others. Routine appointments may not make a lot of sense to people who believe what happens to them is fate. It is useful to keep in mind that culture and religion are two sides of the same coin; many beliefs associated with fate and karma are based on guiding religious principles and, for that reason especially, can not be negated or dismissed by outsiders. It is important to show respect for people’s beliefs, but also to explain that their “higher power” has made western medicine available to them. In western medicine the focus on prevention of illness is very important.

Contributing Factor 3: Status of Health Care Professionals

Consider another cultural component in the case of the mother who kept missing her well-child checks. Imagine that this mom nodded in agreement when her doctor told her to schedule the next check-up. She did not ask the doctor why she should bring her healthy child back to see him in two months time unless he was sick. She didn’t want to waste any more of his time. She followed his instructions and made the next appointment at the front desk. She did not write down the appointment. When the receptionist handed her a card with the appointment time written on it, she tucked it in her pocket. She was nodding and smiling pleasantly but not really looking forward to the next visit in a committed way. She was going through the motions to please the practice; she felt she needed to do this in order to be able to remain a patient of the doctor she liked.

Fast forward: She had forgotten about the appointment until a reminder call came from the doctor’s office. On the day of the appointment her child was healthy and happy. She thought it would be a waste of the doctor’s time to take the boy in. She also thought that if she didn’t show up, it just made the line of patients waiting for the doctor shorter. Where she came from, it was always first-come, first-served at clinics.

Contributing Factor 4: Time Control/Management

As stated at the very beginning of this chapter, U.S. Americans have a very specific attitude about time. We manage time down to the minute. Our health care appointments are based on absolute time, whereas in many societies health care is much more informal. Appointments work like general admission. People who are more relaxed about managing time often do not keep calendars—on paper or electronic devices. They certainly don’t track their personal/family time. Again, using the same parent in the previous examples, she may not be prepared to write down the next appointment in a calendar when she is standing in the doctor’s office. When the practice calls the day before her appointment as a reminder, she may have forgotten all about it and simply can’t arrange transportation with only a day’s notice.

Why wouldn’t a person in this situation explain the problem and ask to reschedule? A parent’s explanation might sound something like this: “Well I hoped somehow I would find someone to take me. I was still trying to get my cousin to help me even when I was already late to the appointment. But when I knew I couldn’t go, I was afraid to call the doctor. They would be angry with me.”

An added note: We all know people who just don’t check their messages frequently, don’t return calls, don’t read their email and respond. Individuals vary greatly with respect to these behaviors—no matter what culture they come from. There may be important messages from a doctor’s office lost in a long backlog of voice-mail messages on someone’s phone. Their phone service may even be cut off. When patients/families have low English proficiency, low literacy, and low health literacy, relying on voice mail messages can be very problematic.

Contributing Factor 5: Money Problems

Imagine another scenario. A father shows up with his son for an appointment only to discover there is an outstanding balance of $800 that needs to be paid before the doctor will see his child. What if the dad is out of work? How humiliating it will be in this situation if he can’t pay. Yes this is the way our system works in the U.S. In many other places in the world, “condition” determines care, not money or proof of insurance. In some cultures, the doctor has established personal rapport with patients/families over time and everything is much more informal. A physician or community healer may allow patients to pay in increments and will still continue care. In our own society, it is common for people to rely on credit cards so they can pay incrementally over very long periods of time. However, those who struggle to establish credit and those who have exceeded their credit limits do not have this option.

IMPORTANT NOTE: Even with Medicaid, families may have outstanding balances that will prevent them from showing up for an appointment.

Contributing Factor 6: Transportation Problems

Finally, transportation challenges contribute significantly to no-show rates. Imagine not owning a car or sharing a car among numerous family members. Imagine, if you are a woman and your culture dictates that women can’t drive; you have to arrange a ride with a male family member. Perhaps you can’t get a male family member to agree. What if you can’t afford gas? If you have no choice but public transportation, it probably won’t be as convenient as a taxi. Imagine walking to a bus stop pushing a stroller in summer heat or winter snow. Imagine waiting for a bus that is late or never comes. Imagine having to navigate the bus with one child in a stroller and one or more toddlers in tow? It isn’t likely patients will call the doctor’s office to explain their problems. They may want to avoid a conversation with a busy front office receptionist. Perhaps their situation produces shameful feelings in them. Too often, people will avoid a situation entirely by not calling, not showing up, not rescheduling.

Summary

Cultural differences often contribute to the problem of missed medical appointments, and socio-economic realities for families are a crucial co-factor. The way practices and clinics communicate with their patients may not eliminate no-shows, but can make a difference in reducing the rate of missed appointments. Being able to anticipate the challenges people face and their degree of understanding about the U.S. health care system is very important. Also, understanding culturally based beliefs and behaviors about a person’s control over their own destiny, the status of doctors versus patients, and individual time control is very important in being culturally responsive. Helping families understand the concept of “preventive care” is enormously important in helping raise health literacy. Educating families about preventive care is a crucial factor in reducing health disparities among certain populations.

Studies indicate that children from low-income and minority families, children with special needs, and children raised in rural areas of the U.S. shoulder a disproportionate burden of oral disease, adding to the list of health disparities among some disadvantaged populations. Contributing factors may include lack of community water fluoridation, dental workforce shortages, and the high cost of care and limited access to dental insurance. Cultural beliefs, values, and practices are also often implicated as causes of oral health disparities, yet little can be found in the dental literature that isn’t epidemiological in nature. In other words, the literature demonstrates disparities in oral health rather than identifying specific oral beliefs and practices among different cultural groups. 1

Indeed, cultural influences overlap with dental health literacy, socioeconomic status, and personal experience in complicated ways, but it is possible to identify some common beliefs and care-seeking practices around oral health that are culturally-based and significantly different from the western dental medicine model. This article will suggest four domains that shape people’s cultural beliefs and practices related to oral health: 1.) help-seeking and preventive care, 2.) oral hygiene practices, 3.) beliefs about teeth and the oral cavity, 4.) the use of folk remedies. Additionally, a list of interesting and useful culturally-related oral health facts are presented.

Help-Seeking and Preventive Care

Many cultural groups don’t have a strong preventive orientation when it comes to their health care, and this is definitely true when it comes to oral health. People often seek care only when there is a problem. An individual might go to the dentist for a painful tooth after suffering with it for a while, and then simply expect to have the bad tooth extracted. Advanced interventions to save a bad tooth, such as root canals and crowns, may be common in the U.S. and other western countries, but are often the privilege of only wealthy people in other cultures.

Oral Hygiene Practices

In many cultures there is little understanding of gum disease. Brushing the teeth may be done to remove left over food from the mouth, but the concept of removing plaque and tartar is less well-understood. It follows that the use of dental floss, mouth rinse, and tongue cleaners may be virtually unheard of and might be viewed with skepticism. Americans are known around the world for being obsessive about perfectly straight bleached white teeth. Hollywood movies and American TV promote the importance of pearly white American smiles.

Beliefs About Teeth and the Oral Cavity

In many cultures the esthetic appearance of teeth may be important, but having “healthy” teeth and gums is not connected to appearance in a direct way. Red or swollen gums, bleeding gums, painful chewing, loose teeth, receding gums, all these symptoms of gum disease may be ignored as long as the visible teeth “look good”. An interesting example comes from China where the appearance of teeth is psychosocially important. Having nice looking teeth can influence social interaction. However, a person with carious or discolored front teeth…is considered to have low intellectual competence.2

Use of Folk Remedies

In some traditional cultures there is a preference for using traditional remedies and cures either in place of western medicine or in conjunction with it. Use of herbs or healing methods like acupuncture and moxibustion are common. Pain in any area of the body, including oral pain, is treated using culturally-accepted remedies passed down through generations. For example, in some African American families the use of cotton balls soaked in aspirin solution, alcohol or salt water is a well-known home remedy for pain and swelling.3

Additional Culturally-Related Oral Health Facts

The Crucial Link Between Primary Care Providers and Oral Health Care

Since dental decay can start as soon as teeth erupt, to be effective, preventive oral health strategies need to target children early when transmission of oral bacteria from mother to infant commences and eating habits are established. Since infants and children are seen by their primary care providers (medical) frequently during the first two years of life, there is an opportunity for these practitioners to promote oral health and refer children for dental care. However, primary care providers receive limited training in prevention of oral diseases, while general dentists care for young children, but their small numbers nationwide made such services unavailable to most children. High-risk children usually have dental insurance through medicaid, but the percentage of dentists participating in Medicaid is low. Only one in five children covered by Medicaid actually receives preventive dental care.

Cavity Free at Three: One promising program in Colorado that seeks to tackle the challenge of preventive dental care for high-risk children is Cavity Free at Three. This three-year, statewide effort was developed to help prevent oral disease in young children. The effort aims to engage dentists, physicians, nurses, dental hygienists, public health practitioners and early childhood educators in the prevention and early detection of oral disease in pregnant women, infants and toddlers. Risk assessment, patient and family education, and fluoride varnish application done in primary care offices are key components of this program. Read more at http://www.cavityfreeatthree.org/

Conclusion: Health care is a cultural construct arising from beliefs about the nature of disease and the human body, and it follows that cultural issues are central to the delivery of effective preventive care and illness intervention- both medical and dental. As the link between primary care providers and oral health care for children becomes more and more important in reducing overall health disparities, it is important to consider the cultural aspects of oral health – treatment seeking-behaviors, hygiene practices, and beliefs about the relationship between teeth and the health of the entire body.

Resources

1, 2, 3, 7 Yogita Butani*, Jane A Weintraub and Judith C Barker “Oral health-related cultural beliefs for four racial/ethnic groups: Assessment of the literature” BMC Oral Health 2008 This article is available from: http://www.biomedcentral.com/1472-6831/8/26 © 2008 Butani et al; licensee BioMed Central Ltd.

4 Henderson L, Millett C, Thorogood N: Perceptions of childhood
immunization in a minority community: qualitative study. J Emerg Nurs 2008, 21(6):569-70.

5 Yellowitz JA, Goodman HS, Farooq NS: Knowledge, opinions, and practices related to oral cancer: results of three elderly racial groups. Spec Care Dentist 1997, 17(3) 100-104.

6 Mendoza FS: The health of Latino children in the United States. Future Child 1994, 4(43–72)

7 Mikhail BI: Hispanic mothers’ beliefs and practices regarding selected children’s health problems. West J Nurs Res 1994, 16(6):623-638

8 Peter K Domoto, Mark A Egbert, Elinor A Graham. Dental injuries due to African traditional therapies for diarrhea. West J Med 2000;173:135-137

• Health care professionals speak “medicine.” The complex technical nature of their language doesn’t always translate easily into plain English. Adding to the challenge of translating medical expertise is a broad range of literacy and health literacy of patients and families.

• Sometimes there is the tension of “getting bad news.” People don’t listen well when they are tense and anxious about receiving bad news from their doctor. Doctors certainly experience some tension upon communicate bad news as well.

• Health care conversations are very personal. Shyness and embarrassment shut down communication. Doctors may be highly trained professionals accustomed to talking about the body very matter-of-factly, but many patients struggle to speak directly about their bodies.

All of the above communication challenges become more significant when culture and language barriers are present, especially if providers have no choice but to depend on the uneven skills of interpreters and the very imperfect technology of telephone interpretation. What could possibly be more impersonal for both the provider and the patient than talking into a speaker phone? And yet, phone interpretation is, for now at least, the best interpretation  resource available, though not affordable  in private practice settings.

The purpose of this article is to offer some very specific suggestions about how providers can effectively talk to interpreters. Though we covered some general tips about using interpreters in an earlier article, we think more specific insights into adjusting speech patterns may be helpful as well.Our premise is that good communication with interpreters depends on constant mindfulness about how we are using language.  These recommendations and examples come from audio-taped pediatric visits in which interpreters were used.

Exaggerate Your Enunciation Slightly:
If you were to take a recording device into a meeting with colleagues, you might be surprised at how monotone everyone sounds when playing it back. The absence of human interaction (eye contact and body language) reduces conversation down to a very flat exchange unless people work at enunciating and using more animated sentences. Similarly, during any health care communication, a purposeful emphasis on important words and clarity of speech become very important to keeping people actively listening.

Always Choose a Simpler Word:
Basic words are the easiest ones to translate clearly to people of all literacy levels. Use the word “eat” instead of “consume”, “try hard” instead of “be diligent”.

Speak a Little More Slowly:
It’s hard to parse a foreign language. (Surely the writer of this article could have found a simpler word than parse – i.e. understand.)

Avoid Running Words Together:
“We wantcha ta take all the Medicine.” / “Whadya think ’bout that idea?” / ”Gotta keep brushin’em.” / “D’sat make sense?

Avoid using meaningless filler sounds and words: Um…uh…huh…yeah…like…
If you were to listen to yourself leaving a long voice message for someone, you might be VERY surprised at how much of your, um, speech is just filler words.

Avoid starting a statement that turns into a question: (and vice versa).We have noticed that providers often start a sentence with a statement that at the end is turned into a question by adding a word like “Right?”  Or by simply ending with an upward intonation.

Examples: Your child has been taking the medication twice a day.   Right?

“You are able to give 5 portions of fruits and vegetables to your child everyday (so far sounds like a statement , but by making your intonation higher pitched on the last word, you turn it into a question so at the end of the sentence there now is a question mark)? We have found interpreters have trouble making it clear to parents that this is a question.

Decrease the wordiness of your sentences in general:

Example: So, what I’m wondering though is how you apply the medication.

Suggestion: How do you apply the medication?

Example: We really like to say like two hours max of TV a day.

Suggestion: We recommend children watch only 2 hours of TV a day.

Example: “So I’m gonna look him over and see what everything looks like.”

Suggestion: I am now going to examine him.

Be explicit. Ask simple questions: Make simple statements. Avoid starting with a statement that winds its way eventually to a question. The interpreter won’t know whether to ask just the question or try to repeat the short paragraph you said before you actually posed a question.

Example: “So the last time your son was here, I suggested you visit the eye clinic. And they ran some tests on his left eye to see if it was weak. So I am wondering what did they say to you about his eye?”

 Suggestion: Did you visit the eye clinic with your son? (Interpreter interprets question and patient’s answer). What did they tell you about his left eye? (Interpreter interprets question and patient’s answer)

Start your answers with “yes” or “no.”  

“Yes. That’s a good idea.” “No. I don’t recommend that.

Answer questions clearly!

Example dialogue:

Mom: He had shots last time. Is there going to have to be a lot shots today?

Doctor : Yeah. A couple.

In a single interaction, making multiple references to the same thing using different words creates confusion: Referring to a topical treatment for excema as a cream, lotion, and moisturizer all in the same conversation. Also avoid using brand names unless you are sure the patient knows the product being discussed. (Aquaphor, Nivea, Eucerin.) The interpreter will interpret, but the patient may just nod and listen but not know what you are talking about specifically.

Absolutely avoid using expressions that don’t translate literally:

• This helps lock moisture in.
• Give it a-go
• We wanna change things up
• It is important that we do diligence.
• I’ll give you guys a prescription (talking to a mom and daughter)
• That’s where the cells in your body that fight infection hang out.

If asked to repeat something, first repeat it as closely as you can to the way you said it the first time:
It could be that the interpreter simply didn’t hear you. If your listener still doesn’t understand, change a few key words in the sentence. Reflect on the sentence. Did you unconsciously use a distracting metaphor, a colloquialism, or acronym? Was your language too complex?

Make requests firmly: Intending to be polite, we are sometimes too indirect.

Examples:

“Would it be possible to….”

“I was wondering if maybe you could…”

“If you wouldn’t mind too much… “

Just say please and thank you which are universally understood as politeness.

Suggestion: Can you take your shoes off please. Thank you.

If the translator seems to summarize a long answer into too few words:Remember that communications styles differ based on culture. Whereas Americans tend to get straight to the point, people who come from other cultures may need to give their answer as a story, anecdote, or example. Their answer may be quite long and involved. If the interpreter summarizes everything that is said, you may doubt you are “getting the full story.” Interpreters may think their job is to weed through all the “excess” explanation and convey only what is essential. But who decides what is essential? Let the interpreter know that a summary can leave out important details, so you prefer that he or she translate exactly what is said a sentence or two at a time. If the patient is talking and talking, politely interrupt and ask the interpreter, “What has he/she just said just now.” Demonstrate with your body language that your are actively listening to the interpreter. Make eye contact with the patient and nod as you listen. If the patient feels you are taking the time to really listen, this will signal caring of the highest sort.

YOUR Body Language says as much as your words: Face the patient while you are talking and while you are listening. Avoid looking at the computer screen to type responses into EPIC. You can type while the interpreter is telling the patient what you have just said. Or, pause the conversation and type. Then turn to the patient and continue. Lean forward slightly which signals you are paying attention (but don’t lean in so close that you make the other person feel cornered). Make eye contact with the patient without staring, and nod as you listen. Smile and use hand gestures to support what you are saying. Avoid looking at the phone when you talk, though it feels natural to do so. Our body language changes when we talk into a phone. We drop the immediate human quality of the interaction, shifting automatically into “talking to someone in the distance” mode.

The above communication tips may seem cumbersome to use at first, but in time do become second nature. Mindfully managing your use of speech when using telephone interpreters will improve compliance and health outcomes with limited English speakers, and these tips will also improve understanding with limited literacy and health literacy patients. In the long run, time is saved because interpreters do not have to interrupt and ask for repetition repeatedly

(Note: Another Dimensions of Culture article related to this topic is “8 Tips for Communicating with Limited English Proficiency Patients.”)

To begin building an awareness of cultural differences so that we actually can make useful comparisons between people’s views of the world, it is useful to pay attention to informed generalizations about the cultures with which people identify. We can’t talk about culture without talking about groups, and we can’t talk about groups without forming generalizations. But HOW we conceive of and apply these generalizations in the context of a medical interaction determines whether or not we are falling back on useless stereotypes.

Dimensions of culture are a useful starting place. To use a medical analogy, they are like the symptoms we pay attention to when we diagnose. We understand that these informed generalizations can’t be applied rigidly to each individual. There are more things involved in making an accurate assessment of the individual patient.

Below are four steps to developing a cross-cultural mindset. Building awareness in each step is also essential to improving cross-cultural patient care and health outcomes.

1. Begin to build awareness around aspects of culture that aren’t visible – the values, beliefs, and attitudes that drive the visible aspects of culture, including culture-based healing practices. This is where the dimensions of culture, such as time control and social power distance are extremely useful.

2. Pay attention to your thoughts. Do you assume your culture’s way of doing things is “normal” or somehow more “real” and everyone different is somehow acting out a cultural variation that is less valid? If so, you trivialize difference automatically, though probably subconsciously. Members of any dominant culture in any society may tend to do this without awareness. We have to step back to understand our assumptions about how people operate in the world. It’s a very complex world.

3. Maintaining “cultural humility” with patients is crucial. If you don’t understand your own culture, including western medical culture, you may think that “ethnic people” have all the culture, and that’s why they are different in the first place. Cultural identity is central to all human experience. Learn more about your own culture to establish a baseline for learning. Making effective distinctions about cultural world views is extremely important in achieving cultural humility.

4. Be willing to adjust your behavior. If you just keep on doing what you’ve always done, you miss opportunities to achieve successful health outcomes with your patients.

“As clinicians, we need to ‘check our own pulse’ and become aware of personal attitudes, beliefs, biases, and behaviors that may influence (consciously or unconsciously) our care of patients as well as our interactions with professional colleagues and staff from diverse racial, ethnic, and sociocultural backgrounds.” — Robert C. Like, MD, MS, UMDNJ-Robert Wood Johnson Medical School
 

‘Developing a Cross-Cultural Mindset’ by Marcia Carteret. Copyright © 2011. All rights reserved.

Today, the US has the fourth largest population of Hmong. There are an estimated 6,000,000 in China, 787,000 in Vietnam, 315,000 in Laos, and between 200,000 and 250,000 in the US.2

As of the last census, California, Minnesota and Wisconsin had the largest Hmong populations. Colorado was sixth on the list with an estimated 3,859 Hmong. 3

A Very Youthful Community

2000 census data showed the median age of the Hmong population being 16, while the average for the overall US population was 35. Similarly, census data showed 56% of Hmong in the U.S. were under 18 years of age compared to 25% for the overall US population. The average Hmong household size was 6 persons compared to the average overall US population household size of 2.5. 4

Diversity Within the Hmong Community

Though a relatively small and close knit ethnic minority in the U.S., there is considerable diversity within Hmong communities in the US.

Diversification factors include:

Religion: Though an estimated 70% still practice traditional Hmong religion, a significant number are Christians. Many combine belief systems. 5

Language & Dialects: The Hmong have their own language, called Hmoob (Hmong in English). It has many dialects. However, most Hmong speak either white or green Hmong, referencing the colors in their traditional clothing. (The green is sometimes called blue.) These dialects are different in the way, for example, that British and American English are different. Hmong language was not a written language until the late 1960s when Christian missionaries came up with a writing system that allowed translation of the Bible. The Hmong language has few medical terms. Older Hmong may tend to use metaphor when expressing themselves, and this can make it difficult for healthcare professionals in the US to understand them without a capable interpreter.

Clans: The central unit of political and social organization in Hmong communities is the clan. Clans are determined by ancestral lineage (great, great grandfather) and which traditional ceremonies they practice. If families practice the same ceremonies, then they probably belong to the same ancestor. Hmong families tend to be large and extended; the entire clan is “family.” A Hmong man stays in his clan for life, but a woman marries into the clan of her husband’s family. Mutual assistance is expected between clan members. According to one Hmong proverb, “One stick cannot cook a meal or build a fence.” Clearly, collective identity is central to the Hmong way of life.

Family Dynamics and Healthcare

Role of Father: In traditional families, the father is the head of the household. When healthcare professionals encounter a more acculturated Hmong family in the U.S., they will likely see more balance of power between mother and father.

Role of Mother: Traditionally, Hmong mothers nurture and take care of the children. They are responsible for the household. Succeeding generations are giving Hmong women increased respect outside the domestic realm. It is often women who will converse with healthcare providers, but men usually will make decisions related to healthcare.

Role of Elderly Hmong: The elderly get the most respect of all members of the family and are consulted when important decisions need to be made. They help discipline the younger children. The elderly remain with the family throughout their life. Grandmothers may or may not actually be present during healthcare visits, but they typically make key decisions about managing illness in the family.

Clan Leader: Each clan has a leader. All adult members of a Hmong clan help in selecting their leaders; a leader must be deemed honest, respectful, and capable of making wise decisions. The leader helps make important decisions whenever there is a problem, such as a divorce, illness, or death in the family. The leader is often the person in the clan who decides whether to go forward with a surgery or whether to resuscitate a patient. He calls people together to discuss issues and then he informs the clan members of his decision. Many clan leaders are very powerful indeed.

Religious Leader: A clan leader is often assisted in decision-making by a religious leader called a shaman. Some Hmong shamans are very powerful. They may make the decisions related to spiritual healing. (The book The Spirit Catches You and You Fall Down is an excellent resource for understanding the clan dynamics in healthcare situations involving a sick child.)

Verbal/Non-Verbal Communications

High Context Communicators: Hmong may not communicate dissatisfaction with regards to the quality of their healthcare directly. They may not feel comfortable speaking up, asking questions, etc. Instead, they may politely refuse care and go somewhere else for treatment. Older Hmong are often accustomed to speaking in metaphor, telling a story in answer to a question. The story is important. Concentrated listening on the part of the provider is extremely important, as is asking for clarification of a story’s intended meaning.

Avoid Addressing Hmong Women by their first name. Use Ms./Mrs. and a last name.

Eye Contact: Hmong people tend to listen attentively to healthcare professionals, but will often avoid direct eye contact because it is considered rude in their culture.

Be Aware of Your Body Language:
Use a normal tone of voice. Be aware of body language. Hmong who don’t speak English fluently will listen intently and interpret what is being said by tone of voice and body language.

Hmong Sense of Time Control

Many Hmong originally came from agrarian societies which tend to relate to time as cyclical, repetitive, and slowly advancing. Some Hmong individuals who are less acculturated to the U.S. may still be unaccustomed to functioning via American “clock time.”

• Information about healthcare appointments needs to be written and carefully explained.

• Allow extra time to get consent forms signed as it may involve discussion with Hmong elders and family members.

• Remind Hmong parents about scheduled immunizations for kids. It is helpful to reiterate that immunizations are part of preventive care, a concept unfamiliar in the traditional Hmong medicine tradition.

Beliefs About Illness Causation

Traditional Hmong view illness from a holistic perspective. Perfect health is a balance between the spirit and the body. Illness is seen as having either spiritual or physical causes. Typical physical causes are exposure to environmental factors and unsuitable dietary practices including hot/cold food imbalances. Physical illness is treated with various traditional curatives and/or western medical care. Spiritual causes of illness include:

• Evil spirits that are unhappy with the ill person

• Loss of one’s own spirit (an ill person has lost their soul)

• Unhappy ancestors (Perhaps someone has done something to offend the family’s spirits or ancestors. An example might be forgetting to provide food to needy ancestors or forgetting to make offerings of paper money. Those in the real world offer paper money by burning it; it is converted to silver and gold in the spirit world.

• A curse upon the family by someone

• (Note: Some Hmong accept western concepts of illness causation along with their culture’s traditional view)

Spiritual Healing and Soul Loss

Hmong believe good health depends on souls living in each person. These souls govern the body. Illness or an invasive procedure of any kind can cause soul loss. Spiritual healing rituals are common, often conducted in the home or even in the hospital. Spiritual healing involves retrieving the lost soul from another plane of existence. The practice of soul calling during ritualistic ceremonies is performed by a shaman.

Preventive Care

Many Hmong, especially older ones, focus on treating illness when it occurs, but do not have an understanding of preventive medicine or of chronic disease requiring daily treatment even when symptoms are not experienced. Similarly, these are often people who have no concept of germs causing disease. Younger Hmong who are raised in the US will naturally be much more familiar with these concepts and will be more likely to value preventive medicine. They will understand that immunizations are required when children enter schools. As cross-generational conflicts are common in refugee communities, it is important that healthcare professionals in the US understand the importance of respect – younger Hmong must demonstrate respect for the opinions of Hmong elders to maintain familial harmony.

Traditional Treatments

Many Hmong continue to use traditional herbal treatments. Others will use herbal treatments as complements to western treatments. Traditionally, someone who is sick is required to eat hot food and certain vegetables. Hmong prefer hot chicken and rice. They drink hot or warm water. Within 30 days of childbirth, Hmong mothers will usually only eat warm foods.

Caring for a Sick Child in a Hmong Family

Sick children are often put on a strict dietary regimen, such as eliminating vegetables and only feeding a diet of rice and chicken. Chicken must be boiled, not fried. Herbal medicines are added to the meal in small amounts. Other treatments for physical illness include cupping, coining, and moxibustion. Treatment for illness of a spiritual nature involves religious ceremonies, wearing amulets, or food/animal sacrifices.

Immunizations

Traditionally not acceptable. Hmong believe it is not a good idea to put something into their bodies. If a person is immunized or has surgery, he/she will be reincarnated with less than a complete body or a body with something foreign in it. However, most Hmong parents will have their children immunized once they know it is required for school or other activities.

Surgery

Usually not acceptable. Opening the body allows the soul to escape; soul loss is one of the Hmong’s greatest health concerns. However, in some cases, with the support of the clan shaman and leader, the Hmong are willing to consider surgery.

Organ Donation/ Blood Transfusions

Traditionally, both are unacceptable. Younger Hmong, however, are more accepting of these medical procedures.
Blood Tests: Hmong accept blood tests. But they may question why they have to have blood taken more than once in one visit or why a large volume of blood is needed.

Practical Tips to Achieve Positive Health Outcomes for Hmong patients

Build trust: Building trust from the very outset is essential with the Hmong. Providers need to be open to the family’s suggestions. Show respect for the family by listening.

Privacy Concerns: Hmong share information among certain clan members. All staff and all interpreters in healthcare settings must honor the privacy of patients and their families. This policy needs to be communicated to the Hmong.

Alternative Medicines/Herbs/Healing: Ask what care, if any, is already under way? What herbal treatments are being used? What is the source of the herbs?

Should You Inform the Patient Directly: Before sharing information regarding a serious diagnosis with a Hmong patient consult the family. If may be a necessary to hold a conference if there is a major problem or surgery is needed. A conference may need to involve all important family decision-makers including clan leader and shaman. Consider the location. Hold the session in a conference room, not in the patient’s room.

Use Hmong Interpreters: Be aware that even if the patient/parents speak English, other important other decision-makers may not. Provide a Hmong interpreter.

Explain Explain! The Hmong may be fearful and distrustful at the outset. Be very clear about details of the patient’s condition and intended care (but be sure to talk to important family decision-makers before informing a patient of bad news).

• Explain why many immunizations are needed.
• Explain what a chronic disease is; asymptomatic does not mean cured
• Repeat information about medicines.
• Explain purpose of blood withdrawals. Explain what the test is and why so much blood is needed.

Conclusion

It is hoped that the information in this article will help guide doctors, nurses and other healthcare professionals in developing culturally responsive practices and interventions for Hmong children and their families. It is important not to apply the general information about the Hmong culture presented in this article too rigidly to individuals; there is great variety to be found in people affiliated with any cultural group. Each individual identifies with his or her cultural heritage to a greater or lesser degree, depending on personality and unique life experiences.
More articles on cross-cultural communications for health care professionals can be found at
www.dimensionsofculture.com
 

Additional Suggested Resources

Patricia Nuttall “Hmong Healing Practices Used for Common Childhood Illnesses”. Pediatric Nursing. Findarticles.com 05 Dec., 2011.

Judy Leaver “Joining Hands Across a Cultural Divide” Copyright 2009 www.Jleaver.com

www.hmongnet.org

www.hmongcenter.org

www.hmongstudies.org

www.learnabouthmong.com
 
Footnotes for census statistics in this article

1, 2, 4, 5 Presentation by Txong Pao Lee and Mark E Pfeifer Ph.D, Hmong Cultural and Resource Center Saint Paul, MN www.hmongcenter.org. 2006

3. United States Census 2010

Culture, Religion & Spirituality

Participants in cross-cultural presentations often ask how to separate an individual’s cultural beliefs and behaviors from those that are based on the person’s religion. The best answer to this very complex question is to think of culture and religion as being two sides of the same coin – it may not be very useful to struggle with separating them (unless you are a theologian or philosopher).

When interacting with patients and their families, religion can be a touchy subject. It isn’t always exactly clear where health care and religious practices intersect. According to Brick Johnstone, professor of health psychology at the MU School of Health Professions, “Some professionals may feel uncomfortable obtaining information about patients’ religious beliefs, (but) it is no different than inquiring about their sexual or psychological beliefs, substance abuse, etc…”  (See MU Center Link below)

In this Dimensions of Culture article, and as part of the cross-cultural communications “toolkit” we have developed for providers and other health care professionals, we suggest six key areas of intersection between a patient’s health care and cultural-religious beliefs. We also delineate five health events of particular interest in cross-cultural health care, suggesting examples of associated cultural-religious tenets from various faiths. Finally, resources for more specific in-depth cultural-religious information appear at the end of the article.

Six Key Areas Where Health Care and Cultural-Religious Beliefs Intersect

Communication with Spiritual Leaders: The need for adequate language interpreters in health care settings is uniformly addressed, but it is also imperative for people to be able to communicate with leaders of their faith community. These influential figures can help interpret what is happening on a spiritual level during a health crisis for patients and their families. For example, in the Catholic faith, a person may gain great strength and peace from the sacrament  of the sick being administered by a priest. In Judaism, it is important to know the variations in practice among Orthodox, Conservative, and Reformed traditions. Religious leaders can clarify which tenets cut across the branches of their faith in matters ranging from birth control to life support. In the Muslim faith, it is considered a taboo topic to talk about death with a patient; a religious leader may be a crucial intermediary in conversations between doctors and second-degree male relatives deciding to whether to immediate family members about a terminal illness.

Religious leaders assist individuals in making connections between their “inner life or spirit” and their communal, social, and cultural reasons for practicing a formal religion. ” Collaboration with the leaders of a faith community can result in strongly positive outcomes for a patient and family.(2)

Gender: It is ethically egregious not to be aware of gender-specific rules for patient care that are extremely important in many faith traditions – for example, among Orthodox Jews and Muslims. It may be forbidden to be touched by someone of the opposite gender. Male Muslims should be examined by men and only female nurses and doctors should examine Muslim women.

Modesty: Nakedness is anathema to members of some faiths, notably Muslims. Health care situations, including hospitalization, do not lessen this sensitivit, especially for women and elderly people. Requirements for putting on a hospital gown may be met with opposition. Studies indicate that concerns about modesty contribute to health disparities among certain segments of the population. Asian women, in particular, if they are very traditional, may often avoid seeking care if a physical examination is necessary.

Diet: Concerns about dietary restrictions are most important in hospital settings where patients have little control over what they are served. Still, general awareness of food taboos predicated by culture/religion is important for all health care providers. Doctors in private practice settings and clinics need to be aware of how dietary restrictions affect patient compliance and should know to ask, for example, if a Hindu patient is vegetarian. Some do eat meat, but do NOT eat pork or beef. Eggs may not be allowed. Hindus and Muslims may both observe strict fasting. Mormons follow a dietary code that prohibits tea, coffee, and cola drinks. It is not as important to try to memorize specific dietary rules as it is to understand something about the beliefs driving the rules. For example, where fasting is practiced, it is related to a widely-held belief that physical cleansing is associated with spiritual cleansing.

Sacred objects: Be they amulets, figurines, portraits of saints, crosses, intaglios – sacred object should be allowed in a patient’s physical space and on the body. All caution should be taken to safeguard them. They should not be removed (or even moved) without talking with the patient/family. Evil eye pendants or charms are common worldwide. In Mexico they are very common, and should never be removed, especially from babies, without permission of family members. Similarly, Sikhs wear a steel bracelet on the right wrist that – like a wedding ring – should not be removed unless absolutely necessary. Called a Kara, this bracelet is a symbol of unbreakable attachment to God. It is in the shape of a circle which has no beginning and no end.
Sacred Time: In our Dimensions of Culture trainings we talk a great deal about how people’s concepts of time vary by culture. In addition to differences between clock time and “fluid” time, health care providers should be aware of sacred time. What day does the patient and family observe as a day of rest? It is Friday for Muslims, Friday at sunset until Saturday at sunset for Jews and Seventh-day Adventists, and Sunday for Christians. Institutions should post calendars that note the holidays for all traditions served. Meetings with families should not be scheduled on these dates, and office appointments should be offered on days other than sacred days. Clergy within certain faith traditions can provide the dates for holidays, like Ramadan, that shift year to year.

Possible Health Events and Associated Cultural-Religious Tenets

(Based on Table 5-1 presented in Rachel Spector’s “Cultural Diversity in Health and Illness” listed in resources below. )

• Use of Birth Control- Sterilization may be forbidden. In some circumstances, Jews may seek rabbinical consultation before deciding about the use of birth control. People of some other faiths may only use natural means of preventing pregnancy.
• Circumcision – Male: In some cultures, males must be circumcised after birth, during childhood, or around puberty as part of a rite of passage. Jewish law states circumcision is mandatory. In Islam it is either recommended or obligatory – worldwide 70% of circumcised males are from the Muslim world. It is also prevalent in parts of Southeast Asia, Africa,the United States, the Phillipines, Israel, and South Korea. Female: While individual Muslims, Christians, and Jews practise FGM, it is not a requirement of any religious observance. Judaism requires circumcision for boys, but does not allow it for girls. Islamic scholars have said that, while male circumcision is a sunna, or religious obligation, female circumcision is preferable but not required, and several have issued a fatwa against Type III FGM. WHO Global Map of Male Circumcision WHO on Female Circumcision

• Surgery (including Cesarian) In some faiths surgery is acceptable with the exception of abortion. In others, all invasive procedures are avoided. In the Hmong culture people fear soul loss during surgery.  A Muslim woman may avoid a cesarian because she believes only Allah can decide whether a baby is born. Jehovah’s witnesses are not opposed to surgery but the administration of blood during surgery is strictly prohibited.
• Use of Blood and Blood Products – Typically no restriction except for Jehovah Witnesses and possibly Christian Scientists
• Autopsy – Tenets about autopsy range from being permitted for medical or legal purposes only to actually being required by law.
• Organ Donation – Forbidden by Jehovah’s Witnesses. For many who follow Judaism this is a complex issue requiring rabbinic consultation.

Summary

Health care providers may sometimes be uncomfortable talking about cultural-religious health beliefs and behaviors with patients and families. This article has suggested six key areas of intersection between a patient’s health care and their cultural-religious beliefs to assist in these important conversations. In addition, five health events of particular interest in cross-cultural health care were presented. Discovering the broader context of a patient’s life is critical to providing responsive care and assuring good health outcomes.  Resources for more specific in-depth cultural-religious information appears below.

PDF Version of Article

Resources

• MU Center on Religion and the Professions, funded by the Pew Charitable Trusts.

• Testerman, John K. Md, Ph.D. “Spirituality vs. Religion: Implications for Health Care” by John K. From lecture given at 20th Annual Faith and Learning Seminar June 1997.
• Kennedy, Maria MD. “Role of Patient’s Religion in Delivery of Culturally-Responsive Care.” MD Anderson Cancer Center Chaplaincy Department
• Spector, Rachel E., “Cultural Diversity in Health and Illness” (7th Edition) July 19, 2008 Publisher: Prentice Hall; 7 edition (July 19, 2008)Language: English

What is Heritage Consistency?

The term heritage consistency is used to describe how much or how little a person’s lifestyle reflects his or her traditional culture. If one is very “consistent” with their heritage,  then one maintains more of the core values, beliefs, attitudes, and behaviors of one’s cultural heritage. If one is more “inconsistent,” then he or she deviates from that cultural heritage. Usually, the more one acculturates to American society, the less consistent they are with their original culture.  Asking questions that reveal heritage consistency is an important means of zooming in on the individual patient’s experience which helps avoid stereotyping.

Three Key Factors Related to Heritage Consistency

Especially when working with immigrants and refugees, it is important to determine three key factors related to heritage consistency: socialization, acculturation, and assimilation into the dominant U.S. culture.  Though close in meaning, the three are distinct.

Socialization: The process of being raised within a culture and acquiring the characteristics of that group. Formal K-12 education in the U.S. is a key means of socializing children in our society.

Acculturation:  This is the process of becoming a competent participant in the dominant culture. Acculturation is necessary to survival so it is involuntary. The degree to which one becomes acculturated and the speed of the process are affected by an individual’s circumstances and choices. Children, who can easily avail themselves of socialization via public schools, tend to acculturate quickly in the U.S. They have an easier time learning a new language. Grandparents, on the other hand, often acculturate slowly. They find adaptation more stressful and thus are often less willing to engage the dominant culture. They may seek the safety of their own close-knit ethnic communities, even resisting learning the language of their new country. Finally, literacy – in one’s native tongue as well as the language of the new country – affects the acculturation process.

Assimilation – Very much like acculturation, assimilation refers to the extent of identification with the dominant culture. Beyond becoming a competent participant in the dominant culture, an assimilated person chooses to identify with the members of the dominant culture. Behaviors that indicate this include marrying into the dominant culture, engaging in the civic activities of the dominant culture, living and working within dominant-culture communities, and so on. “The process of assimilation is complete when the “foreigner” is fully merged into the dominant cultural group.” (McLemore, 1980, p. 4)2

Many European Americans today – Irish Americans, Italian Americans, French Americans, etc. – are disconnected from their cultural heritage. Exploring the assimilation experience of one’s forebears can be very eye-opening. America’s history is truly a history of immigration, acculturation and assimilation (with notable exceptions/variations).

Indications of Heritage Consistency

The following list of questions can help establish heritage consistency for a particular patient/family. Used skillfully, they reveal attitudes about health and illness as well as important family dynamics. For older children and adolescents, it can be especially stressful straddling two cultures. These questions can be especially helpful in facilitating discussion about acculturation and assimilation with bi-cultural children struggling with identity confusion.

1. Did the person’s childhood development occur in the person’s country of origin or in an immigrant neighborhood in the United States?
2. Do extended family members encourage participation in traditional religious or cultural activities?
3. Is the individual’s family home within their ethnic community?
4. Does an individual/family frequently visit the country of origin or return to the “old neighborhood” in the United States?
5. Was/ is the individual raised in an extended family setting?
6. Has the individual’s name has been Americanized?
7. Was the individual educated in a school with a religious or ethnic philosophy similar to the family’s background?
8. Does the individual engage in social activities primarily with others of the same ethnic background?
9. How fluent is the individual in the family’s language of origin?
10. Does the individual possess personal pride about his/her cultural heritage?

(This list adapted from Cultural Diversity in Health and Illness, 7th Edition)

Summary:

Along with the socio-economic factors of poverty, literacy, and health literacy, culturally responsive care takes into account the heritage consistency of individual patients within the context of family dynamics. In an effort to avoid applying cultural generalizations too rigidly, providers explore the indicators of cultural consistency with their patients from different cultural backgrounds to understand how closely each individual adheres to the traditional culture in which they were raised.  Deviations in attitudes and life experiences affect each person’s health beliefs and behaviors including their ability and/or willingness to comply with the treatment plan their doctor recommends.

Sources:

• The 12 questions to use for indications of heritage consistency are adapted from the Cultural Diversity in Health and Illness by Rachel E. Spector. 7th Edition,
• Heritage consistency is a concept developed by Estes and Zitzow (1980) “The degree to which one’s lifestyle reflects his or her respective tribal culture.”

The Diversity of “Black” Experience

It’s helpful to make a distinction in terminology – “blacks” can be defined as all persons of African descent, whose genealogical connection is to Africa, and in particular West Africa. However, because skin color and culture are not the same thing, when discussing cultural beliefs and practices among this group, the term African American best refers to “blacks” in the United States, people whose sociocultural roots are in the North American experience, but who are of African descent. When applying this definition, it should become obvious that skin color is not the best indicator; people of African descent can have very light complexions. Many are of combined heritages. It is particularly important not to generalize about the African American experience when meeting with patients and families. Seeing the individual in each encounter is, as always, most important.

Social Structure

Many aspects of African American culture today reflect the culture of the general US population. However, the structure in African American families is often extended to include non-related “family” members or “fictive kin.” The family may be matriarchal, although father or mother may take on the decision-making role. For African Americans, women more than men tend to remain unmarried, and more women have been educated at the college level.

Respect for Elders

In general, the older generation is more conservative, may have a more traditional view of gender roles, and may shun interracial dating and marriage. Elders are respected and often provide care for their grandchildren. Institutionalization of elders has historically been avoided, with sons and daughters taking on the family caretaker role.

Diet & Health Disparities

Studies in health disparities show residents of disadvantaged neighborhoods often have little to no environmental support for healthy behaviors which increases their risk for health disparities. For most African Americans and others residing in low-income neighborhoods, the abundance of fast food chains (fast food companies have specifically targeted African American communities as a growing market for their products), high-priced food marts, and a lack of access to healthy affordable foods contributes to the prevalence of obesity and chronic illness. Convenience and cost have an especially strong influence on low-income individuals’ likelihood of adopting healthy dietary behaviors; fresh fruits and vegetables and lean meat are more expensive than packaged processed foods. Similarly, lack of transportation can be a pressing problem for low-income families, something middle class Americans of all ethnic groups are spared. If you have to take a bus to do real grocery shopping, it is more likely you will rely on the corner 7-11 for convenience food.

Obesity, especially in children, is an enormous problem across America. National programs to improve diet quality and the overall health, especially among African Americans and other minority groups, have been initiated. Body and Soul: A Celebration of Healthy Eating and Living for African Americans offers information targeted to African Americans on eating a healthy diet rich in fruits and vegetables. (PDF of Body & Soul Manual— Body and Soul was a collaborative effort among two research universities, a national voluntary agency (American Cancer Society), and the National Institutes of Health to disseminate and evaluate under real-world conditions the impact of previously developed dietary interventions for African Americans.)

Religion

African Americans often have strong religious affiliations, especially with Christian denominations—notably Baptist and Church of God in Christ. However, many follow Islam. Maintaining good health is often correlated with good religious practice. Many churches maintain a health ministry through which congregations and parish nurses support good health with flu shots, blood pressure checks, and health education.1 Research has shown that the affluent among all social groups tend to move away from their communities of origin, and to become less traditional, whereas the poor are more likely to follow traditional cultural and religious practices.2,3

Asking About Religion and Spiritual Matters

According to Dr. Terri Richards, keynote speaker at a recent noon conference for the Department of Community Pediatrics’ residents at the University of Colorado School of Medicine, it can be very important to find out about a patient’s religion or faith. However, asking your patient directly “What religion do you practice?” or “What is the faith you follow?” is not as effective as asking more indirectly about where an individual turns for support in difficult times. Often times, the answer to this question among African Americans will be church. “I go to church every Sunday” or “My child wasn’t feeling well enough to make it to church on Sunday.” Encourage the patient to elaborate. This opens up an avenue for further exploration of how a person’s faith informs their health beliefs and behaviors. Also, because our formative experiences are so long-lasting, it may be helpful to learn not just what the patient’s religious and cultural affiliation is now, but what the beliefs of the family of origin were.

Trust & Medical Care

African Americans are becoming increasingly health conscious, seeking health screenings and treatments, although health literacy in this population tends to vary by generation. Older African Americans may be suspicious of clinicians, because of experiences of past generations of African Americans with health care.  Even African American parents today have heard about the Tuskegee experiments on African Americans, so they may be a little reserved or suspicious until it is apparent that their health care provider is friendly, wants to listen, and is interested in them.  There may be reluctance to share personal or family issues, so building a trusting relationship is absolutely crucial.

Child Rearing

African Americans describe their approach to child rearing as being less permissive than Americans of European descent. For example, telling a child that he is “in time out” may not seem as effective as giving a spanking, and culturally spanking is not frowned upon. The American Academy of Pediatrics suggests that parents be encouraged to develop methods other than spanking for managing undesirable behavior in their children. However, among African Americans, studies show a preference for using “harsh” or “authoritarian” forms of discipline that include physical punishment. This does not mean to suggest that abuse is considered acceptable among African Americans. Culture must be taken into account in childrearing. “Because parenting occurs in a socio-cultural context, recommendations about what constitutes an effective approach to discipline may not be generalizable to all populations among or between similar cultures. 4,5

Death and Dying

When considering the ways different cultures respond to death and dying, it is important to look at three variables: heritage consistency (the extent to which a person’s lifestyle identifies with traditional cultural values an reflects their cultural roots), social class, and spirituality.

Generally speaking, in the African American experience, spirituality is a fundamental part of how many people process and reconcile the experience of death. African Americans tend to believe in the sanctity of life and rely on a strong sense of community and family at times of loss. Family-centered consensus is valued in decision-making and there’s often a strong need for extended family to gather at a time of death; the family should be informed of an impending death so that extended family members who live out of state can be notified.

Many African Americans have a holistic view of death and dying so that birth and death are understood to be part of a cycle or continuum. At the same time, many older African Americans, who believe that death is God’s will, may also tend to believe that life support should be continued as long as necessary. Cremation is generally avoided in this community and organ donation may be viewed by some as a desecration of the body.6

In medical settings, the spiritual aspects of caring for people who are dying have often been neglected. So much emphasis is placed on the physical care of the dying that spirituality is often overlooked, and health care providers do not always recognize that this should be an integral part of the continuum of care. In hospital settings, one way to accomplish this is to offer the support of the hospital chaplain. Naturally, it would be ideal to involve clergy from a person’s own faith community, but if that is not possible, then certainly make sure that the hospital chaplain is available as an integral part of the care team.

Conclusions

Understanding a patient’s practice of cultural norms can allow providers to more quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities among African Americans must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community. Again, get to know your patients on an individual level. Generalizations in this material may not apply to your patients. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions.

PDF of this Article

References

1 www.stratishealth.org African American  cultural guide

2. Barrett RK. Sociocultural Considerations for Working with Blacks Experiencing Loss and Grief. In Living with Grief: How We Are—How We Grieve, K Doka (ed.). Washington DC: Taylor & Francis Publishers, Inc., 1998, 83-96.[Return to International Perspectives]

3. Perry H. Mourning and Funeral Customs of African Americans. In Ethnic Variations in Dying, Death, and Grief, DP Irish, KF Lundqust & VJ Nelson (eds.). Washington: Taylor & Francis Publishers, Inc., 1993, 51-65.[Return to International Perspectives]

4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2568462/pdf/jnma00178-0030.pd

5. Larzelere RE. A review of the outcomes of parental use of nonabusive or customary physical punishment. Pediatrics. 1996 Oct;98(4 Pt 2):824–828. [PubMed]

6. Barrett RK, Heller KS. Death and dying in the black experience: An interview with Ronald K. Barrett. Innovations in End-of-Life Care. 2001;3(5), www.edc.org/last acts

If your American family story is like mine…

your ancestors were probably voluntary immigrants to this country, not refugees. My maternal grandfather came over from Poland at the turn of the last century, knowing eight languages, but not one of them English. He was thirteen, alone, with just a note hung around his neck with a destination written on it. In honor of his memory, I wanted to help another newcomer to the United States, and that is why  I volunteer to teach English as a Second Language (ESL) in the Colorado Refugee English as a Second Language Program (CRESL) at Emily Griffith (http://www.refugee-esl.org).

A person doesn’t choose to be a refugee. It happens to you.

Refugees have been forced to flee their homeland, and through the United States refugee resettlement program, have found refuge in our country.  By official definition, a refugee is any person who is outside his/her country of nationality, and is unable or unwilling to return to that country because of persecution or a well-founded fear of persecution on account of race, religion, nationality, and membership in a particular social group, or political opinion.

Women refugees are often isolated at home.

The refugees in the CRESL in-home tutoring program are overwhelmingly women who are to unable to attend the regular ESL classes for various reasons – perhaps health issues or small children at home or cultural and religious issues that forbid women from appearing in public without being chaperoned by a male family member. The in-home tutoring program was established to aid these women in learning English and becoming acculturated so that they are not isolated. They learn the English language and American cultural ways so that they can ride the bus and do their own grocery shopping, go to their children’s school appointments, rent an apartment, and basically live day to day in an American city.  Also, as I discovered firsthand, learning English is crucial in helping these women refugees access much-needed health care.

Literate in three languages, zero health literacy.

I was first assigned to tutor a woman in her mid forties named *Fatima. In some ways Fatima shares similarities with my grandfather, as she is literate in three languages but speaks no English. She and her family also share his courage and desperate longing, maybe you could say a determined optimism, for something better.

I was considered very lucky as a tutor; my student knew how to read and write in several languages, one of them Russian, a rather complex language. And, she was used to living in large cities. Often refugees are illiterate and from rural areas. Literacy made it much easier to teach a second language and familiarity with urban, modern living meant many of the tasks of teaching daily skills could be skipped. Thankfully, I wouldn’t have to pantomime why one should put chicken in a freezer or refrigerator to keep it fresh.

Fatima lives with her husband and two teenage sons. She also has a married daughter in Ohio. Fatima and her family are Muslims and would be considered rather liberal. For example, Fatima wears a head covering, but it looks more like a large headband that does not cover her head like a traditional Islamic head covering.

The doctor suspects cancer.

One day Fatima asked for my help arranging a follow-up visit to a health clinic. Her teeth and gums were in terrible condition, due in large part to her time in a refugee camp. She was unable to eat solid food and continued to lose weight. It turned out her gums were so inflamed and full of sores that she had previously gone to the clinic on an emergency basis where the doctor, suspecting cancer, had done a biopsy.

I was able to assist her with scheduling the second appointment. Upon her request, I also went with her and her son to that appointment.  She wanted me to stay with her during the actual visit, and I did. Thankfully she didn’t have cancer, but she was in a great deal of pain and had been for months. The clinic sees and serves many people. They are overwhelmed. What I had to explain to Fatima was that although she was in terrible pain, and although her mouth looked so bad that they had initially thought it might be cancer, they could not see her for dental care for at least 6 months. Further, they would not give her help with pain management while she waited for dental treatment.  After a brief statement from the doctor and the interpreter I was left trying to explain this.  My pantomime skills – never any good to start with, and any dexterity I had paging through the English- Russian dictionary, were inadequate to explain the situation. But with her experience as a refugee Fatima grasped the totality of the situation more completely and more quickly than I did.  “No money, too many people, has to wait.”

Family culture can be a health care barrier.

Our overburdened public health care services weren’t the only challenge I would have to navigate to find Fatima the care she needed immediately. I was in for a real “cross-cultural awakening.” After searching the internet for a few hours I found that the University of Colorado School of Dental Medicine runs an emergency dental clinic (open Mondays – Fridays sessions at 10 a.m. and 2 p.m.) that was open and available to Fatima. Yes, they assured me, if I got there early I could get Fatima into one of the slots that next day.  But I had to convince Fatima’s two young sons, since her husband was out of town, to let their mother receive the emergency dental care she needed. One of the sons would need to get up early enough to accompany us to the clinic because Fatima was not allowed to go anywhere without a male member of the family. We finally negotiated to have one of the sons would go with us, but only to an afternoon session; we would have to hope that one of the afternoon slots might be open. Also, I assumed I would drive,  but oh no! Her son had to drive us because no woman could be allowed to drive. I am thankful that we made it without being stopped for his myriad traffic infractions.

Eventually, Fatima had all her teeth pulled, got dentures, and is much happier and pain free.  Not long after, her family moved to Ohio to find work and to be closer to her daughter’s own growing family. I miss Fatima – her laugh and good spirits and her attempts to teach me a bit of Russian.  But I am pleased for her that her loneliness is eased with having her daughter close by.

I learned more than I ever imagined working with Fatima, maybe more than she did. I learned that for a refugee trying to get health care there are both obvious and invisible barriers. Language differences and the financial limitations of both the refugee and the care providers themselves  are easy to see. It was the cross-cultural barriers that caught me by surprise. This woman’s culture, her values, beliefs, and attitudes from a remote area of Turkey, determined whether or not a she could leave her house to visit an emergency clinic or choose a safe convenient method of transportation to get herself there.

Perhaps your American family’s story is more like Fatima’s than mine. At the very start, I imagined the refugee I would be tutoring would have much in common with my maternal grandfather. Well, Fatima shares some traits with him, indeed. As I noted earlier,  she and her family share his courage and determination to build better life in a new country. But Fatima, being a woman and being Muslim, has a much harder road to travel here with a unique set of barriers she must struggle to overcome.