Culture and Health Literacy
Geri-Ann Galanti, PhD
By Tina Beychok
One issue that invariably comes up when dealing with low literacy patients is that of culture. How might a patient’s culture or belief system affect their health literacy? How do we take this into consideration? Medical anthropologist, Dr. Geri-Ann Galanti, led a lively discussion of cultural differences in healthcare and issues that may occur due to misunderstandings. She started her talk by noting that the cultural beliefs she would be discussing should be seen as generalizations, rather than stereotypes.
Galanti went on to identify three major issues in dealing with patients with varying cultures and belief systems: Conflicting beliefs on health and illness, lack of trust in the healthcare system, and differing time orientations. She reminded the audience, “Not everyone who utilizes our medical system necessarily shares our beliefs regarding health and illness.”
One example of conflicting cultural beliefs is the “evil eye,” often seen in Hispanic and Middle Eastern cultures. Galanti shared a story of a home care nurse who admired the child of a patient. In Hispanic cultures, this is seen as calling the attention of evil spirits to the child, or “giving it the evil eye.” The nurse obviously meant no harm to the child, but, as Galanti explained, “because of this cultural misunderstanding, there was a decreased level of trust between the nurse and the family.”
Galanti suggested using what she calls the “4 C’s of Culture” to gain insight into the patient’s perspective.
What do you CALL your problem?
This allows the patient to express what they think the problem might be in their own words. Galanti recommended the book The Spirit Catches You and You Fall Down as a perfect example of what can happen when healthcare professionals don’t take the time to ask this question. The book tells the story of a young Hmong girl who was brought into the ER suffering from seizures. At that point, as Galanti described it, “everything that could go wrong did go wrong.” Due to miscommunications, mistrust and misunderstandings on the part of the family and her physicians, the girl eventually died.
What is the CAUSE of your illness?
This allows the patient to talk about what they may have done to bring on the illness. Galanti provided an example of an African-American woman who refused an angiogram because she thought she had sinned, and God was punishing her with the illness.
How do you COPE with the problem?
This allows the patient to talk about traditional remedies they may have tried. Such remedies can range from herbs to acupuncture to cupping. Asking about these remedies is important because it can alert you to possible bad interactions with Western medicines. In the case of cupping, asking about coping strategies may stop you from reaching the conclusion that the patient has been abused, since the technique can leave bruise-like marks on the body. As Galanti explained, “They key is all in how you ask this question. You don’t want to come across as being mistrustful or dismissive of traditional remedies.”
What are your CONCERNS about the problem or treatment?
This provides the patient or family members to tell you, in their own words, what worries they may have. In the case of the young Hmong girl, taking the time to allow the parents to explain their concerns in their own words might have allowed healthcare providers to better understand that the family viewed their daughter’s condition as one of the spirit, and not just the body.
Galanti noted that a failure to consider these four C’s of culture can lead to the next major issue in cultural considerations – patient mistrust of the healthcare system. One example she shared was within the African-American population. She noted that there has been a long history of mistreatment and racism within the healthcare system, including the infamous Tuskegee Experiments, in which a group of African-American men with syphilis were allowed to go untreated so that doctors could study the course of the disease. “The key here is to acknowledge and apologize for any slights, even if completely unintentional,” she noted.
In the case of Hispanic patients, a failure to take a personal interest in the patient can also lead to mistrust. Healthcare providers, particularly doctors, are expected to show personalismo toward the patient and family. The sort of professionalism that it expected within Western medicine is seen by the Hispanic patient as uncaring and impersonal.
The final issue with cross-cultural differences that Galanti discussed was that of time orientation. Patients with a future time orientation have an interest in preventive medicine – taking action now to stop future illness. Those with a present time orientation – often the poor or minorities – may have difficulty imagining into the future because they are so concerned with what is immediately affecting them. Finally, patients with a past future orientation are most concerned with holding to traditions and values that have been passed down to them. Oriental medicine is a good example of this type of orientation.
The key to helping patients with a present or past time orientation understand the benefits of preventive medicine is to tie it to something concrete that has meaning for them. “Being able to dance at a daughter’s wedding or play with future grandchildren has meaning for these people. It can often be the incentive they need to take better care of themselves,” Galanti noted.
She wrapped up the discussion by urging participants not to be afraid to ask questions, even if they are afraid they will offend patients and family. “Cultural factors such as beliefs about health and illness, issues of trust and expectations of providers, and time orientation all play an important role in health literacy. We need to be able to understand these things to help our patients.”