Miranda Law, PharmD, BCPS
Stephanie Lukas, PharmD, MPH
Jonathan Thigpen, PharmD
Cultural competency/cross-cultural care
At the end of this case, students will be able to:
- Recognize cultural aspects that influence and impact patient care
- Apply a skills-based approach using concepts of cross-cultural care to a patient case
- Determine how to approach unfamiliar cultural situations focusing on communication, awareness of cultural differences, adopting information, eliciting patients’ illness experiences, assessing how decisions are made, and determining health beliefs
- Utilize tools to elicit illness experiences and cultural information to tailor and improve patient care
Culture can be defined as the “integrated pattern of human behaviors that includes thoughts, communications, languages, practices, beliefs, values, customs, courtesies, rituals, manners of interacting and roles, relationships and expected behaviors of a racial, ethnic, religious or social group; and the ability to transmit the above to succeeding generations.”1 Each individual is part of an extraordinary number of cultures at any given time, influencing one’s beliefs, attitudes, and lifestyle. It is impossible to know every culture and how that culture may impact a person’s health. The ability to account for the myriad of different cultures, especially from provider and public health perspectives, is an important but at times overwhelming task.
Unfortunately, cultural misunderstandings are common when seeking to provide care for individuals or a community, potentially leading to poor health and health disparities. Accordingly, the challenge for healthcare professionals is to acknowledge this barrier and seek to bridge cultural divides. Applying cross-cultural care is important for patient care, public health, and policy development, and those designing and implementing interventions for patients or large-scale interventions for populations need to keep in mind those groups with non-mainstream cultures and those who may have cultural aspects vastly different from their own. So, how can you provide care for a community you don’t understand? Cross cultural care involves “learning how to transcend one’s own culture in order to form a positive therapeutic alliance with patients from other cultures.”2
Cross-cultural care requires utilizing a skills-based approach, focusing on communication, being aware of cultural differences, adopting information, eliciting patients’ illness experience, assessing how decisions are made (e.g., the role of family), and determining health beliefs.3 Cultural aspects that may influence the health of an individual encompass a range of variables and include more than just ethnicity.4 Underlying beliefs and assumptions develop at a young age and are determined by the environment that a child grows up in. As an adult, perspectives on what is respectful, what is rude, and even what is fun, is determined by culture. As a result, a patient’s actions with regards to their own health are inherently connected to their culture.5 For example, consider your own assumptions on the topic of eating dinner: (1) What time should dinner be eaten? (2) What should dinner consist of? (3) Is it okay to eat dinner alone without waiting for your family? (4) Is it okay to skip dinner? (5) Is it okay to leave food on your plate? (6) Where do you eat dinner? (7) Can the television be on?
Various tools are available to help clinicians extract important cultural information from their patients, leading to better understanding and tailored care. The 4Cs is a tool often used by clinicians to “elicit the patient illness experience” and consists of asking patients:
- What do you CALL your problem?
- What do you think CAUSED your problem?
- How do you COPE with your condition?
- What CONCERNS do you have regarding your condition?6
Case (part 1 – communication)
You are a pharmacist in a family medicine clinic.
CC: “My physician, Dr Simmons, sent me here.”
HPI: Sijin Kim is a 38-year-old South Korean male (69 in, 165 lb) who reports he immigrated to the US ten years ago to provide a better life for his family. He is a new patient and was diagnosed with T2DM six months ago, and is having a very hard time keeping his glucose and HgA1c controlled.
- Married with 2 children
- Father died at age 45 from a motor vehicle accident
- Mother alive with T2DM and osteoporosis
- 1-2 alcoholic beverages daily
- ½ pack cigarettes per day
- No illicit drug use
Surgical history: N/A
- Metformin 1000 mg PO BID (started 6 months ago)
- Glipizide 10 mg PO daily (started 1 month ago)
- Ginseng 200 mg PO daily (started 8 years ago)
- POC glucose (today): 224 mg/dL
- HgA1c: 8.2%
Additional Context: Mr. Kim arrives to your clinic and greets you with a bow. You politely smile back, say hello, and ask him to have a seat. You begin by reviewing his past medical, family, and surgical history as well as reviewing his medications with him. The visit seems to be going great, Mr. Kim can speak English and is nodding with understanding to everything you are saying to him. You ask him about medication adherence and if he is taking all of his medications; he says, “yes,” with a smile. You ask him if he ever misses any of his medication doses, and he says, “no,” with a smile. You proceed to review his diet and exercise regimen with him and realize he is likely eating too many grains – causing his T2DM to be uncontrolled. He confirms that he eats rice with every meal. You review the plate method with him and show him how much rice he should be eating for each meal. Mr. Kim nods with understanding and smiles, saying he will do as told. The rest of the visit goes equally smoothly. Mr. Kim is able to repeat the general instructions back to you and smiles and bows as he leaves, being very gracious and thankful for the time taken to see him. You begin working on documenting the visit, and have a funny feeling that this visit was way too “easy.” You begin questioning if Mr. Kim was just saying what he thinks you wanted to hear.
1. What type of miscommunication may have happened with Mr. Kim?
There are many types of miscommunication. In this case, because Mr. Kim was providing all the “right” answers to the pharmacist’s questions, the pharmacist perceived that there were no issues with Mr. Kim’s medications and his adherence. The pharmacist could have benefitted from better understanding the culture that Mr. Kim comes from and realizing that “yes” does not always mean the “yes” that we assume it to be in the US. Often, those with Asian cultural backgrounds may agree or provide the answers they think are expected, but hold a different meaning behind those words. Pharmacist’s should try and ask the same question in different ways to determine the true answers.
2. What cultural factors may have influenced this interaction?
Mr. Kim comes from a cultural background where it is important to respect health care professionals and always do as they say. He also comes from a culture where it is important not to disagree publicly with someone so as not to cause someone to “lose face”, a concept found in many Asian cultures that refers to losing respect or being humiliated. Additionally, Mr. Kim may feel that if he reports he was not following the pharmacist’s orders, he may also “lose face”. For these reasons, Mr. Kim may have been providing the answers to the pharmacist that he knew would be “right” despite what he was actually doing. In this way, he felt he was being respectful and allowing the pharmacist to complete their job well.
Case (part 2 – perception of illness/disease)
Mr. Kim returns to clinic four weeks later. He brings his medications and his glucose log with him as he was instructed at the last visit. You find that his glucose is still very out of control. You check his medications to confirm adherence and find that he seems to have more pills than he should in his bottles. When you ask him if he has missed any doses, he politely smiles and says he rarely forgets and tries his best to take his medications according to the instructions. You feel you need to dig deeper into the root of his non-adherence.
3. Using the 4C’s model, what questions should you ask to find out more about Mr. Kim’s view of his illness?
The 4 C’s include asking questions regarding what the patient Calls their problem, what Caused their problem, how they Cope with their problem, and what Concerns they may have. A number of questions could have been asked to Mr. Kim to find out more about how he views his illness. Some of them include, but are not limited to:
- We have discussed diabetes before, but regardless of what I have told you, can you tell me what you think the problem is?
- In Korea, how to people identify and call this problem?
- Why do you think you have problem? (note, at this point, you can replace the word “problem” with a term they may have used when discussing how they identify the disease)
- What do you think is causing your problem?
- What have you done to try and make it better?
- How serious do you think your problem is?
- What complications from your problem are you afraid of?
- How does this problem interfere with your life?
- Do you know anyone else who has tried the treatment that you are being given? What was their experience with it?
Case (part 3 – cultural dimensions of health)
After asking some questions, you find out that Mr. Kim has been speaking with his mom in South Korea and despite agreeing to follow your instructions, is listening to advice from his mother, since she also has the same diagnosis. She told him that she doesn’t always take her medicine and her doctor doesn’t correct her, so it must be okay to miss it sometimes. She also says she has had diabetes longer than him, and she is okay, so he will be fine if he does the same. He says that he has seen his mother live with this problem for many years and doesn’t think it’s anything to be too concerned about.
4. Why do you think Mr. Kim would listen to his mother’s advice over yours?
Mr. Kim comes from a culture where respect for parents and family is of utmost importance. His respect and trust for what his mother says outweighs what his health care providers may be telling him. From Mr. Kim’s perspective, his mother has the best intentions for him and will always provide the best advice for him to follow.
5. What is Mr. Kim’s perception of his illness and how has that been impacted by his life experiences?
Mr. Kim does not seem to be too concerned about his diabetes and is not worried about it causing any complications in the future. He has seen his mother live with this disease for many, many years and her current state of well-being is an example of the fact that this disease must not be that serious. Again, Mr. Kim’s respect and trust in his mother influences how he perceives his current problem and impacts how he chooses to manage it.
Case (part 4 – cross-cultural care in population health)
You acknowledge the advice from his mother, and ask if it is okay for you to provide your own professional advice that may be a little different from his mother’s. You spend the rest of the visit educating Mr. Kim about the importance of taking the medications as prescribed and why you really want him to try to take all his medications when they are scheduled. He responds positively, and it seems you have really reached him this time. Just to be safe, you go back and also review the diet and nutrition advice regarding his rice consumption, and he nods with understanding.
Mr. Kim returns in another four weeks. His glucose seems better but is still not at goal. After checking his medications, you are happy to find that he seems to have been adherent. Before adding or adjusting his medications, you want to find out if his lifestyle habits have changed at all. Upon some questioning, you find that his diet and exercise has not improved and Mr. Kim is still eating a full bowl of rice at every meal. When you ask him why, he says, “I have to set a good example for my children during meal time”. Additionally, Mr. Kim comes from a country that is predominantly Asian, where it is near impossible not be served lots of grains at a meal when eating out. Currently, he still lives in a community in the US that has a high Asian population that has retained a very similar diet. He states that he understands what you are asking him to do, but it is very hard.
6. What is Mr. Kim’s greatest barrier currently and how might you help him overcome it?
Currently, Mr. Kim is struggling with his diet. Consider finding ways to involve his family – especially the main cook – so they receive education and gain an understanding of the importance of this issue. One way to do this could be to ask Mr. Kim to bring some family members to participate in a portion of his future visit to talk about nutrition and the connection with disease outcomes as well as meal planning.
You are concerned about his diet as well as the potential to develop or worsen diabetes for both Mr. Kim and his entire community. You speak with your supervisor and are given permission to develop a community-wide intervention on diabetes education.
7. What cultural factors will you consider when developing your community educational materials? What resources could you use to create your educational materials?
You can start by thinking about the information you gained when asking Mr. Kim and similar patient questions related to the 4C’s. For example: What terms does the community use? Think about how would be message be best received (e.g., by visiting a community center or a religious center, through brochures vs online resources, etc.) It is important to remember communities are always the experts of their culture. With this in mind, consider involving community members – especially leaders who are well regarded by others – to help craft and potentially distribute your message.
When creating materials, you don’t always need to recreate the wheel. Are their resources already available that you could use and/or modify? This is important when you consider the need for materials to be available in multiple languages and to have culturally appropriate images/graphics (e.g., picture of people who look like your patient or meals that look like what your patient would eat). Ethnomed.org has a variety of language and culturally appropriate resources – with English versions so that the healthcare provider knows what they are distributing.
8. How will you gain trust within the Asian community that you are reaching out to?
Trust is slow to be built and quick to be destroyed, so it is always important to approach with humility. You may be the medication expert, but remember the community will always be the expert of their own culture and workings. It is important that you do your homework – learn as much as you can about the community you will be serving and when you don’t know, it’s better to ask than to assume. It can also be helpful to have a cross-cultural counterpart(s) – someone(s) who will help you navigate through the community and serve as facilitators. They can also be the champion to help the interventions be successful.
As a pharmacist, you will likely encounter patients from a wide variety of cultures, often with patients that belong to more than one culture. It is vital that you understand how each patient’s cultural make-up influences his/her actions both in and outside of your interactions with that patient. Although it is impractical to try and become competent in all cultures, understanding the right questions to ask to understand your patient’s frame of mind is a crucial skill. You will be better equipped to meet your patient’s individual needs if you respect his or her culture and establish a trusting relationship with each of your patients. Lastly, remember, culture is influenced by a patient’s larger community; so sometimes, it is important to ask not only about the patient in front of you, but also about aspects of his or her life and community.
Patient Approaches and Opportunities
As you consider and review the chapter case questions, recognize that depending on where and how someone grew up, the answers to these questions may all be drastically different. These different answers, for example, may influence how someone perceives your advice if he or she is being counseled on lifestyle changes for diabetes mellitus. Apply this train of thought to what your patients may be thinking as you provide medical advice and try to help them with their medications. Pharmacists must consider how patients will interpret and implement their suggestions or whether their suggestions will be ignored.
In many cultures, respecting elders is more important than listening to healthcare providers – an important point to remember when trying to change someone’s behavior. Although it is impossible to touch upon all of the ways culture impacts a patient’s health, it is essential to recognize that culture is always an underlying factor to consider. Cultural awareness and competency allows pharmacists to provide better care to patients from various cultural backgrounds.
Related chapters of interest:
- More than just diet and exercise: social determinants of health and well-being
- Ethical decision-making in global health: when cultures clash
- The cough heard ‘round the world: working with tuberculosis
- The ‘state’ of things: epidemiologic comparisons across populations
- U.S. Department of Health & Human Services and Office of Minority Health – Think Cultural Health https://www.thinkculturalhealth.hhs.gov
- U.S. Department of Health & Human Services, Health Resources & Services Administration – Culture, Language, and Health Literacy:
- Centers for Disease Control and Prevention – Cultural Competence
- Journal articles:
- O’Connell M, Korner E, Rickles N, and Sias J. ACCP White Paper: Cultural Competence in Health Care and Its Implications for Pharmacy, Pharmacotherapy 2007;27(7):1062–1079.
- The Spirit Catches You and You Fall Down by Anne Fadiman
- Essentials of Cultural Competence in Pharmacy Practice by Kimberly Vess Halbur
- “Kleinman’s Questions” derived from Kleinman A. Patients and healers in the context of culture: an exploration of the borderland between anthropology, medicine, and psychiatry. Berkeley, CA: University of California Press; 1980.
- Goode TD, Sockalingam S, Bronheim S, Brown M, Jones W. A planner’s guide—infusing principles, content and themes related to cultural and linguistic competence into meetings and conferences. Available from research/gucchd/nccc/documents/Planners_Guide.pdf. Accessed July 30, 2018.
- Deagle GL. The Art of Cross-Cultural Care. Can Fam Physician. 1986; 32:1315-8.Brian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, Editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Chapter 6: Interventions: Cross-Cultural Education in the Health Professions. National Academy of Sciences; 2003.
- Brian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, Editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Chapter 6: Interventions: Cross-Cultural Education in the Health Professions. National Academy of Sciences; 2003.
- Sunita Mutha, Carol Allen, Melissa Welch. Toward Culturally Competent Care: A Toolbox for Teaching Communication Strategies. Center for the Health Professions University of California, San Francisco; 2002.
- Lisa M. Vaughn, Farrah Jacquez, Raymond C. Bakar. Cultural Health Attributions, Beliefs, and Practices: Effects on Healthcare and Medical Education. The Open Medical Education Journal, 2009, 2: 64-74.
- Stuart Slavin, Alice Kuo and Geri-Ann Galanti. The 4C’s of Culture.