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Ch 7. Cultural Awareness

Introduction

Communication and rapport with a patient is vital to the healing process. Cultural sensitivity - the awareness and understanding of another individual’s cultural background - greatly enhances communication and the building of relationships with patients and thus is an essential skill for all medical providers. However, a complete understanding of a culture, especially one very different from your own, is an unrealistic goal. With this mind, though, there are a set of general cultural sensitivity practices based in mutual respect and politeness that will allow visiting medical professionals to be effective providers and help mitigate cultural misunderstandings.

General Principles

Assumptions

Be careful when making assumptions. While it is completely natural to assume things, especially when struggling to adapt in a foreign environment, making assumptions can have devastating consequences. For example, you are a man and you go to Pakistan. You meet a woman physician. You are pleased to meet her and stick out your hand to shake hers. It may not have occurred to you that religious Muslim women should not socially touch unrelated men. Or, you are working on a Dineh Indian Reservation. You have just sewn up a child's leg. The child is cute and you pat him on the head and tell him he was very brave. The grandmother glares at you. You were not aware that touching the head of another is very rude. The best way to avoid such understandings is to be aware of the assumptions you are making and to question them.

Questions

Ask questions. Don’t be afraid to ask the people you interact with, “I would like to___. Is this ok / acceptable to you?” Overall, letting the individuals you are interacting with lead, using respectful silence, and frequent "Please", "May I?" and "Thank you" are always useful in avoiding unintended rudeness.

Generalizations

While each region of the world may have certain commonalities in language, ethnicity and/or culture, there are also great differences. For example, differences in regional dialects mean that the same word can have very different meaning to different people. As only one example, in some Spanish-speaking countries, “intoxicado” can mean that something is wrong in general. If the medical practitioner assumes they feel unwell from intoxication from alcohol or drugs they might miss an important alternative diagnosis.

Observation and Imitation 

Observe and imitate. Observe your environment and the interactions between other individuals carefully. Choose a person of similar age, gender and social status and watch for behaviors you can mirror. Be aware of interpersonal distance: how far that person stands from different types of people, who sits first, who serves whom, who touches whom, and even who speaks first. While all of these “social graces” may seem minor, being aware of and adhering to the cultural norms of a society can enhance your relationship with those you are trying to serve, and not doing so can severely hinder it. This will matter to local people at a level they may be unconscious of. 

Misunderstandings 

Expect misunderstandings. Cultural misunderstanding goes both ways. If you are coming from the United States, you will meet people who will make assumptions about you as an American. Each country has its own complicated relationship and history with the United States, and this history may distort people’s view of you as an individual. If you are going to be traveling to a country for significant period of time, take the time to read and learn about that country’s history and think about its relationship with the United States. Remember that the image they have of America comes from politics and American media; they may think Hollywood and TV portray America accurately! For example, if you are a Mexican-American traveling in the Andes, many native people are confused when you identify yourself as an American. They expect Americans to be tall, blonde and blue eyed instead of looking similar to them. 

Restraint 

Wait and reflect before you react. Cultural sensitivity is easier said than done. You may come across practices that conflict with your values or upset you. It is okay to be upset, but before you tell others what to do it is important to understand when, and if, it is appropriate for you, as a foreigner, to voice your responses and thoughts. Being culturally sensitive is a learned skill that requires understanding, communication and most importantly, respect for all human beings. 

Titles and Respect 

Age and profession are achievements deserving of respect. If the patient appears older than the practitioner, offer respect. Ways of demonstrating respect and humility can also vary by culture. In Nigeria, for example, a slight head-bow (by a male) or a slight genuflection by a female physician is sufficient. When a title is offered by the patient or is included in previous documentation, use it. Titles such as 'Chief', 'Professor', 'Reverend', even 'Engineer', etc. may be highly valued. When in doubt, 'sir' and 'ma'am' can be used. 

Gender 

Gender matters. Cultures vary widely in the rigidity in which they separate gender roles. What is appropriate behavior for a male physician may not be for a female physician. Homosexuality may be ignored, or punishable by death. In many cultures men rarely suffer social consequence from extramarital sex while the same by a woman is shameful. Women affected by sexually transmitted diseases may not know, or may not want to know, if their husbands have “strayed”. 

Religion 

Eighty-five percent of the world identifies with some type of religion or faith.1 Regardless of whether this describes you or not, it would be impossible to discuss culture without discussing faith and religion. It can determine culture, behavior, attitudes, prejudices, legal matters, and almost every aspect of a country or region of the world. A working knowledge of the predominant religious practices in the community in which you will be working will be of utmost importance to you as you attempt to care for its people. That being said, we will refrain from commenting here on any specific religion. We encourage you to do your own research using sources that you find useful, as there is no one correct source for any commentary on such an expansive topic. 

Resources 

Disclaimer: The following are just a few of the resources that are available to you to help prepare for your trip. Remember that culture is dynamic, evolving and ever changing. Whole careers have been devoted to cultural practices and thus even the careful and thoughtful research you may do before your trip will not make you an expert. Common sense, respect, and asking for feedback should be your touchstones along with all the topics discussed above. 


US State Department:  Country specific information, especially useful for researching learning about foreign relations and legal issues that may affect you while traveling abroad. Make sure to read country specific fact sheets. Remember that these are written by the US government and thus reflect their views!

CDC: This series of five guides aims to increase the knowledge and cultural sensitivity of tuberculosis program staff that provide services to foreign-born persons.

The Spirit Catches You and You Fall Down:  Best-selling book about a Hmong child and American Doctors Caring for her and the cultural differences between the two. Author - Anne Fadiman

Executive Planet:  Country specific guides geared towards doing business abroad.

References 

  1. C Hackett, B Grim, M Stonawski, V Skirbekk, M Potancoková. The Global Religious Landscape. Pew Research Center’s Forum on Religion & Public Life. Washington DC