Do you want to achieve cultural competence?

If so, there are some basic concepts you need to understand. Continue scrolling to learn some of the most important ones. Or, click on the topic links below to go directly to a concept. The material is taken directly from my book, "Caring for Patients From Different Cultures, 3rd ed."

I will be making many generalizations throughout this website. They should not be mistaken for stereotypes. A stereotype and a generalization may appear similar, but they function very differently. An example is the assumption that Mexicans have large families. If I meet Rosa, a Mexican woman, and I say to myself, "Rosa is Mexican; she must have a large family," I am stereotyping her. But if I think Mexicans often have large families and wonder whether Rosa does, I am making a generalization. A stereotype is an ending point. No attempt is made to learn whether the individual in question fits the statement. Stereotyping patients can have negative results. A generalization, on the other hand, is a beginning point. It indicates common trends, but further information is needed to ascertain whether the statement is appropriate to a particular individual. Generalizations may be inaccurate when applied to specific individuals, but anthropologists do apply generalizations broadly, looking for common patterns, for beliefs and behaviors that are shared by the group. It is important to remember, however, that there are always differences between individuals.

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Values are the things we hold as important. Just as each individual holds certain values, each culture promotes different ones. American culture (and I use this term loosely because there are literally hundreds of subcultures within the United States) currently values such things as money, freedom, independence, privacy, health and fitness, and physical appearance.

One way to assess a culture's values is to observe how it punishes people. In the United States wrongdoers are punished by being fined (taking away their money) or incarcerated (taking away their freedom). The Mbuti pygmies of Africa value social support, and they punish people by ignoring them. The kind of health care provided by the American medical system is often influenced by financial considerations, whereas concern for family, low on the list of "American" values, influences much patient behavior. Hence conflict may develop between health care providers and patients.

In the United States, independence is manifested by the desire to move away from home as soon as one is financially able. In many cultures that value family more than independence, adult children rarely move out before marriage and often not thereafter. The health care culture also supports the values of independence and autonomy in its efforts to teach self-care and in often giving information only to the patient, excluding other family members.

Privacy is also very important to most Americans, who build fences to separate their houses from each other. The U.S. health care culture tries to provide privacy for patients by limiting visiting hours and offering no sleeping accommodations for visitors. Many non-Anglo patients, however, prefer just the opposite.

Health and fitness are popular movements, particularly on the West Coast. There are hundreds of food products labeled "low fat" and "low cholesterol." People can be seen jogging on most city streets, and attendance at gyms is high. This obsession with health leads the medical profession to expect patients to comply with suggestions regarding changes in diet and exercise, assuming that health and fitness is a value shared by all. It is not. Furthermore, what is considered "healthy" varies cross-culturally.

Concern for physical appearance is manifested at every magazine stand. There are few women's magazines that do not have articles on the latest diet, makeup, hairdo, and clothing. The incidence of cosmetic surgery for both men and women is at a record high. Surgical techniques are developed to minimize scarring and maintain beauty. What is considered "beautiful," however, is not the same for every culture.

Understanding people's values is the key to understanding their behavior, for our behavior generally reflects our values. A dramatic example occurred in the early 1980s, when a Japanese ship captain was bringing a boatload of cars to the United States. There was a disaster at sea, and the cargo was ruined. The captain had done nothing to cause the disaster, and he could not have prevented it. If an American ship captain had had a similar experience, the first thing he probably would have done when he reached land was call his insurance agent to see who would pay for the damages. The Japanese captain killed himself. There is obviously a big difference between calling one's insurance agent and killing oneself. The different reactions are dictated by different values. The hypothetical American captain would probably value money; his concern would be for the financial loss. The Japanese captain was concerned with his honor. As the captain of the ship, he considered himself responsible for the accident. The loss of the cargo meant the loss of his honor. Without honor, he felt he could not live. Committing ritual suicide was the only way for him to regain his honor.

Values influence our everyday behavior as well. Why are you reading this? Is it because you value knowledge and hope to learn something? Is it because you are required to read it for a course and you value good grades? If so, are you motivated because good grades will get you a better job, and with a better job you will earn more money, and you value money? Nearly everything we do reflects our values on some level.

Values and the American Health Care Culture

One reason for so many conflicts and misunderstandings in hospitals is the great disjunction between the values of the health care culture and that of the patient population. As mentioned earlier, the health care culture values autonomy and independence. Patients, on the other hand, often value the family over the individual, and prefer to make decisions as a group and to assist the patient in "self-care" functions the staff thinks the patient should do on his or her own. Furthermore, many prefer to have family members with them at all times, leading to chaos and loss of control from the perspective of the nurses. The health care culture's value of efficiency often conflicts with patients' value of modesty. Many doctors and nurses find concern about keeping patients covered difficult when their primary focus is performing an appropriate procedure. The health care culture also values self-control. Many patients, however, come from cultures in which emotional expressiveness is the norm. This can lead to resentment toward such patients on the part of the staff. Problems also result from a disparity between the world view of the health care culture and that of the patient population.

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The second most important concept for understanding people's behavior is to understand their worldview. Problems can result from a disparity between the worldview of the health care culture and that of the patient population. People's worldviews consist of their basic assumptions about the nature of reality. These become the foundation for all actions and interpretations. For example, people whose worldview includes the notion that everything happens for a reason will tend to find meaning in all events. A childless thirty-five-year-old woman who goes through the emotional agony of finding a breast lump, only to have the biopsy turn out to be negative, may interpret the experience as a message from the universe reminding her that now is the time to decide whether or not she wants to have children (breasts metaphorically representing nurturing). As another example, someone who believes that the world is a hostile place and “out to get them” may perceive a health care provider who is late for an appointment due to a sudden emergency as deliberately displaying prejudice.

An individual’s worldview can have an important influence on his or her health care behavior. For example, someone with a scientific worldview might perceive birth defects as a mistake in the transcription of DNA during the process of meiosis, while someone whose worldview encompasses the notion of reincarnation might see it as resulting from improper behavior in a past life, and someone who believes that God rewards good behavior and punishes bad behavior might interpret it as punishment for one’s sins. Thus, one’s worldview might affect one’s interest in genetic counseling during pregnancy. Again, if part of an individual’s worldview is that the physical body is all there is, that person might want everything possible done to extend their life. A person who believes that this life is but a precursor to the next, however, might be more willing to “let go.” If one’s worldview holds that life begins at conception, abortion will be viewed as murder; if, however, life is thought to begin at the point that the fetus becomes viable, a first trimester abortion is simply a medical procedure.

While we all have our own individual worldview, our culture can influence the way we perceive things. Religion often defines the worldview of people who are devoutly religious. Belief in the existence of God, for example, might be part of their worldview. If people believe God confers both health and illness, it may be very difficult to get them to take certain medications or change their health behavior. They might not share the health care culture’s belief that germs cause disease and that diet and exercise contribute to one’s health. They may see no point in worrying about high blood pressure or bacteria when moral behavior is the key to good health.

Since people's worldviews consist of their assumptions about the nature of reality, they rarely question the veracity of their beliefs. For example, a devout Christian might not be likely to conclude that God does not exist on the basis of the accidental slaughter of innocent children. Rather, the Christian might simply remark that "God works in mysterious ways." No matter how much "evidence" is presented to the contrary, people rarely change or even question their worldview. Instead, they reinterpret events in a manner consistent with their beliefs.

People’s Relationship to Nature
Another aspect of worldview involves people's relationship to nature. The culture of the United States, for example, believes people can control nature. If the land is dry, they irrigate. If bacteria cause disease, they destroy them. If the heart does not work, they replace it. This also relates to the health care culture’s view of the body as a machine; if it becomes broken, one should simply turn it over to the mechanics (doctors and nurses) to be fixed. To the consternation of many health care professionals, not all cultures share that belief.

Other cultures, such as Asian and Native American, see people as a part of nature. They strive to maintain harmony with the earth and look to the land to provide treatment for disease. Herbal remedies are important in their cultures. Still other cultures, such as Hispanic, believe people have little or no control over natural forces. Que será, será. What will be, will be. Preventive health care measures are likely to be ignored; they would do no good anyway. Thus worldview can have important implications for health-related behavior.

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Two key anthropological concepts are ethnocentrism and cultural relativism. They refer to attitudes. Ethnocentrism is the view that one's culture's way of doing things is the right and natural way. All other ways are inferior, unnatural, perhaps even barbaric. Cultural relativism is the attitude that other ways of doing things are different but equally valid. It tries to understand the behavior in its cultural context. Most humans are ethnocentric. It is natural to think one's own culture's way is best. Anthropologists, however, strive to be culturally relativistic.

If I were to tell most Americans about a group of people in Africa who sometimes kill healthy newborn infants, they would probably take the ethnocentric attitude that these people were barbarians. If I were to explain that they were hunters and gatherers living on the edge of starvation and that if a second child is born too close to the first, chances are about 100 percent that both will die because the mother does not have enough milk to support both, their attitude might change. They still might not condone infanticide, but they might understand it as the only viable choice in a desperate situation. Rather than seeing the Africans as barbarians, they might realize that the people were forced to extreme measures by hopeless circumstances. Their attitude would thus change from being ethnocentric to culturally relativistic.

The Western health care system tends to be ethnocentric because practitioners believe that their approaches to healing are superior to all others. There is a lot we can learn, however, from other cultures. Many modern drugs, including quinine, were derived from plants used by native peoples. Westerners are beginning to acknowledge the effectiveness of acupuncture for certain conditions. The goal of all systems of healing is the same - to help people get well. If all cultures could study each other's techniques with a culturally relativistic perspective, the cause of modern medicine would be greatly advanced.

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Time orientation, one's focus regarding time, varies in different cultures. No individual or culture will look exclusively to the past, present, or future, but most will tend to emphasize one over the others. Chinese, British, and Austrian cultures have a past time orientation. They are traditional and believe in doing things the way they have always been done. Interestingly, in many cases, countries that emphasize the past are ones that were once more powerful than they are now. This may be their way of recognizing and valuing that time in their history. These cultures usually prefer traditional approaches to healing rather than accepting each new procedure or medication that comes out.

People with a predominantly present time orientation may be less likely to utilize preventive health measures. They reason that there is no point taking a pill for hypertension when they feel fine, especially if the pill is expensive and inconveniently causes unpleasant side effects. They do not look ahead in hope of preventing a stroke or heart attack, or they may feel they will deal with it when it happens. Poverty often forces people into a present time orientation. They are not likely to make plans for the future when they are concerned with surviving today.

Middle-class white American culture tends to be future oriented. That is reflected in the medical system's stress on preventive medicine and enthusiasm for each new medical technique or drug. In contrast to past-oriented cultures, progress and change are highly valued. China is also shifting to a future orientation, as evidenced by the long-term plan to reduce the country's population by limiting family size.

Hispanics and African Americans tend to have a present time orientation. This does not mean that they do not recognize the past or the future, but living in the present is more important to them. Their concept of the future may also be different from the Anglo concept. For example, African Americans are more likely to say "I'll see you" than "I'll see you tomorrow." The former implies the future but is not specific. The future arrives in its own time. From this point of view, one cannot be late. Conflict may occur, however, in interactions with white middle-class people, for whom time is very specific.

As the last statement implies, time orientation can also refer to degree of adherence to clock time. From the perspective of one oriented to the clock, someone who arrives at 3:15 for a 2:30 appointment is late. For someone who does not focus on clock time, both represent mid-afternoon. This type of time orientation appears to be related to subsistence economy. In countries with economies based on agriculture, people tend to be more relaxed about time; as I like to say, "The crops don't care what time they get picked." Many people in traditional agricultural villages do not own clocks; the pace is slower and more attuned to nature's rhythms. In contrast, industrialized nations must pay attention to clock time. There are large numbers of people to organize, and each must complete his or her task according to schedule in order for the next person to begin. Without clocks, chaos would reign.

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Just as cultures differ in time orientation, they also vary in social structure. American culture is organized according to an egalitarian model. Theoretically, everyone is equal. Status and power are dependent on an individual's personal qualities rather than age, sex, family, occupation, or any other characteristic. In reality, things may operate differently, but we hold equality as our ideal. Some cultures such as Asian are based on a hierarchical model. Everyone is not equal. Status is based on such characteristics as age, sex, and occupation. Status differences are seen as important, and people of higher status command respect. Social structure, then, can have an important influence on the way people interact.

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