Why Does Culture Matter in Health Care and What Can We Do About It? Arthur Kleinman November 3, 2006

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.”

Why Does Culture Matter? Strong evidence of health inequalities along race and ethnicity. Systematically worse health outcomes for members of minority racial and ethnic groups. A greater dissatisfaction with health services expressed by members of minority groups. Because “culture” affects medical experiences, it is a vital component in effective care.

Taking Culture Seriously In the last 20 years health care providers have increasingly taken culture into account, albeit through oversimplified models. This “index-card” model that views cultures as static, unchanging, and homogenous is inadequate. Culture is not a thing; rather it is more usefully conceived as a process through which ordinary activities take on emotional tone and moral meaning for participants.

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 affect and is affected by all of these. Treating “culture” as homogenous misses that cultural meanings and practices may differ within the same group owing to age, gender, political faction, class, religion, ethnic group, and even personality.

The Culture of Biomedicine At an earlier period in health care, culture referred almost solely to the culture of patient and family. Now it’s been shown that the culture of the professional caregiver, including both the background of the medical professional, as well as the culture of biomedicine, has importance. This biomedical culture is expressed in particular institutions such as hospitals, clinics, medical schools and is now seen as key to the problems in patient-professional relationships, clinical communication, transmission of stigma, institutional racism, and the development of health disparities.

Explanatory Models In the 1970’s I introduced a technique that tries to understand how the social world affects and is affected by 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? How does 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)

Explanatory Models II Problems with this approach include: Questions can become a conversation stopper rather than facilitating dialogue These can lead to the medical professional fixing beliefs as if they were unchanging The model has, at times, been implemented as cultural stereotypes However, when it is applied with attention to these problems, explanatory models can be extremely useful in clinical dialogue.

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 (DSM-IV). See appendix I

Step 1: Ethnic Identity As part of this questioning it is crucial to affirm a person’s experience of ethnicity and illness, communicating an awareness that people live their ethnicity differently. Ask about ethnic identity and whether it is an important part of the person’s sense of self. Rather than assuming knowledge about the patient that can lead to stereotyping, asking the patient about ethnicity and its importance is the best way to begin.

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.

Step 3: The Illness Narrative The goal in this step is to draw on the questions from the explanatory model to develop a dialogue between the patient and medical professional about the patient’s story of the illness taking into account cultural meanings and care. The clinician should be open to cultural differences in stories about local worlds and the patient should recognize that doctors do not fit a certain stereotype anymore than they do themselves.

Step 4: Psychosocial Stresses The goal is to understand the ongoing stresses and social supports that characterize people’s lives. These may include family tensions, problems at work, financial struggles, and personal anxieties. These stresses are often overlooked in the rush to explain behavior in cultural terms, and so it is important for the clinician to remain attentive to multiple explanations.

Step 5: Influence of Culture on Clinical Relationships Clinicians are grounded in multiple social worlds: the world of the patient, their personal networks, and the culture of biomedicine. Working between these social worlds creates an opportunity for critical self-reflection and the unpacking of the formative effect that biomedicine has had on clinical practice (i.e. bias, inappropriate/excessive use of high-tech approaches, and stereotyping).

(II) Step 5: Translating and Interpreting Translation should always be medically informed and oriented towards commonsense meaning and practical action. Interpretation means understanding and facilitation communication across different local worlds.

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 a cultural approach is that it may be seen by patients and families as intrusive or even contribute to a sense of being singled-out and stigmatized. There is also the misguided belief that if we find the cultural answer, we’ll be able to resolve the issue, but often cases are much more complex than a simple fix.

Conclusion The most important thing that clinicians can do is to find out what is at stake for patients and for themselves in the clinical interaction. This goes beyond simplistic notions of cultural competency. It is a focus on the patient as an individual - a vulnerable human being facing danger and uncertainty - not a cultural stereotype. In the future it will be vital to conduct research that demonstrates the cost-effectiveness of a culturally informed approach.

References Kleinman, A. (1988) The Illness Narratives. New York: Basic Books Kleinman, A. and P. Benson (2006) “Anthropology in the Clinic” PLoS Medicine3(10): e294. Kleinman, A. “Culture and Psychiatric Diagnosis 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