Biocultural Interactions
Clinical Significance of Mexican Illness Beliefs
The illness concept caida de mollera is important for medical practice because associated conditions require medical attention and can provide information about symptoms useful in diagnoses (Baer and Bustillo, 1993, 1998). Caida de mollera refers to a depressed, sunken, or fallen fontanel. A common belief is that it is caused by pulling the baby away from the breast or bottle too quickly or by falls, tossing the baby, or otherwise bumping the baby's head. Caida de mollera is all too often viewed as just a cultural belief by health care providers. This emic cultural concept, however, reflects something real: an entity with etic status and reflecting life-threatening conditions. The sunken fontanel likely reflects severe dehydration. Cultural treatments for it are not likely to be adequate, but a parent's diagnosis of caida de mollera can indicate recent dehydration in the child. Physicians presented with the symptoms associated with caida de mollera typically consider them to be life threatening and requiring medical attention.
In the vast majority of cases, however, mothers of the children with these illnesses do not present them for medical care unless symptoms persist for a long time and do not respond to ethnomedical remedies. Most patients never receive biomedical attention. Reporting these conditions to physicians is increasingly rare because of their negative and critical reactions. Given that these conditions reflect symptoms that physicians consider to be worthy of biomedical attention, the importance of the ability to communicate about these conditions is apparent. Culturally sensitive communication between mothers and physicians can provide patient education as to the necessity of bringing specific conditions for treatment. If health care providers continue to view these folk illnesses as superstitions, their ignorance will contribute to increased morbidity and mortality from treatable life-threatening conditions that Mexican Americans recognize (Baer and Bustillo, 1993). Appropriate care requires the development of cultural competence.
cultural competence , which includes both individual and organizational capacities, behaviors, attitudes, and policies that effectively address cultural differences through the use of cultural knowledge and intercultural skills. Cultural competence involves the ability to address a range of cultural factors. These include cultural knowledge and personal awareness, as illustrated in the classic assessments of areas of cultural knowledge required in social work practice (Bartlett, 2003):
■ Cultural systems, including work organization and culture
The internal processes of communities, including their social resources Health service resources and their access organization and procedures
■ —Socialization processes
Economic, social, cultural, and interpersonal influences on human development The effects of group processes and influences on individual health behavior The effects on health of religious and spiritual beliefs
■ Personal, interpersonal, and group dynamics
How the interactional processes between groups affect health behaviors
The culture's social psychology of providing and receiving help
Patterns of expression, especially feelings and nonverbal communication
The practitioner's awareness of how emotions and attitudes affect healing relations
Overcoming cultural barriers to clinical competence requires several distinct approaches:
- A systems approach to understanding the nature of culture
- Knowledge of the other cultures' health perspectives
- Assessment of the effects of socialization processes on health and health behaviors
- Cultural self-awareness, especially regarding health and care values
- Skills in managing intercultural dynamics
Knowledge of cultural systems and organizational culture is part of the ability to address clients' problems by recognizing economic, political, and other social factors that have effects on well-being and health behaviors. Effectively adapting to others' health behaviors requires knowledge of both their cultural influences and the effects of the provider's culture. These differences can produce conflicts that impede effective cross-cultural relations and clinical communication. Cultural knowledge and intercultural skills together can help overcome these barriers through an accommodation to the cross-cultural realities of clinical care and public health.
Cultural competence levels range from destructiveness (ethnocentrism), incapacity, and blindness through varying degrees of skill represented in the concepts of cultural awareness, sensitivity, responsiveness, competence, and proficiency. Awareness of cultural differences may be followed by sensitivity in response to them. Competence involves the capability to deal effectively with cultural differences. Proficiency involves the ability to transfer this knowledge and these skills to others. Cultural awareness and sensitivity assist in adapting to other cultures through a knowledge of specific cultural information and the ability to provide culturally responsive care by addressing general barriers to effective cross-cultural relations. The ability to deal with cultural differences begins with overcoming ethnocentrism and developing an awareness of other cultures that leads to an understanding of the more sophisticated skills necessary to adapt effectively to cultural differences and intercultural processes.
Enhancing cultural competence requires the assessment of an individual's level of development and needed skills. A self-assessment is provided here (see Self-Assessment 1.4. Cross-Cultural Development) to help readers to assess their intercultural attitudes, beliefs, behaviors, and accomplishments. Cultural competence requires personal cultural awareness and an understanding of one's own professional culture and its unconscious assumptions, values, and motivations that affect patient relations (see Chapter Three). Learning about the effects of one's culture on health expectations and the medical encounter provides the basis for understanding intercultural conflicts in provider-patient relations and enhancing patient care by providing caregivers and consumers greater knowledge of one another.
Areas of Applied Medical Anthropology
The many different areas of medical anthropology reflect a growing trend of applying cultural knowledge to resolve health problems; a variety of aspects are listed below in "Applications: Areas of Medical Anthropology." Cultural knowledge and intercultural perspectives help facilitate relations among provider cultures, patient cultures, and institutional cultures. Cultural perspectives inform providers regarding how patients, families, and significant others conceptualize health problems and will respond to proposed care. Cultural perspectives enhance effectiveness in clinical practice and community health by enabling changes in professional style, institutional practices, and community behaviors where appropriate. Understanding a patient's personal and social life in relationship to the treatment plan helps ensure effective communication, appropriate resource utilization, and the success of treatments. Culturally sensitive approaches also help patients by helping providers accommodate to patients' concerns with alienation, powerlessness, distress, and despair (Kleinman and Good, 1985). Cultural approaches empower health care consumers by providing perspectives that enable them to respond to interpersonal and institutional aspects of health care.
Medical anthropology addresses interfaces between culture and health in the following ways:
- Training health care providers in cultural sensitivity and competency
- Mediating among the different community segments and between providers and clients
- Researching health threats and responses in a community
- Developing policies and programs to create culturally responsive health programs
- Participating in advocacy and community empowerment to ensure the development of responsive programs
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