Colombia

According to Levin (2005: 63) studies investigating patients speaking less dominant languages perspectives on barriers to care often find that cultural factors are of prime importance. In a 2003 study on linguistic and cultural barriers to care, Chinese and Vietnamese-American patients who wanted to discuss non-Western medical practices with their healthcare providers and patients found their healthcare providers’ knowledge, inquiry and non-judgemental acceptance of traditional Asian medical belief as part of quality of care. This study also focused on the potential implications of alternative explanations for disease. In the African setting, non-Western medical beliefs is often regarded as a cause for decreased assessment of severity, late presentation of a clinical condition, non-adherence to medical treatment and the use of potentially dangerous traditional remedies (ibid).

As a linguistically and culturally diverse country, South Africa faces challenges related to the cultural dimension of communication between healthcare service providers and their patients. People from dissimilar cultural groups may differ in their views about health, illness and treatment (Watermeyer & Penn 2009:4). For an example, in the Crawford study (1994: 14), it was found that most patients had a deep-seated idea that the presence of the disease in their lives was related to a dislocation in their spiritual context. Mines (1989) as quoted in Crawford (1994:14) states that an illness reality for an individual is not a simple reflection of disease processes and is not only reducible to disease processes. An illness or symptom condenses networks of meaning for the sufferer including life stresses, personal trauma, fears, and expectation about the disease and social consequences (ibid). “Illness is culturally constructed and there is no training to enable western doctors to relate to certain diseases found among IsiXhosa people, and as a result, the doctor’s only recourse is intuition and experience” (Crawford, 1994: 14).

Where the doctor’s explanatory model diverges widely from the patient’s and this divergence is not explored and negotiated there is a greatly reduced chance of developing a therapeutic relationship that enables healing. Western doctor’s training has been such that there is an enormous lack of understanding of how illness might be constructed and experienced in other cultures, besides the general side-lining of the emotional and psychological aspects of illness. This, therefore, means that healthcare service providers need to take place in a culturally safe environment.

The notion of “cultural safety” is a relatively new concept that has its origins within the Maori nursing education context of New Zealand. Over the last decade, this concept has transcended national boundaries and increasingly gained international influence across a variety of provider and political organizations and associations concerned with redressing health inequities and achieving social justice, (Smye et. al. 2010:1).

2.7.1 Cultural safety & intercultural communication

Smye et al. (2010:7) define culturally safe practices as:

Those actions that recognize respect and nurture the unique cultural identity of others and safely meet their needs, expectations and rights.

According to Williams, (1999: 213) another commonly accepted definition of cultural safety is

An environment which is safe for people; where there is no assault, challenge or denial of their identity, of who they are and what they need. It is about shared respect, shared meaning, shared knowledge and experience, of learning together with dignity, and truly listening.

Smye et. al. (2010:7) state that culturally appropriate program approaches are crucial in enhancing personal empowerment and as a result, promote more effective service delivery (be it education, health, etc.) for indigenous people. A central tenet of cultural safety is that those people who receive the care decide what is culturally safe or unsafe and as a result shifts power from providers to consumers of healthcare (ibid). “Cultural risk or unsafe practice occurs when actions diminish, demean and disempower the cultural identity and well-being of an individual” (Smye et al. 2010:7).

According to Crawford (1994: 14), cultural differences operate within particular relations of power. Culture is the space where people construct identity, and within culture there exists the culture of domination or the culture of marginalisation. Western medical culture is the culture of power, in contrast to disempowered culture which has been enforced on black and non-Western cultures. Any discussion of cultural differences or closing cultural gaps has to acknowledge the present unequal power relations if these are not to be reproduced.

Due to the racial, linguistic and cultural diversity which takes place in a diverse country such as South Africa, the interaction which takes place, take place at an intercultural level.

Many different scholars tend to use the terms “intercultural” and “cross-cultural” interchangeably. However here they will be defined as distinct from each other. Gudykunst (2003:159-160) makes the following distinction:

Cross-cultural research involves comparing behaviour in two or more cultures (e.g., comparing self-disclosure in Japan, the United States, and Iran when individuals interact with members of their own culture). Intercultural research involves examining behaviour when members of two or more cultures interact (e.g., examining self-disclosure when Japanese and Iranians communicate with each other). Intercultural behaviour often is compared with intracultural behaviour (e.g., behaviour within a culture). To illustrate, Iranian self-disclosure when communicating with Japanese might be compared with Iranian communication with other Iranians.

Gudykunst (2003:163) further defines intercultural communication as:

communication between people from different national cultures, comparing how different linguistic communities manage, for example, communication between members of different social classes, intergenerational communication, and interracial/interethnic communication. Investigation of this type of communication therefore unravels the communication process between members of two or more different cultural groups who are situated in a shared environment.

In the context of healthcare, interpersonal communication also refers to provider-patient communications (2007: 91-92). Interpersonal behaviour is influenced by several cultural factors. Although each individuals has their own style of interacting with others, social conventions as well as traditional values in a given group or community play an important role in how behaviour and communication take place and are interpreted, (Shiavo, 2007: 92). In interpreting people’s behaviour, it is important to be aware of cultural interpersonal behaviour. The patient’s cultural values, language preferences, differences in style, and specific meanings attributed to verbal and nonverbal expressions are fundamental in establishing a satisfactory relationship (2007: 107).

Lack of understanding of these differences often undermines the impact of well-meant communication efforts. In the healthcare field, understanding how cultural variables and interpretations affect interpersonal behaviour has positive influence on communication that may lead to better patient outcomes and increased patient compliance to treatment (Schiavo, 2007: 93).

Smye et al (2010: 12) have identified several core competencies to achieve cultural safety when working in an intercultural setting. First, culturally safe practice necessitates an understanding of colonization and post-colonial forces and their effect on the lives of indigenous people (Smye, 2004; Smye & Browne, 2002; Smye et al., 2010). In particular, this would involve recognizing the role of social determinants of indigenous health and the relationship between residential school experience and historic trauma transmission and their resultant intergenerational health outcomes (ibid). It also includes knowledge of how historical and current government practices towards indigenous people have mediated and perpetuated health disparities and inequities, (ibid). This necessitates understanding the position of the patient from a historical, political as well as socio-economic stand point. A patient from a lower educational and socio-economic background might have a healthcare experience different to a patient with a higher educational and socio-economic background. These social determinants affect the behaviour of people in various intercultural interactions. Second, cultural safety requires commitment to the key principles that are driving the indigenous health movement, such as reciprocity, inclusivity, respect, collaboration, community development and self-determination (ibid). This means a focus on relationship­ building and collaboration with indigenous community contacts and support structures inclusive of elders, families and healthcare providers (traditional/medicine peoples/ healers), (ibid). Healthcare providers need to become immersed in communities they service in order for them to fully understand the cultural contexts their patients come from. The interaction between healthcare providers and their patients should therefore not only start and end in the medical consultation room.

Third, central to cultural safety is the concept of culturally safe communication and language (ibid). Like culture, language is a fluid and dynamic concept that is enacted relationally through a number of contextual features, such as history and social position, “with similar potential for negative consequences for indigenous people” (ibid). The contextual features of the language used in culturally safe communication are also important. The historic and

current social position of the language might influence the behaviour of the patient in an intercultural communicative context. If the patients’ language does not hold the same social status as that of the healthcare provider, the patient might immediately assume a position of cultural marginalisation.

Healthcare providers must therefore explore the socio-cultural (which include linguistic) dimensions that impact health and well-being, in order to not run the risk of hindering positive health outcomes for the patient (Wilson, 2006).

Levin (2005:76) states that a common thread amongst the articles on cultural safety is stressing the provision of culturally similar health practitioners and increasing the training of all health practitioners. The effect of training in cultural competence on satisfaction and health outcomes has been reported in a randomised clinical trial in 2004. In this study, 114 healthcare providers and 133 patients were assigned either to experimental training or control groups and followed for 18 months. After one year, cultural sensitivity training improved knowledge and attitudes among healthcare providers and patients who received care from trained providers showed better utilization of health resources and overall functional capacity, without an increase in health expenditure (Levin 2005: 76).

Recommendations for the incorporation of issues of culture into medical curricula have been proposed. These include teaching the rationale for learning about culture in healthcare as well as practical tools for productive cross-cultural clinical encounters, (ibid).

Although awareness of cultural beliefs, values and practices by healthcare providers and researchers can promote cultural sensitivity within a healthcare context, culturally sensitive approaches tend to omit a critical analysis of the influential social structures within which all healthcare interactions take place (Smye et. al. 2010: 15).

Levin argues that there is interplay between race, ethnicity, communication explanatory models and health outcomes. He developed a framework on the interplay between these factors for cultural competence and safety in healthcare.

L e v i n ’s c o n c e p tu a l f r a m e w o r k f o r c u ltu r a l c o m p e te n c e a n d s a f e ty in h e a lt h c a r e

• Race, Ethnicity, gender • Age, occupancy/profession • Length of relation

• Organisational contest • Situational context • Socio-political context

Communication styles and behaviours of doctors and patient

_______________▼______________ Interaction, information exchange, negotiation during medical encounter

Congruence between patient’s and doctor’s explanatory models of sickness

1

Affective responses Behavioural responses

• Trust • Use of health and disease self-

• Satisfaction management techniques by patient

• Adherence to recommendations • Empathy

(diagnosis, preventative, therapeutic) • Use of complementary and

alternative therapies

• Building a sustained partnership

The above model shows that race, ethnicity and communication have a role in the health outcomes of patients. The patient is from a particular race, gender, ethnicity age and interfaces with a healthcare system, with a particular organisational and structural context and with a healthcare provider of a particular background. Communication between the healthcare provider and patient takes place against the backdrop of such influences. These influences affect the communication styles and behaviours of the healthcare provider and patient which have a bearing on their interaction and their exchange of information during medical encounters. It also has a bearing on how the patient responds to their healthcare provider and vice versa, issues of trust and patient satisfactions. Levin states that these cultural influences and responses affect the patients’ health outcomes as it affects the healthcare providers’ ability to diagnose and heal the patient and affects the patient’s engagement with the healthcare provider.

Cultural competence and safety therefore forms part of the healthcare provision process of a patient and has a bearing on the healthcare outcomes of the patient.