Dealing with Cultural Differences Dr. Jill Benson Director, Health in Human Diversity Unit, University of Adelaide Senior Medical Officer, Migrant Health Service, Adelaide and Tullawon Health Service, Yalata Aboriginal community

Dominant vs Minority cultures 25% of the current Australian population was born in a foreign nation where English is not the dominant language Culture is about more than just the country of birth - it is also about age, gender, education, socio-economic status, religion, language, occupation, sexuality, politics and life experiences

What is culture? What is your culture? Are there any other ‘cultures’ in your life? Does living in Adelaide give you a different culture? Do doctors have a culture of our own?

Culture The total way of life – the underlying pattern of thinking, feeling and acting – of particular groups of people How people make sense of their surroundings including attitudes and behaviour, assumptions and values What people ‘take for granted’, what they notice about others but is largely invisible to themselves The interaction between language, social structure, religion, world view, environment, economy, technology, belief and values

Other cultural concepts Multiculturalism: An ideology advocating that society should consist of, or at least allow and include, distinct cultural groups, with equal status Cultural awareness: Knowing and understanding that there is a difference between people or cultural diversity; having insight into the physical, psychological, social, spiritual, economic and political context in which people live or have lived

Ethnocentricism The unconscious tendency to assume that how we behave, think and feel is the absolute (behaviour, thoughts, feelings) way of being for everyone Normal Good Right Appropriate Expected

Where does this come from? Genetic predisposition Childhood history Culture Spirituality Personality Finances Education Health Sense of Humour Personal Insight

Differences in other cultures Communication styles Attitudes towards conflict Always agreeing Approaches to completing tasks Tomorrow will be fine Decision-making styles Procrastinators Attitudes towards disclosure Only if I know you and trust you Approaches to knowing “You’re the doctor”

Will this impact on patient care? Eye contact Medication – cure vs treatment Appointments Relationship with people in authority Are they telling the ‘truth’ anyway? Is health a priority in their life? Consulting with other people – family, other healers

World-view ‘Western’ individualistic world-view Individualism and consumerism Body and mind are separate Usually assumes people are responsible for their own misfortune Collectivist world-view (Indigenous cultures and the developing world) Spiritual and ecological Consensual and communal Spirituality pervades every aspect of the lives of people from most indigenous cultures and cannot be differentiated from either their physical or mental well-being

Health literacy Understanding of anatomy and how the body works Must be taken into account when talking to patients from different cultures Causes of illness might be seen as spiritual or environmental rather than as bacteria or lifestyle What causes disease, pregnancy etc? What does this illness mean to the patient?

Concordance and communication About 50% of our patients do not take the medication, have the investigations or follow the advice we give If we listen to our patients for just 2 minutes they are more likely to comply with our advice During this time we need to practice active listening techniques

‘The answers to health problems must include giving people a sense of personal self-worth, a sense of being needed or loved, an ability to influence and control their own environment, and an ability to manage their own problems.’ (Trudgen)

Cultural Awareness Tool What do you think caused your problem? Why do you think it started when it did? What do you think the illness does to you? What are the chief problems it has caused for you? How severe is your illness? What do you most fear about it? What kind of treatment/help do you think you should receive? Within your own culture how would your illness be treated? How is your community helping you? What have you been doing so far? What are the most important results you hope to get from treatment?

Working with different views of illness The doctor works exclusively within the biomedical model The patient and doctor function exclusively within each of their own cultures The doctor works within the patient’s cultural framework The patient and doctor negotiate between their concepts of the cause of the problem/illness/disease and the most appropriate management to reach mutually desirable goals

Styles of communicating Authoritarian Instructional Empathic Collaborative with the family, community and management team Which are you most of the time? Are any of these inappropriate? Are there times when each might be appropriate?

Are any of these styles more helpful if there are different health beliefs? Authoritarian if their life is in danger Instructional if it is important to understand what is going on so that will feel safe, have the investigations, have the treatment, return for follow-up Empathic if what is happening is overwhelming or frightening Collaborative if there is a strong collectivist world-view or there is a need for support

Language Competency Tips Asking people their name, address, date of birth and other predictable information is not an adequate test of English skills Having social conversation skills does not always mean that the person understands complex information in spoken or written English Verbal skills do not always equate with reading and writing skills People often lose their second language skills in stressful situations Always use a properly qualified interpreter

Family members If you use family members They might filter the information to "protect" their parent, relative or friend They might not be able to handle, or cope with things they will hear They might use information for private advantage or gain They cannot be expected to know the specialised terminology, and might make a serious or even fatal mistake They will not be impartial

Jargon ‘I think your ticker’s on the blink’ ‘I guess you’re keen to hit the road’ ‘That probably drives you up the wall’ ‘Hey dude, how’s it hanging?’ It is important that health professionals do not use jargon or local dialect when speaking to patients from a different culture, even if that culture has English as a first language Always ask the patient if you don’t know what something means

Conclusion Culture is an important aspect of any interaction with patients Reflect on your own ethnocentricism Ask the patient about the impact of their culture on their health Remember to take health literacy into account Be aware of what style is appropriate Use the right interpreter if necessary Don’t be afraid, be compassionate – courage and a good heart go a long way

Thank you