The Importance of Culture in Care
Culture and Cultural Competence
America is a culturally diverse society and, consequently, people from a wide range of cultural backgrounds seek services in health care settings. The scope of health care paradigms cannot be limited to those that work for the dominant culture. Clinicians must be prepared to address each patient's needs in culturally responsive ways. Accordingly, health care professionals need cultural competence skills and training, regardless of their ethnic heritage.
Cultural competence is a set of congruent behaviors, attitudes, and policies that come together to enable systems, agencies, and professionals to work effectively in cross-cultural situations.12
Culture is an integrated system of beliefs and values that serve to guide thought and behavior.1213 It is shared by a group of people with a common history, place of origin, or social experience. Culture is normally associated with racial, ethnic, and religious groups. However, professions and organizations can also develop a culture that guides behavior, thought, and action. One primary function of culture is to maintain and foster the growth and development of those who share in it. Thus, in this respect, culture is necessary for our very existence. Culture helps to guide choices and decisions about what is appropriate. It provides a sense of what is right or wrong, good or bad. Culture can be viewed as a distinctly consistent worldview. It helps us to interpret our world and the events we encounter in our everyday existence.14 Cultural influences permeate every aspect of our experiences. This influence is particularly strong in areas that are relevant to our welfare, quality of life, and survival, such as our health care.
Cultural competence is a set of congruent behaviors, attitudes, and policies that come together to enable systems, agencies and professionals to work effectively in cross-cultural situations.12 Cultural competence training cannot be limited to learning about specific groups and their commonly held beliefs. Learning about Latino, Asian American/Pacific Islander, American Indian/Alaska Native, or Black/African American cultures can be helpful in the health care setting; however, providers must be cautious not to create a set of stereotypes or generalize patient characteristics within ethnic groups. Rather, knowledge of a culture's shared experiences should be used by clinicians as a foundation on which to build a personal care relationship with each particular patient.
Both providers and patients come to the health care relationship with their unique cultural perspectives. In addition to their personal culture, providers are influenced by their professional culture. For example, within U.S. health care systems, several common values are honored, including the efficient use of time and a strict adherence to schedules and appointments, the assumption that professionalism requires a certain degree of detachment from patients, the reliance on often-complex technology and procedures, and the belief that causes of illness can be practically determined.14 These values often conflict with the values of some ethnic and cultural groups. For example, traditional healers may perceive an illness as emanating from negative spiritual forces. The solution may be a spiritual or natural intervention such as the use of herbs. Additionally, a number of issues that arise in HIV care tend to press our value/belief button. They have the potential to create challenges in the provider-patient relationship, as described below.
Having children is highly valued in most cultures. Within American society, it is so important that there are numerous medical interventions to help people facing infertility (inability to give birth to children). Having HIV infection does not extinguish the desire to have children. However, providers may feel that HIV-infected women should not carry a pregnancy unless they take medication that has been shown to reduce the risk of transmitting HIV to the infant. Still others may feel that HIV-infected women should not consider pregnancy at all and that HIV-infected parents are contributing to the problem of AIDS orphans.
Patients and providers may not see eye to eye regarding sexual choices, orientation, and practices. Effective HIV care requires open discussion of sexuality. However, providers may experience a range of emotional responses to their patients' sexual behavior that includes everything from acceptance to rejection. Providers may find their comfort level and sense of morality challenged.
Use of mind-altering substances increases the likelihood that someone may engage in behavior that presents a high risk of becoming infected with HIV. This empirically proven fact is of utmost importance to providers. Drug use also may interfere with medication treatment regimens. Although patients may be aware of these risks, they may use such substances anyway. Providers may experience disappointment or even anger when dealing with substance-use issues.
Meaning of illness:
Providers may examine illness from a completely scientific perspective whereas spirituality may influence patients' understandings of illness. For some patients, becoming infected with HIV may represent an opportunity to get their lives together and correct past behavior. They may view their illness as a journey, an opportunity to help others as medical professionals learn from their experience. If providers focus solely on the medical understanding of illness, they may miss this very important point of view.
Most professionals are taught that making eye contact with patients is essential. However, patients may come from cultures where looking someone directly in the eye is disrespectful. Whereas providers may view lack of eye contact as discomfort, patients may see it as a gesture of respect.
Involvement of family members in health care is a natural occurrence in some cultures. Although providers may feel that the patient is the sole focus of care, a patient may view family members as an essential source of support. Thus, providers may be required to move out of their comfort zone and engage family members in the treatment process.
Help seeking/Role of helpers:
Certain kinds of helpers such as ministers, teachers, doctors, and nurses may be widely accepted within various cultural groups. Others, such as mental health professionals, may be less accepted. Whereas providers may consider mental health care to be an integral part of health management, patients may not share this perspective.
Turning to one's religion or spiritual resources is both a proactive and reactive strategy. Ministry, meditation, ritual, and prayer may be as important to patients as taking their medication is to providers. The spiritual resources that support people in their daily lives often become more pronounced when someone is faced with chronic or life-threatening illness. Providers may easily prescribe an appropriate medication, but they may be less able to suggest a helpful spiritual intervention. For this, they may have to be educated by their patients.
Gender roles are very influenced by culture. Providers may come from a perspective of freedom and gender equality whereas patients may believe that women must be subservient to men. Even more challenging for providers may be those instances when they are working within in a culture where gender is not a binary concept but there are more than the usual male and female roles.
Death and dying:
Numerous culture-based rituals involve the phenomenon of death. Some of these rituals may preclude the conduct of an autopsy. Providers may value the scientific contribution of this procedure, but families may see it as a violation. If families have a cultural tradition in which funerals are important, providers who work with them may be expected to participate in the last rites. This may violate the professional cultural value that providers must be impersonal and maintain a proper distance in their relationships with patients.
In summary, providers may be faced with bridging gaps between their cultural worldview and those of their patients. Health care solutions are most likely to be multifaceted. Effective implementation requires negotiation of provider and patient perspectives on the nature of the problem as well as how to resolve it.
- Cross T, Bazron BJ, Dennis KW, et al. Towards a Culturally Competent System of Care. Washington: National Institute of Mental Health, Child and Adolescent Service System Program; 1989:13.
- Lewis S. Discovering Our Human Tapestry: A Cultural Competence Curriculum. Newark, NJ: National Pediatric and Family HIV Resource Center; 1992.
- Ka'opua L, AIDS Education Project Hawaii Area AIDS Education and Training Center. Training for Cultural Competence in the HIV Epidemic. 1992.