Lecture 4 Culture

8/17/2019 Lecture 4 Culture

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Why Does Culture

Matter in Health Careand What Can We Do

About It?

INC532 – Health Communication


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Culture and Medicine

American society today is enormously

pluralistic.

This complexity is revealed in the racial,ethnic, cultural, and linguistic diversity

that characterizes our society.

As health care providers, we experience

this diversity in our daily clinical practice

and must grapple with this issue of

“culturally competent care.”


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Why Does Culture Matter?

Strong evidence of health inequalities alongrace and ethnicity.

Systematically worse health outcomes formembers of minority racial and ethnicgroups.

A greater dissatisfaction with health servicesexpressed by members of minority groups.

Because “culture” affects medicalexperiences, it is a vital component ineffective care.


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Taking Culture Seriously

In the last 20 years health care providers haveincreasingly taken culture into account, albeitthrough oversimplified models.

This “index-card” model that views culturesas static, unchanging, and homogenous isinadequate.

Culture is not a thing; rather it is moreusefully conceived as a process throughwhich ordinary activities take on emotionaltone and moral meaning for participants.


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What is Culture? Cultural processes include:

an acute attentiveness in different situations to what is most at stake

the passionate development of interpersonal connections

the serious performance of religious practices

common sense interpretations and everyday actions

the cultivation of individual and shared identities the embodiment of meaning

Culture is inseparable from economic, political,psychological and biological conditions; that is it can affectand is affected by all of these.

Treating “culture” as homogenous misses that culturalmeanings and practices may differ within the same groupowing to age, gender, political faction, class, religion,ethnic group, and even personality.


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The Culture of Biomedicine

At an earlier period in health care, culture referredalmost solely to the culture of patient and family.

Now it’s been shown that the culture of theprofessional caregiver, including both the

background of the medical professional, as well asthe culture of biomedicine, has importance.

This biomedical culture is expressed in particularinstitutions such as hospitals, clinics, medicalschools and is now seen as key to the problems in

patient-professional relationships, clinicalcommunication, transmission of stigma, institutionalracism, and the development of health disparities.


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Explanatory Models

In the 1970’s I introduced a technique that tries tounderstand how the social world affects and is affectedby illness.

The questions:

What do you call this problem? What do you believe is the cause of this problem?

What course do you expect it to take? How serious is it?

What do you think this problem does inside your body? Howdoes it affect your body and your mind?

What do you most fear about this condition? What do you most

fear about the treatment? These were intended to open up conversation on cultural

meanings that may hold serious implications for care

(source: Kleinman, A.(1988) The Illness Narratives. Chpt 15)


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Explanatory Models II

Problems with this approach include: Questions can become a conversation stopper

rather than facilitating dialogue

These can lead to the medical professionalfixing beliefs as if they were unchanging

The model has, at times, been implemented ascultural stereotypes

However, when it is applied with attentionto these problems, explanatory models canbe extremely useful in clinical dialogue.


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A Revised Cultural Approach

Step 1: Ethnic Identity

Step 2: What is at Stake?

Step 3: The Illness Narrative

Step 4: Psychosocial Stresses

Step 5: Influence of Culture on

Clinical Relationships Step 6: The Problems of any

Cultural Approach

1) This is a revised version of the cultural formulation included in the fourth edition of the Diagnostic and Statistical Manual (!"#$%). !ee appendi& $


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Step 1: Ethnic Identity

As part of this questioning it is crucial toaffirm a person’s experience of ethnicity andillness, communicating an awareness thatpeople live their ethnicity differently.

Ask about ethnic identity and whether it is animportant part of the person’s sense of self.

Rather than assuming knowledge about thepatient that can lead to stereotyping, askingthe patient about ethnicity and its importanceis the best way to begin.


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Step 2: What is at Stake?

Ask the patient and their loved ones what

is at stake for them - what really matters?

What is it, at a deep level, that the patient

stands to gain or lose?

This may include close relationships,

religious values, and even life itself.


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Step 3: The Illness Narrative

The goal in this step is to draw on thequestions from the explanatory model todevelop a dialogue between the patient and

medical professional about the patient’s storyof the illness taking into account culturalmeanings and care.

The clinician should be open to cultural

differences in stories about local worlds andthe patient should recognize that doctors donot fit a certain stereotype anymore than theydo themselves.


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Step 4: Psychosocial Stresses

The goal is to understand the ongoingstresses and social supports thatcharacterize people’s lives.

These may include family tensions,problems at work, financial struggles, andpersonal anxieties.

These stresses are often overlooked in therush to explain behavior in cultural terms,and so it is important for the clinician toremain attentive to multiple explanations.


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Step 5: Influence of Culture

on Clinical Relationships Clinicians are grounded in multiple social

worlds: the world of the patient, theirpersonal networks, and the culture of

biomedicine. Working between these social worlds creates

an opportunity for critical self-reflection andthe unpacking of the formative effect that

biomedicine has had on clinical practice (i.e.bias, inappropriate/excessive use of high-tech approaches, and stereotyping).


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(II) Step 5: Translating

and Interpreting Translation should always be

medically informed and oriented

towards commonsense meaning andpractical action.

Interpretation means understandingand facilitation communicationacross different local worlds.


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Step 6: The Problem of any

Cultural Approach The final step is to ask if this approach works

in a particular case.

Perhaps the most serious side-effect of acultural approach is that it may be seen bypatients and families as intrusive or evencontribute to a sense of being singled-out andstigmatized.

There is also the misguided belief that if wefind the cultural answer, we’ll be able toresolve the issue, but often cases are muchmore complex than a simple fix.


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Conclusion

The most important thing that clinicians can do isto find out what is at stake for patients and forthemselves in the clinical interaction.

This goes beyond simplistic notions of culturalcompetency. It is a focus on the patient as anindividual - a vulnerable human being facingdanger and uncertainty - not a cultural stereotype.

In the future it will be vital to conduct researchthat demonstrates the cost-effectiveness of aculturally informed approach.


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References

Kleinman, A. (1988) The Illness Narratives.New York: Basic Books

Kleinman, A. and P. Benson (2006)

“Anthropology in the Clinic” PLoSMedicine3(10): e294.

Kleinman, A. “Culture and PsychiatricDiagnosis and Treatment.” The Trimbos

Lecture. Harvard University. October 31, 2004. Kleinman, A. (2006) What Really Matters:

Living a Moral Life Amidst Uncertainty and Danger. Oxford University Press

Lecture 4 Culture

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