Why Does Culture

Matter in Health Care

and What Can We Do
About It?
INC532 Health Communication

CultureandMedicine
Americansocietytodayisenormously
pluralistic.
Thiscomplexityisrevealedintheracial,
ethnic,cultural,andlinguisticdiversity
thatcharacterizesoursociety.
Ashealthcareproviders,weexperience
thisdiversityinourdailyclinicalpractice
andmustgrapplewiththisissueof
culturallycompetentcare.

WhyDoesCultureMatter?
Strongevidenceofhealthinequalitiesalong
raceandethnicity.
Systematicallyworsehealthoutcomesfor
membersofminorityracialandethnic
groups.
Agreaterdissatisfactionwithhealthservices
expressedbymembersofminoritygroups.
Becausecultureaffectsmedical
experiences,itisavitalcomponentin
effectivecare.

TakingCultureSeriously
Inthelast20yearshealthcareprovidershave
increasinglytakencultureintoaccount,albeit
throughoversimplifiedmodels.
Thisindexcardmodelthatviewscultures
asstatic,unchanging,andhomogenousis
inadequate.
Cultureisnotathing;ratheritismore
usefullyconceivedasaprocessthrough
whichordinaryactivitiestakeonemotional
toneandmoralmeaningforparticipants.

WhatisCulture?
Culturalprocessesinclude:

anacuteattentivenessindifferentsituationstowhatismostatstake
thepassionatedevelopmentofinterpersonalconnections
theseriousperformanceofreligiouspractices
commonsenseinterpretationsandeverydayactions
thecultivationofindividualandsharedidentities
theembodimentofmeaning

Cultureisinseparablefromeconomic,political,
psychologicalandbiologicalconditions;thatisitcanaffect
andisaffectedbyallofthese.
Treatingcultureashomogenousmissesthatcultural
meaningsandpracticesmaydifferwithinthesamegroup
owingtoage,gender,politicalfaction,class,religion,
ethnicgroup,andevenpersonality.

TheCultureofBiomedicine
Atanearlierperiodinhealthcare,culturereferred
almostsolelytothecultureofpatientandfamily.
Nowitsbeenshownthatthecultureofthe
professionalcaregiver,includingboththe
backgroundofthemedicalprofessional,aswellas
thecultureofbiomedicine,hasimportance.
Thisbiomedicalcultureisexpressedinparticular
institutionssuchashospitals,clinics,medical
schoolsandisnowseenaskeytotheproblemsin
patientprofessionalrelationships,clinical
communication,transmissionofstigma,institutional
racism,andthedevelopmentofhealthdisparities.

ExplanatoryModels
Inthe1970sIintroducedatechniquethattriesto
understandhowthesocialworldaffectsandisaffected
byillness.
Thequestions:
Whatdoyoucallthisproblem?
Whatdoyoubelieveisthecauseofthisproblem?
Whatcoursedoyouexpectittotake?Howseriousisit?
Whatdoyouthinkthisproblemdoesinsideyourbody?How
doesitaffectyourbodyandyourmind?
Whatdoyoumostfearaboutthiscondition?Whatdoyoumost
fearaboutthetreatment?

Thesewereintendedtoopenupconversationoncultural
meaningsthatmayholdseriousimplicationsforcare

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

ExplanatoryModelsII
Problemswiththisapproachinclude:
Questionscanbecomeaconversationstopper
ratherthanfacilitatingdialogue
Thesecanleadtothemedicalprofessional
fixingbeliefsasiftheywereunchanging
Themodelhas,attimes,beenimplementedas
culturalstereotypes

However,whenitisappliedwithattention
totheseproblems,explanatorymodelscan
beextremelyusefulinclinicaldialogue.

ARevisedCulturalApproach
Step1:EthnicIdentity
Step2:WhatisatStake?
Step3:TheIllnessNarrative
Step4:PsychosocialStresses
Step5:InfluenceofCultureon
ClinicalRelationships
Step6:TheProblemsofany
CulturalApproach
1) This is a revised version of the cultural formulation included in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV). See appendix I

Step1:EthnicIdentity
Aspartofthisquestioningitiscrucialto
affirmapersonsexperienceofethnicityand
illness,communicatinganawarenessthat
peoplelivetheirethnicitydifferently.
Askaboutethnicidentityandwhetheritisan
importantpartofthepersonssenseofself.
Ratherthanassumingknowledgeaboutthe
patientthatcanleadtostereotyping,asking
thepatientaboutethnicityanditsimportance
isthebestwaytobegin.

Step2:WhatisatStake?
Askthepatientandtheirlovedoneswhat
isatstakeforthemwhatreallymatters?
Whatisit,atadeeplevel,thatthepatient
standstogainorlose?
Thismayincludecloserelationships,
religiousvalues,andevenlifeitself.

Step3:TheIllnessNarrative
Thegoalinthisstepistodrawonthe
questionsfromtheexplanatorymodelto
developadialoguebetweenthepatientand
medicalprofessionalaboutthepatientsstory
oftheillnesstakingintoaccountcultural
meaningsandcare.
Theclinicianshouldbeopentocultural
differencesinstoriesaboutlocalworldsand
thepatientshouldrecognizethatdoctorsdo
notfitacertainstereotypeanymorethanthey
dothemselves.

Step4:PsychosocialStresses
Thegoalistounderstandtheongoing
stressesandsocialsupportsthat
characterizepeopleslives.
Thesemayincludefamilytensions,
problemsatwork,financialstruggles,and
personalanxieties.
Thesestressesareoftenoverlookedinthe
rushtoexplainbehaviorinculturalterms,
andsoitisimportantfortheclinicianto
remainattentivetomultipleexplanations.

Step5:InfluenceofCulture
onClinicalRelationships
Cliniciansaregroundedinmultiplesocial
worlds:theworldofthepatient,their
personalnetworks,andthecultureof
biomedicine.
Workingbetweenthesesocialworldscreates
anopportunityforcriticalselfreflectionand
theunpackingoftheformativeeffectthat
biomedicinehashadonclinicalpractice(i.e.
bias,inappropriate/excessiveuseofhigh
techapproaches,andstereotyping).

(II)Step5:Translating
andInterpreting
Translationshouldalwaysbe
medicallyinformedandoriented
towardscommonsensemeaningand
practicalaction.
Interpretationmeansunderstanding
andfacilitationcommunication
acrossdifferentlocalworlds.

Step6:TheProblemofany
CulturalApproach
Thefinalstepistoaskifthisapproachworks
inaparticularcase.
Perhapsthemostserioussideeffectofa
culturalapproachisthatitmaybeseenby
patientsandfamiliesasintrusiveoreven
contributetoasenseofbeingsingledoutand
stigmatized.
Thereisalsothemisguidedbeliefthatifwe
findtheculturalanswer,wellbeableto
resolvetheissue,butoftencasesaremuch
morecomplexthanasimplefix.

Conclusion
Themostimportantthingthatclinicianscandois
tofindoutwhatisatstakeforpatientsandfor
themselvesintheclinicalinteraction.
Thisgoesbeyondsimplisticnotionsofcultural
competency.Itisafocusonthepatientasan
individualavulnerablehumanbeingfacing
dangeranduncertaintynotaculturalstereotype.
Inthefutureitwillbevitaltoconductresearch
thatdemonstratesthecosteffectivenessofa
culturallyinformedapproach.

References
Kleinman,A.(1988)TheIllnessNarratives.
NewYork:BasicBooks
Kleinman,A.andP.Benson(2006)
AnthropologyintheClinicPLoS
Medicine3(10):e294.
Kleinman,A.CultureandPsychiatric
DiagnosisandTreatment.TheTrimbos
Lecture.HarvardUniversity.October31,2004.
Kleinman,A.(2006)WhatReallyMatters:
LivingaMoralLifeAmidstUncertaintyand
Danger.OxfordUniversityPress