Culture and patient education: Challenges and opportunities

Culture and patient education: Challenges and opportunities

Padilla, Rene

ABSTRACT The efectiveness of clinical care is enhanced when the professional is aware of and can accommodate the client’s cultural perspective. This approach to patient education requires individualized attention. This article takes the position that all encounters with clients have a degree of culture “crossing,” Therefore, the notion of “culture” is presented as socially, constructed, both objective and subjective, conscious and unconscious, and dynamic. The influence of culture on patient education is discussed, and potential pitfalls. such as stereotyping, exoticizing, and imposing dominant values, are described. A self-reflective approach to cultural sensitivity is proposed, and activities for enhancing one’s cultural awareness are suggested.


One of the most interesting roles we play as health care professionals is that of educator. Patient education, however, can be notoriously discouraging because patients rarely follow our recommendations.1 The diversity of patients’ needs and expectations from health care contributes to the complexity of our teaching in the clinical context. However, our effectiveness in reaching patients is often enhanced if we are aware of and can accommodate our patients’ perspectives. This approach to patient education requires individualized attention if we hope to convey the benefits of our knowledge and skills while working with our patients’ expectations for treatment. Increasingly. health care practitioners have come to appreciate both the potential and the pitfalls of the concept of culture to guide them in creating such individualized interactions with patients.

In recognition of the value of an approach that considers culture, more and more conferences, continuing education programs, and curricula increasingly feature topics such as “cultural competency,” “cultural sensitivity,” “diversity training,” or “cross-cultural communication.” Often cross-cultural care is presented in terms of exotic encounters with patients newly immigrated from other countries or members of ethnic groups with whom professionals have little familiarity. In this article, however, we take the perspective that all encounters with patients have a degree of “crossing” culture. Every interaction with patients requires sensitivity to culture.

This approach raises several questions: What is meant by the term “culture,” and how can it enhance our patient education skills’? Why is it important for clinicians to incorporate a cultural dimensions in their work with patients? As educators, how can we teach our students to have greater appreciation for a cultural approach to patient education’? What are the drawbacks to relying on the concept of culture for patient education? What are the challenges that can limit practitioners’ use of a cultural approach?

This article responds to these questions in three main sections. We begin with an examination of what is meant by the term “Culture.” We then discuss some considerations of culture in the teaching process, ending with suggestions of activities teachers may consider using to help students appreciate the complexities of culture in their own lives and in the lives of their clients.


Many scholarly disciplines study culture, including anthropology, sociology, education, psychology, business, and the military. These disciplines offer literally hundreds of definitions of culture that fine-tune the subtleties of the term.* In spite of the range of definitions, most scholars share a common understanding of culture as a dynamic perceptual “lens” through which individuals view and interpret the world we inhabit. The meanings humans make from these perceptions tend to shape how we live. As such, culture influences the nature of our relationships@ the availability and use of resources; the range of our choices; our interpretation of universal experiences such as birth, illness, and death; and many other dimensions of our lives.

Some insights derived from this understanding of culture are particularly useful in examining the influences of culture on the teaching-learning process: culture is socially constructed; it is both objective and subjective and conscious and unconscious@ though endlessly shifting and adapting, culture is patterned and provides sources of identity for individuals and groups in varying configurations.

Culture Is Socially Constructed

The lens of culture is a human construction. Unlike some other animals, humans are not born with the genetic programming or the physiological capacity that “automatically” prepares us to defend ourselves against predators and find food and shelter. For our survival, we must depend on other people to care for us and teach us throughout our lifetime.

Culture enables us to connect meaningfully, repetitively, and, for the most part, predictably with others. From the moment of our birth, we begin to learn cultural ideas and understandings that form the basis of our communication with others inside and outside of our group. In this way, people come to recognize and, to an impressive extent, share the knowledge, attitudes, and values of one another in their group-whether referring to our family, our church, our school, our profession, our nation, and so on.

In other words, in the course of learning how to live with others, individuals acquire the cultural lenses of the groups they inhabit. Without such a shared perception of the world and how to act within it, the cohesion and continuity of any human group would be impossible. Even in societies disrupted by war, migration. domination. or epidemics, if adequate numbers of a cultural group still exist, at least some shared cultural identification is transmitted from one generation to the next through formal means (eg, schooling, religious instruction, professional education) and informal means (eg, traditions, mass media entertainment),

Culture Is Both Objective and Subjective Culture both reflects and defines a group’s shared knowledge and shapes how knowledge is presented (eg, literature, arts., rituals) and evaluated. In health care training in the United States, for example, the case conference, or “rounds,” is a highly stylized, structured mode of communicating particular kinds of information about patients as well as the interpretations and recommendations of the presenter.5 In health care practice, the patient chart is the accepted documentation of a patient’s experience with illness. Outside of these contexts of understanding, however, neither the rhetorical style of a case conference nor the abbreviated language of documentation in a patient’s chart make much sense to the untrained layperson.

This is because cultural knowledge is both objective and subjective.6 Objective elements include the numerous physical artifacts people create, such as clothing, food, and furniture. Observable features of nature and trends of events over time are also usually considered objective elements of cultural knowledge. Subjective elements, however, are the invisible, intangible aspects of peoples lives, such as attitudes, values, beliefs, behavioral norms, learning styles, and hierarchy of roles. These dimensions of culture have been likened to an iceberg: what can be seen above the surface of the ocean (objective culture) is only a very small part of the whole, whereas the great majority of the iceberg lies beneath the surface (subjective culture).7 Cultural knowledge-whether objective or subjective–becomes real and valued when it is understood by others as real and valuable. As a human construction, cultural knowledge is influenced certainly by the natural world, but not entirely determined by it. Human interpretation of nature and the natural world shape each other. Cultural knowledge ultimately is expressed in the form of attitudes, values, and behavior patterns we have toward the natural environment.

Our patients’ culturally constructed knowledge about their health conditions presents another example of a weave of objective and subjective elements. A patient’s broken bone, for example, is an uncontested physical reality. So too is the resulting pain from the fracture. Neither the fracture nor the physiological existence of pain is considered culture. However, culture informs the meanings of the fracture and the pain and what we do about them. This point was brought home 20 years ago when one of the authors witnessed a bonesetter’s work in Sierra Leone, West Africa. The bonesetter was a traditional Mende health practitioner who, one day, was called from his rice fields where he was working to attend to an adolescent boys broken wrist. He came only after being ritually called three times by the boy’s relatives. The bonesetter’s work was done in public, serving to demonstrate not only his skill but also the boy’s bravery. Even as we all heard the wrist bones click back in place under the bonesetter’s gentle manipulations, the boy did not flinch from pain-much to the admiration of the assembled group.

As the bonesetter plaited a brace of grass and wood around the boy’s wrist, he provided a twist in logic that illustrates how culture also can shape our explanations for physical injuries and disease. Humans all around the world explain accidents and diseases with reasoning that transcends physical evidence to include such things as emotional or spiritual imbalance. In this case, the bonesetter explained that the bone would mend well only if the boy’s parents abstained from sexual relations for two nights.

Cynically, one might interpret this explanation as an adroit move on the part of the bonesetter to shift responsibility for the bone’s healing from himself to the boy’s parents. However, the bonesetter’s explanation might serve equally well to remind us of the significance of social supports in the healing process. Either way, the example illustrates our human capacity for giving subjective significance to the seemingly objective physical properties of healing.

Culture Is Conscious and Unconscious

There is conscious and subconscious culture.8-10 Conscious culture is that part of culture that we are aware of, can describe, and about which we can talk. Unconscious culture, on the other hand, affects our behavior and thoughts without our awareness. This part of culture operates at the subconscious level, shaping our perceptions and responses to those perceptions. These unconscious frameworks of meaning include not only many of our assumptions about what is real and how we should relate to reality, but also how we communicate with one another about that reality. Until we meet someone who does not share these internalized meanings. it is possible to remain largely unconscious of the influence of culture in our lives.

In most contemporary health care settings, however, such cultural insulation is soon eroded. Whether face-to-face or in a lecture, a book, newspaper. or some other media, we are likely to meet people who trigger confusion, impatience, or lack of response in ourselves or others. Such reactions could signal some kind of intercultural misunderstanding. A simple example of this is experienced daily by rehabilitation professionals who encounter resistance when they ask patients in postsurgical units to walk on the first day after surgery. Although these professionals are trained to know that this will assist with recovery by helping to clear their patients’ lungs after surgery, their patients are often doubtful of its benefit. From most patients’ perspective, it is simply counterintuitive to leave the security and comfort of bed, risk failing, and experience pain as a means of recovery. Culturally, the bed is where you stay when you are not well–or such is the internalized message to many of us from influential cultural experts such as parents.

In all likelihood. it is conceivable that we will never be able to bring to consciousness all of the ways that culture influences how we think and act. However, given that our unconscious culture can inadvertently harm someone, some degree of self-reflection in this regard is ethically advisable. Years ago, one of the authors, who worked in rehabilitation at a major academic medical setting, received a referral to work with a client who had come to the United States from India in order to receive treatment for a cerebrovascular accident (CVA). Given that the client had gone to such extent to receive care, this author assumed that the client was seeking state-ofthe-art treatment. Therefore, an aggressive schedule was implemented. The client was unable to speak due to aphasia, and often his brother accompanied him to the treatment sessions.

After a few sessions, the brother began canceling sessions, stating that the client was not feeling well. This was puzzling because no other professional on the care team reported complications. Being familiar with the depression that often accompanies a CVA, the author decided that the next few treatment sessions should occur in the client’s room. When the author arrived, the client would not look at him and became active only after much coercion. In frustration, the author finally asked the brother what he thought was occurring. The brother reported that the client was distressed that his bare feet were often being touched while adjusting his standing position. In addition, the client was deeply offended that the author often used his own feet to stabilize the client and control some of his movements. In the client’s cultural framework, the feet were considered dirty, and it was a significant invasion of his sense of body space to have touched them or used them in treatment. The author had approached the client from the perspective of the culture of rehabilitation, assuming that means of treatment are secondary to reaching the goal of regaining function. The client was so deeply offended that he continued to resist any rehabilitation, having come to associate the author’s insensitivity with the whole treatment process. Had the author taken the time to review his own assumptions and interview the client and his brother more carefully regarding their expectations and fears, it is likely that this unfortunate situation would have been avoided.

Culture Is Expressed in Social Subgroups

The beliefs. values, and norms of culture are not expressed uniformly in terms of whole societies. Instead, culture is expressed in terms of various social groups within a society, A subculture. for example, is a group with shared characteristics that distinguish it in some way from the larger cultural group or society in which it is embedded. The characteristics that may distinguish a subculture may be demographic (such as “adolescent culture,” or the “culture of poverty”), ideological (such as a political party or a religious group), or related to common practices (such as the corporate culture or the drug culture).11 A minority group refers to a social group that occupies a subordinate position in a Society.12 An ethnic group refers to people who share a common heritage, history, celebrations, and traditions and who enjoy similar foods and might speak a common language other than English.13

It is also helpful to view culture as a series of mutually influencing social levels. Within each level there are a number of subgroups, each influenced by the larger culture. However, each subgroup in each level also has unique and distinctive features of its own. These levels include the individual, the family, the community, and the geographical region.14 At the individual level are the relational, one-to-one interactions through which people learn and express their unique perception of culture. It includes a sense of personal space, sense of humor, coping style, and other personal attributes. At the family level are the beliefs and values shared within a primary group. It is in this group that most of a person’s early socialization takes place and includes such dimensions as gender roles and family structure. At the community level are the various secondary groups in which a person participates, such as school, neighborhood, profession. church, and so on. Finally, at the regional level are the cultural elements that a person shares with people in a broader geographical area. such as language, mass communication media, holidays, and ethnicity. among others. In most cultures, the family and community levels have the greatest and most direct influence on the individual. Through participation in these levels, people learn which values, beliefs, and behaviors are acceptable and unacceptable and how to deal with contradictions between levels.

The notion of levels of culture can be seen, for example. in the way in which clients follow rehabilitation home programs. Some clients very diligently separate time in their daily schedules to move through a prescribed exercise routine, whereas others move fluidly between their daily and therapeutic activities, so it is difficult for us to be certain that they are following the home program. From an individual level, we can say that the differences in personality styles account for some of this difference: some clients are more organized and structured, whereas others prefer life to be more free-flowing. It may be, however, that these “personality styles” stem from a general cultural approach to life learned in their families: some families reinforce organized and planned lifestyles, whereas others prefer a more casual and spontaneous approach to life, In the first case, the family is likely to plan days in advance when the therapeutic home program will be carried out; in the second case, the family is more likely to “fit it in” more casually on a day-to-day basis. Furthermore, the client’s broader social groups or communities also may be reinforcing these apparent personality styles: the way in which social groups value the use of time, for example, can be seen as monochronic or polychronic.10 Monochronic groups value time focused on single activities, and thus people are less likely to interrupt each other while working or carrying out their home programs. Polychronic groups, in contrast, value social time, and their members are more likely to interrupt their work or home programs in order to attend to social relationships.

Virtually every dimension of a person’s life is influenced by culture, and groups tend to derive their cultural identity by clustering aspects of their social lives into particular lenses through which they interpret the world and expect the world to judge them.15 These sources of cultural identity are intricately related and can include factors such as race, ethnicity, gender/sexuality, age, religion, language, social class, and health status, among others. 13 These sources of cultural identity are based on particular shared values that coalesce even within a temporary grouping and can often only be understood within the particular group in which they are defined. That is, which characteristics are considered part of a particular source of identity vary from culture to culture and, as stated earlier, to some degree from member to member within that culture.

Culture Is Dynamic

Because culture is constructed and shared through a lifelong socialization process, individuals’ culture changes as their environmental circumstances and group associations change. We can say, then, that every person is “multicultural” because each of us participates in various groups and contexts that have their own sets of values, beliefs. attitudes, and acceptable behaviors. For example, while at school, an adolescent’s gender-related knowledge and beliefs about how to express pain may predominate, and no voice may be given to severe discomfort. At the same time, when that adolescent is at home, the beliefs about being a child to be cared for may be more important, and the discomfort may be exaggerated, People affiliate more or less strongly with one cultural group or another, sometimes depending on their life circumstances and opportunities. For instance, after experiencing hearing loss from an car infection, a person may find comfort in learning the cultural cues of deaf culture. Or recovering alcoholics might discover that the belief systems, rituals, and mutual trustworthiness of friends in Alcoholics Anonymous take the place of their family of origin.

Each individual in a society is in the ongoing course of “learning” culture and cocreating it. Each person is at different point in this process at any given time. Both shared and individual events in people’s lives shape what people learn and how they learn it. This is why the boundaries of culture are often vague. Although superficially individuals in a society might seem to behave in the same way, to some degree each person is acting on the basis of his or her own perception of what he or she has learned as culture. Consequently, cultures are never really homogeneous-they are constantly changing as the individuals in a group move through the process of learning, sharing, and shaping culture.


Sensitivity to culture can inform therapists’ processes of patient education in two main ways. First, we will consider the influence of culture on the patient education process itself. Then, we will discuss how therapists can adapt their patient education strategies to incorporate an understanding of their patients’ cultural expectations and perceived needs.

In all its forms, education is the major way that cultural information is passed along. Our teachers are many, including parents, schoolteachers, peers, religious leaders, healers, and nowadays television, of course. Therapeutic relationships are themselves instruments of cultural education. Patients and clinicians teach and learn cultural knowledge about and from each other. This knowledge concerns. but is not limited to, such things as information and beliefs about a disease or injury, expectations about everyone’s behavior in the recovery or rehabilitation process, logistical details for navigating the architecture and the bureaucracy of a health care system, personal preferences and intolerances, and so on.

It is amazing how quickly patients learn how to be patients. Even on short-term admissions to hospitals, patients learn to expect the routines of care, interruptions, and paperwork. They learn about formal and informal power hierarchies within the organization and how best to influence others to ensure their well-being. Given the long-term nature of many patient-practitioner interactions in chronic care, it is conceivable to imagine that a specific therapeutic context can actually give rise to specific cultural features, especially if the encounter is repeated sufficiently over time, Consider, for instance, Erving Goffman’s description of patients who became “institutionalized” in facilities for patients with mental illness on his book Asylums: Essays on the Social Situation of Mental Patients and Other Inmates.16 Goffman observed that patients in these longterm care facilities actually learn how to be patients so well that it can become tragically difficult for them to return to life Outside of the institution.

As in other realms of education, in health care our choices of how to teach patients are mediated by our cultural beliefs about how people learn. For instance, although behaviorist theories inform us that across cultures people learn through reward and punishment, there is cultural variation in what is considered legitimate reward and punishment. In the case of contemporary rehabilitation practice, it is not considered ethical to pay patients to achieve therapeutic goals, although to do so might improve adherence to a therapeutic program. It is, however, acceptable to take away payment from patients, such as dropping them from workers’ compensation rolls, if they do not seem to be making every effort to improve their condition. Similarly, although it would not be suitable for a therapist to threaten physical harm if a recommendation was not followed, in some cases therapists find it motivating for patients if they describe the potential pain that may result if a recommendation is not followed.

Culture also has something to say about what is important for patients to learn. This observation is evident, for example, in discussions of what may constitute a good “fall prevention” program. Some practitioners may take a problem-solving approach, believing it is most important for clients to learn to apply prevention principles. Other practitioners may take a more pragmatic approach, believing that unless clients learn to make specific changes in their environment, they will not decrease the risks of failing in any significant way.

In a broader perspective. curriculum decisions about what needs to be taught to prepare students to enter a field are always subject to culture. In health care, these cultural perspectives are evident in changes in standards of practice, accreditation requirements, theory, technology, and societal trends. Standardized board examinations and continuing education regulations further reinforce this dynamic consensus about what is important to learn and teach in the field. In a yet broader perspective, different rehabilitation disciplines view treatment goals from their own professional cultures, Consequently, some disciplines approach patient education from a medical model, whereas others take on a psychosocial perspective.

Culture also influences the balance of power between the teacher and learner or, for our purposes specifically, the therapist and client. Culture is evident in how we delineate who is a teacher, what teachers are supposed to do, and how others ought to act toward them. Different cultural models of patient education, for example, give patients and practitioners relatively more or less scope of influence over the direction, content, and tone of a given clinical session. Some models feature the practitioner as an expert with information to impart to patients. Other models depict a more egalitarian relationship between the professional and patient. The degree to which patients are viewed as equal collaborators in therapy can also vary according to whether there is an emergency situation or whether the patient is rational, of sufficient age, and generally adherent to standard recommendations. These conditions, of course, are all subject to judgment and thus potentially fall within a cultural analysis.

When therapists want to incorporate aspects of their patients’ cultural background in patient education, it can be useful to differentiate between general and specific cultural knowledge. Cultural knowledge that is general applies broadly to all cultural groups. This knowledge helps us understand universal features of human existence. For example, one cultural universal relevant to patient education is that learning style is related to socialization processes.17 This statement does not tell us anything about a specific individual’s experience, but it helps us understand that learning styles will vary from culture to culture because socialization experiences vary from culture to culture. The insights about culture discussed earlier in this article are other examples of general cultural know] edge that applies to all cultures, By understanding these insights, therapists can be alert to cultural influences and design patient education that considers and respects them.

Specific cultural knowledge, on the other hand, is knowledge that applies to a specific group or to specific individuals within a group. This knowledge often applies only to those individuals and can help the therapist’s intervention be particularly meaningful for those people. For instance, after visiting Samoa over 20 years ago, a gerontologist had to revise her functional analysis scale when she realized that all of her research subjects, regardless of their age, could clip their own toenails. This lower-extremity agility was unremarkable to a people who sat crosslegged on the floor all their lives (M Mackenzie, personal communication, August 30, 1999).

Although general cultural knowledge is composed of general principles applicable in abstract terms to all cultures, specific cultural knowledge represents the individual’s perspective and may only be relevant to a single person. Recognizing the difference between general and specific cultural knowledge can help therapists avoid several pitfalls while developing culturally sensitive patient education. As we have seen, within a single cultural group there can be significant variance in values and behaviors. Therefore, culturespecific knowledge applied as general cultural knowledge can easily become stereotypical. Stereotyping is rooted in our assumptions about the characteristics of one or more members of a group. which we then impose upon all individuals from the group. Stereotypes lead us to expect certain behavior from people, which may not, in fact, be part of their value system. Stereotyping occurs from the cultural perspective or filter of the person making the assumptions. Consequently, stereotypes reflect the value system of the person interpreting others’ behavior. This is why both positive and negative behaviors can be stereotyped. Ultimately, all stereotypes are potentially dangerous because they fail to recognize the individual’s perspective and impose expectations for behavior that may contradict the patient’s best interest.

To the extent that we recognize how our patients and colleagues negotiate between multiple cultural affiliations (just as we do ourselves). we can resist the tendency to stereotype on the basis of one evident feature of someone’s cultural background. Subtle forms of stereotyping occur often when we ask a staff member to translate another language spoken by a patient simply because we know they are from the same country. Factors such as one’s accent, gender, age, social class, and political and immigration history might well impede the staff person’s ability to communicate effectively with the patient, even though they share the basics of a common language. Similarly, however well meaning, when health educators ask patients, colleagues, and students to generalize about “their” culture, we deny the complexity of their cultural identities.

This tendency to stereotype on the basis of one aspect of someone’s cultural background can also lead to a form of distancing ourselves. When we transform our patients, coworkers, and students into “cultural beings” rather than human beings, we run the risk of “exoticizing” them or making them “other” than ourselves. This is particularly dangerous when it links to unconscious cultural assumptions about the superiority and inferiority of one cultural group or another, A focus on static cultural differences too often overlooks the many ways that we are similar, sharing a range of common and changeable concerns, fears, hopes, emotional highs and lows, ethical commitments, ideological preferences, and material and physical needs, Further-more, such a view in health care, although it may begin with the best of intentions, can result in using culture unwittingly to obscure social and economic injustices that create differential rates of poor health and limit access to care.


There is no single “best” way to develop cultural sensitivity or culturally appropriate patient education. This will undoubtedly be an ongoing, lifelong process. Because what may be considered culture is so broad and. as we have seen, so unique to each individual, care must be taken that each patient encounter be considered a “cross-cultural” mediation of sorts. Therapists and clients each bring to the encounter their own values. beliefs, expectations, hopes, and fears, which will undoubtedly serve as a filter of meaning for them. Therefore. for any treatment to be relevant or appropriate, it must include consideration of the cultural context from which the client functions. The therapist must take the time to consider what treatment is critical and be willing to compromise on everything else. Time, however, is a major constraint facing practitioners who value working within a cultural model of patient education, It has been proven efficient in the long run to work with patients toward a shared understanding about how best to respond to their needs, In spite of this, short-term concerns may take precedence given the time pressures in most clinical situations.

Perhaps nowhere is the dilemma of time more obvious than when the patient and practitioner do not share the same language. Given the extended period of academic socialization required in health care training and practitioners’ need for technical terminology, it is rare that every word of their conversations will be understood by patients. even when they share a common language. As a result, one key part of patient education is always necessarily the translation of therapeutic assumptions and terms. This takes time. Clear articulation of terms and the use of visual aids such as drawings and videos can help translate these features of health care specialization. However, as with any language acquisition, repetition is needed for learning, and discussion is required for meaningful understanding. When neither patient nor practitioner has even a basic language in common. the effort for mutual understanding is all the more demanding.

The keystone to using a cultural perspective in health care rests on practitioners’ willingness to acknowledge their own culturally based predispositions. To do so takes an active commitment to ongoing critical reflection. Unless therapists understand their own culturally mediated values and biases, they may be misguided in believing that they are encouraging divergent points of view or facilitating meaningful learning on the patient’s part. It is possible to believe in the need to change, to learn new language and technique, and to, just the same, subtly overlay new ideas with old biases and stereotypes. Exploring who we are and what we believe culturally can help us identify ways in which we may unknowingly be exerting dominance over patients. When we clarify our own cultural biases, we are better able to consider how they might subtly but profoundly influence the degree to which patients feel included, respected, and motivated to learn.

Health care educators have a special role in helping students establish the kinds of insights and habits that will prove useful for cultural self-exploration throughout their careers. It is especially important for clinical educators to model degrees of sensitivity, openness, and bounded tolerance with patients that they would want their students to demonstrate. In the classroom, teachers have an opportunity to structure learning experiences that can set a foundation for these skills. Here is a list of learning strategies designed for students to explore the role of culture in their own lives and work.


A place to begin exploring one’s cultural biases is to ask the following questions:

“What values do I hold that are consistent with the dominant culture?” This question allows us to identify not only our dominant cultural values but also ways in which we are different from others. Some of the values or cultural themes and orientations generally associated with white, upper middle class American culture are an emphasis on achievement. success, activity, independence, and productivity. In addition, there is a humanitarian mores (tendency to root for the “underdog”) and a moralistic orientation. Efficiency, practicality, progress, material comfort, and equality are other values associated with American culture.18 In addition, science and secular rationalism, nationalism/patriotism, democracy, individuality, and racism or related group superiority have been identified as frequent biases of American culture.19 To each of these American values there may be alternative perspectives that reflect beliefs and values of some of the patients a therapist may encounter in his or her work.

“Have I examined the values embedded in my discipline that may confuse and disturb my patients? ” Many disciplines often strongly reflect the American values listed in the previous paragraph, and practitioners proceed in their work without questioning the professional assumptions derived from those values. It is important to as questions that encourage patients to question what they do not understand or to represent their own perspectives.

“Are the examples I use to illustrate key points meaningful and sensitive to my patients?” After giving examples from their own experiences, therapists should ask patients to create their own examples to illustrate different points, thus providing opportunity for discussion. In this way, the therapist acknowledges the experience of people from different backgrounds at the same time as obtaining valuable specific cultural knowledge regarding each patient.

“Do I have creative and ef[ective wa.s to learn about my patient’s lives and interests?”

Incorporating creative strategies to permit patients to represent their heritage, values, and so forth can greatly facilitate communicating theor cultural perspectives. An example of such a strategy might be identifying social celebrations the client holds valuable and structuring treatment around preparing for one of those celebrations.

Illness Narrative

Obtaining a narrative from the patient’s perspective can be a powerful way to open a window of insight into the uniqueness of other people. One approach is for students to interview someone from another culture about an illness episode. Arthur Kleinman, an anthropologist and physician, recommends a list of eight questions that are useful for eliciting patients’ side of the story when they are sick or disabled.20 These questions include inquiry about patients’ descriptions of their problems and beliefs about what has caused them, what should be done about them, and who are the most appropriate people to do it (Table). The trick is for the listener to suspend judgment and postpone the urge to correct or educate until hearing and understanding the patients’ point of view as fully as possible. Understandably, many patients might be hesitant to share this information, for fear of seeming ignorant and risking humiliation.

It can also be useful for students to begin with an illness autobiography, where they took back retrospectively and describe their own perceptions, beliefs, and behaviors about a past sickness or disability of their own before they entered their physical therapy training. Students can be asked to write their answers to such questions as: What did they think was wrong-not from the perspectives they have learned as physical therapists. but back then, as a layperson? Beyond any physiological explanations for their condition, did the existential question of “why me?” ever arise, and if so, what was their answer? Did they seek assistance for their condition? Who? Why? Why not? What, if anything, did they learn from the experience of their condition?

Cultural Autobiography

Writing a cultural autobiography can be useful for students to bring to consciousness the multicultural influences shaping their daily lives. Beginning with a simple exploratory exercise of cultural identity, they can list their ethnic heritage(s ‘), social class, parents’ occupation, place of upbringing (eg, rural/urban, region of the country, size), political leanings, favorite television shows, religion, and so on. Under each cultural category, they can identify how it has influenced their food preferences, expectations about friendship, leisure activities, aesthetics. opinions about a controversial topic, behaviors toward authorities, dating practices, and so forth.

Ethnicity and Racial Prejudice

To stimulate discussion about ethnic heritage, ask students to reflect on whether they have the privilege of “choosing” their ethnicity(ies) and identifying with it (them) given context. Part of this examination can be an analysis of how they go about choosing their ethnicity in that context, They may also examine whether ethnicity is something others feel free to ascribe to them because of the color of their skin, accent, or some other visible feature. In concert with this inquiry, students might enjoy reading Ethnic Options.Choosing Ethnic Identities in America,21 by Mary Waters, an anthropologist. This insightful book examines some of the serious and absurd ways that ethnicity plays out in our lives in the United States. Waters’ analysis underscores the significant relationship of social privilege and Euro-American ethnic identity in the United States. Able to “pass” in society, Euro-Americans are free to celebrate or not elements of their ethnicity and to make claims on multiple ethnic identities as it benefits them. For instance, on St Patrick’s Day, everyone is Irish! Everyone except someone who is African American. Although an African American may indeed have more Irish “blood” in his or her background, skin color more often defines this person’s ethnicity because of racial prejudices in the United States. Students might profit from a discussion of what other privileges accrue to Americans with “white skin” and how this affects their work lives. Peggy McIntoSh22 has published an honest self-reflection about this question, listing a number of explicit and implicit advantages she enjoys simply because she is Euro-American.

On-Site Observations

Students could keep a log of their observations of hospital dress codes and provide their interpretations of what cultural messages various types of clothing convey (eg, social status, beliefs about infection control). Students can observe an interchange between practitioner and patient and simply count the number of questions each asks. Candace WeSt23 has done a systematic study of the sociolinguistic conventions used by physicians and patients, noting that power is held by the person who asks the questions. She observed that physicians ask conspicuously many more questions than patients ask during a typical office appointment, but female physicians are likely to ask relatively fewer questions.

Medical Ethnographies

Numerous medical ethnographies exist to enlarge students’ understanding of the cultural influence on the illness experience. One recent book, The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures,24 by Anne Fadiman, is an especially gripping tale of about a Laotian child with epilepsy. The book chronicles the details of miscommunication between the child’s family and her physicians in California. There are several advantages of these in-depth ethnographies over the brief textbook chapters describing cultural generalizations of various ethnic groups or subcultures. First, students can appreciate the complex process of how culture influences and is influenced by power dynamics, socioeconomic forces, history, personalities, and so on, which in turn shape health care beliefs and practices. Second, students get more of an appreciation of the diversity that exists in a seemingly homogeneous group. Lastly, like a novel or movie, a wellwritten ethnography will transport students to an experience of empathy where otherwise foreign or “bizarre” behaviors and beliefs will make sense in light of shared human desires.

A Panel of Experts

Invite panelists who share some cultural identity to talk about a controversial topic in health care so that students can appreciate the diversity of opinion, experience, and understanding that people even from, for instance, the same ethnic group will bring to a specific issue. The “experts” can be either from the community at large or from the class itself.


Students should be encouraged to travel across boundaries of all kinds–across town, into another region of the country, outside of the country, Have students reflect verbally and in writing about the experience in light of such questions as: What surprised you most? What never made sense to you? What was surprisingly familiar? When did communication get tough? What did you do to make yourself understood? When did communication just flow, even without words, between yourself and a stranger?


Cultural sensitivity is a lifelong process that involves both learning how to gain information from clients and unlearning personal assumptions and stereotypes that interfere with the professional’s ability to see clients for who they are. The professional interaction is, in itself. a process of negotiating and constructing culture. The diversity of clients’ need and life contexts contributes greatly to the complexity of patient education. If we are to be effective in reaching clients, we must be aware of and able to accommodate their individual perspectives. In order to begin addressing issues of diversity in practice, students and professionals must first examine their own beliefs and assumptions about others. They must also first understand which values they share with the dominant culture, acknowledging they are likely to impose such values on others subconsciously. By understanding general cultural knowledge, practitioners can better take advantage of specific cultural information that clients provide directly. By examining their cultural lenses, practitioners can take advantage of interactions with other cultures as resources for understanding and, ultimately, personal growth.

*One of the most famous definitions of culture is that of anthropologist EB Taylor, who in 1871 wrote that culture is “that complex whole which includes knowledge, beliefs, art, moral, law, customs and other capabilities and habits acquired by man as a member of society.”2 Other definitions emphasize the ideational nature of culture, describing it as consisting of “systems of shared ideas, systems of concepts and rules and meanings that underlie and are expressed in the ways that human beings live.”3 Webb and Sherman4 described culture in a functional way, stating that culture provides people with a means of communication (language), a power structure (status), regulation of procreation (family) and a system of rules (government). In addition, they stated that the rules of culture may be written (laws) or unwritten (customs), but are always present. Webb and Sherman suggested that culture provides a system through which significant lessons from history can be given physical representation and stored and passed on to future generations (in the form of dance. poetry, song, handcrafts, architecture, and so on.) They stated. “Cultures solve the common problems of human beings, but they solve them in different ways…. What makes cultures similar is the problems they solve, not the methods they devise to solve them.”4(p50)


1. Lerner B. From careless consumptives to recalcitrant patients: the historical construction of noncompliance. Soc Sci Med. 1997:9:1423-1431.

2. Leach E. SocialAnthropology. Glasgow, Scotland: Fontana; 1982:38-39.

3. Keesing R. Cultural Anthropology: A Contemporary Perspective. New York, NY: Holt, Reinhart and Winston Inc; 1981:518.

4. Webb R. Sherman R. Schooling and Society. 2nd ed. New York, NY: Macmillan; 1989.

5. Hunter K. Doctors ‘Stories: The Narrative Structure qf Medical Knowledge. Princeton, NJ: Princeton University Press; 1993.

6. Triandis H. The Analysis of.Subjective Culture. New York, NY: Wiley-Interscience: 1972.

7. Cushner K, McClelland A, Safford P Human Diversity in Education: An Integrative Approach. 2nd ed. New York, NY: McGraw-Hill Inc. 1996.

8. Harris M. Cows, Pigs, Wars and Witches: The Riddles of Culture. New York, NY: Vintage Books; 1989.

9. Peacock J. The Anthropological Lens: Harsh Light, Soft Focus. London, England: Cambridge University Press; 1986.

10. Hall ET. The Dance of Lit@: The Other Dimensions of Time. New York, NY: Anchor Books,1984.

11. Bullivant B. Multicultural Education: Issues and Perspective. Boston. Mass: Allyn and Bacon; 1989.

12. Yetman NR, Majority and Minoritv: The Dynamics of Race and Ethnicity in American Lift. Boston, Mass: Allyn & Bacon; 1991,

13. Lynch EW. Conceptual framework: From culture shock to culture learning, In: Lynch EW, Hanson MJ, eds. Developing Cross, Cultural Competence. 2nd ed. Baltimore. Md: Paul H Brookes Publishing Co, 1998:23-45.

14. Krefting L, Krefting D. Cultural influences on performance. In: Christiansen C, Baum C, eds. Overcoming Human Performance Deficits. Thorofare, NJ: SLACK Inc; 1991:101-124,

15. Hellman CG. Culture, Health. and Illness. 3rd ed. Oxford, England: ButterworthHeinemann; 1997.

16. Goffman E. Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York. NY: Doubleday Books; 1961.

17. Brislin R. Understanding Culture @ In/fluence on Behavior Fort Worth, Tex: Harcourt Brace Javonovich; 1993.

18. Locke DC. Increasing Multicultural Understanding.- A Comprehensive Model. Newbury Park, Calif Sage Publications Inc@ 1992.

19. Williams RM. American Society: A Sociological Interpretation. 5th ed. New York, NY. Alfred A Knopf Inc; 1990.

20. Kleinman A, Eisenberg L. Good B. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med. 1978:88:251-258.

21. Waters M, Ethnic Options: Choosing Ethnic Identities in America. Berkeley, Calif: University of California Press; 1990.

22. McIntosh P hite Privilege and Male Prii@ ilege: A Personal Account of Coming to See Correspondences Through Work in Women’s Studies. Wellesley, Mass: Wellesley College, Center for Research on Women, 1988. Working Paper No. 189.

23. West C. Routine Complications: Troubles With Talk Between Doctors and Patients. Bloomington, Ind: Indiana University Press; 1984.

24. Fadiman A. The spirit Catches You and You Fall Down: A Hmong Child, HerA merican Doctors, and the Collision of Two Cultures. New York, NY: The Noonday Press; 1997.


Charmaz K. Good Days, Bad Days: The Self in Chronic Illness and Time. New Brunswick, NJ: Rutgers University Press; 1997.

Based on qualitative research, this book examines how people with chronic illness create meanings of their illnesses and of themselves. Part I presents three ways that people experience illness: chronic illness as an interruption, intrusive illness. and immersion in illness–each of which has implications for the self and the relationship to the world. Part II describes how meanings of illness become stark when people must deal with the logistics of disclosing illness and living with it. In part III, the author examines the temporal aspects of illness that lead people to anchor themselves in the past, present, and future. This book offers the reader some insights into how people experience chronic illness and how others misinterpret them. Fadiman A. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of-Two Cultures. New York, NY: The Noonday Press; 1997.

Written in narrative form, this book explores the clash between North American health care professionals and a refugee family from Laos over the care of a Hmong child.

The author provides a well-balanced account of a true story from the perspectives of both the professionals and the Laotian family, describing sources of misunderstanding and of acceptance of differences. By placing the notion of culture within a historical and sociopolitical context, the author emphasizes how underlying dominant-culture values predispose health care workers to devalue the patient’s perspective and undermine the healing process. The narrative provides ideas for how to approach cultural differences and how to elicit from patients the Cultural framework

from which they interpret their illness and needs.

Leavitt R, ed. Cross-cultural Rehabilitation: An International Perspective. Philadelphia, Pa: WB Saunders Co; 1999.

An excellent source for health care professionals. The book is developed around five sections: (1) theoretical basis for developing cultural competence, (2) professional issues, (3) rehabilitation case examples from crosscultural and international settings, (4) examples of cross-cultural research, and (5) cultural competence. An international multi

disciplinary team of authors provide advice and guidelines on how to deal with the problems that arise in rehabilitation contexts that are relevant to all rehabilitation professionals. The underlying philosophy within this book is of cultural pluralism, with an emphasis on professionals developing cross-cultural competence through continued selfassessment regarding culture, acceptance of and respect for differences, vigilance toward the dynamics of differences, ongoing expansion of cultural knowledge and resources, and adaptation of services to meet the needs of a particular group.

Mr Padilla is Assistant Professor and Chair and Dr Brown is Associate Professor. Department of Occupational Therapy, School of Pharmacy and Allied Health Professions. Creighton University, 2500 California Plaza, Omaha, NE 68135.

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