INTRODUCTION

Changes in demographics in the United States (U.S.), health disparities, and patient safety are among the reasons that cultural competency must be emphasized in healthcare. Decisions and attitudes about healthcare are affected by multiple cultural variables including race, ethnicity, age, gender, sexual orientation and religious beliefs. Developing communication skills to interact with diverse populations involves recognizing personal styles and cultural values of communication as well as barriers to patient understanding. To interact more effectively with individuals from different cultural backgrounds, providers should develop cultural and linguistic competencies. Cultural competency refers to the attitudes, knowledge, skills and values that an individual has and uses in working effectively in a cross-cultural environment. Linguistic competency is defined as providing culturally appropriate oral and written language services to limited English proficiency (LEP) patients.¹ To provide culturally and linguistically appropriate services, the clinician must be respectful of and responsive to the cultural and linguistic needs of diverse populations.

Census data indicate that people of European American descent will no longer make up the majority of the population in the United States and projections for 2050 provide additional support for this shift depicting a demographic picture of the U.S. that is very different from today’s population. According to the 2017 National Population Projection, by the year 2050 the U.S. population will be 70.1% Caucasian, 14.6% African American, 1.4% American Indian or Alaska Native, 8.4% Asian, 0.3% Native Hawaiian and Other Pacific Islander, and 25.7% will be Hispanic or Latino.² In order to value diversity and be able to navigate in this everchanging dynamic, the clinician will need to acquire the knowledge of the intricacies of communication styles, familial roles, and health care practices in addition to other cultural values and beliefs unique to specific ethnicities. This manuscript will provide the initial knowledge base necessary to recognize various cultural traditions and beliefs to remove the barriers of cross-cultural communication and improve patient care.

CULTURE IDENTITY

Numerous factors can influence cultural values and beliefs toward healthcare. Age, gender, race, ethnicity, sexual orientation, religion, geography, neighborhood, acculturation and linguistic identities all shape how people behave and what they value. One of the dangers of learning to work with patients and families from different cultures is confusing stereotypes with generalizations. Stereotypes may be damaging to patients as they are an end point or assumption about the way people will behave. Generalizations, however, can provide a framework or a beginning to understand how patients may respond in healthcare situations.³ When developing a framework to work with patients, understanding the degree to which individuals identify themselves within different cultures is important to consider.

An understanding of social identity is an important concept in cultural competency. Social identity can be described as a person’s sense of self based on memberships to various social groups.⁴ Social group membership can be based on gender, age, ethnicity, race, family, sexual orientation, religion or other cultural factors. Individuals’ social identities consist of membership to multiple groups. For example, a person may identify as a young (age), Catholic (religion), female (gender), Hispanic (ethnicity), of African descent (race). There are instances in which one social group membership may become more salient and thus be more influential on behaviors than other group memberships. For example, a Latino woman may identify more strongly with her gender in the presence of several Latino males but identify more strongly with her race in the presence of several Caucasian women. Understanding how strongly a patient identifies with a particular social group will assist healthcare providers in identifying the influence of that social group’s cultural norms and expectations on the patient’s healthcare decision-making.

Culturally competent providers should be familiar with the concept of acculturation and its role in healthcare. Acculturation can be defined as the process by which individuals from one cultural group experience changes in behaviors, attitudes and beliefs as a result of continuous contact with a different culture. Levels of acculturation have been associated with differences in help-seeking behavior, healthcare utilization rates, adherence, presentation and perception of illness, attitudes toward healthcare providers and treatment, and beliefs about healing.⁵ It should not be assumed that immigrant populations are able to choose to participate fully in American society and that the ultimate goal is to assimilate into American culture. Models have been proposed to help understand the concepts related to acculturation. One model that provides a framework for understanding acculturation describes assimilation, integration, marginalization, and separation as four possible outcomes of the acculturation process. Individuals may have the least difficulty adapting to a new host culture when they are able to assimilate or integrate. Through the process of marginalization and separation, individuals have a more difficult time adapting to a new host culture.⁶ Understanding where the person falls in the acculturation perspective will help to identify which culture they more closely identify with and will in turn influence their health behaviors to a larger extent. Each of the possible levels of acculturation are described below.⁶

• Assimilation occurs when individuals lose (willingly or unwillingly) much of their identity from their home culture and adopt the new host culture.
• Integration occurs when the individual is able to adopt identities from both the host and home culture. These individuals may be considered bicultural or even bilingual.
• Marginalization occurs when individuals have strong identities to their home culture and may not be able to adapt well to the host culture. Marginalized individuals may include more recent immigrants or refugees.
• Separation occurs in individuals who never really understand their home culture or their host culture. They may live “in between” cultures, never fully learning the home culture or host culture. This phenomenon may occur in children who have never completed their basic education in either culture (thereby never mastering one language) or who do not have enough exposure to cultural events and traditions from their home or host culture to entirely understand or appreciate either heritage. 

Different cultures place varying emphasis on the importance of individual and the collective influences on decision-making. Those persons who come from more individualistic cultures, such as the United States, are more likely to place greater emphasis on an individual’s self-reliance and emotional distance from others within the individual’s group. Patients from individualistic cultures expect greater individual responsibility for healthcare decisions. Alternatively, persons who come from collective cultures experience greater emphasis on interdependence and family unity. Patients from collectivist cultures experience increased community participation with their healthcare decision-making.⁷ A study was done to determine the differences in the attitudes of elderly subjects from different ethnic groups toward disclosure of the diagnosis and prognosis of a terminal illness and toward end-of-life decision making. The researchers found that Korean-American and Mexican-American subjects were more likely to hold a family-centered model of medical decision making rather than the patient autonomy model favored by most of the African-American and European-American subjects.⁸ These results suggest that it is important to determine how patients wish to receive information and who will make decisions. Determining these preferences will reduce the barriers to cross-cultural communication and demonstrate respect for the differences in the decision-making process displayed by various cultures.

COMMON CHARACTERISTICS OF CULTURAL HEALTH BELIEFS AND PRACTICES

Pharmacists and technicians are expected to understand numerous cultural values while avoiding stereotypes and harmful biases. However, becoming culturally proficient in all cultural nuances may be an impossible task. Although it is not feasible to understand the intricacies of every culture, it is possible to explore common characteristics of various cultures in order to learn more about them. It is important to recognize that the following traits identified are generalizations about a cultural group and not every member of these groups will demonstrate these characteristics. Ultimately, care should be individualized, but the following generalizations can serve as a guide to working with patients from a particular race, ethnicity, religion or other cultural group. 

Individuals from different cultures may have different beliefs about the origins of health and illness and may not subscribe to the Western biomedical model beliefs that there is a pathophysiologic or etiologic reason for disease. In many cultures the source and meaning of illness may be attributed to a variety of other causes such as spiritual or religious influences, social factors and the environment.⁹ Various cultures describe illnesses that are only recognized within that culture. These culture-bound syndromes are also referred to as folk-illnesses.¹⁰ There are a variety of culture-bound syndromes that have been documented. For example, conditions such as susto (illness arising from extreme fright) or mal de ojo (illness caused by the “evil eye” resulting from excessive admiration or envy) can be found in Latin American and Middle Eastern cultures.¹¹Dhat is a culture-bound syndrome reported in Indian cultures that manifests as fatigue, weakness, or sexual dysfunction thought to be caused by a loss of semen during urination, masturbation, or nocturnal emission.¹⁰ Culture-bound syndromes are also found in Western cultures. Anorexia nervosa is well-recognized in Western cultures but may not be acknowledged in other cultures.¹²

Certain healthcare practices may stem from historical events or experiences. Geophagy, the practice of eating clay or dirt, is common in Central Africa and the Southern United States. It usually takes place during pregnancy, as part of religious ceremonies, or as a remedy for disease. The clay commonly ingested in Africa contains important nutrients such as phosphorus, potassium, magnesium, copper, zinc, manganese and iron and supplements the needs of pregnant women. Historically, the tradition of geophagy spread from Africa to the U.S. with the institution of slavery.¹³ Additionally, African Americans may not trust the healthcare system or research projects because of previous injustices such as the Tuskegee syphilis study. This study was conducted by the U.S. Public Health Service from 1932 to 1972, in which African American men with syphilis were recruited to participate in a study to investigate the natural course of untreated disease. As an incentive for participation in the study, the men were promised free medical care but were deceived by the investigators who never informed subjects of their diagnosis, disguised placebos, and used ineffective methods of treatment. This project continued until the early 1970s despite confirmation in the 1940s that penicillin was an effective treatment for syphilis.¹⁴

Clinicians should be aware that cultural beliefs may lead to the practice of alternative forms of healing and this should be taken into consideration when evaluating a patient. Members of various cultures may employ the use of traditional healers who may use different integrative practices including massage, yoga, herbal medicine, acupuncture or aromatherapy. Traditional healers include curanderos(as) in some Latin American cultures, “medicine men or women” in various Native American communities, voodoo doctors in African American cultures, or santeros (mediums) among individuals practicing Santería, a religious practice originating in Nigeria.¹¹ Religious rituals or ceremonies are often an important part of treatment in many cultures. Native Americans participate in symbolic healing rituals and ceremonies are held to bring participants into harmony with themselves, their tribe and their environment. Native American healing includes beliefs and practices that combine religion, spirituality, herbal medicine, and rituals that are used to cure both medical and emotional problems. In some tribes, healing rituals may involve entire communities where participants would sing, dance and paint their bodies to persuade the spirits to heal the sick person.¹⁵ Patients of Asian descent may practice coining (coins dipped in oil, heated, and then rubbed on skin), cupping (heated glass cups placed on skin to create a vacuum), moxibustion (heated incenses or wood applied over the skin), or pinching of skin in order to draw out illnesses.¹¹ These practices may produce bruises, burns, or welts on the skin that might be confused with signs of physical abuse. Developing a general understanding of common cultural health behaviors can help clinicians to approach patients in a sensitive and respectful manner and provides a background to ask questions to determine cultural differences.

KEY CHARACTERISTICS AMONG SPECIFIC CULTURES

Although there are common characteristics between all cultures, there is also merit in addressing only those domains most prevalent to specific cultures. The following will address some of America’s major cultures and present some key characteristics that a pharmacist or technician should be aware of when working within each population. Communication styles, family structures and health care practices unique to each culture will be explored below.

Hispanic/Latino

Though the terms Hispanic and Latino are used interchangeably they are far from the same. The U.S. Office of Management and Budget defines Hispanic or Latino as a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.¹⁶ The term Hispanic is derived from the Latin term for “Spanish” and is referencing the language. Hispanics are people who speak Spanish and/or whose origins or ancestors are from a Spanish-speaking country. Latino is a term that refers to geography and means from Latin America. Those born in or with ancestors from Central, South America or the Islands of The Caribbean can be described as Latino. The main difference between Hispanics and Latinos is that Hispanic is based on whether you or your family speak Spanish whereas Latino is focusing on the geographic location (e.g., Latin America).¹⁷

Communication Styles

Traditionally, the primary language spoken within the Hispanic/Latino culture has been Spanish. However, the primary language largely depends on the individual’s country of origin. Other languages may include Portuguese, Quechua, Mayan languages, Guaraní, Aymara, Nahuatl, English, French, Dutch and Italian.¹⁸ In 2014, 68.4% of Hispanics reported they spoke English at home or that they speak English “very well” as compared to 59.0% in 1980.¹⁹ In addition language, there are other common aspects of communication to consider. Respect is very important in this culture and the greeting can either signify respect or lack of respect. Using a title and full name in the greeting will convey appropriate respect. In addition, Hispanics expect a caregiver to show warmth to a patient and family members and should not be strictly business.²⁰ This means interacting in a caring manner that extends beyond the individual and into other aspects of his/her life, often referred to as personalismo. When used in a genuine manner, the application of personalismo has been shown to improve patient compliance because a bond has developed between the patient and provider.²¹

Family Structure

The family unit is very important and decisions are typically made by the male head of the household.²¹ Although this dynamic continues to evolve, males traditionally work outside the home and females are responsible for parenting and running the daily activities of the household.²² Extended family members usually live in close proximity and have frequent interactions.²¹ Since the family unit is highly valued, when a family member is sick, it is a family crisis and more than one family member may participate in the healthcare encounter. Integration of all family members into the decision-making process is important for treatment success.²⁰

Healthcare Considerations

Risk factors for diseases coupled with decreased health care access make Hispanic/Latinos disproportionately vulnerable to disease and death. Recent reports show that the leading causes of disease are heart disease, cancer and hypertension, while the leading causes of death are cancer, heart disease, and unintentional injuries.¹⁹ This population is disproportionately affected by obesity, with 42.5% of Hispanic adults currently classified as obese. This reflects a significant increase in prevalence since 1999, when approximately 20% of Hispanic adults were classified as obese.¹⁹ The prevalence of diabetes has been steadily rising when compared to non-Hispanic cultures. Hispanics are approximately 50% more likely to die from diabetes in comparison to non-Hispanics.²³ Liver disease is the eleventh most common cause of death in Americans, but the sixth most common cause of death in Hispanic populations. Hispanic individuals have a 48% higher death rate from liver disease and cirrhosis than non-Hispanic patients.¹⁹  

There are many factors to consider in health care seeking behavior. According to the 2012 National Health survey 35% of Hispanic men and 20% of Hispanic women were without a usual place of health care.²⁴ While lack of insurance coverage is a considerable factor there may be others that are more influential when related to health seeking behaviors. Men tend to seek healthcare when the illness interferes with work and they cannot provide for their family.²⁶ Women are primarily responsible to make sure other family members seek health care and place their healthcare priorities below that of other family members resulting in less devotion to their own needs.²⁶

The supernatural is believed to contribute to the general health of the members of the culture and as a result there are many types of healers and practices that are sought when suffering from an illness. Different specialists from whom an individual may seek care include a yerberos who focuses on herbal therapy, parteras practice as midwives, sobadores practice massage therapy and curanderos practice curanderismo and can treat a multitude of symptoms.²⁷ There is also a culturally unique perception of pain. It is believed that pain is a required part of life that must be tolerated and occurs because of wrongdoing. This may lead to a misperception in pain assessment scales and undertreatment of pain as the individual may tend to rely on prayer or other alternative methods to relieve pain.²⁸ Lastly, the use of mental health services is lower in this patient population perhaps due to stigmatization, lack of coverage or language barriers.²⁹

African Americans

Throughout history African Americans have been identified by many different names. It began with Negro ("black" in Spanish and Portuguese), then colored, and eventually Black. Then in 1989, Jesse Jackson, the civil rights activist, promoted the term African American to contextually dignify the origin of Black people in the Americas. Definition of Black or African American used in the 2010 Census refers to a person having origins in any of the Black racial groups of Africa. The Black racial category includes people who marked the “Black, African American, or Negro” checkbox. It also includes respondents who reported entries such as African American; Sub-Saharan African entries, such as Kenyan and Nigerian; and Afro-Caribbean entries, such as Haitian and Jamaican.³⁰

Communication Styles

Generally, African Americans are passionate and animated in their speech and language patterns. In professional greetings, many prefer to be addressed as Mr. or Mrs. or by their professional title. Generally, the direct approach is preferred and facing the person while having direct eye contact is considered appropriate. More physical touch is employed when with friends as compared to European Americans but less than that usually seen among people of Latin or Arab cultures.³¹

Family Structure

Great value is placed on familial relationships which tend to include extended family and it is not uncommon for more than one generation of an African American family to be sharing living quarters. African Americans are raised to care for family members no matter what the circumstances. Thus, elders may also play a key role in family and community systems and often share in child rearing.³² In a two-parent household, families are often matriarchal although the father or the oldest male child may be the spokesperson. The rate of African American marriage is consistently declining, and trends are so pervasive that families who are married are now considered a minority family structure. In 1970, 64% of adult African Americans were married; this rate was cut in half by 2004, when it was reported as 32%.³³ While research has shown that marriage rates have dropped for African Americans, the birth rate has not. Thus, the number of single-parent homes has risen dramatically for black women. Black male incarceration and higher mortality rates among males are often pointed to as reasons for the decreasing marriage rates and increase in single parent homes. The chance that a black male will be arrested and jailed at least once in their lifetime in many areas around the country is extremely high, in some states it has been shown to be as high as 90%.³³ African-American families historically have relied on extended family structure, religion and spirituality, and strong ethnic identity to survive slavery, racial discrimination and chronic poverty.

Healthcare Considerations

The death rate for African Americans decreased by 25% from 1999-2015 primarily for those aged 65 years and older. Despite these improvements, new analysis shows that younger African Americans are living with or dying of many conditions typically found in Caucasians at older ages including hypertension, diabetes and stroke.³⁴ According to the 2012 National Health Interview Survey, 35% of non-Hispanic black women and 30% of non-Hispanic black men had hypertension and 36% of black adults were found to be obese.²⁴ Health differences are often due to economic and social conditions that are more common among African Americans such as lack of access to providers, poverty or other health disparities.

Many African Americans attempt to alleviate medical conditions with home remedies or folk medicine. Some African Americans allow their illness or disease to progress due to distrust in modern medicine and seek integrative methods to alleviate illness. African American traditional healing methods include root doctors, folk medicine, and the use of root and herbal medicine. Religious faith is also a traditional healing method utilized by African Americans. The culture believes that God decides life and death, as well as pain and suffering and through prayer and faith miracles of healing can occur. If healing does not occur, it is thought to be a part of God’s plan, and that provides closure and acceptance within the culture.³⁵

ASIAN AMERICANS

Asians and Pacific Islanders are one of the fastest growing ethnic populations in the United States and represent 49 different ethnic groups and over 100 languages. ² In the 2000 U.S. Census, the Federal Government defines “Asian American” to include persons having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. “Native Hawaiian and Other Pacific Islander” includes Native Hawaiian, Samoan, Guamanian or Chamorro, Fijian, Tongan, or Marshallese peoples and encompasses the people within the United States jurisdictions of Melanesia, Micronesia and Polynesia.³⁶

Communication Styles

Approximately three quarters of Asian Americans speak a language other than English at home. Roughly one-third of Asian Americans are limited-English proficient (LEP) and experience some difficulty communicating in English.³⁶ In relation to non-verbal communication, the control of emotional display is highly valued and overt displays of strong emotion are considered unacceptable. Hand gestures may be viewed as an insult and direct eye contact lasting longer than a second or two is avoided, especially with those superior to oneself in the hierarchy or with elders. In public settings, touch is often so rare as to be virtually non-existent and even within the family structure touch is still reserved. Being direct is considered appropriate in communication and may be viewed by other cultures as evasive or obscure.³¹

Family Structure

Asians place a strong emphasis on family connection and the family model is an extended one including immediate family and relatives. Most Asian cultures emphasize a patriarchal family hierarchy and the responsibility of taking care of elderly parents and grandparents usually falls to the eldest son. In the traditional Asian family, parents define the law and the children are expected to abide by their requests which makes respect for parents and elders critically important. This manifest in rules of conduct such as only speak when spoken to or speaking only if one has something important to say. Most decisions will be made by the family patriarch and family matters are typically private and only discussed within the family. As a result of the importance on the family unit, often healthcare decisions involve the entire family.³⁷ 

Healthcare Considerations

Asians have often been labelled as the minority that paints a picture of optimal health. From the data gathered by the National Health Interview Survey in 2012 this can be easy to discern when Asians are compared to other cultures. The data showed that only 10% of Asians were smokers; 58% of adults were at a healthy weight; and 42% of adults were lifetime abstainers from alcohol.²⁴ According to the Office of Minority Health, despite this low risk behavior profile, Asian Americans are still at risk for cancer, heart disease, diabetes and conditions including hepatitis B and liver disease. Asian Americans have a lower incidence and mortality than non-Hispanic whites in all cancers combined, but higher rates for certain cancers especially liver and stomach cancer. ³⁸ Also tuberculosis (TB) seems to be of rising concern in this population. In 2019, Asians in the United States accounted for nearly 36% of all people reported with TB nationally. The rate of TB disease is 32 times higher for Asians as compared to Caucasians. Several important factors contribute to the higher rates of TB among racial and ethnic minority groups, including Asians. These factors include being born in a country with a high rate of TB or traveling to a country with a high rate of TB. Many people born outside of the U.S. have been given the BCG vaccine for TB which may cause a false positive reaction to a TB skin test.³⁹

Traditional Chinese medicine remains popular and many traditionally oriented Asian patients will seek medical help through Western based medicine systems only as a last resort. Chinese medicine is based on keeping the body’s yin (cold) and yang (hot) energies in harmonious balance. If there is an imbalance of yin and yang, the body’s immunity is disturbed, making the body susceptible to disease. Traditional Chinese medicine practitioners use various mind and body practices such as acupuncture and tai chi as well as herbal products to address the imbalance of yin and yang.⁴⁰ The practice of Ayurvedic medicine is also common. Many modern comprehensive Ayurvedic treatments typically include nutritional programs, herbal medicines, lifestyle recommendations, yoga and other exercises, meditation, and detoxification and rejuvenation techniques.⁴¹ Many Asians are less likely to pursue psychiatric care and counseling because they consider psychiatric conditions shameful. ⁴⁰ For many Asians, mental illness is thought to be associated with a disruption of harmony as well as the work of evil spirits. Therefore, coping treatments will often consist of a combination of herbal and traditional remedies such as shamans or spiritual consultants.⁴² In healthcare settings, Asians may be unwilling to acknowledge strong emotion, grief, or pain due to their cultural value of remaining poised and reserved and this often makes it difficult for the clinician to interpret symptoms.³⁷

NATIVE AMERICANS

The U.S. Census Bureau defines an American Indian or Alaska Native as a person having origins in any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment. Indian tribes maintain the power to determine its own form of government including the power to interpret its own laws and ordinances. These laws will often be upheld by courts and other government agencies.⁴³ 

Communication Styles

The preferred communication style is restrained and indirect. Eye contact is usually fleeting, and the gaze of listener and speaker will often focus on other facial areas besides the eyes since direct and prolonged eye contact is seen as invasive. In formal group speaking situations, turns are taken by everyone present, and no one speaks until the previous speaker is finished and a few moments of silence have passed. Speaking too quickly shows disrespect for the importance of the other person or of what they had to say. Interrupting another speaker is rude and may lead to severe social consequences if the person interrupted is an elder. Interacting with members of other cultures in which appropriate pause times are shorter, is a stressful experience for the Native American who feels forced to violate their own cultural values in order to be heard. Native Americans often prefer a larger physical space for conversation (greater than an arm’s length) and prefer side-to-side rather than face-to-face conversations. A handshake is very light and fleeting to avoid imposing energy on the other person or receiving unwanted energy.³¹

Family Structure

The Native American family structure was changed by contact with Europeans, who misinterpreted, misconstrued, or simply misunderstood Indian customs. Extended family groups formed their communities and were made up of blood and non-blood relatives. Most Indian cultures were matrilineal, married couples lived near the wife's family, the mother was the center of the family, and her children received their identity from her family. Division of labor consisted of women who grew crops, erected houses, and did everything related to the home while men hunted, fished, and made war. Children were lavished upon and considered valued members of society representing the renewal of life. As the number of Europeans increased, American Indians were pushed to the edge of extinction, pushed off their land and their familial structures were greatly affected.⁴⁴

By 1871, most Native American groups had signed treaties and were placed on reservations. Native families have suffered because of federal policy mandates, including removal of children from their homes and communities to boarding schools, orphanages, foster care, or reform schools. In the late twentieth century, social ills plagued reservation and urban life. Alcoholism directly or indirectly affected most Native American families and some reservations had exceedingly high rates of homicide and suicide. Compounding these problems was a high unemployment rate on most reservations and many families living below the poverty level. In addition, Native Americans found that the government had banned many spiritual ceremonies making it increasingly difficult for Native Americans to find balance their new world that seemed unholy and no longer sacred. There were economic changes and gender role conflicts that eventually paved the way to a patriarchal society.⁴⁴ In the midst of this oppression, Native American families found this change necessary to endure in a new society.

Healthcare Practices

The Indian Health Service (IHS) is an agency within the U.S. Department of Health and Human Services funded by the federal government to provide care to Native Americans across the country. Despite a legal obligation on the part of the U.S. to provide health care to this community there is still a significant inequality in healthcare. Native Americans have a life expectancy that is 4.4 years less than all other race populations in this country.⁴⁵ They continue to die at higher rates than other Americans in many categories of preventable illness, including chronic liver disease and cirrhosis, diabetes, and chronic lower respiratory diseases. Challenges in healthcare include chronic underfunding provided to IHS and shortage of clinicians, especially in remote reservations.⁴⁵ The National Health Interview Survey in 2012 showed that 19% of Native American adults were current smokers and 41% reported being obese²⁴ with the leading causes of death as heart disease and cancer.⁴⁶ According to the CDC, Native Americans have a greater chance of having diabetes than any other U.S. racial group. Diabetes is considered to be the cause of kidney failure in two-thirds of Native Americans.⁴⁷

The foundation of the Native American belief system is built upon the necessary harmony of individual, family and community, nature, and spirituality. Health is maintained only when harmony exists between these principles. Although Western medical providers may be utilized to heal illness, it is only the traditional healers and their sacred ceremonies that can address the true cause of the illness. The traditional healers include specialists such as diagnosticians, herbalists, singers, medicine men and women, and holy men and women. These specialists rely on the earth’s vegetation for herbal remedies. For example, the buds of cacti are used to produce the powerful narcotic peyote used to provide sacred visions to the healer.⁴⁸

The Native American perspective of life is based upon the Five Great Values which include generosity and sharing, respect for elders, harmony with nature, freedom and courage. The adaptation of these values in life has a great influence on their healthcare practices. As a matter of respect, generosity and sharing, a sick family member would never be left alone. Many family members will often be present when caring for a patient in a hospital or other clinical setting. There is a great respect for nature and allowing it to take its course. This may strongly infer a limited acceptance to long-term artificial life support. Native Americans are taught to suppress any expressions of pain and therefore the need for pain medication is often overlooked.⁴⁸ A clinician must inquire and respect the patient’s wishes for pain relief. Understanding these values will help the clinician interpret the behavior of Native Americans in the traditional Western medical system. 

Middle Easterners

Choosing Middle Eastern on the U.S. census is not an option. Instead it is defined as white, along with European and North African identities. In the 2020 census the U.S. Census Bureau offered a space for people selecting the White and Black race groups to write in a subgroup. Currently, Arab Americans comprise most of the projected Middle Eastern population and data on population statistics is usually derived from this population as a rough proxy for the Middle Eastern community.⁴⁹

Communication Styles

More than one in five Arab Americans marked they speak English less than very well according to the 2016 U.S. Census data.⁴⁹ Other languages spoken include Arabic, Farsi (Persian), French, Berber, Kurdish, Armenian, Hebrew and Azerbaijani. Middle Easterners demonstrate a ritual courtesy toward strangers in the constant flow of offers of hospitality and complements which to Westerners may sound insincere. They tend to invest a huge amount of time establishing personal relationships and are very comfortable with touch as part of communicating. There is less of a need for personal space and will typically stand close to someone they are conversing with in order to read the other person’s reactions. Direct eye contact is usually avoided with members of the opposite sex.⁵⁰ They are often very expressive and loud in communications as a way of relaying emotion.⁵¹

In a healthcare setting, the clinician should speak first to the family spokesman who is usually the oldest and most highly educated member of the family. When speaking, there may be a pattern of repetition which can be interpreted as condescending. This repetition simply means there is a recognition of the significance of the situation. Until trust is established, they will not disclose information to a stranger, including a healthcare professional. Once trust is established the patient is usually cooperative and willing to comply. To build a relationship the clinician should show that names and other aspects about their families are remembered. The clinician could share something about themselves that the patient can identify with as a means to establish the relationship.⁵¹

Family Structure

The extended family is central in this culture and families gather and make spontaneous visits almost daily. Children live with their parents until they marry and maintain close contact with parents after marriage. Children are expected to care for their parents until death. The family is patriarchal in nature and often the husband makes decisions for the wife and the children in relation to healthcare. The intense caring and involvement with family and close friends is accompanied by mistrust and doubt about the intentions of those outside the intimate circle which can impact interactions with healthcare providers.⁵⁰

During illness or crisis, Middle Easterners rely heavily on their families instead of trying to cope more individually. Patients are usually accompanied by family members who not only listen for the patient but may answer questions. Family members see it as their duty to ensure the best possible care and persistent and demanding behavior is the family’s indulgence of the patient and is intended to show caring. This may interfere with the care of the patient unless the clinician is aware of the intentions and cultural customs of the family. Same sex caregivers are typically preferred and should be assigned to patients when possible.⁵¹

Healthcare Practices

Middle Easterners are a historically understudied minority group and as a result their health needs and risks have been poorly documented. Estimates of diabetes prevalence in Arab American populations range from 4.8 to 23%.⁵² Research has indicated that vitamin D insufficiency and hypovitaminosis D were common among Arab Americans and were linked to insulin resistance, metabolic syndrome and glucose intolerance.⁵³ Studies have documented a higher incidence of psychological distress in the years following September 11, 2011. However, the overall prevalence of depression and other adverse mental health outcomes is still relatively unknown. Small studies have indicated a higher risk for depression and PTSD due to discrimination, stigmatization, and the stress of immigration.⁵² The prevalence of Hepatitis C virus antibodies among Arab Americans in Southeast Michigan was found to be triple the national average (5.4%) suggesting the need for more studies assessing the burden of Hepatitis C in this community.⁵⁴ Cancer rates among Arab American populations are relatively unknown however small studies have shown women to be at a higher risk for thyroid cancer and men to be at an increased risk for lung, bladder and prostate cancer.⁵² As common with other minority cultures, Middle Easterners resist seeking help from psychiatrists because of the stigma associated with mental illness.⁵⁰ Participating in high-risk behaviors such as smoking and alcohol use depend on how strictly one follows religious beliefs. Islam opposes alcohol and drug use, due to the belief that drugs impair a person’s ability to serve God by acting as an escape from reality.⁵⁵

Illness is often associated with bad luck and poverty and it is commonly believed that illness is sent from God as a punishment for sins. Food and other substances are believed to play a role in health and illness as well. Some use teas and believe in eating only fresh foods and avoid canned and frozen foods to prevent illness. Preventive care is not typically practiced in the Middle East and medication is heavily used. At times, if a prescription is not received, one may feel the clinician did not do anything for them. Hospital admission may be feared because hospitals are considered places of misfortune where people go to die. Should a family member die in the hospital, Muslims are usually concerned for the dignity of the body and if it is being handled with appropriate care, in accordance to religious customs. Thus, they may refuse to leave until the body is removed from the hospital.⁵⁰

BARRIERS TO CROSS-CULTURAL COMMUNICATION

Communication can suffer when people have different ideas about how to communicate thoughts, feelings and behaviors. These can be caused by stylistic differences or differences related to cultural values. Various barriers exist and are outlined in Table 1 as well as methods to overcome these barriers that are applicable to pharmaceutical care.

Communication skills needed to work with patients from diverse cultures include looking for both verbal and non-verbal cues. Clinicians can often gain clues for how to interact with patients by observing their behaviors and following their mannerisms. By following a patient’s lead one can often interpret the preference for eye contact, personal space and physical touch. For example, letting the patient initiate the greeting will give insight if a handshake, nod of acknowledgment, a light tap on the shoulder, or perhaps a hug is acceptable. Verbal cues include recognizing whether patients prefer to be called using their first name or last name or professional title. Some patients embrace the opportunity to talk and get to know their provider before jumping into medical information. It is important to understand the intricacies of cultural differences regarding verbal and nonverbal communication to know when behaviors cause patients to become defensive. Armed with this insight, one can identify and recover from mistakes in cross-cultural communication as well as overcome barriers.

CROSS-CULTURAL COMMUNICATION TOOLS

Tools have been developed to help clinicians address unique cultural situations that can arise in the patient encounter and can be used to communicate effectively with patients in cross-cultural interactions. Several of these tools will be discussed below.

LEARN Model

One model frequently cited for working with patients from diverse cultures is LEARN (listen, explain/empathize, acknowledge, recommend/respect, and negotiate). In the LEARN model, clinicians first listen to their patients’ perceptions of their problem with an open mind. Clinician should then take time to explain their perceptions and empathize with the patient. Acknowledgment of commonalities and differences in the approach to understanding health and treatment options can help to build trust. When clinicians recommend a treatment plan in a way that is respectful of the patient’s culture and beliefs, a common ground can be established. With this baseline respect, a plan can be negotiated to navigate through the healthcare system.⁵⁶

Kleinman’s Model

Kleiman’s Model includes eight questions to evaluate a patient’s explanation of disease. The model may best be used when clinicians sense discordance with the patient relating to adherence to a treatment plan or to the overall visit.⁵⁷ The questions for the model are illustrated in Table 2.

BATHE Model

The BATHE Model provides questions the clinician can use to assess psychosocial factors affecting the patient’s health. These questions allow for understanding of the context and significance of the patient’s problem, mood, the way in which the patient is handling the problem, and a direction for intervention. BATHE stands for background, affect, troubles, handling and empathy.⁵⁸ The details are described below.

• Ask the patient to describe the problem in a few sentences.
• Ask the patient how the problem makes them feel. Help the patient name an emotion if necessary.
• Ask what troubles the patient most about the problem.
• Ask how the patient is handling the problem. If possible, offer options to help with the problem.
• Express your understanding of the problem and support and reinforce the patient’s plan.

Working with Interpreters

Using professionally trained interpreters has been shown to improve clinical care and improve patient safety for patients with limited English proficiency.^59,60 In addition to having qualified interpreters, it is important to train healthcare providers to use and interface with professional phone interpreter services. The Refugee Health Technical Assistance Center provides best practices for working with health care interpreters and resources can be found at https://refugeehealthta.org/access-to-care/language-access/best-practices-communicating-through-an-interpreter/.

If a trained interpreter is not available, clinicians may find it helpful to work with a bilingual coworker or family member. However, be aware this poses a greater risk for error versus working with a trained interpreter. Children (minors) should not be used as interpreters. If the interpretation appears to be muddled or the process seems confusing for the patient it is appropriate to insist upon finding a more reliable source of interpretation. Additionally, consider creating a positive environment for patients with limited English proficiency by having written materials translated into the common languages found in the patient population that is served. These materials should always be translated by a professional medical interpreter.

Other Tips

• Treat all patients as individuals and use generalizations about cultural values and behaviors as questions and not facts.
• Perform self-assessments in cultural competency on an ongoing, long-term basis.
• Use empathy and active listening in all cultural communication encounters.
• Engage diverse patients on their view of how pharmacy can incorporate their culture into the practice setting.

CONCLUSION

To excel in diverse patient care, pharmacists and technicians need the knowledge and skills to elicit a patients’ explanation of their health status, recognize potential cultural influences on healthcare beliefs and practices, and communicate effectively with patients from different languages and cultures. While barriers continue to exist for cross-cultural communication, these challenges can be alleviated by understanding specific differences in the intricacies of communication styles, familial roles, and health care practices of different ethnic groups. Various tools can be used to communicate effectively with patients in cross-cultural interactions and can help to uncover the patient’s perception of the disease and establish a treatment plan that will honor the patient’s culture and values. As we continue to meet the medical needs and expectations of an increasingly culturally and ethnically varied population, a better understanding of cultural differences and their relationship to healthcare values and beliefs becomes essential to show the respect, sensitivity, and inclusiveness that each patient deserves.

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