Advice

Advice for treating patients coming from a different culture

Content

Different cultural approaches to illness
Dfferences in how people perceive and describe Symptoms
Different associations concerning Human Organs
Culturally different approaches to Healing
Different religious Rituals and concepts of Hygiene
Specific Religious Food Restrictions
Emphatic, personal Communication
Avoid to Embarrass the patient

1. Different cultural approaches to Illness

Understand that the patient may have a different cultural approach to illness

Try to overcome any possible distrust by the patient towards your own culture’s approach to medicine through explanation and where possible integrate his/her way of understanding illness. For example, wherever possible, allow the patient to continue wearing religious symbols or amulets, since they may give her/him the faith, strength and belief to recover.

Underpinning ‘scientific’ approaches to illness mean that, in our culture, we view the self as divisible into body and mind, and also that we conceive of diseases as affecting single organs. Patients who share this understanding are able to identify and describe their symptoms in a way that is immediately comprehensible to us.

However, for many other cultures, for example those from Asia, illness is the result of a disharmony affecting the whole person, rather than a single organ. Patients who understand illness in this way may not be able to single out and describe their problem in a way which is immediately intelligible to you.

In some cultures there is a belief that illness is caused by supernatural forces (for example, the evil eye, demons or spirits), or because of a transgression on the part of the patient. There may be a belief that illness is not intrinsic in the body but is brought from outside, for example as a punishment. Patients with these beliefs may also find it difficult to describe their problem in detail and simply report that they are ill.

People in some cultures believe that spirits can cause diseases such as malaria; or that spirits are the reason for fainting or stress. However, not all spirits are regarded as evil. Some cultures believe that people with a mental health problem have received a special gift from the gods or spirits and are therefore particularly respected.

2. Dfferences in how people perceive and describe Symptoms

Be aware of the fact that the kind of symptoms which people describe, and how they express them (verbally and non-verbally), is culturally defined

Be aware of the fact that when patients are unable to specify the exact location of their pain (for example, by saying ‘I have intense pain down the left side of my back’), this may be due to the way they understand disease and illness. If they say “I have terrible pains all over my ….” or “My … burns like fire”, they probably really do feel pain all over and are not able to single out the particular location. Try to remember also that smiling can have different meanings in other cultures, including being an expression of stress, fear or sorrow.

People from, for example, Mediterranean cultures tend to express pain more vigorously both verbally and non-verbally than do people from northern European cultures. This is because of differences in the extent to which the expression of pain, or emotion in general, is culturally acceptable. Cultures also vary in the use of metaphors or figurative language to describe pain and other symptoms. Some cultures, for example, some Asian cultures, prefer not to express pain at all, which does not mean they do not feel it – it may often be hidden by a smile.

The way in which people diagnose their own illness also varies from country to country and culture to culture. In Mediterranean countries such as Italy and France, people frequently attribute their indisposition to liver or other digestive disorders; in German speaking countries people more often complain about cardiovascular problems; people in Muslim and Arab countries may communicate mental stress by describing it as a headache. Make sure you have understood the patient correctly by reformulating the question to double check their answer.

3. Different associations concerning Human Organs

Listen carefully to what the patient says: a word in one language may have different connotations when translated into another

The meanings associated with specific organs tend to be culturally defined. For example, in Turkish the word for liver can refer to both the liver and the lung, and is also associated with various mental conditions. For example: ‘My liver hurts’ is an expression of sorrow; the liver ‘growing’ expresses the anticipation of very painful experience (or even death); and ‘my liver is breaking up’ is an expression of general severe affliction. In Turkish, organs in general can ‘fall’ ie. be the cause of various physical and mental disorders such as sickness, back pain, fatigue or depression.

Describing where particular organs are located in the body is also culturally defined. For example, in Somalia, when people describe the location of the kidneys, they will probably point to a region more in the direction of the abdomen than the back.

4. Culturally different approaches to Healing

Accept,- and if possible integrate, culturally different approaches to healing

Many cultures around the world conceive of illnesses as either ‘hot’ or ‘cold’ and believe they should be treated with food and medicines which embody the opposite concept. People from such cultures may believe, for example, that fever should not be treated with aspirin, which is a ‘hot’ medicine, but rather with a long cold shower.

In some cultures, for example in Russia, people believe that fresh air is not good for colds, whereas in Germany, the Netherlands and Belgium, this is regarded as beneficial.

5. Different religious Rituals and concepts of Hygiene

Accept and if possible integrate, different religious rituals and concepts of hygiene

Accept, and if possible integrate, ritual washing, fasting, prayer, or other religious practices followed by people of different faiths.
Accept that in Asian countries it is common to wear a mask in order to avoid infecting other people.
Jehovah’s Witnesses may refuse blood transfusions and organ donation. Ensure that this is discussed openly and that alternatives are considered.
Accept, and if possible integrate, Hindu concepts of purity. For example, do not put shoes (which are considered impure) besides clothes, as they might ‘contaminate’ the clothes.

Patients whose religion is Islam may expect to wash after bleeding, ulcerating, vomiting, having been to the toilet, menstruation and sex. Water should be used for ablutions but if no water is available, washing can be replaced symbolically, for example by touching a stone or a wall.

Fasting during the month of Ramadan is an integral part of the Muslim religion. However, sick persons, children, old people and pregnant women are exempted. Nevertheless during this period patients may refuse to take medicines. If fasting is likely to be damaging you can remind the patient of the exceptions permitted in the Qu’ran and explain the implications of refusing medicine or food.

Fasting is also an integral feature of Judaism. Jews fast at Passover, Yom Kippur and on four other religious holidays. At Passover Jews do not eat food based on cereals and may also refuse to take medicines containing glucose, dextrose or sorbite.

In some Asian countries people may wear a mask out of consideration for others. This is because they wish to avoid infecting other people.

Hinduism has many religious rules. For Hindus, shoes, menstruation blood, fish, eggs, alcohol are not pure. Fasting is practised before some religious festivals but can be avoided in case of illness.

6. Specific Religious Food Restrictions

Accept, and if possible integrate, food restrictions

Many Hindus do not eat meat. Some may also refuse eggs, garlic, or mushrooms as these foods are believed to influence the psyche and perception.
Jehovah’s Witnesses do not eat food which contains blood.

Muslims do not drink alcohol and may refuse medicines which contain it.
Muslims do not eat pork, eat only ‘halal’ meat (butchered in a particular way), and may refuse gelatin capsules;
Jews do not eat pork or any kind of shell fish and meat must be ‘kosher’ (butchered in a particular way). Dairy products may be problematic and combining meat and dairy food should be avoided.

7. Emphatic, personal Communication

Establish a personal relationship by using verbal communication

Establish a personal relationship by chatting about the patient’s family, home town or origins. This helps the patient to open up, develop trust and cooperate. Many patients from a wide range of cultures will appreciate this.
Listen actively for, and acknowledge, feelings of fear or helplessness. This will make the patient feel more at ease and understood. It will help especially chose from some Asian cultures who are not used to expressing emotions.
Be sensitive when dealing with topics like death, rape, female genital mutilation (FGM), genital diseases, marital status and childlessness. Be particularly careful when mentioning these topics with patients from Muslim and African cultures. Hindus may feel not at their ease with topics like pain, digestion, or discussion relating to the genito-urinary system, especially if their husband/wife is present.
In some cultures it may not be advisable to give a diagnosis in a matter-of-fact way directly to the patient. Try to avoid naming diseases directly and speak to the patient’s relatives first if you are unsure how the patient will cope with this information due to their cultural background.
Remember that communication styles vary between cultures: while German speaking cultures tend to be very direct, others, including Asian cultures, are much less so.

8. Avoid to Embarrass the patient

Be careful not to embarrass the patient: even non-verbal communication can be misunderstood

Eye contact in most European cultures tends to be used as a way of building trust and creating openness in a relationship. However, in other cultures, for example those from Asia and the Middle East, it can be seen as impolite and aggressive and eye-contact with a woman may be seen as compromising her honour or integrity.
Be aware of the greater need for privacy in some cultures when medical treatment involves physical contact or when the patient has to wear a morning gown in the presence of strangers.
Nudity is shameful in some cultures, for example in Japan. Patients from these cultures will not expect to undress completely, only the part of the body which is strictly necessary. Such patients should be provided with the means to cover themselves whilst waiting to be examined.
Be aware that in Muslim and Arab countries as well as in some Asian countries (China, Japan, Indonesia and India) physical contact between men and women who are not married can be highly compromising. It is advisable, therefore, to avoid touching a patient if not strictly necessary. For the same reason, it is better not to initiate shaking hands with the opposite sex.
Try, even in an emergency situation where possible, to have Muslim patients examined or medicated by doctors/nurses of their own sex – although clearly in an emergency situation the immediate needs of the patient must override religious reservations. Hindus too appreciate being examined by a doctor of the same sex. If this is not possible, the presence of a nurse of the patient’s own sex may help to make the patient feel more at ease.
Be careful which part of the body you touch. In Muslim cultures the private sphere of a man extends from the waist to the knee, while that of a woman extends from the chin to the ankles (or, in less traditional Muslim cultures, to the thigh). Some Asian countries believe that the head is holy (India) or the home of certain spirits (Vietnam, Thailand) which can be disturbed. It is advisable, therefore, to avoid patting children or even adults on the head as this is deemed to bring bad luck.