Caring for Patients from Different Cultures FOURTH EDITION Geri-Ann Galanti PNcop © 2008 Getern Gate i ars en, ct fo ont amor st purrs frie ty Tete core ttn oe goes many fom ny meee itd (ern sem epson pure Gray ferris et prise Pray 91084112 ary ofan atogiresin Oat Ea meen cent aSieppearreawnn enemas Perce nile cme trang ite arte era Bali | san Nang as apart, 7 Cull carpeeroy— Cae wet ah heme Tothe many students and ctnicans ho generousy shared the cas stucie win rege thn te 20ksi Acknowederents seats and residensIthas given me an sition ented ito the al ‘ure of mde, aswell astbe opportunity to organize my thoughts. Jean Gilher, Rober ike, and Noel Chrisman have earned ny eternal gra ‘ade by generously sharing heir comprehenrive nowledge with me and swering all my many questions. ve been forsunate to have had the ‘opportunity fo work wih Jean ona numberof projets thaak you ea. Taleo want to thank Judy Eighmy, my extremely howiedgeable and help fal resource on Bospice Ta le ike to recognize mo people who have helped gee my work out tno the public arena: Michael Woods and Jackie Brockman ve clay brated with Michael Woods ona cultural seasiity booklet, now being published by Joint Commission Resouces and an elearning course on ‘Euural competence, being ured at merous hospital nd Uough Uni ‘ery Healthy Consortiom Learuing Exchange. Jackie Brook ‘han cacouraged me to develop 3 “pe” booklet for foreigarborn nurses seorking inthe Unltd Stats, 2b wel asa taining manual for health ed ‘ators, orienting feregh-born nurses to ork ellecuvely in American hoe Dll, The reorganization of the chapter on staf lations reflec some ‘fat nook Hopeflly through their efor, xy work wl each more ‘inicans than ever before Inesenrching the material for dhe lat chapter (“Making Diference) Invade by msn tlduals In parcoar, would ike wo acknowledge the many members of the CLAS alk litery who responded to ay request out hat hospital te doing to pote re culrallyeompetet care: lm Bates, Candy Brac, Linda Choi, Martha Datl, lorena Dit, ‘Wendy Fri, Yolanda Gaskins, Viisn Green, Irina Greenchtein, Bors Kalan} Natal Belly, Becky Wat Knight, Susan Mareorel, Jacqueline Veg sud Aimy Wilon Stronks. Special thank o Jus Puebla Forler for ru ‘ing he tere Lam ako grateful to Nataly Rely for providing noves fom the National Coun in lntzpreting in Health Care Open Call on ‘Mag 25, 2007 on the topic of onsite and remote interpreting ‘Wiehoat my husband, Donald Sutherland there would be to book, He cxginaly coocesed of th bot, aswell as mad my ite easy wile vast sng this dition, Lam eternally grateful Taank yoo, Den, for everything, also wat to thank my huge Sephardic family. never realized how ‘iferene my upbringing was rom that of most Americans Unt Twas in ‘olege nd read the elaie are “The Folk Sotety” by Raber Red Feld iy fst ceaction was: “The folk sciey? This sours just ike my faci Being vale in ay farly gate me insight into more tadionat ‘cultures a wel as sureouadhag ma wa the love and secur hat gave te the courage 1 make my ay in the worl. nally Ianto ak my fends who, oe are Uke family. As always, sou mae the worl a much beter place. Chapter 1 Basic Concepts a the United Stasis meling po the enltarl se il has ot of hips. intreduetion ‘Whathiappens when an iranian doctor an Flipne nurse west Mex ican pent When a Naao patente ncdatne nant apes Or when an Anglo nse relies a eabe orden ftom 2 eguane ce Generally, he resis conten nd conte antes yall have soe ‘ndertanding of clu ference ‘The hea cae tem inthe United Sas has been fa ane of. {Srsome tine. An obsiou problem sth cestand ppoctoanestotteat ical cae. Recently, mach anton has been pa the heals eae ig re that exist in his country Despite the est intetonsol pnp Ininority Americans ufer ‘rom agree proportion of daceee hate ing diabetes cancer cardiovascular dese, HIV/AIDS, anarhns Re seize ta shown tac minorides aio receive les eeatent ln ay ‘acting sugieal estan of ang eancer oes catng area theripeuc poeta a fewest fo teat Senn ee Betancourt an Ananefensong 2004 Although let sucerconoee Sans and lack of naanes ae tar continues to tase dao, cx fain playa important role sty by Has Wy ood co leagues (200) fon that minors pains ond to recene ene fag lower quai ost. The gup war parila age neta of pate counseling Thisfinding underors de need fortes Conmuonen ‘uy ap olathe ened yee alf te mia te eo provide optima cae forall Iw amlithale voce tha goal can beacon ely ine heakh cate providers underta mchcing at why sen patos see oe {or pn mediccion wheres pains om feeranean counts eey {o ned it fr the sighs dscomtor wy Middle Esteroes wil er alow mile pic o examine tes wren: and that con raking ‘a8 Asian form of medical weatment, not a form of child sbuse.2 chapter Cultural Competence ook ats te a oust ne ls a ‘misunderstanding and nat may rela inferior eel care. The eto hei the eater achieve eultral comp Tt gis math nde standing oir own alae snl bites, becoming ene to the eltares ‘tothe, ad spreiting te difereaces, The necaep invokes aque Ing knowledge ar ndersanding of ote caltren ope her vaies an belts The inal epi to apply tat knowlege: Cala compe: tence car wl ead to geste patent satsfction, improve cel ‘comes and reser com efi Note that teougout de book. ‘ie deter “clara competence” and "sural esti” someat "tuld be remembezed, however, tht clr! competence isa jour ep ota destination, I was rind of this recently when Twat 2 {pealer ata conference inthe South The sein ws inch inthe grand Biltoom There were over 100 people in the room. Slade xt wating at very plate My presentation wa ovr [as ungr: ited eer i= ‘tes fr peopl to gin eating. Noone dd aly Fasked one of my ton if here wa sone ceo no one was eating. He wa rather note ‘pontine snd Tas starving 0 ga to eat No oe le flowed se ‘Nemes ats mens oe cg ee ep and {sid grace Then, everyone picked wp tei fork ae gana eat What hadn't considered was that people in the South tendo be moe et fone than those inthe Were Coast urban cemerhere Ne paren ‘Sy how inde vane to serra an by pont ony igorance ‘hea Tate aos tng Iva he a Someries ne forge ht here CG be cura ferences even wid ou own cular And no mater howmich we think we know we cn sill make mistakes Asking the Right Questions: The 4 cs tray camper are een aencnre ear Alia the ce tie cd nti too cn avr of eee cpr wanpencs hale sped apace Tice rin seving cturdcompeeace eng ok Bei tee av utd oe patents pi SER mncamnis tne tes Sbchped wy heipfeeeioncs tunbe vin gastans Wak uml one epee ad fils StS and les scaled Te Cro anaes [etn The Qin” opened by Arbor Renn ed ‘veateges 08 “Te res for “Callas What do you cll our pra Tis to asi Conepte 9 ‘etnies oa “Wha oyun is wrong? eg at the paints perception of he probicn This ean nborcneegat ‘cate he sme smpromsiyhaeery diferent a sul and ay en ares to couples Pore te Hoot pep eet oas-ae nt atheee eo eva" Sein eps) as it poseaion trick hisaone ene 2etatons or the posed) nvr aifren Romseang aan the cect gnal inthe brain Ths tould ad Sea doce: convention an mighty expan whyatinane en imaybe es raiou ante psn to op testes Ree den example of what an happen whe earn conpecen ponte "olundentnd the patients perspectne ace Same eek ey Tein Cat io and oP oon Underage polenta fe can op she ealh ere roicer dal wih fede nk Adereace and inpror he patent pracisonee Mision Anetra aatropsogt nt | were sadn eda at sealing on os young Neos by aed ao ee tho tonitig. His mother epored ei epnode hed Ssconnncio i pera The rev Palos eg sun oi the sect nde athe is aera) te ee be Body int the hose The second athens fendur be aa wee Ye he as tang next to im us before hs oe rte ‘star informea te family athe dad) wastonng bck hoes Or the dy of mmlsion, Pablo tater ued a er os ee Ate rong. Hs mater was aldo ick monies es emi My leu an bth ied reds ee ‘ta This Hspani folk nse nied sek ne eos {i boyeaperinedcaiser teu oleae thebads epee wedi’ fect was oa place todo 0 But we lef wondering vec on ‘ending bad sad something Ie “That sounds Hk eco eon Pesaps the moter didn se that my But what be nb os fae changed the clinical management ofthe boys conto’ Poke tet Hissmprons wee read sveceafily twhat might eae for de etnship beween the patent and te panies ‘Me tend thigh that everyone respects te knowledge of doctors, ut das noe as dhe case, Whe jou bad ja moe oie coun and were cagnosed with woul ow ye wate nce4 ompter [No one i expecting physicians or murs to work within dhe Health ‘mode oftheir patients, but by showing some respect and understanding fort chy can greatly increase patieats trust Finding out and acknow ‘edging patient interpretation of what is wrong can aid in that ‘The second C efor “Cause.” What do you dhink caused your fralen? “This gene the patient «belief searing the source ofthe problem Not ‘everyone belies that disease is caused by germ In some cults, 8 thought to be caused by upset in body balance, breach of taboo (stalar towhatisscenin the United Sates a diseases duet "sin" and punished boy God), orspirit possesion. Trestmentmastbe appropriate tothe case trpeople wll not perceive themselves as cared. Doctors tise fn tut wa he patent believes caused the problem, and eat Wat a Wl For example itmay sometimes be appropriate to bring in lengyt pray wil cher they beliene God is punishing them fr some transaresin. “Emma Chapman, a axhitvaqearald Black woman, was aited to the coronary care nit berate she had contin eprodes of acute chest pin alter evo heart stacs, Her physician recommended an angiogramn ‘with a possibe cardiac bypass ot angioplasty to follow Nir. Capra ‘efused saying, "Ty fais is stg enough and Ife meant to be, Cod ‘il eare me” When her murs asked whet she though eared her heart problems, Mrs. Chapman sid she ad sinned and her ies was 2 pur Eien. Her aurse Sally got he to agee to the surgery by suggesting she speak with her minister The cae be dicamed again in Chapter 12 with an additonal posible solution suggested (se case 254). “The third Cis for "Cope" How do sou cope with our con? This i to remind the praerone oak “What have ou done try to make t beater? Wha elec ave you Been ofr eaten” Thiel give the health cate provider important information on the ute of allermalive healers and Geamens. As discussed in Ghapter 12, most people wl ry home ‘emai before cong in tothe pylelan; however few wl share uch information duc to fear of rice or chassement I's important that health eare providers learn to aa about auch remedies ia nonjudge rental way Secaate the occasional sactional remedy maybe dangerots ‘r could lead toa drug interaction with prescribed medications (Og Salesda sas a serengethrecyearold Mexican woman who had {jotta afenoralpopliteal bypass Anabel, her nurse, observed that Mis Saleed's lg ns extemcy re and volln. She often moaned in pain and vas too uncomfortable wo begin pial dherapy: Ye drier hie ‘eprt her previous nurse 1ld Anabel tat Ms Salcedo deaied needing ‘in sedation, Later that day, Anabel spoke wih the patient through Sn interpreter nd asked what she ad done forthe pain in her leg por to srgery Mi, Sleedo sid that she had sipped herbal tess given to hee ‘ya candi (a waional healer, see Chapter 1); she dia’ want t0 ‘tse Concepts take the medications prescribed by her pysian. Abel sing cor Gomptince sted Mis Sani dugtr'o tng nt ee Fed the physician abou he renady and brought eto te acne wh sca te ingens ecrae tee ashing ‘ated, he pharmacist comacted Ms Sedo's pes eho she could ae the ea fo er pin The ex eh in eines ha {08910 phil serapy and ms rich ne mort and poner sneanr Althigh tok ame tne to coordinate te effee rik di reed ina beter pallet outome Had Anabel nooo ok ste had ben using to cope wi Ber pa kis Mkt Mrs len ae delajed psa htyy and hes ene The fourth and final Cl fo "Cones" When do you ha going cndion This should adden quesions nhs Hoe woe us do ou shin "Wat paenal compcason os Tene “How does icinerer with your hi a jour sity eet 'iportn to understand the patient's prception af he cose ele ft ad he sty ye abut 8 ou ea acs ao cermsand corer anynssenceptons Youaowantt knoovngion of conn poss pb fr de pate is my elo a Ce fatneting very different from what you might have expected, This {Case ince Wha ae our cna rganing cece ee {sao imprint iow pacts ocean odo el pce ‘ez ued upon the or tes epee, Jorge Vile a mileage Lino pens prota ih proven dh poorly man- aged cabs When Dr: Ainge, hs pin ld bn er be ge ave i aking inne beste peta Lt pana ‘mano nslin"Notunil De Alera ated ie Valdes eaters heh abot innlin dd he tel her tn bots mates eat gone ind er ihe sare aligns, He made geal lenge Sncornect—astnron hat isn eased blindness Te the an tint expen his fears and becase te pei wes eee 2eugh to pickup on tem and explore them se tarae slg ha Inman ca Renn cin ya ‘rus, patients wl a nothing sn gly ot adhere nese ssking the eal care poet can corte ay moose ieee with reac aan “he emai of hs hope i devoted wo several anthopologial cenesps tat may help the ener waerand the toee chaste a ‘onli and iondersancngscotaned within the Book Sa an Serene in he chaps hat low ave, when atonal nsdn doe iusuate te princes ae desrbd,6 chapter culture A basic working definition of culture is that it encompases beliefs and behaviors tha are learned and share by members of group. ‘Ama Tino removes his shoes when Ie enters the bose. He has in oor shes and outdoor shoes and will ot west one forthe aber Its ‘cultural wait ora personal idionynrany? Fors the information given, Icisimposible co tel: One must krow his ethnic background. [the were Jspanereitwonld bea cult tat He not erate Anglo Stn Protetant from New York. Thus this wait va personal ilonyerany For lbchvior to be cultural, mst be learned and share by members of group, New York WASPs donot mike a practice of removing ther shoes ven entering a house, The Japanese do. Subeurtures ‘Within most cultures, smaller groups of people share certain characte: sts not share by the cule large. Ahopoogit cll such groupe subcultures, Sabenltures may be based upon a vanes of things ined {ng ety (Hispanic Arerteans, Asian Americans), occupation (nics, ‘hisicians), activ (gangs, o sexual orientation (lesbian) When one Subculture has more paver than another, tis referred to asthe "du rant” culture Those subealtares oth less power ae called “minis” fluc and are often dicririnatd against, ‘very culeare and subealsre as its cw values, worldview Language ‘argon’ and nore (rules ofaccepable behavior) Fr example, Anglo ‘American culture values independence, a value not shared bf many of the other esta raups found in the United States Pato the American worldview ito belie that hush control nature. American seca nore Include the fellowing rule of behavior i romeone offers you something you nant youmayacceptitwih thanks dhe fist tne i oered rain uleral rales, in contas, dictate that you wait anti oer w soc ‘ond time he fists wo be polite; the second is sincere. Chinese cltal ules woul have you wat tn i ofered 9 third ime, Another Ane Jan cultural ler hat he needs of your eilren come before those of Your parents, direedy opposite to te norm in most Asian eulures A "hued American role of behavior ithat you firmly sha hand in greeting someone, This may violate the nor of many Middle Eastern cultures ‘thich probit touching henseen members ofthe opposite sex Narsng and medicine ae to examples of subeuleares Ifyou are 2 neath care practitioner, consider chat values, workdven, language, an norms crite your gobcutore, When Iwas eachng a nursing et ser al yearsago, cing a break, several of we were inthe restroom oie ase concepts 7 ne ofthe nurses following an elaborate ial. Afer using the toilet she ent tothe sak ened onthe water and sere he Meo pihsnch ets igor tin oughocesar fr ecries ae Shnlngs gern tombs ning Pi No stents ae to en vbr ‘adie ueson fe cnet Serenping hee Ly Khali was forseightyearld woman fom al woman fom the Middle Ease She asin the coun hospital io have surgery or alates Sathana ican muse, was caring for ber prior to surgery. Sandy coed ter ae forward to Mrs. Kat's surgery al and she coal go home, alten Sandy returned to work aweck ae she learned eh Mr Khalid not ha gallstones after al, When the surgeons apened he py es {ior and in extracting pane ree ston he angio res. MPO or Saychaste “While taking a course on cularal diversi, Anike Oghogho, a nurse fom Nigeria, reognized his tendency to stereope, He elated an exam: ple ofan African American male patent who presented witha sell Fei foot. The patient, eferson Boll, Rep ringing the ell ight and ask ‘ng for more pan medication. Anke std that in the past, he would have assumed Me. Bel was merely seeking pain meds. This ime, howe he reasese the patent Te discovered that Mi Bell’ furth nd ith oes ‘were more ed and swollen snd had ps. ike sunmoned the physician, fn Mr Bel was evensualyeakea tothe operating room fot tion and {rainage of his let foot Steeomping could have severely harmed the psens fortunately, Anike had learned te leon of no seecsyping in fis cass. ‘A generalization, in contrast, isa beginning point. Ie indicates cote ‘mon trend, but firth information is needed to ascertain whether the statement i appropriate oa parscular individ, Generalizations aay bbe insceurate when applied vo speci invduals, hu anthropologss do apply generalizations broad looking for common pattern for belies and behaviors tat ae shared bythe group. tis important to remember, however, that there are ahwaysiferences between individuals each case mst be considered by uel So why even bather witha generalization? Because itean help us understand and aniipate behavior. Rather ian becoming annoyed because Mexican patients moaning and groaning Inthe absence of any serious problems, I might net, “Ah, Mexican el tne encourage emotional expreivenst.*Or knonng that stan ale lois might help me tanember to pay more auention to an Asan patents pain needs rather than dra conclusions based on the fact hat the paieatisn't moaning or requesting pain medication, Of cours, this should be done with of pens. ‘One of the reasons that tereonping is se inappropriate i that o one ‘ver belongs to just one cuftare. We belong to numerous alte, inc Jing hose of exhniciy, religion, region of the country, generation, sex ‘ceupation, education, and ocioeeonemic ats, All of thes have ome ‘varying degre of ntluence onus. Ad to that che degree of esimalation, Wich neues sich factor athe length ef ene spentin the United Stat the age of immigration, desive to animist, and residence in an ethic communityor an “American” one, When yu also consider the afar ‘of personal factors and individual fe experiences it hould be obvious ny steecmping snot us dangerous batmore ike ta be incorrect than snything ee T have purposely chosen example of individu who have not asin laced toa grea degree and whose bir and beer ceva from those ‘exptesied in the American healthcare system Re should not be inferred Ural or even most members of dese groups would actin the mannet roblems tis tose who adhere to tradonal way dee ee {2 601 Bence the lection inthis hook ould be ene toweertaasinenacarsia umpires age adie be quite Wetenized in ne steas bu adoad oe ll be making say generalisations coughont the ok. lao be lumping together groups tat ae actualy pede on ie The et “pan or"atno* nla lorem en yu coe = no enact people oa cdeent, ite atten ifn den heater ‘irs Nanya sora enemies Thre baleen ee slice and eseonping within cahlagercdoens se ‘ie shared htny Chine ink har amas ee oe teckbones, Koreans hare sal ena epee na Bisbee scat lotr aac fein eet ese A Chinese peson would promot be tushen eae for Korean ie term Ethocenian i ‘ng oceurs even within ethnic groups, om tal pe ne Cra a patent tows Mees Catia aun Mev Avo ark nc a and nal ese ‘cn Inin phat ih te chraon Cansei ana ‘oipeah che rer snp mle mrccsio a gh het tne nahi te ed pene Mgnt Me Actor Cah ae Casas had sever eer ominhret pains wpe lgafors manent She ele,‘ noe neg eae Me. Asp repent, "es {hgh n mich ae ‘Provincial people; you are very different." 7 Thee ae sm ons led om since One hat10 cmapter tough wierones re of pee, rob staf us on hough ne may Ehivare not Another i at even within the same alte, people oder ae serene each ces Final, tiara fo sereogpe peo. ie onthe bso eppeaance Pi Generalizations made in this book about large cultural groups such as Asim or Hispanics maybe sen aa wa) of singling Bond geo. cl growpings from each other we recognising at there ae trecain than Aon ocason thon ets icety ges {orapaventisAtn or pani been more detaed oration mas ‘ot kno, bu cae rated genta pot common oe oa tires win a group. It's imports o recognise sat the cates chosen for thi ook were teleed epciealy bee the mesndertandgy were die cara ‘Eterencts, Many teractions between nvidia of the tne ov ct tursvall occerwitow conflict or misunderstanding eens nt evry ‘oer os ee gmp ae a he ia ts ceo hat group. Altre, onfets nd minaderstanding® ‘Sica between menbeivof diferent nic groups tat hare nothing #2 Go wih cae, bet rel from indvidallferenes and personaly ‘ses Thats whys extremly important nto sereompe nid ‘Te porto joven Gk ae mea bead {sidepos sot rece, etalod maps del thy wil fp elt cae Froviderstatlpte poses tar sould be conidre, and ake ‘one of beaver hath sready occurred. Prejudice and Discrimination ‘An importa related sue in d's weld, gen strained interethnic ‘eats that of prude and carina, To on story ofa Cerin tis coun, folowed by Reconstruction apd i aera, along SSthies insnatonalied rain at le any Afeean Americano ie {Pont de beat care stem. Wir Haris asanriggearol Aftan Ameen man, wasscheded to bine hi cancerous promate removed a4 goverotent oop. TO Sayer ching te roses, he cilet Rae, hr np [HU kad spoken ore inde sb i upeongsagey and a sraned know about various forms ofaleraae weaupents Kaen spent our an Ban de one wit hand ae hima grest deal ot {eemion well t phone numbers he cold ell to lars abou ther, pion She realzed abe wat probably overtsimed snd ghee Roache diagnos Basie Concepts t1 ‘Right before hanging up, Mr: Harris, You koow I ust es Kate {ust don’ Know if1 trust che hospital to take care uf me Tae ale ‘fiends wt were subjected o government stuces without hacwing tac in the “4s ands Karen suldeny realized it wast jus the cancer be feared, but what white instwtion might do to it, Black mam, The ‘experiments dove with spite blac-men who weve left usestod ia ‘order to stdy the course ofthe disease are infamous ino wonder chat many Aftean Americans ae distrust of hospi ‘al+—and white insitutions in general. Prejudice nd discrimination real. Not surprisingly if you have been fequent victim of deine: ion, you ar ely 1 come to expect i eve a in he nex me ease, when its ot cere, Ducig a prenatal exam, an obstetrics resident asked the patent whether she had considered having er bes ed atthe time of deere ‘The patient, Loty Parker, as afortpehreeyesroll Black woman, arog "an with ber swe child rs Paha inmoeately became angry ying, “Taint gonna have no white doctor messin’ with my insides" The endo, ‘ay have ek thatitwashisresponsiblty to explain incensed pga "iss afer for, bu ie Black woman apparently viewed his sugeson st ‘form of racial genocide. Health care personnel mas be expec so, tiie to this isu wen dealing with patients from minoriy ethnic grou, Rather shan diel asking ise wanted her cubes tie, a culturally cone petent physician might have begun by asking Min Parker if she enjoys having such large fami I she sid she lores the doctor wouldnt {o puri che sue and would ad asking a racsesounding question owen, she said chai’ dificult raising so nany children the pila ould then ask fee would lke Co it he fay size wo ele Tae Said yes, the physician could sugges having her tubes Ged. Im general ‘alt care providers should ry to ascertain the fens eins rate than imposing their om, Another cae, whic could have ended a bly the previous an. ws ‘rescued bythe clara sensi ofthe clinician, Mis Washington a tg, yeareld Afican American woman, ha had anges lease for carpal ‘unnelsmdronie—a work-related injury. Line was asigned wa her exe Fre months after the surgery, Line called to see how she was dog. Mi ‘Wiashington replied that she nasil having some discorfort when eiving ad doing household chores Linse commented that as per test dint al guidelines, she should have been showing improvement si to ight weeks postop. Linne was concerned tht five mols ater she war sul having problems. rs. Washington, however, imedatlybesaane defensive and hod replied, Tm notin ic forthe money I don tant beim painor 1 sot INGO 0) tay dnd ow sto a oe a ne "pro1o nanyo a ur Gucuam pre sapecdape ose oman: ‘sped 99 0100 ‘rode oy aun ap age oe sued up roms prod. up 2 ae Soins seh ete ou aos ge Soh oD uPD o4s Qs9 5 T EL noua te tomes 2droped io mii searing and malas beau. What consider “penal however, notte ame forever lite derstanding people alae the ey co hndervanding their beh io, for our bebo general elles our alues A dramatic emp tec inte early 108 when Japan hip captain string {Sontond fen tolbe United Seat Pew inter sae. adhe fargo wat roe, The apa had dove noting wo eae he nase, She could noth prevented sn Ameria hip capes ad a Ssindar experience, he fat ting be probably wosld bane done when itech naling owl par The Japanese ape io inset nti obriniyabig erence ene cling oe ssc get and liling onrele The ferent veacins ae ded by deren ale te The ppotetal American cpcin wos probaly ae omg is oncrn would be forthe nancial loa Te Japanese Capa con. erned abouts hr A ihe capan of the sp, be considered Bisel feoponsbl for he ctden The lo of eco mca te los of is anor Wihoatonorhefeche cont ot Ire. Comming ul ude ‘eth nw or ent regain his honor “alc infocnce on eee boar ar el Why ce ou reading dhs hat Ll becaae yuh lnwige ad hope tera eng? {eitbecaut you are reed to red it fora couse and you value good fader eo ave you rntaed because good grades wil get you a ber {Erjo, and witha beter ob yu wll ean more mone, an ou ale ‘nome Ney eveyiing we doles ou values on coe lee Velues and the American Health Care Culture ‘One reason for #9 many conflicts an migunderstandings in hospitals is ‘he qret disjunction beeen the values ofthe health care caleere and the of the pains popsason. ‘sentinel te bealth car oltre valves sstonomy and inde pendence, Patients in contax, often valu the fri ovr the vidual ‘Te family may prefer to make deckions ata group and to assist he tent in "selfcare hansons he staf thinks the patent shoul do on fis or her own. Furdermore,maiy patents prefer to have fanly men ‘ers with them aval nes, leading to chaos and los of eontrol fom the perspective ofthe mes “The alt are clere value of sien often cot lb paints ‘value of mode, Macy doctors and nurees ind concern abou keeping Daten covered dificale when thes peimasy focus is performing an ap- Droprate procedure. The healt cae clr also values leona! Many pte, however, come rom csltzesin which email expressiveness Baal Concepts 15 {isthe norm, Thiscan lead to resentment toward sich patients on the part ofthe sale Worldview ‘he second mosinportant concept for underanding people's bebior isto understand dr world: Prolene can teu femn 8 pay conten the worldview ofthe Beals ere cates tha ofthe pcm Fopuaion. People's wslins conse bale sumptions aot theatre af ely: Thee become the foundation for alfseons sod inerpretos For example, people hase wore nce the aon state yinghappensfrsieaon lend ond meaning alee ‘Acide thrreyearold wor cho gos tough he enero ‘ony of findings reutlnp on ohare ebay tem ont eae ‘the my mespretie experience ra nesage ome uivererene inp datsiwh ane o decde heer or oot wat have dren Geass etaphorcalyeepreseting turturag) Avante ‘pe someon who betes th he weld hse ace al "oto ten’ nay pout sesh car pre bo lator an spp ‘Ben duct a sudden emergency delineate dplayng prio ‘ainda sworlsewean Bae singer tenon hs her Jal cae beer For example, someone mh a tent wore miph pcre bith defects asaraisaie nthe ancspion of DNA ing tt pots fone mone hse wore emcees nod of encarmaon might see ceaung om supp tees ‘er vapast and someone who ees tt God reared oe dor and pnishes ad betavir igh iespeitas punabmsor een si Ths one's worden mig aet nts terest in gence rose ining regan Ag pana sone et pial body ial here cha peron mig want cory ng po 1 done extend tir ie-A penn no belere tans gs Pesirior othe next however, might be more ego tone ‘ose hos hat ite bins st eonepin, abortion el fennel re ower Ke tho tobi he po he ea resale, etter abortion nply a medal posed ‘While weal Sve or ow nda mardi our recon ah ace the may we perce hinge Raligon often defines he wane of people wo ate devout religous Bela inthe existence of Gl or txampc, ight be part of tir worse I peopel Cod confers ‘ot ealh andes, say be very dint ge them ota te tin medion or chang thir bea blair Fhey might sot sere dhe tealh ear cates beet at germs nse dace wdc eed ‘rite contribute wo one's health They may eto poi noeeene16 cnaptert bout high blood presure or bacteria when moral behaviors the key to 00d heath ‘ona hd the opportuni to use her understanding of worview when ‘arng for Ramon Diaz, « Hispanic male wi had been somite Wo the hospital thtee times ins sngle yer for uncontrolled diabetes Despite being ginenasriet diet and insulin orders to fllo; he cootinued to eat hater he wanted an refused b monttor his blood suger When Mons. ‘questioned him about chi, he replied, “Olay, stare my diabetic diet ‘omorray, but i's not going to make any difference, Ie in God's hands nv" Mona's nial reaction wast become frustrated wi him, but Send, noted his fale wordview She elie hat her ual “letire™ sand instructions were not going wo be enough. So she ook the Geto ‘explain to him ad his wile that i not managed cay, diabetes cas have {atl complicacans She alo went over with them ways to gradual change bis diet which made adherence wioe likely than would demand for & complete nd sudden change. Mona ao used cultural competence sis loyimcluding hs wie in dhe teaching, since the fay ithe primary it in rational Hispanic cultures, Since she varalso the fans cok, as Jmportant to get heron board wh the plan Maria took a further tp by taking to her comorkers about a fatale worldview, hoping this noe ‘ge Would keep them fom geting frustrated and “ving up" on vies patients they often did. Cultural empetencecan be cantagious, ales ‘ae practitioner shouldbe encourage to shave thet knomledge ad ex periences with comarkere ‘Since peoples worldviews consist oftheir anumgionabou the nature of realy. sey arly question the veracity of tei ele For example, a devout Crasian might not be kay to eanlide that God doesnot exist ‘on the basis ofthe accidental laughter ofinncentculdren ater the (Carstian might simply remark, “God works in yeeros ways No mat ‘er how mnch "evidence" ispresened to the contrary, people rely change or even question their worldview. Instead, they reimterpres ees i a ‘manner consistent with thet bel People’ Relationship to Nature Another aspect of worldview lols people's eationship tone. The flee of the United States, for example, bees people can contol anu If dhe land ls dy, they lrrgne, Ie acteris cause dines, they ‘emoy them Ifthe heart des not wrk, hey replace it This lo scltes > to the heath care culture's view ofthe bod ae4 machine fit becomes broken, one should spy tar i ver to the mechanics lowers a ‘nuxses} abe fed. ‘To the consternation ck many ea eave prOfeal als sora elmzes shave that belie ther utes suchas Aslan nd Nae Antica se people as art sae Thesis to maintain hattony wth ie aoe cok ak uo provide estat for dete. Heal remedies onan {tr utes, Sl ther culties sich as spn toe ee cl oF cnt one natural nce Qu ste What haa te. Presnthe heal care meats ay obe gue dete 20 god anya, Thus waive can hn import incon health-related behavior. me v= « Emic and Etie a terms “nie and ei” dered rom lingua ey wedi inary if, ace extremely portant in andtepolgg Thea eer ae specives Emie perapecesare We insier® perpen rose ey ‘thc own behavios Etc perpactnes are asec suchen Tae Simply present diferens vantage pnts snd knowing both els pe, idea more complete cure, ast caregners would beck Pe Ser when treating pains rm diferent cure Try totes a Peipeive on tik condion swe sso or ‘An Etic Perspective on American Medicine one aia, in the cack TS Ca You nd ou a Doe 8) conzane ln rea fan lading sitlpusose Monedcine hemes oting tional Finong meine omen eee ‘an edie dou tcane fared nye “tn nga rn arate ce So See aaage mm - esate carnaemngees Set fatter score oreeenoe it eae Sohcloprastesnsne mea fhe results co come back from the laboratory—and then, afterall dha, Sa crckoe et ce18 chepter doctors ask patents to ake of al their lots, and sometimes dare to [put ee Sager inside women’s vaginas + Tradidonal Hmong healers know tate weatthe body withoutreating the soul san acto patent folly American doctors never even mention the sul + Tradional Hong healers preserve unblemished seputaions even if ‘er pens don't get vel since te blame laid onthe intransigence ‘of che spirits rather than the competence ofthe negotiator, whose ‘sock might even ise dey had had tod bate with parcel dare serous opponents when American doctor ful o heals thei own fa Ethnocentrism and Cuftural Relativism ‘Teo kay anthropological concepts ate ehnocensiem and clu rel thse, They fer to ates Enon hc i hens nC tare’ ayo doing Ung he igh and natural oy. Al oer ways ate Inferior, natural, a perhaps even barat. Cults te aitude that he ways of ing things ae dierent ut equal rai Te ‘lest undentand the bebo a altaral conten ost harman re stmocentz Iisnataralto think otters cbs Ado ogists, however sre oe eturallyvelast Pier elses Ainercane abouts gtoup of people in Aft wo somes lal sewbora nfs they would probaly take thee ‘ocentsc atte that tese people wee barbaric Il wee to expla {nx they were hunters and gateresslvng on te edge of arvana that fs second cid oem too close othe se hance are close wo 100 percent ca: both wl de becase the nother doe nat hae eno ralkto support both, their eae ght change: The sll might m0 ‘usone anid, but they might uncer ite he ony able choice ina desperate sitvation. Rates than seeing the Arcass barbarians, they might realize that the people were force to exten means by tite creumstances. Theis would ches change om eto ‘ict cata reltite “The Western helt are mem ed to be ethnocentric beeae pra toners belie that their approaches to ean are operon walle. ‘There lotwe can learn however, tn oles cle Many oder drags incudng quinine, were deste fom plans used by nave peo. ples, Westerners ate beginning to acknowiedge the eleven of oer Functre fr cern cotons The gol of alse of healing he amet ep people get wl al clnes could vy each eter tect iq tha culty lave pepe, de cause of moder iene would be great advanced, sie Conca 19 Time Orientation ‘Te orientation, one's focus regarding tine, varies in diferent culties ‘Noinivual or ulare willook exclu othe pase, presen oft, ‘butmost wil tend to erophasze one ove the ars Chere, Bashan Austrian cultutes ave past oreataton. They ae tadiional and bene in doing things the way they have aay een done, Inteesinly in many «cases, countries tht emphasize the past are ones that were ce snore Powerful than they are nov. This maybe their may of recognising sed ‘aking that tne in tei history Thee ulate aly prefer traded sPposchestohealing rather han accepting each new proce or ede People wit a predominanly presente orientation maybe ls ely to uiize preventive health measures. They reason that there ho point in taking a pill for hypertension when the ee fine, especialy pil expensive and causes unpleasant side efers, They do not ook ahead ln hope of preventing a stoke or hear ata, ot they may feel theyll eal wit when ic happens. Poverry often forces people ints poset time orientation. Tey ae aot Hey to ake plans for the fuses hen {ey are concerned with surviving tay Midéiechss Anglo American culeure tends tobe future onented. That ‘a mflected in the medical system's suas on preventive medicine and «endusasm for eal new medial technique or drug, ln contrast o past oriented cultures, progres and change are highly valued. China balso Shiting to a fur orientation, as evidenced by the longterm plas redce the country’s population by lnitng family see ispanis and African Americans tend t have a present tine erent tn. This does noc mean tae hey do noe recognize the past or the fuse, buc hating in the presen more important other, Ter concep ofthe future ay also be diferent trom the Anglo concept For aap, Alcan Americans re more likely ay “I's ou than “ite pos tomorrow." The former implies the fre but snot specie The fare {zzves in its ov time. From tis point of view one cat be late Com. ‘ie may cee, howenes,in interactions with wit mide poopie {oe whom time every spetic, As thelast statement pli, ine arentation can also refer to degree ‘ofadhereace to clock ine versus alerence ta actives From Uae por spective of one oriented to the clock, sotneone eho arrives 9 for & 230 appointment is ate For someone wha dors not focus cock ts, Doth represent midternoon. The tne to aie atthe afternoon ap Polnunent is after che morning acct is completed “This ype of tne orientadoa appents co be relate to subsistence eon ‘omy. In countries with economies based on agtinlure, people ted ote20. coaptert ‘more related shout tm; 251 keto sy, “The crops dont cae what ine ‘hey et picked.” Many people in tracitonal agriltral ilages do not ‘1m leks the pace is siower and mare stoned eo nature's yeh They ‘end to focus more on activites, rather than on the clock Im contra, industrialized! nations must pay ateation to clock tine, There ae large ‘umbers of people o organize, and each must complet histor her tk scoring 10 schedule in order fr the next person to begin, Without locks, chaos would reign Hierarchical Versus Egalitarian Cultures Just as cles difer in time onenaton they alo varyin social rues “American culture is organized secordig to am egalitarian model Theo. retcally everyone is equal Sraus and power are dependent on an in ‘uals personal qualities rather than characteris such as age, 200, fay o occupation, In reality things stay operate dierenty Bit we hold equality as our ideal Many Asian culeares are based on 2 era ‘ical model. Everyone isnot equ. Status based on such eharactens- visas age sex, and occupation. Sats difference are seen a importa, and people of higher status command respect, Hospis are baked on 9 dierarchical model Socal stuctre, then, ca have an eporant nf {nee on the way people interact a wll le een in maty ofthe examples goon Inter in the book Family of Orientation Versus Family of Procreation During the course of thei ves, many people are members of we die ‘ent fail groups: the fama dhe) are Horn nto and the one they erste through marrage and dldren. Anthropelogiss distinguish the oe at “family of orientation” and “Tamil of prosetion,"The family orien. ons he oe persons bora int, the ne o which one st niente ce sei Ieinehes the individual paren, brothers and sisters ad another ‘household members, The family of procreation isthe ove formed hve ‘marrying and procreatng includes the india spouse, at dren Sonne cultures, particulary those in which the marvied couple contines ‘reside with the parents ofthe bride or grooms, enphasive de Lami of bvientation, Other eulures enphasze the family of proceston. Ames ‘ans tend to set yp their own muclear fry houteils, and ha ary takes precedence over al thers The rent isa dering st of loyalties, Models of Disease ‘Three primary heath belef models have been identified by dict ser Ihropelogisa: They are the folowing Moticemigicusmadet The worl isan arena which sepernatial forces dominate: One's health depends upon the action of gods o her spe tural frees, which can at on thet own of be manipulted by otnee Juma, ta some cases ness is seen as punishment for wansprecion Bionac made: Life seen as Being controlled bya eres of physical and Biochemical proceses, which canbe studied and manipula, istic mde The forces of mature must be kept in balance os barony, both within the body and bene the individual and the pine oot ‘etapbpsical universe. Health isa posite state of meletg, snd ‘empastes broader environmental, ocicultural, an beberioel eee ‘nants. Healing is ame at vestoring balance, ‘Noe tha witinanygien cular bang stem, elements of more than ‘ne paradigm or mel msy spp As yon el the nen section, noses hich “causes” of aisease belong to which paradise loep famed that common reason for lack of adherence is & eonfle Deswees the alent’ model of disease and tat of the tamed! praciones Why adhere oa treatment regime that uses no sene to yur Disease Etiology Most Americans believe hat germs cxuse disease: Not all eltres share that belies, however: Other causes of dense lnchade ypc in boy ba ‘ce; sul los, sul ef. and spire possession; breath of taboo, sod tect intrusion. Treatment for diseases renling fom such etolices mist ary tobe appropriate o the cause, bse in ty alncrs a notion cat appears to have originated in China snd spread from tere influence belies nia, Indi, Spin ad Lads America. lcefersto the belief that healthy body isin asec oftalancn ‘When gets ou of bance ines results In Asa the balance i ato hand yong. Al things inthe universe are primarily ether vn Orang, inching diseates, which may reat fom exces yin, exces yang ack ‘ent yin, or deficient yang. Yin and ang are generally transac w hee (amg) and cold (yn) aiough these refs to qualities nos emperacne ‘The balance beeween hot ad cod ean be upset ya numberof ton, Including an improper balance of foods and srong tational states, The fl of teamene iso rexore balance tothe stem Thin geseray ‘Ecorplished through the use of food (for example. cod foods shou be eaten to cue hotillaes), herb, other weasments Te presence {286 one shuld avoid exten, such a ee water Dit i exceedingly Inporean. (Diesarysaples sucha ee are genraly ouphete be ne ‘al, fortunate ne pretial designation22 chapter Foods dat are hot in one eutare maybe old in another, so its cult to mae up a comprebensive sz: Palens’ beliefs in ota cold ‘qualities can generally be ascertained only by observing thei behavior. Iehey refuse certain foods or medications, may be tat an ilnes hey pereete as hots being wrested witha oe ined or medication, Offering ‘ther foods or liquids to take wit the ple etre” ety sore the problem. 1'they wll not ake the pill th ice watt they might tae with hot tea, orange juice, or hot chocolate “Although the impertance of msintaning a balance benven hot and «olds not recognised in Western medicine, there is grving recogni tion dat ses plays an important cole in afeting te mane tes bility o fight disease. Stes represents and of imbalance. Roce su ‘esindcate tha peron'semesional sate may alsa Have agua ‘nce on the immune sam. Thus, hough the word weve ae diferent body balance isa notion to which we ould be able wo relate Paradoxically, China is moring vay from tradkionalsedisine in ‘wor of Western medicine, whe there increas interest inthe United States in traditional Chinese bealing practices. When I asked! several Chinese uurses how they integrate the cancept of yn and yang with germ {heory, they explained that when yin and yang ae ou of baler, gens can ctuse disease. This i early ideal ta the Western noton ofthe ‘elatonshipherseen sess and diteave. ‘Soul fon along With uh is anor category of disease etiology The concept i selfexplnatory. The soul ha eter left the bed on ite ‘xn or been stolen, lsving the body in wetkened and il sate The goal ‘of weatment sto rear the sul to the bo. usualy equiv aspect [ny such ara shaman, who can “eave” his or her own byt earch for snd resun the ising soul Although Westera medicine tacks slat ‘tiological category catatonic schizophrenis can be dese tether Teal bodies with "pone horse" ‘St posusion involves the aking ove of the victim's body by a spirit being: The iti usually acs in way tat ae inappropriate for hit or hes In some cultaes this may give the vem a form of pow. Its gen rally the poor the oppressed, ad minorities who become “possessed” Forexanple, in Ethiopia, women may beaome poses by powerful Zar spirit, When this occurs their husbands most reat thes wath unaccas tomed kindness and respect forthe are none dealing with ee es bout with powerfl Zar The negative se of possesion bya Zari that {he wor is thought to be crazy and must sock elp through a Zar cle Exorels isthe reaunent for spins ames. “The next eologeal category s bach of tao whic mean doing some ‘hing fovbidden—for exmple, eating Sood cocked ya tnesaratng “won, spe iret ond smothering uae | : Sasi cancopts 22 sect, having extramarital or homosexual relations Diseases the pun ‘ment meted outty a supernatural force suchas God, Treatment voles enatee and sonement ‘The fal major category sabe nrusion It refers to the condition in hich a magical foreign object enters the Rody and cases the nll 'o become il. Treatment invokes removing the eject In mos ees 8 shaman will suckit out from the afficed pat ofthe patients body The ‘aman then prodices te offending object. Upon anabss, the object often turns out tobe bis of har animal parts, eth. or place mater, mined wih blood from the shaman’s mouth, One shaman, accuse yan anthropologist of practicing lgerdeman, ree admitted oseteing ts object in his mut prior to sucking tout of the patients body Hee laine tha the eal object he removed vas vise, ut tat i waren ‘ant forthe padient co see something tangible, she practiced 2 Be of sleight of hand (or mouth) forthe pasents pyehologeal bench “Two impartns points should be made regarding disease eulogy: Fig, ‘he etmené mt Be eprops oth cae If germs case disease, Ml the germs IF the body is eu of balance, restore balance fee souls gone, ese It Ifa sprit has taken over the body, exorcise Hue fe been volte, do penance, Ifan object has entered the body remmare le All these remedies are perfesy logical. Whether these etiologies are the true causes ofthe disease sielevant A patient who belies he oF she it ‘because of soul loss wil note cared By any ammount of anbes, The mind is ery powerful. asthe placebo effect demonstrates, The patients bits as wells body. mute be teatod. Many American fee they ave noc ben created propery if they 2 not eeitc an ano for iro, ‘en though sndbiocs are eflcive only again bacteria. ajehaogsealy ‘hey need the pl to gece. This has wnforanately ed toa slerion foe ‘rier more powerful and antibiotic resistant baer, Stone mus ne tour then ind uf th ers in he el of thereat. They maybe eight Ils ea to lodk down on other eth, ‘icing seience to support Western medical beliefs Bat allmedca! sens ave based on observed canseand effect relationships The major fife, ‘ence wit the scientie approach is that science i asic scenic Iypothess can be proven rong The belief of eter sytem cannot [At dhe level ofthe individual, however, Atericans deta no TO proof than do people of any oxher culture. Mort elev germs case di fase because their mothers eld them so. Few have eve acl ae erm, an fever demand to see proof ofvruses or bacteria work The Sxpetshave done that and their word, slong with our mothers chug same i true in other eure. 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