Cultural Considerations for Working in Hospitals

All cultures have beliefs about the causation, diagnosis, and treatment of disease. Biomedicine is focused on the germ theory of disease. Diagnosis is made with the use of blood tests and other diagnostic procedures. Most Non- Western cultures do not rely on the germ model of disease but instead believe that illness is caused by object intrusion, spirit possession, soul loss, or breach of taboo. Diagnosis is made by a healer, and the appropriate treatment is prescribed.

According to the American Speech-Language-Hearing Association (ASHA), speech-language pathologists (SLPs) are responsible for demonstrating cultural competence when providing services to patients from diverse cultural and linguistic backgrounds.

• ASHA Position Statement on Cultural Competence in Professional Service Delivery

• Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services

Purpose

This webpage intends to provide the busy SLP with an overview of cultural beliefs related to diet, disease, and communication. The quote above emphasizes the importance of cultural competence in a medical setting—many of the patients we serve are not familiar with Western notions of medicine. The cultures included here are based on the demographics of the Portland, Oregon, Tri-County area but could be helpful for SLPs serving in other areas. The focus is on dysphagia-related information and how best to communicate with a culturally and linguistically diverse adult patient in an acute hospital setting. This information presents many traditional viewpoints and may not reflect a patient from a different culture. Presenting characteristics on the speech and language of the cultures profiled is beyond this project’s scope; clinicians are encouraged to explore the websites listed on the resource pages for more information.

Asian and Pacific Islander (API)

The Asian and Pacific Islands refer to the group of islands between Asia and Australia/New Zealand.

Communication & Cultural Norms

In most API cultures, the communication style is indirect. Internal negative feelings such as unfairness, disappointment, and anger may not be culturally appropriate for external expression. This communication style is critical to remember in working with family caregivers. Patients may smile or nod as a sign of respect to the care provider though this could also be misinterpreted as understanding or agreement.

Furthermore, direct eye contact may be considered a sign of rudeness, aggression, or having sexual connotations. Making eye contact with a healthcare provider is viewed as a sign of disrespect for the provider’s status or questioning their expertise.

Views on Illness and Disease

In general, illnesses are believed to result from unbalanced physical, mental, or spiritual elements in an individual, with many within-culture variations. In some East Asian and South Asian cultures, health is based on balance across various elements of nature (e.g., air, earth, fire) or the idea that suffering is inevitable or that lifespan is predetermined. Members of the API culture may also believe in karma and destiny, which links illness in their life to sins in a previous life.

Healing Practices

Traditional healing methods include acupuncture, Ayurvedic medicine (the view that health is a relationship between the universe and the body), qi gong (pronounced “tshee-gong”), energy-balancing, and shamanistic healing. These methods are widely used by APIs in the U.S. Traditional healing is generally considered a primary form of health care and takes a holistic view of the physical, mental and spiritual selves.

Barriers between Western medicine and traditional healing may be witnessed. For example, when an elder is recovering from a stroke, there is a tendency to lovingly attend to the elder’s every need and make their last days comfortable rather than pursue rehabilitation to aim to return to ambulation and independent self-care.

Unique Health Concerns

Diabetes and obesity are common in API cultures. A high level of untreated illnesses leads to the rate of serious lower extremity infections, amputations, and premature death from diabetes to be greater than in the U.S. API populations than other U.S. ethnic minorities.

Typical Diet

Starch is the foundation of the traditional diet. For example, the traditional Hawaiian diet is 75% starch, 10% fat, and 15% protein. Fish and other seafood are also abundant in the API diet. Breakfast is usually cereal and coffee, while more traditional meals are eaten at lunch or dinner. There is a high prevalence of lactose intolerance as dairy products are rare in this diet. However, many APIs eat a very Americanized diet containing fast food and highly processed foods.

For the SLP

It is vital to enlist the support of family and caregivers. Get to know the cultural community leaders, such as chiefs or ministers, so that the approach is much more likely to succeed.

• • The use of oral and written instruction would benefit the patient, especially in areas of literacy.

  • Build trust with clients by showing respect and curiosity about their belief systems, making patients more likely to be open and share their concerns and follow treatment guidelines.

  • Clients and families should be encouraged to ask questions; the clinician may also ask specific questions though they should avoid asking questions in a judgmental or accusatory way.

  • It is usually appropriate to express a lack of knowledge about the culture and concern that the interaction is meaningful.

Burma

Burmans are the largest ethnic group in Burma, and their language is Burmese.

Communication & Cultural Norms

Burmese culture does not value direct, up-front communication. Use both hands to give and receive something, and do not touch a patient on the head—it is considered the spiritually highest part of the body. Older people deserve the most respect in Burmese culture.

Views on Illness and Disease

A disease is caused by an imbalance between the four elements: earth, air, fire, and water.

Healing Practices

Spells and black magic are commonly used.

Typical Diet

Based on white rice (preferably firm rather than soft-textured) with fish, vegetable, or meat curries (highly spiced dishes) 1). Their protein is derived from a variety of meats, fish, and insects. Common staples are vegetables and grains such as corn, millet, sweet potatoes, eggplant, bamboo sprouts, and gourds.

Certain foods and medicines are considered hot or cold and can affect a person’s health—the terms hot and cold are not to be taken literally; however, many Burmans will avoid cold drinks when in a cold state. Hot foods include salty, sour, or protein-rich; cold foods are sweet or bitter.

May follow a dietary system based on the calculations of the zodiac of stars, planets, and the time of birth and age; these calculations are linked to prescribed dietary practices.

Below are subcultures and various languages that are spoken in Burma.

Karen - Burma

The Karen are not Burmese and should not be referred to as such; they are a separate ethnic group.

Communication & Cultural Norms

Many Karen are reluctant to share openly with health care providers; ask open-ended questions, and make sure to follow up with the patient after they have had time to discuss with their family. Indirect communication is highly valued—talking loudly and using large gestures should be avoided. It is impolite to walk in front of seniors or elders or someone sitting down; if one must, apologize first.

Views on Illness and Disease

Many Karen believe that every person has 37 souls, called kla, that are vulnerable to loss or theft by spirits, which puts the person at risk for illness (5). To ensure against loss of kla, an elder or shaman may tie a string around the person’s wrist.

Healing Practices

Traditional Karen healers may sacrifice chickens or other animals to appease spirits, though this practice is not generally observed by Christian or Buddhist Karen. Western medicine is generally well-accepted by the Karen, particularly those who have lived in refugee camps for some time.

Typical Diet

Karen food is highly spiced and seasoned with chilies, salt, and fish sauce or fish paste. The principles of hot and cold food may apply (see Burmans, above).

Chin - Burma

The Chin language is Hakha Chin, although many refugees are also proficient in Burmese.

Communication & Cultural Norms

Elders are highly valued; walking bent over at the waist and crossing both arms in front of the chest are both signs of respect. Stoicism is valued among the Chin; ask more direct questions rather than open-ended ones. Use both hands to give and receive something. Direct eye contact may be considered a challenge.

Views on Illness and Disease

Chin from urban populations are familiar with Western medicine; traditional medicine is rarely practiced. However, traditional practices may still be common in rural areas and among some urban Chin. If Western medicine fails to treat illness, some Chin may attribute the problem to hnam, an evil spirit that lives inside humans.

Healing Practices

Typical Diet

Rice is the staple of the Chin diet. Corn, potatoes, fried meat, and various vegetables are also standard, and fermented soybeans are a primary source of protein. The principles of hot and cold food may apply (see Burmans, above).

Hmong - Burma

The Hmong language is Hmong.

Communication & Cultural Norms

Direct eye contact may be considered rude or inappropriate. Take time to make small talk before discussing the patient’s health needs, and encourage family participation and incorporate their ideas into assessment and treatment plans. It may be helpful to seek out a culture broker or someone within the patient’s community to help communicate Western ideas.

Views on Illness and Disease

The Hmong generally believe that many illnesses are caused by natural forces, such as aging or environmental factors. Many Hmong are animists and believe that spiritual beings and forces exist in nature; people have many souls, and illness can occur when a person loses a soul. A txiv neeb, or shaman, is called upon to encourage the soul to return to the body.

Healing Practices

A Hmong person may first see a shaman or traditional healer before seeking help from a Western health care professional; often, the cure will include an animal sacrifice.

Typical Diet

White-rice based with a variety of vegetables and meat, when available 14). Food is typically seasoned with lemongrass, cilantro, chile peppers, green onions, ginger, and fish sauce. The principles of hot and cold food may apply (see Burmans above).

Oromo

The Oromo language is Oromiffa.

Communication & Cultural Norms

Oromo are generally more formal than Americans—use formal language and maintain a professional attitude. Find out who the head of the family is (most likely father or grandfather), and make sure you have their approval in assessment and intervention plans. Find out how the client and family feel about the cause of their illness/accident/communication disorder (see The Eight Questions, below) before moving ahead with intervention.

Views on Illness and Disease

Wellness is generally viewed as a balance between the person and the outside world; excess heat, cold, food, drink, worms, and sun can upset the balance and cause illness. Hygiene is understood and considered important, but other factors, such as punishment from Waaqa (God) for sins, are believed to affect a person’s health.

Healing Practices

The familiarity with Western medicine depends on whether the person is from an urban or rural area.

Typical Diet

Many animal products are part of the Oromo diet—meat, eggs, cheese, and milk; pork is not eaten for religious reasons. A fermented flatbread (bideena) made with teff flour is eaten with most meals.

Mexico

Spanish is spoken in Mexico.

Communication & Cultural Norms

Find out the patient and family’s level of acculturation (whether traditional Mexican or more typical of American culture). Involve the whole family in the treatment process; the oldest male will usually have the final say. Show the patient and family respect, warmth, kindness, and interest in them (personalismo). Acknowledge their intelligence and expertise (preface recommendations with “as you know” to preserve their pride)

Health care professionals are very highly regarded in Mexican culture. In Mexico, someone with a disability is accepted by society & family; it is the community’s and family’s role to care for them. It is not as necessary for them to become more independent—instead, it is essential that they function well within the family. Because it is the family’s responsibility is to care for them, institutionalization is rare. For example, there are no retirement homes, nursing homes, or homes for people with disabilities in Yucatan—families may be reluctant to consider this option for their loved one.

Views on Illness and Disease

In traditional Mexican medicine, illness may have emotional, spiritual, social, and physical factors. Illness may be caused by an imbalance between hot and cold. Food and medicine also have hot and cold properties, and the opposite is used to cure the illness. Mal de ojo or evil eye and susto (fright disease) are also thought to cause disease.

Typical Diet

Staples include beans, corn tortillas, fruits, and vegetables—especially tomatoes, chiles, and cactus—meats, chicken, and fish. The principles of hot and cold food may apply (see Burmans, above).

Russia

Russian is the most common language spoken in Russia. Russian immigrants may also speak the language of the republics where they formerly lived (e.g., Belorussian, Ukrainian, and Uzbek). Other possible native languages spoken at home are Yiddish and Ladino.

Communication & Cultural Norms

The typical greeting is a firm handshake with a proper oral greeting while maintaining a firm handshake. Direct eye contact is appropriate. *It is important to remember when shaking hands with someone to take off your gloves, as it is considered rude not to.

Typically, when ill, the family members and friends are expected to visit to provide support to the individual and immediate family. Typically bad health news is delivered to the patient’s family first and is not directly given to the person who is ill or disabled. The family will then decide whether to tell the patient the condition or prognosis. Eastern European immigrants tend to value quality medical care and the services provided in America.

The birth region, education, and income level make a difference in how patients and their friends and family members make health decisions. Make sure to know what questions to ask to learn more about the patient and their family. Russian immigrants often do not answer questions regarding a family history of mental illness or past treatment.

Views on Illness and Disease

Some Russians believe that disability/illness is caused by something the individual did not do correctly or by social experiences (e.g., not eating well, not dressing appropriately for the weather, stress). Good health is correlated with the absence of pain. Mental illness is regarded as shameful in many Eastern European countries.

Healing Practices

Homeopathic medicine may be preferred, while prescriptions and over-the-counter drugs are rejected. When it is an option, ask the patient what they prefer. Home remedies are often used (e.g., oil rubs, exposure to fresh air and sunlight), and seeking medical attention is often the last option.

Typical Diet

Russian Americans often maintain a diet high in fat, carbohydrates, and sodium. Foods to consider for some Russian American patients include pickled and dried meats, fish, bread, potatoes, dumplings, porridge, cabbage, and beet soup, and vegetables.

Vietnam

Vietnamese is the language spoken in Vietnam.

Communication & Cultural Norms

Greet patients and family warmly and with respect—encourage involvement from all family members. Greet elders or higher-ranking family members first. Encourage patients to ask questions—many Vietnamese may try to save face by not asking questions, which they feel makes them look unintelligent. Show interest and acceptance of patients’ health beliefs—use the Eight Questions to build rapport and not show judgment.

Views on Illness and Disease

Vietnamese believe that the balance of the equal and opposite forces of yin and yang can explain illness. Yin is the female principle and is associated with the right side, cold, breath, and even numbers, while yang is the male principle and is associated with the left side, heat, blood, and odd numbers. The harmony of these forces can be affected by different foods and behaviors.

Illness may be attributed to organic or physical problems, an imbalance of yin and yang, an obstruction of chi (life energy), a failure to be in harmony with nature, punishment for immoral behavior (in this or past lives), or a curse placed by an offended spirit.

Healing Practices

Traditional healing practices may still be in place in the U.S., but there is also a general acceptance of Western medicine. Nursing homes are rare in Vietnam because it is considered the family’s responsibility to care for an ill family member.

Typical Diet

Rice forms the basis of their diet and fresh fish and vegetables; pork and chicken are also eaten, especially in the U.S., where they are readily available. Many elderly Vietnamese may be lactose-intolerant and consume minimal dairy.

The Eight Questions

It is important to remember that not every person embodies all of their cultures’ characteristics. The following eight questions, developed by Arthur Kleinmann in 1978 and cited in “The Spirit Catches You and You Fall Down,” by Anne Fadiman, will assist in learning more about your patient’s particular beliefs about their illness and in developing a rapport with your patient.

1. What do you think caused the problem?

2. Why do you think it happened when it did?

3. What do you think your sickness does to you? How does it work?

4. How severe is your sickness? Will it have a short course?

5. What kind of treatment do you think you should receive?

6. What are the most important results you hope to receive from this treatment?

7. What are the chief problems your sickness has caused for you?

8. What do you fear most about your sickness?

Student Contributor: Sarah Breeze, Winter 2012; Stephanie Barnard & Brianna Berthoin-Hernandez, Spring 2014.