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Cross Cultural Medicine at Home and Abroad 2007 Gregory Juckett, MD, MPH Associate Professor of Family Medicine West Virginia University

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1 Cross Cultural Medicine at Home and Abroad 2007 Gregory Juckett, MD, MPH Associate Professor of Family Medicine West Virginia University

2 America is Changing “Global Village”: We now live in multi- cultural, multi-ethnic societies both at home and abroad By 2050, almost half of U.S. population will be comprised of minorities Today’s “Tossed salad” vs. Yesterday’s Melting Pot U.S. minority populations are quite diverse and not limited to urban areas

3 What is Culture? Beliefs and behaviors that are learned and shared by members of a group World view of a culture may have a profound effect on healthcare e.g. fatalism Cultural Competence (knowledge, awareness, respect for other cultures) is now an necessary clinical goal for which we should strive Cultural Sensitivity/Humility: caring awareness which tries to avoid giving offense to those of another culture (achievable) Importance of R-E-S-P-E-C-T

4 Cross Cultural Terms Stereotyping (bad) : the mistaken assumption that everyone in a given culture is alike—closed to exceptions (ending point) Generalizing (ok): awareness of cultural norms— open to educational, generational differences (starting point) Ethnocentrism: the usually unconscious conviction that ones own culture should be the norm—this is almost a universal human trait Racism: the misguided belief that ones own race/ethnicity is superior to that of others Discrimination: treating people differently due to prejudice may be unconscious: “you people”

5 Remember that every person is unique

6 Cultural Dynamics Influencing the Clinical Encounter American CultureConcept HEALTH BELIEFS Non-Western Culture Heath is the absence of disease Core Health Beliefs and Practices Health is state of harmony between body, mind, and spirit Seeks medical system to prevent and treat disease Seeks medical system in acute stage of illness Seeks practitioners (doctors, nurses, etc…) Seeks herbalists, priests, shamans, etc… Doctors may be sought out later in the “hierarchy of care” Scott Cottrell

7 Cultural Dynamics Influencing the Clinical Encounter American CultureConcept CULTURAL NORMS Non-Western Culture Efficiency: Time is important – tardiness is impolite Cultural Values, Norms, and Customs Efficiency: Time is flexible Values individualism: focus on self-autonomy Values collectivism: reliance on other and group acceptance Value independenceValues interdependence with family and community Personal control over environment and destiny Fate controls environment and destiny Scott Cottrell

8 Cultural Dynamics Influencing the Clinical Encounter American CultureConcept COMMUNICATION Non-Western Culture Greeting on first name basis denotes informality/ builds rapport Communication Styles Greeting on first-name basis denotes disrespect Being direct avoids miscommunication Being direct denotes conflict Eye contact signifies respect and attentiveness Eye contact is considered disrespectful (unless among equals) Personal distance denotes professionalism and objectivity Close personal space valued to building rapport Scott Cottrell

9 Cultural Dynamics Influencing the Clinical Encounter American CultureConcept FAMILY DYNAMICS Non-Western Culture Individual interests are valued and encouraged Family Dynamics Individual interests are subordinate to family needs Individual is the focus of health care decisions Family is the focus of health care decisions Reliance of nuclear family bonds Reliance on nuclear and extended family bonds Scott Cottrell

10 The Cross Cultural Interview & Exam Developing Trust (view this as an investment of time that pays you back later) and listening to patient Eliciting pertinent history —always ask (non-judgmentally) what alternative therapies your patient is using and what providers have they already seen (“hierarchy of care”) Understanding how the illness is viewed ( its “meaning”) and acknowledging differences in worldview Culturally Sensitive Physical Examination Explaining diagnosis to patient and family in understandable terms Negotiating treatment plan and follow-up — have patient repeat your instructions and have them written down (if patient or family member is literate) Teach-Back Knowledge of language and culture = Effectiveness

11 LEARN Model for Cross Cultural Interview Listen to the patient and the family's concepts of the illness. Explain your medical diagnosis in understandable terms. Acknowledge differences (and similarities) in cultural perspectives. Recommend your diagnostic and therapeutic approaches. Negotiate all areas of care. Reference: A teaching framework for cross-cultural health care. Application in family practice. West J Med Dec;139(6):934-8.

12 ETHNICS Mnemonic: a framework for culturally appropriate care Explanation: why do you have this problem? Treatment: what have you tried for it? Healers: who else have you sought help from? Negotiation: how best do you think I can help you? Intervention: this is what I think needs to be done. Collaboration: how can we work together on this? Spirituality: what role does spirituality play in this? Kobylarz, Heath, Like. The Etnics Mnemonic: A Clinical Tool for Ethnogeriatric Education. J Am Geriatr Soc 2002; 50:

13 The Spirit Catches You and You Fall Down by Anne Fadiman Poignant story about a Hmong refugee child from Laos with intractable epilepsy Clash of Hmong-U.S. health care cultures with difficult consequences for all involved Asks what questions could have led to better cross cultural understanding? Should be required reading in medical schools

14 Kleinman Cross Cultural Interview What do you call the problem? What do you think has caused the problem? Why do you think it started when it did? What do you think the illness does? How does it work? How severe is the sickness? Will it have a long or short course? What kind of treatment do you think is necessary? What are the most important results you hope to receive from this treatment? What are the chief problems the sickness has caused? What do you fear most about the sickness? Adapted from Kleinman A, Eisenberg L., Good B. Culture, Illness and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research Annals of Internal Medicine 1978; 88: Always ask about alternative therapies, herbs and supplements the patient may be using—if you don’t ask, the patient is unlikely to volunteer this information.

15 Applying Kleinman Questions and LEARN L What is the problem? “ Qaug dab peg” = Spirit catches you and you fall down L What caused the problem? Caused by soul loss when Yer, Lia’s sister, slammed the door and frightened Lia’s soul out of her body. L How do you feel about the problem? It makes us sad to see Lia angry at Yer. It also makes Lia special because she could grow up to become a shaman. L What do you think should be done about the problem? Lia should take medicine for 1 week but not get blood tests. After she gets better she should stop the medicine. L What have you done to treat the problem? Lia has been treated at home with Hmong medicines and rituals (sacrificing pigs and chickens). InformationExample Center for the Health Professions

16 Applying Kleinman Questions and LEARN E Explain providers perception of problem Lay language explanation of seizure disorder and symptoms, emphasizing long-term need for treatment. A What do you fear most about the sickness? That Lia’s soul will never return. A Acknowledge and discuss similarities and differences in perspectives Acknowledge that many things (like brain injury and perhaps even soul loss) can contribute to a chronic seizure disorder. Empathize w/ family’s fear and frustration. Information Example Center for the Health Professions

17 Applying Kleinman Questions and LEARN R Provider’s recommendations for care Agreement that meds needed until seizures resolve (set time period) but this will take a long time. If possible, recommend seizure med that doesn’t require monitoring blood levels. N Negotiation of plan with patient Discuss med plan with family. Negotiate treatment. Schedule follow up visit in 1 week. Instructions for what to do in event of a seizure at home. Center for the Health Professions InformationExample

18 Cross Cultural Interview Establishing trust (and understanding each other) may take much more time—often mistrust is inherent Eye contact issues: may be avoided among less Westernized Asians (unless of equal status/gender) Personal space/Touch issues (low touch) Gender issues and casual touch Facial expressions/Body Language e.g. smiling as embarrassment instead of happiness Time and Punctuality: Agrarian “rubber time” vs. Industrial time

19 Interpreter Pitfalls : Family or Friends Limits scope of inquiry: unlikely to share intimate or embarrassing details (family violence, sex, mental illness) Lack of training: medical terminology may be either misunderstood or mistranslated out of embarrassment No confidentiality guarantee Sometimes family member has a personal agenda Better to use trained medical interpreters if available; but if unavailable must recognize the limitations Try to speak directly to the patient, not to the interpreter

20 Name Conventions Best to use formal title (especially with older patients) until given permission to be informal—never assume it’s ok Chinese and SE Asian names are usually written and pronounced “backward”: Surname precedes given name if not already U.S. acculturated: e.g. Xumiao is Dr. Xu. Married women usually don’t take their husband’s name. Latino names: complex surnames usual (father’s name precedes mother’s) e.g. Senorita Maria Sanchez Rodriguez becomes Senora Maria Sanchez de Gutierrez (usually Senora Gutierrez) after she marries Senor Gutierrez—mother’s name is usually dropped; some Latinas just retain their maiden name however or adopt U.S. customs Maria’s children will go by Gutierrez- Sanchez Don and Dona indicate respect for older Hispanic patients If in doubt, just ask “How do you wish to be addressed”?

21 Language and Body Language Signals Embarrassment or respect prevents the asking of many necessary questions Patients will say they understand when they really have no clue…instead have them repeat what you want them to do Nodding vigorously may indicate respectful attention but not agreement or understanding!!! Don’t confuse Indian head wagging with disagreement! It means I hear what you’re saying. Speak slowly and simply but not loudly (unless your patient really is deaf!) Short sentences! Eye Contact in non-western cultures may indicate disrespect of authority and/or sexual interest Avoid idioms and don’t use negative queries “You don’t…” or “you wouldn’t mind if…)

22 Culturally Appropriate Gestures Beckoning should not be with index finger (S. America, Asia) since this is either reserved for dogs or considered very rude. Instead the palm of the hand should be held down and all fingers used Displaying your feet is insulting in Asia— never touch anyone with your feet Patting a child on the head is an insult in SE Asia since the head, as the seat of the soul, is sacred “Thumbs up” sign is the same as the U.S. middle finger in Iran

23 Reciprocity and Gifts In many cultures, it is required to demonstrate one’s gratitude with a gift and its refusal may well cause offense However, gifts are often offered to ensure best possible care for the patient (a “soft” bribe for the care-giver!) If gift is inappropriate (e.g. money), suggest an alternative (such as food) that could be shared with staff

24 Giving Bad News In many other cultures, it is customary to first inform the family and let them decide if and when the patient should be informed—violates U.S. HIPAA regulations Anger against the provider is often expressed if this custom isn’t followed as it is felt that giving someone a bad prognosis not only takes away any hope but also becomes a self-fulfilling prophecy. At least in the U.S., ask the patient how they would like their family involved. Explain to the family that informing the patient first is the standard U.S. practice

25 African-American and African Immigrant Culture Historically the largest U.S. minority but recently replaced by Hispanics (some African-Americans are also Hispanic) 12.3% U.S. population—22% live in poverty and life expectancy 5.9 y less (2x stroke death, 36% B w/ HTN vs. <25% W, homicide #1 cause of death in young black men 15-34) Health Care Inequity and Race Most are long term U.S. residents but immigration from Caribbean and African countries is increasing (immigrants have better life expectancies than native blacks!) Mistrust of white institutions common place (and sometimes historically justified e.g. Tuskegee syphilis experiments)—reluctance to donate organs Conspiracy theories regarding HIV, birth control common in some areas

26 African-American Folk Conditions “Falling Out”: stress-related collapse (inability to move but normal senses) preceded by dizziness—may be confused w/ stroke “Bad blood”: suggests blood contamination, usually by syphilis (or other STI) Slang terms: miseries = pains, low blood = anemia, sugar = diabetes “High blood”: while this is may be slang for HBP, it may also refer to “hot, thick” blood that “rises” in the body for extended periods and its treatment involves cooling and thinning the blood “High-pertension”: episodic but temporary “shooting up” of blood to the head which then resolves (over 3.3 x as likely to be non-adherent as a patient who believed in biomedical hypertension) MMWR Oct 12, (40):

27 The Why and How of Non-Adherence A 65 year old African American woman with hypertension is noted to have a BP of 180/105 on follow up even though she had been well controlled on the last visit. When asked if she was still taking her medicine, she responded “Those things are supposed to lower the blood, aren’t they? So I just cut them in half and only took them for another week, then threw them away.” Why did she stop taking her medicine after being told that the pills were working well? Adapted from Culture and the Clinical Encounter—Rena Gropper

28 Hypertension Control in Blacks More sodium sensitive than white population Thiazides are good first-line therapy Long-acting calcium channel blockers also helpful for hypertension Beta-blockers may be less effective than in white population Blacks and Asians have 3- 4x greater risk of angioedema from ACE Inhibitors compared to whites Controversy over race-specific marketing of pharmaceuticals

29 Hispanic or Latino Culture Now the largest, fastest growing U.S.minority (12.5%)—not just in S.W. USA, NYC, and Florida Many nationalities and subcultures: Mexican, Puerto Rican, Cuban, Brazilian, Guatemalan, Colombian Machismo vs. Marianismo : dominant male culture; women traditionally submissive The Importance of Balance in Health: Cold/Hot Duality similar to the Yin/Yang of Asian Medicine

30 Issues in Latino Medicine Confianza/Personalismo: necessary trust or rapport should be established prior to the medical part of the interview Some Latinos resent “Americans” for usurping the name of both continents—they are Central or South Americans whereas Gringos are North Americans Personal space is less, sometimes resulting in a “dance” where the gringo retreats (and therefore is perceived as being “cold”) Being a little fat “gordito” is often perceived as healthy; While Mexican–Americans have up to 5x as much type 2 diabetes mellitus as non-Hispanic whites—still the risk of coronary death is lower (The Latino Paradox) More relaxed concept of time—people are more important than schedules

31 Latino Folk Medical Diagnoses Mal de ojo (evil eye) Empacho (GI blockade from overeating) Susto (magically induced fright w/ “soul loss”) Mal puesto (unnatural illness due to sorcery) Ataque de nervios (anxiety attack) Frio de la matriz (frozen womb) Caida de la mollera (fallen fontanelle) Fatiga (shortness of breath—not just fatigue)

32 Case Study: Upside Down Baby A nurse visiting a Mexican family was shocked to see a baby being suspended upside down over a bowl of steaming water and it appeared as though the baby’s head was about to be dipped in. What should she do? Dx: Caida de la mollera (fallen fontanelle) Sx: irritability, diarrhea (r/o dehydration) Adapted from Culture and the Clinical Encounter—Rena Gropper

33 Hispanic Folk Medicine Hypertension Diabetes mellitus GERD and PUD Pregnancy Sore throat/Infection Susto Mal de Ojo Bilis URI “colds” Pneumonia Menstrual cramps Colic Headache Cancer Frio de la Matriz Empacho “HOT”“COLD” Key Distinction of natural vs. supernatural causation: Mal natural vs. Mal puesto

34 Vitamins Stopped A Puerto Rican family brought in their 4 month old with diaper rash. After a prescription was written, the nurse-practitioner asked if any more vitamin drops were needed. “I’ve not used up the drops from before. As you can see, my baby has a rash so I stopped giving them to him. I try to take good care of my baby” Why were the drops discontinued? Another example is a Latina’s reluctance to take iron supplements during her pregnancy Adapted from Culture and the Clinical Encounter—Rena Gropper

35 Hypertension: a “hot” condition Hot etiology: thick blood, caused by susto (fear) or corajes (anger) May be viewed as a temporary rather than long-term condition—therefore patients may not adhere to long-term therapy Cool treatments: lemon juice, passion flower tea, zapote blanco Hot diseases are always treated with cool remedies and vice versa but what constitutes “hot” or “cold” varies by cultural tradition

36 Curandero Herbalist Curandero--Brujo Peruvian Healing cuyes sapo

37 Asian Culture Third largest U.S. minority (3.6%) but multiple nationalities: Chinese, Japanese, Korean, Hmong, Vietnamese, Thai, Cambodian, Filipino (many differences) Hierarchical family structure Poverty is still a problem for many Asians although there is usually a strong family commitment to work, education and advancement Accommodation rather than assertiveness valued: yes may really mean no in some instances (you may also be told what your patient thinks you want to hear) “Face” (personal honor) issues very important so be sensitive to this—always provide a “face-saving” way out

38 The Stigma of Mental Illness Stigma of mental illness is often devastating—viewed as a disgrace to the Asian family and seldom discussed Somatization is therefore common and depression must be suspected early and dealt with tactfully as an “imbalance” Mental illness often presents with physical complaints! Counseling viewed by many Asians as suitable only for the hopelessly mentally ill—unlikely to follow through Multiple Asian culture bound psychiatric presentations: Amok (violence w/ dissociation), Hwa-byung (suppressed anger w/ abdominal fullness or “mass”), Tajin kyofusho (intense fear of being offensive e.g. imaginary body odor), Latah (hypersensitivity to fright with trance-like behavior)

39 Chinese and Asian Illnesses Wind Illness: fear of being cold or exposed to wind which would cause of loss of yang Shen kui: anxiety, panic, sexual complaints attributed to semen loss (believed to be life- threatening by patient) Hwa-Byung (Korea): epigastic pain attributed to an abdominal mass that pt believes will result in death—thought to be caused by unresolved anger Taijin Kyofusho (Japan): pathological fear about embarrassing others by an awkward behavior or a physical problem such as body odor (social phobia)

40 Health Care Concerns for Asians A loud tone of voice (or a friendly slap on the back) may be misinterpreted by some Asians as showing hostility Correcting or even joking about a personal mistake in a public setting may cause intolerable “loss of face” The left hand is often used for personal hygiene and is considered unclean—if medical samples or business cards are offered with the left hand, they may be discarded. Ice water is often refused (upsets hot/cold balance)—warm or hot water preferred, esp. during Chinese “sitting month” after delivery Avoiding Foot Contact: feet are unclean and should not come in contact with another or be elevated/in view; shoes should be removed before entering homes

41 The Bruised Baby A Vietnamese mother brought in an infant girl for acute respiratory infection manifested by cough and fever. Physical examination also showed numerous bruises on her chest and back. When the child’s mother was asked about these, she became embarrassed and changed the subject. When the matter was pressed further, the mother attributed these bruises to the grandmother. What should be done? Adapted from Culture and the Clinical Encounter—Rena Gropper

42 Coining Coining is a common Asian healing practice Coining is used for conditions associated with "wind illness". It is also used with a wide variety of febrile illnesses and for stress related symptoms (headache, muscle aches and pain, and fatigue). The practice produces linear petechiae on the chest and back which resolve over several days. It is believed that the bruises bring out the wind illness and that their manifestation confirms that the disease was present.

43 Coining in Cambodia -Debra Coats Treatment of “Wind-Cold”

44 Cupping in China G. Juckett Herbs

45 Mongoloid Spots Mongoloid spots are common in children from many racial backgrounds. Patches of dermal melanocytosis are found in the majority of Asian, Latino and Black infants. Although they are often seen in the lumbosacral /gluteal areas they are not limited to those regions. Mongoloid Spots need to be distinguished from bruises of child abuse. Compared to a bruise they are more uniform in skin color, their borders are better defined, there is no induration or tenderness and they are stable over time. The Influence of Culture and Pigment on Skin Conditions in Children-Dinulos and Graham

46 Moxibustion Scars Photo by Debra Coats--Cambodia Sometimes may be confused with physical abuse (cigarette burns)

47 10 “Rules of Thumb” in Cross-Cultural Medicine Allow more time for cross-cultural visits Use formal address until invited to do otherwise Develop trust—note that intrusive questions by some of your patients may be a way of determining if they can trust you Try not to rely on family/friends as interpreters if at all possible Ask about the use of cultural therapies and herbs—if you don’t ask, they probably won’t tell Ask about how the illness began and how the patient perceives it Hesitation (or discomfort) is often indicative of “hitting an invisible cultural wall” Ask the patient to repeat—in their own words—your instructions to them rather than ask “Do you understand?” Treat your patients the way they would like to be treated not necessarily the way you would like to be treated. However you are not obligated to meet unreasonable demands Negotiate your treatment plans, acknowledging cultural differences Adapted in part from Culture and the Clinical Encounter by Rena Gropper SUMMARY

48 Benefits of Improving Cross-Cultural Skills Better Outcomes: much better patient adherence results if your instructions are culturally relevant: non-adherence may be due to medication side effects, poverty, depression, lack of understanding, conflict w/ traditional therapies Improved Access to Care Reduce Health Care Disparities Awareness of the hazards and benefits facing your patients from traditional care givers Know what aspects of traditional care can be adapted to your healing setting Know what needs to be rejected due to danger to either spiritual or physical health

49 Books on Cross-Cultural Medicine Culture and the Clinical Encounter : an Intercultural Sensitizer for the Health Professions by Rena C. Gropper Intercultural Press, Inc., Yarmouth, Maine 1996 (case studies) Caring for Patients from Different Cultures : Case Studies from American Hospitals by Geri-Ann Galanti University of Pennsylvania Press, Philadelphia 1997 Cross-Cultural Medicine edited by JudyAnn Bigby American College of Physicians, Philadelphia 2003 Cultural Diversity in Health & Illness 6 th Ed. by Rachel E. Spector Pearson/Prentice Hall, Upper Saddle River, New Jersey 2004 Transcultural Health Care : a culturally competent approach 2 nd Ed., edited by Larry D. Purnell, Betty J. Paulanka. F.A. Davis Co., Philadelphia 2003 Pocket Guide to Cultural Assessment, 2 nd Ed., by EM Geisler, St. Louis, Mo. Mosby, 1998 The Spirit Catches You and You Fall Down Anne Fadiman

50 Website Resources: Cross-Cultural Medicine Culture Clues: Russian, Latino, Albanian, Vietnamese, Korean, African- American information sheets EthnoMed: Univ. of Washington website with many cultural profiles and resources Culture Grams: fee for service online information by country (limited free information) The Providers Guide to Quality and Culture Resources for Cross-Cultural Health Care Physician Toolkit Curriculum Univ. of Mass Medical School March Cross Cultural Medicine in American Family Physician 12/1/05

51 Web-based Interpreter Services (fee involved for first three) Language Line: ( ) Cyra-Com: American Translators Association Babel Fish (Altavista) translates blocks of text

52 Lost in Translation-1 Coors put its slogan, "Turn it loose," into Spanish, where it was read as "Suffer from diarrhea." When Gerber started selling baby food in Africa, they used the same packaging as in the US, with the beautiful baby on the label. Later they learned that in Africa, companies routinely put pictures on the label of what's inside, since many people can't read English. The name Coca-Cola in China was first rendered as Ke-kou-ke-la. Unfortunately, the Coke company did not discover until after thousands of signs had been printed that the phrase means "bite the wax tadpole" or "female horse stuffed with wax" depending on the dialect. Coke then researched 40,000 Chinese characters and found a close phonetic equivalent, "ko-kou-ko-le," which can be loosely translated as "Happiness in the mouth." In Taiwan, the translation of the Pepsi slogan "Come alive with the Pepsi Generation" came out as "Pepsi will bring your ancestors back from the grave."

53 Lost in Translation-2 Scandinavian vacuum manufacturer Electrolux used the following in an American ad campaign: "Nothing sucks like an Electrolux." When General Motors introduced the Chevy Nova in South America, it was apparently unaware that "no va" means "it won't go." After the company figured out why it wasn't selling any cars, it renamed the car in its Spanish markets to the Caribe. Ford had a similar problem in Brazil when the Pinto flopped. The company found out that Punto was Brazilian slang for "tiny male genitals." Ford pried all the nameplates off and substituted Corcel, which means horse. When Parker Pen marketed a ballpoint pen in Mexico, its ads were supposed to say "It won't leak in your pocket and embarrass you." However, the companies mistakenly thought the Spanish word "embarazar" meant embarrass. Instead the ads said that "It won't leak in your pocket and make you pregnant.“ In Chinese, the Kentucky Fried Chicken slogan "finger-lickin' good" came out as "eat your fingers off."

54 Lost in Translation-3 Chicken-man Frank Perdue's slogan, "It takes a tough man to make a tender chicken," got terribly mangled in another Spanish translation. A photo of Perdue with one of his birds appeared on billboards all over Mexico with a caption that explained "It takes a hard man to make a chicken aroused.“ Or, my personal favorite: “it takes a virile man to make a chicken pregnant.” Hunt-Wesson introduced its Big John products in French Canada as Gros Jos before finding out that the phrase, in slang, means "big breasts." In this case, however, the name problem did not have a noticeable effect on sales. “You are invited to take advantage of the chambermaid.”—from a guest directory in a Japanese hotel (1991) Japan's second-largest tourist agency was mystified when it entered English- speaking markets and began receiving requests for unusual sex tours. Upon finding out why, the owners of Kinki Nippon Tourist Company changed its name.


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