CULTURE

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We are going to be talking about culture in this presentation. Culture can be defined as a:

Set of values, beliefs and assumptions that are used by an individual to interact with the world.

Through culture an individual has a framework of how the world works, what is important to them and also determines the way they view illness; what causes illness and what cures it. An individual's culture determines their conduct. Each individual develops in a unique way within that framework that their culture provides so it is not possible to stereotype. Doing so is a mistake.

So if culture determines an individual's conduct (and language) and these differ from the dominant culture's language and behavior that may cause certain cultural conflicts. In dominant culture in the U.S., many people have been raised with the concept that you treat others as you would like them to treat you (with respect and justice), a concept that has been termed the “golden rule”.

African Americans are the largest racial minority group. Many African Americans reflect cultural roots including African healing, medicine of the Civil War South, European medical folklore, West Indian voodoo religion and other belief systems including Christianity.

There are 5 major Asian populations in the U.S.: Chinese (includes Taiwan and Hong Kong), Korean, Japanese, Filipino and Southeast Asian (which includes people from Laos, Cambodia, Vietnam and Thailand).

According to Wikipedia: Hispanic and Latino Americans (Spanish: Latinos estadounidenses) refers to an ethnolinguistic group of citizens of the United States with origins in the countries of Latin America or the Iberian peninsula. More generally it includes all persons in the United States who self-identify as Hispanic or Latino. Reflecting especially the Latin American population, which has origins in all the continents and many ancestries, Hispanic/ Latino Americans are very racially diverse, and as a result form an ethnic category, rather than a race. The traditional definition of race and ethnicity is related to biological and sociological factors respectively. Race refers to a person's physical appearance, such as skin color, eye color, hair color, bone/jaw structure etc. Ethnicity, on the other hand, relates to cultural factors such as nationality, culture, ancestry, language and beliefs While the two terms (Hispanic and Latino) are sometimes used interchangeably, Hispanic is a narrower term which mostly refers to persons of Spanish-speaking origin or ancestry, while Latino is more frequently used to refer more generally to anyone of Latin American origin or ancestry, including Brazilians. Hispanic thus includes persons from Spain and Spanish-speaking Latin Americans but excludes Brazilians (who speak Portuguese) while Latino excludes persons from Spain but includes both Spanish-speaking and Portuguese-speaking Latin Americans. Latino is a broader term encompassing more people.

The choice between the terms Latino and Hispanic among those of Spanish-speaking origin is also associated with location: persons of Spanish-speaking origins residing in the eastern United States tend to prefer the term Hispanic, whereas those in the West tend to prefer Latino. Hispanics or Latinos constitute 16.7% of the total United States population, or 52 million people, making it home to the largest community of Spanish speakers outside of Mexico according to the Pew Research Hispanic Center, surpassing Argentina, Colombia, and Spain within the last decade. Latinos overall are the second largest ethnic group, after non-Hispanic White Americans (a group composed of dozens of sub-groups, as is Hispanic and Latino Americans). Hispanic and Latino Americans are the largest of all the minority groups, but Black Americans are the largest minority among the races, after White Americans in general (non-Hispanic and Hispanic). Mexican Americans, Cuban Americans, Colombian Americans, Puerto Ricans, Spanish Americans, and Salvadoran Americans are some of the Hispanic and Latino American national origin groups. Middle Easterner: is a general term that includes diverse groups of people including: Arab Americans, Egyptian Americans and Iranian Americans. American Indian refers to members of the Indian tribal nations living in the U.S. The term “Alaska Native” refers to Eskimo and Aleut populations. “Native American” is a term that refers to American Indians, Eskimos and Aleuts as one racial and ethnic group.

When an interpreter acts as a cultural broker he/she stands with one foot on each culture and puts those cultural differences into context, helping to avoid miscommunication based on a cultural differences.

One simple example is how different cultures view time. In Latin America it is not unusual for people to be late to a social gathering. Tardiness in some cultures is seen as a problem, as rude, inappropriate but for others it is not a problem, something to even be expected and as such we see a “cultural relativity” in regards to time perception.

So, being culturally competent means knowing more than just how to interpret 2 languages, taking it a step further and learning/ knowing about the culture and needs of a community.

AMERICANS (DOMINANT CULTURE) • more eye contact • ask more questions • no folk beliefs • less editing • less consulting with family- early independence

HISPANICS/LATINOS • limited eye contact • limited asking of questions • folk beliefs (curanderismo) • family editing (censoring) of news to patient • family involved in patient's care ( patient consults with their family, group decisions, family present in the exam room during visit) • Great respect for provider (seen as an authority figure) • Good health is a matter of luck that can easily change relying on “fate” ( “When it's time to go...it's time to go”)

AMERICAN INDIANS • Warm greetings • Eye contact and smile • Include family in their matters

MIDDLE EASTERNERS • Family editing of medical rapport to protect patient from “bad news” • Prefer same sex interpreter. • May speak louder ( means the matter discussed is of importance) • Woman covers her body and face. • Include family in the medical decision making process • Fatalistic acceptance of disease or death ( part of God's plan) • Humoral theory ( hot/cold imbalance)

ASIAN AMERICANS • Look away ( avoid eye contact) • Consider western medicines “vey hot” (very potent), compliance issues • Head is the most sacred part of body, ask permission before examining • Everything in the universe is classified as either Hot (yang), Cold (ying) • Hot/cold diseases/ treatments • Concept regarding health known as Ch'i or Qi (life force) that must be in balance to maintain life and have a long life. Disease disrupts the flow of this vital energy which can be restored with acupuncture. • Coining, cupping, moxibustion

ACCULTURATION AND ASSIMILATION:

Acculturation is the acquisition of a new culture identity but does not mean ridding oneself of the elements of one's first culture. Languages, beliefs and traditions become integrated. Something like navigating using one's old familiar boat through new waters. Acculturation is a dynamic process which move along a continuum. Assimilation is the extreme of acculturation and it implies that the individual has lost or given up the old values and becomes totally incorporated into the new culture.

DIFFERENT VIEWS ON MEDICINE/ DISEASES:

Some cultures have a different understanding of what causes illness like for example:

• Humoral Imbalance : an imbalance between “hot” and “cold” can cause illness. This is a concept and has nothing to do with actual temperatures. A hot tea may be considered a “cold” remedy adequate to treat a “hot” imbalance. Oral Rehydration Salts (ORS) may be rejected by the mother as a treatment for her child's diarrhea because they are considered “hot” and the diarrhea also considered “hot” ( hot needs cold to cure). The ORS offered in a tea made of a “cool” herb would be acceptable however.

• Magical Thinking: that the illness is a test from God or provoked by a spirit or witchcraft. This is an example of magical thinking where who thinks this way tries to find significant and meaningful relationships between actions and events where convention says there is none.

• Traditional/ Folk Healers: these are people who are not medical doctors who use herbs and roots, ceremonies or rituals, bone setters, midwives ( help deliver babies) and diviners (diagnose illness).

The importance of knowing about these beliefs and interpreting (not editing them out) is to:

1) Avoid any adverse interactions between the active ingredients in the herbs and roots the patient is taking and prescription medicine. 2) To be able to act as a culture broker and explain that these beliefs are normal in the patients culture so that the patient is not confused as having a psychiatric disorder like schizophrenia for example. 3) To avoid conflicts between cold/ hot diseases and treatments so that the patient will be compliant with the treatment prescribed or indicated.

Comments on Video: Kaiser Permanente's CULTURAL ISSUES IN THE CLINICAL SETTING.

CASE1: Hispanics: showcases • views on illness as “God's Will” • issues with diet • problems with using a family member as an interpreter who: uses incorrect interpreting techniques, lacks knowledge of how to manage the flow of communication, faulty positioning, omissions, talks about herself, interjects her opinions and makes suggestions.

CASE 2: Shows how a culturally competent interpreter can make all the difference. Culture brokers, explains the importance of including the family in the patient's healthcare decisions/ treatments. Professional demeanor :empathy ( “I understand”). Mother-in-law included in decisions.

CASE 3: Showcases stereotypes.

CASE 4: Showcases that communication styles vary distinctly across cultures and can cause misunderstandings. The foreign doctor's highly directive communication caused her to be viewed as “rude and cold” and rubbed the child's mother the wrong way leading to comments like: “Where did you say you were from”??? “Can I get an American doctor”?? (racist comments) leading the doctor to feel discriminated.

CASE 5: Depicts lasting effects of stress on a Southeast Asian patient after having lived through the traumatic experience of fleeing her country and becoming a refugee. Among many Asians, there is a belief in unity between the mind and body, so emotional disturbances are often reflected in somatic symptoms. Headaches, insomnia, fatigue and loss of appetite are seen as less stigmatizing than are emotional or psychiatric problems. Depression is often expressed as a feeling of tiredness deep in the chest. Southeast Asian groups are more likely to experience depressed affect and anxiety.

CASE 6: Showcases gender-based issues ( female doctor/ male patient)

CASE 7: Showcases issues that have to do with: • sexual orientation issues (“coming out of the closet”) • confidentiality • safe sex • crisis • suicidal thoughts • empathy

CASE 8: Showcases same-sex couple/ parents- issues of: • fear of provider disapproval or insensitivity to their sexual orientation as a significant barrier to accessing health care. • that assumptions about sexual orientation or sexual behavior should not initially be based on a heterosexual norm; Listen for cues like the women expressing themselves as “us” or “we”. • legal issues (power of attorney, parenting rights). The interpreter should be prepared to interpret for same sex couples and transgender LEPs in a non-judgmental and sensitive way.

CASE 9: The Hmong: • birth rituals (placenta, jacket for the soul). • culture, not superstition. • shows a judgmental provider, lacking cultural competency.

CASE 10: Middle Easterners: avoid prolonged eye contact. Less independence for women. Women are responsible for raising and educating children and providing a safe and comfortable family environment. The care of the spouse and family is very important to the Muslim wife. Acculturation issues.

CASE 11- Rural Hispanics- emphasizes: • religious ideas regarding diseases • poor compliance to treatment- high risk for a bad outcome in their health. • Stereotypical remarks “they always”, “they never” ( do this or that). • Ethnocentric assumptions ( my way is the only “right way” )

CASE 12- Female Circumcision that certain cultures believe to be aesthetic, purifying, more hygienic and moral. Practice favored by women themselves (to secure a good marriage). Illegal in the US ( to be reported to child welfare services if there is suspicion there are plans to do this to a child).

BOTTOM LINE: we try to learn about different cultures, not judge them.

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