Download counselling in a multicultural society

C E C O M P L I A N C E C E N T R E N AT I O N A L C O N T I N U I N G E D U CAT I O N P RO G R A M • J U N E 2 0 0 4
>Statement
of Objectives
After reading this lesson you will be
able to:
1. Describe the Canadian cultural mix.
2. Define culture.
3. Describe how culture affects perception
and values.
4. Describe how culture affects verbal and
nonverbal communication.
5. Describe how culture affects health
beliefs.
6.Describe how cultural issues affect
health care.
7. List cultural/racial issues that affect
disease and treatments.
8.List ways to improve inter-cultural
communication.
9. Describe techniques and tools to improve
counselling in a multicultural society.
>Instructions
1. After carefully reading this lesson, study
each question and select the one answer
you believe to be correct. Circle the appropriate letter on the attached reply card.
2. Complete the card and mail, or fax to
(416) 764-3937.
3. Your reply card will be marked and you
will be advised of your results in a letter
from Rogers Publishing.
4. To pass this lesson, a grade of 70%
(14 out of 20) is required. If you pass, your
CEU(s) will be recorded with the relevant
provincial authority(ies).
(Note: some provinces require individual
pharmacists to notify them.)
1.5 CEUs
Approved for 1.5 CE units by the
Canadian Council on Continuing
Education in Pharmacy.
File # 094-0204
www.novopharm.com
COUNSELLING IN A
MULTICULTURAL SOCIETY
by Melanie Rantucci, M.Sc.Phm., Ph.D
INTRODUCTION
A young middle-eastern woman wearing
a hijab (head covering) approaches the
dispensary along with an older man. The
man hands a prescription to the pharmacist,
a female Asian-Canadian. He asks, in
accented English, if the prescription is for a
liquid, explaining that his daughter will not
take pills. The pharmacist notes that it is a
vaginal cream and wonders how she is going
to provide pharmaceutical care for this
woman.
Communication and counselling are
important factors when it comes to patient
compliance. However, communication and
counselling can be challenging in a multicultural society. Canadian pharmacists and
their patients come from diverse cultural
backgrounds which can affect their perceptions of health and medication use and how
they communicate.
Understanding ethnicity and culture
can be useful in communication and counselling, however it won’t always accurately
predict individual behaviour and should
not be used to limit options for diagnosis or
treatment.1 In spite of cultural diversity, all
patients share feelings of need, fear, mistrust, lack of control and hope.1 By becoming “culturally competent,” acknowledging
and respecting cultural diversity, pharmacists can build partnerships with patients in
which cultural issues can be discussed in
order to reduce noncompliance.1
THE CANADIAN CULTURAL MIX
CANADA IS A DIVERSE SOCIETY WITH A RICH MIX
of cultures. Prior to 1950, immigrants to
Canada were largely European. However,
in 2001 only 50% of immigrants were
from Europe and the United Kingdom,
36.5% from Asia and the Middle East, and
5% each from the Caribbean, Africa,
Central and South America.2 As a result,
18.4% of Canadians are now foreign-born,
with many second-generation Canadians
maintaining cultural ties. This cultural mix
is most evident in large urban areas,
accounting for 18% of the immigrant population – more than one-third of the total
population of Toronto and Vancouver.3
Canada also has an Aboriginal population, representing about 3% of the population (two-thirds North American Indians,
30% Métis, and 5% Inuit).4,5,6 Most live
in rural areas in Ontario (17.7%), British
Columbia (17.5%) and Manitoba (16.1%),
while 30% live in metropolitan centres,
particularly Winnipeg, Edmonton and
Vancouver.5,6
Another cultural group in Canada is the
Francophone population which accounts
for 22.6% of Canadians.7 Quebec is home
to most French-speaking Canadians (86%
of the Francophone population). Other
provinces with French-speaking communities include Ontario (7%), New Brunswick
(3.5%) and Manitoba (0.7%).
Depending on where a pharmacist practices in Canada, the patient population may
be comprised of immigrants from many different cultures (many Asian and Middle
Eastern), second-generation immigrants
(more European), and possibly Francophones
and Aboriginal people. And pharmacists
themselves are likely to be from one of these
cultural groups. Added together, you have a
complex situation.
2
COUNSELLING IN A MULTICULTURAL SOCIETY
EFFECT ON COUNSELLING
AND COMPLIANCE
THE EFFECT OF CULTURE AND RACIAL DIFFERENCES
on counselling and compliance is as complex
as our Canadian population mix. Culturallybased issues may affect treatment choice (from
the patient’s and health professional’s clinical
and personal perspectives), reaction to illness
and treatment, and communication – all of
which can affect compliance. As a result, providing pharmaceutical care may be affected at
many points by culture and race (see Table 1).
THE MEANING OF CULTURE
TO UNDERSTAND HOW TO ADDRESS MULTICULTURAL
issues in pharmacy, we need to understand
the meaning of culture.
Definition of culture
Culture is defined as a “shared learned
behaviour, transmitted from one generation
to another, to promote individual and social
survival, adaptation, growth and development. Culture has both external (e.g. artifacts, roles) and internal (values, attitudes,
beliefs, cognitive/affective/sensory styles,
consciousness patterns and epistemologies)
representations.”4,8 Culture is elaborate and
multi-dimensional, encompassing language, nonverbal behaviour and how you
relate to others. It helps us determine our
beliefs, values and world view.
Culture is learned through conscious or
unconscious conditioning from various
sources.9 Each of us belongs to a culture
(although individuals vary in the degree to
which they adhere to a set of cultural patterns), identifying strongly with a particular
group or combining practices from several
groups. Humans tend to be ethnocentric;
we see other cultures from the perspective
of our own culture. Ethnocentricity can
impede intercultural communication and
sensitivity.
Cultural differences occur internationally
(immigrants from many countries) and
domestically (African-Americans, Native
Canadians, Francophone, etc.), and can have
FACULTY
TABLE 1
CE COMPLIANCE CENTRE • JUNE 2004
Effect of Culture on Pharmaceutical Care
Pharmaceutical
Care/Counselling
Effect of Culture or Race
Developing rapport
with patient
• May feel discomfort with one-on-one personal relationship.
• May not wish to speak to a male or female pharmacist.
• Verbal and nonverbal communication may be misunderstood
by patient or pharmacist.
Gathering informa- • Communication barriers may limit response to questions.
tion to assess
• May view role of pharmacist as simply dispenser and is,
patient’s needs
therefore, reluctant to provide information.
• Environmental factors may not be recognized by pharmacist,
e.g. smoking, alcohol use.
• Biologic factors affecting drug effects i.e. genetic differences may not be recognized.
• Patient’s beliefs about nature of disease and perception of
symptoms may affect response to questions.
• Beliefs about health and illness may affect symptom
response, e.g. belief that pain is part of life may delay seeking
relief or reporting symptoms.
Identifying drugrelated problems
and compliance
issues
• Patient’s perceptions and trust of health care system and
treatments may contribute to noncompliance.
• Beliefs about medications may make patient more reluctant
or over-reliant on medications.
• Biologic factors, i.e. genetic differences, may make patient
more susceptible to adverse effects.
Providing information and developing
pharmaceutical
care plan
• Communication barriers may limit ability to understand
instructions.
• Poor health literacy may limit ability to understand and
follow instructions.
• Patient may not be comfortable with partnership approach
to care.
• Health beliefs may affect patient’s expectations of treatment.
Follow-up
• Communication barriers may limit discussion.
• Health beliefs and attitudes to health care provider may
affect pharmacist’s follow-up.
• Family values may provide support networks and improve
compliance.
influence to varying degrees through successive generations.
Effect of culture on perceptions
and values
Our individual culture tends to affect how we
perceive and make sense of the physical and
social world. It affects how credibility is perceived. For example, Americans view expressing opinion openly and forcefully as
admirable. They see people who are direct and
confidant as credible, and place only moderate
importance on social status. Japanese people
admire quiet people who listen more than
COUNSELLING IN A MULTICULTURAL SOCIETY
ABOUT THE AUTHOR
Melanie Rantucci has a doctorate in pharmacy administration. Her research involved
patient counselling for nonprescription drugs
and factors affecting drug misuse in the elderly. She has published numerous articles on
counselling, as well as books which have been
distributed to pharmacists and pharmacy
schools around the world. In addition, Melanie
has presented workshops on patient counselling for practising pharmacists across
Canada and in the U.S.
REVIEWERS
All lessons are reviewed by pharmacists for
accuracy, currency and relevance to current
pharmacy practice.
CE COORDINATOR
Heather Howie, Toronto, Ont.
For information about CE marking, please
contact Mayra Ramos at (416) 764-3879,
fax (416) 764-3937 or mayra.ramos@
rci.rogers.com. All other inquiries about CE
Compliance Centre should be directed to
Karen Welds at (416) 764-3922 or
karen.welds@pharmacygroup. rogers. com.
This CE lesson is published by Rogers Media
Healthcare/Sante, One Mount Pleasant Rd.,
Toronto, Ont. M4Y 2Y5. Tel.: (416) 764-3916
Fax: (416) 764-3931. No part of this CE
lesson may be reproduced, in whole or in part,
without the written permission of the publisher.
CE COMPLIANCE CENTRE • JUNE 2004
TABLE 2
COUNSELLING IN A MULTICULTURAL SOCIETY
Some of the Dimensions of Cultural Values10
Dimension
Description
Individualismcollectivism*
Independence and uniqueness of person in culture vs. greater
emphasis and dependence on the group.
Uncertaintyavoidance*
Extent to which persons in culture are made nervous by
unstructured, unclear or unpredictable situations.
High-avoidance cultures maintain strict codes of behaviour
and beliefs to avoid uncertainty.
Power-distance*
Distance between members of society with and without power.
Cultures with large power-distance believe people are not
equal, everyone has rightful place, rigid value system.
Cultures with small power-distance minimize inequality and
de-emphasize rank and status.
Masculinityfemininity*
Degree to which masculine and feminine traits are valued and
revealed.
Masculine culture values ambition, acquisition of money, men
taught to be domineering, ambitious, assertive.
Feminine culture values caring, nurturing, promotes sexual
equality, people and environment are important, gender roles
more fluid.
Confucian
dynamism*
Degree of adherence to Confucian values: long-term orientation,
perseverance, status, sense of shame, face-saving.
Relationship with
nature**
Culture may see people as subject to nature, in harmony with
nature, or master of nature.
Sense of time**
Past, present or future-oriented.
Value placed on
activity**
Culture values being (spontaneity) vs. becoming (spiritual life
more than material) vs. doing (accomplishment judged by
things you do).
High context low context
orientation***
High context: more meaning in gestures, silence, awareness of
surroundings, status and friends.
Low context: verbal message more important.
Level of formality
Cultural emphasis on formality vs. informality in way people
address others, dress, conduct themselves.
Level of
assertiveness
Culture values assertive and aggressive style vs. harmony and
accord.
From: * = Hostede; ** = Kluckhohn and Strodtheck; *** = Hall as cited in Ref.#10.
speak and view indirect, sympathetic, and
humble people as more credible. They also
place major emphasis on social status.10
Beliefs, attitudes and values are also affected by cultural perception. Culture conditions
us to hold certain beliefs to be true and worthy, and discourages us from questioning
those beliefs.10 Cultural values determine what
is important to an individual and how they
perceive stressful situations. A number of
theorists, including Hofstede, Kluckhohn,
Strodtheck and Hall, have suggested different
sets of cultural values (see Table 2).
The effect of differences in cultural values is
seen in the ways that we perceive others, our attitudes toward them and how we communicate.
CULTURAL DIFFERENCES IN VERBAL
AND NONVERBAL COMMUNICATION
WHEN DEALING WITH PATIENTS FROM DIFFERENT
cultures, pharmacists must contend with
English as a second language and the cul-
tural context of language, words and nonverbal language.
Use of language
Language, thought processes and perceptions are intertwined with culture, affecting
how people express themselves, how frequently they speak, the meaning of their
words and expressions, and how they interpret other’s words and behaviour.
Words can elicit many meanings.11
Linguists estimate that 500 of the most-used
words in the English language can produce
over 14,000 meanings.11 In conjunction with
different cultural values, language can
become even more confusing. For example,
“pain,” “freedom,” “sexuality,” “wealth,”
“leadership,” and “security” have different
meanings in different cultures.11 Some cultures have many meanings for one word. For
example, the Sami language in Sweden has
500 words to explain “snow.” Some cultures
3
use different words for the same thing. British
say “lift” and Canadians say “elevator.”
Further complexity is added when you
consider how language reflects cultural values (see Table 3). This can make translation
into English difficult, resulting in inaccurate or misleading interpretation because all
characteristics of the language cannot be
translated.
Nonverbal communication
Much of what is lost in translation is still
communicated nonverbally. However, if
nonverbal communication is not recognized
or is misinterpreted, it can lead to miscommunication. Nonverbal communication is
actually believed over verbal communication
and is hard to control because it is subconscious and automatic, making it difficult for
a new English speaker to adjust.12
Cultural differences in nonverbal communication are seen in body behaviour,
proxemics (space and distance), and use of
silence.12
Body behaviour provides a nonverbal
message, including general appearance,
attire, body movement, facial expression, eye
contact, touch and paralanguage, which
includes volume of voice and noises, communicates different things in different cultures.12 An individual’s general appearance
may send a message about the value of modesty (use of head and body covering for men
or women); religious values (use of turban,
yarmulke) and traditional values (wearing
traditional costume). Different cultures also
regard different body types as attractive.
Body movements (kinesics), such as posture and how one seats oneself, may illustrate respect and manners. Pointing, for
example, has widely different meanings,
some rude or vulgar. And there are many
different ways to beckon someone using
fingers, hand gestures or head movements.
Luckily, facial expressions of happiness,
sadness, fear, anger, disgust and surprise are
universal, but culture will dictate when, how
and to whom they are displayed. Generally,
Mediterranean cultures show exaggerated
signs of grief or sadness; North American
white males tend to suppress showing emotions as the Chinese do, in order to save face;
Japanese hide expressions of anger, sorrow
and disgust by laughing or smiling.
Eye contact is highly valued in Western
society but is considered an insult in Asian
cultures. Latin American, Caribbean and
African cultures tend to avoid eye contact as
a sign of respect.12
The gesture of touch sends messages
about what you are thinking and feeling,
but can be confusing. Gestures such as kissing, hugging and shaking hands are used
more or less in different cultures and may
be miscontrued as having a sexual meaning.
4
COUNSELLING IN A MULTICULTURAL SOCIETY
Those with more emotional restraint are
less likely to touch (English, German) while
others encourage signs of emotion and
touch (Latin American, Middle Eastern,
southern European).
A loud voice communicates strength
and sincerity for Arabs, strong belief for
Israelis, authority for Germans, impoliteness for Thais, and lack of self-control for
the Japanese.
Proxemics: In general, cultures that stress
individualism demand more personal space
than collective cultures which may view the
violation of personal space as aggressive.
Africans, Arabs and Mexicans tend to speak
much closer than Western and European cultures. Asians use extended space to denote
deference and esteem. In North America, 1.5
feet distance is considered intimate; 1.5 to 4
feet is personal (conversation with friends and
acquaintances); 4 to 12 feet is social distance
for more formal and impersonal interaction;
and 12 feet and more is for public communication such as lectures.13
Use of silence: Some cultures, such as
Eastern, Indian and Native American,
believe silence has meaning and feel less
uncomfortable in silence. However, North
Americans, Arabs and Europeans consider
talking an important activity and often
avoid silence.
From this discussion, it is clear that one
must be careful not to assume that people
are communicating only when they talk.
Cultural variations in use of talk, silence
and body language can speak volumes.
CULTURE AND HEALTH CARE
A PATIENT’S HEALTH BELIEFS MAY BE THE MOST
important aspect of culture for pharmacists
to recognize when it comes to compliance.
Different cultures understand the cause,
treatment and prevention of illness differently, and this affects how they perceive their
health problems and treatments. Culture
teaches us what causes people to become sick
or injured, what words to use to describe
body parts and symptoms, how to behave
when we are ill or injured, and what we need
(or are allowed) to say or do to feel better.14
Failure to recognize these health beliefs and
match treatments accordingly can result in
misdiagnosis, unnecessary procedures and
treatments, and failure to treat.
DIFFERENT HEALTH BELIEF SYSTEMS
THREE GENERAL SYSTEMS OF HEALTH BELIEFS are
held by various cultures around the world:
biomedical, personalistic and naturalistic.15
The biomedical system is the dominant
health belief system in Canada. It focuses on
an objective diagnosis and scientific explanation for disease. Illness is believed to result
from abnormality in body functioning or
structure through agents such as bacteria,
TABLE 3
CE COMPLIANCE CENTRE • JUNE 2004
Culturally Diverse Language Usage11
Cultural
Characteristic
Language Usage
Directness
Some cultures use more direct language, e.g. N. Americans
favour explicit, blunt language. Other cultures are less direct
to preserve feelings, dignity and save “face”; many Asian cultures reverse “yes” and “no”.
Maintain or enhance Expression of formality: Latin languages have formal and
social relationships informal versions of verbs depending on person being addressed.
Communicate social status: Many languages have different
vocabularies when speaking to superiors.
Emotive expression
Ability to verbally express feelings: Some cultures avoid strong
expression of feelings, restrain emotions vs. frequent expression
of gratitude.
Enjoyment of
language
Some cultures have oral traditions, enjoy verbal play.
Patterns of language may be rich with intonation, repetition,
exaggeration.
viruses or physical conditions such as injury
or aging. Disease is diagnosed when the body
is clearly deviating from the norm. The focus
of the biomedical belief system is on the
body, not the mind.
The personalistic system of health beliefs
is held by some Asians, Vietnamese and
Laotians. They believe that disease or illness
is caused by a supernatural or nonhuman
being (deity, ghost or evil spirit), or a human
witch or sorcerer as a form of punishment.
The basic belief of the naturalistic system is that disease is an imbalance between
elements in the body, mind or environment. For Asians, the balance is between
yin and yang; Mexicans and Puerto Ricans
believe in the need to balance 4 body
humours: blood (hot and wet), yellow bile
(hot and dry), phlegm (cold and wet) and
black bile (cold and dry); African, Haitian,
Jamaican and Native Americans believe that
illness is caused by disharmony with nature.
Native Americans view illness as a fate to be
accepted like birth or death.15
EFFECT OF HEALTH BELIEFS
ON TREATMENT CHOICES
AND PREVENTION
TREATMENT CHOICES AND PREVENTIVE MEASURES
may be significantly affected by health
beliefs. For those who believe in the biomedical system, the goals of treatment are
to return the body to normal by destroying
or removing the causative agent, repair
affected body parts, control the affected
body system and return the body to normal
with medication, surgery or nutrition.
Preventing illness involves avoiding the
causes of illness.
Believers in the personalistic system aim
to create a positive relationship with the
entities causing the illness by shocking or
scaring the spirit into leaving the body. They
prefer treatments that physically ward-off
evil spirits, consulting with folk healers and
conducting ceremonial exorcisms.
In the naturalistic belief system, treatment involves restoring balance, often with
a remedy that is opposite in nature. Foods
and herbs restore balance by treating cold
illness with hot remedies, and hot illnesses
with cold remedies. Folk remedies involve
looking beyond the symptoms of the illness
for imbalances in relationships with the
environment, emotions, social, spiritual
and physical factors. Prevention involves
maintaining the balance of forces.
There are also beliefs about what keeps
you healthy. Luck, religion, keeping spirits
happy, and avoiding cultural taboos may
come into play.
Many health beliefs and approaches to
illness and treatment are difficult to recognize. Often, patients will not reveal that they
are being treated by a nontraditional healer
or that they are using folk remedies.1 They
may not seek treatment or will wait until
conditions are at a late stage, due to culturally-based attitudes that illnesses should be
kept private or illness is simply fate.1
CULTURAL ISSUES THAT AFFECT
HEALTH CARE
BEYOND SPECIFIC HEALTH BELIEF SYSTEMS, religion, family roles, personal health disclosure, language barriers, nonverbal communication, health literacy and attitude to
health care workers can affect health care.
Religion: Spirituality may have an impact
on prevention and treatment of illness. In a
review of 212 clinical studies, 160 positive
effects of religious commitment were found
compared to 15 negative effects.15 Positive
effects include diet and social practices as
well as mental attitude. Alternatively, fatalistic beliefs can lead people to deny responsi-
CE COMPLIANCE CENTRE • JUNE 2004
TABLE 4
COUNSELLING IN A MULTICULTURAL SOCIETY
Varying Drug Effects Among Racial and Ethnic Groups1,14
Drug
Racial Group Affected
Clinical Effect
(in comparison to Caucasians)
Cardiovascular Drugs
Enalapril
Blacks with left ventricular
dysfunction
No reduction in high blood
pressure and hospitalization
for heart failure.
Captopril
Blacks
Less effect in lowering blood
pressure.
Isoproterenol
Black men
Less relaxing of blood vessels.
Propranolol
Chinese
Lower blood levels, twice as
sensitive to effects on blood
pressure and heart rate.
Nifedipine
South Asians, Koreans,
Nigerians
Higher blood levels.
Hydrochlorothiazide Blacks
More likely to achieve blood
pressure goal.
Antidepressants/Antipsychotics
Clomipramine
Indian, Pakistani
Higher incidence and severity of
side effects.
Nortiptyline
Japanese
Higher blood levels.
Alprazolam
Asians
Lower blood levels.
Clozapine
Korean Americans
Need lower dose, higher rate of
CNS side effects.
Haloperidol
Chinese, Japanese, Filipino,
Korean, Vietnamese
Lower effective dose.
Lithium
Asians, Indians, Pakistanis
Lower effective dose.
Antidepressants
Hispanic, African-Americans Need lower doses, more side
effects.
Clozapine
Ashkenazi Jews
Increased risk of agranulocytosis.
Codeine
Caucasians
5 - 10% are poor metabolizers
of codeine to morphine receiving
no analgesic effect.
Codeine and
Morphine
Asians
Fast metabolizers of morphine
and of codeine not converted to
morphine, so cleared from body
faster resulting in weaker effect.
Analgesics
bility for health or illness, and specific religious teachings may cause refusal of treatment (e.g. Jehovah Witness).
Family: Some cultures have fairly rigid
family roles that dictate male dominance,
modesty and female purity, and specific rituals involving pregnancy and childbirth.15
In cultures where men are in authority, such
as Middle Eastern, Asian, Latin American,
Mexican and African, a male family member will generally be the spokesperson,
answering questions and making decisions
about a family member’s health care, and
may refuse to deal with female health care
workers. In other cultures, such as
Hispanic, the mother or grandmother may
make health care decisions.1
Cultural beliefs about modesty prevent
some women from seeking care or medical
advice and they may refuse to undress for a
medical exam. A girl may be punished for
immodesty in order to preserve family honour.
The family may also play a role in
response to treatment because social support is an important part of recovery. Some
cultural groups have close-knit extended
families, church and community organizations which provide support. Conversely,
some groups may react negatively to conditions such as mental illness or unwanted
pregnancy, making treatment difficult.
All cultures have attitudes, practices and
behaviours surrounding childbirth and
5
pregnancy. Some cultures value male more
than female children; some place status on
the number of children. The expression of
emotion or pain during child birth may be
considered shameful (Asians) or welcomed
(Middle Eastern, Mexican, Italian).
Personal disclosure: Culture may influence the ability or willingness of a patient to
discuss personal information with health
care providers. Some may not wish to discuss “female problems” and some high-context cultures view talk about personal matters in poor taste. When family members or
others are translating, the patient may feel
inhibited about discussing issues. Lack of
trust of Canadian medicine or health care
providers may also inhibit discussion.1
Language barriers and literacy: Language
and different meanings of words for symptoms, etc. greatly affect communication.
Health jargon may be non-translatable and
certain symptoms or feelings may be difficult
to articulate. Lack of health knowledge may
be due to low literacy, resulting in poor selfmanagement skills and noncompliance.1
Nonverbal Communication: The patienthealth care provider relationship may be
fraught with difficulty when cultural issues
affect nonverbal messages such as eye contact, facial expression, space and touch.
Attitude to health care workers and health
care: Cultural ideas of formality may cause
patients to view Canadian health care
providers as less credible because of casual
dress or informal forms of address. It may be
difficult to treat patients with a chronic illness
because they view treatment as symptom
removal. Once symptoms are gone, they see
no need to continue.1 Western treatments are
often viewed with great caution. Fear of
addiction or toxic effects may cause patients
to take smaller doses or stop taking medications altogether. Finally, because other countries have fewer drug regulations, drugs that
are available only by prescription in Canada
may be accessed from the patient’s home
country for self-treatment without the
knowledge of Canadian health care providers.
This can result in confusion and dangerous
side effects.1
EFFECT OF CULTURE ON DISEASE
AND TREATMENTS
CULTURAL ENVIRONMENT, HEALTH BELIEFS,
behaviour and genetic differences lead to
increased susceptibility for some people to
some illnesses, varying effects of treatments,
and the types of treatments patients expect,
accept or adhere to.1,14
Genetic variation in drug metabolism
enzymes and proteins involved in drug
response or disease progression result in poor
metabolism and increased side effects.1,14
Some racial groups have a higher likelihood
of having these gene variations, most clini-
6
COUNSELLING IN A MULTICULTURAL SOCIETY
cally significant in cardiovascular and central
nervous system agents as shown in Table 4.
Some ethnic groups are more susceptible
to certain disease conditions. People of
African descent are more likely to suffer
from death and disease from smoking and
because of higher rates of smoking and
slower metabolism of nicotine. They also
have a higher prevalence of hypertension,
retaining more salt.1
Diet and lifestyle also contribute to ethnic differences in disease and drug effects.
In Canada, Aboriginal people suffer from a
higher rate of rheumatism and arthritis,
high blood pressure and diabetes as a result
of genetic predisposition to fat storage combined with a less-active lifestyle and a highfat diet.6,16 Conversely, Canadian immigrants of less than 10 years have been found
to have a lower prevalence of chronic conditions, disability, cancer and heart disease
than other Canadians. However, this difference tends to decrease over time, probably
as a result of acculturation to Canadian
lifestyle and diet.6
Not surprisingly, mental and emotional
health problems are a major problem for
refugees in North America due to loss of
personal and cultural identity, depression
and post-traumatic stress disorder.17
Patients from different cultures may also
have different expectations of treatment
because of health beliefs and past experiences. They may expect to get an injection
rather than an oral medication, and a quick
resolution to symptoms that may be chronic. Health professionals in white coats may
also represent authority figures, causing
reluctance or distress for immigrants who
have suffered from torture or abuse.
Language and communication issues and
dissatisfaction with health care professionals
can also result in poor response to medications due to misunderstandings.13
TECHNIQUES AND TOOLS TO
ADDRESS MULTICULTURAL ISSUES
TO PROVIDE PHARMACEUTICAL CARE AND COUNselling to multicultural patients, pharmacists
need to improve intercultural communication
by addressing personal attitudes and biases.
Pharmacists can then use techniques and tools
to address language differences and cultural
sensitivities.
IMPROVING INTERCULTURAL
COMMUNICATION
PEOPLE PREFER TO BE WITH PEOPLE LIKE THEMselves. Unfortunately, those people are
viewed as a “group,” with stereotypical characteristics. Some characteristics ascribed to
the group may create negative feelings and
prejudice.
Whether pharmacists are North American
in culture, first- or second-generation non-
North American, or from a co-culture, they
tend to be ethnocentric, viewing others from
their own cultural biases. Pharmacists should
remember that they are also viewed from
other cultural biases, which may place them in
a negative light. To improve intercultural
communication with patients, pharmacists
can take a number measures:18
1. Know yourself, your attitudes and how
others perceive you. First, recognize your own
cultural biases and stereotyping of other
cultures. Examine your beliefs and how
they influence your attitudes to individual
patients. Some of these ideas may not be
based on your individual experiences but on
those of your family or society in general.
Examine how you tend to communicate
with people who are different. Consider
whether you are tolerant of strong accents
or react negatively to mode of dress.
Consider whether you are a good listener or
tend to dominate the conversation.
2. When possible, make concessions to cultural preferences and customs. Although it
can be daunting in a multicultural city such
as Toronto or Vancouver, one generally
works in a setting where a few cultural
groups are predominant. Attempt to get to
know some of their important customs,
forms of communication and health beliefs,
perhaps by attending cultural events.
Address these issues in your interactions
with them. Make sure that all pharmacy
staff are educated on cultural issues.
3. Learn languages and hire bilingual staff.
Match your pharmacy staff to the cultural
mix in the community so there is someone
who can translate or clear up misunderstandings resulting from cultural issues. Learn
ways of addressing people (last names are not
always used and family names can be confusing) and pronouncing common names.
Learn key phrases, greetings, ways of referring to symptoms, common medication
instructions and, if possible, translate medication labels and patient information with
dispensing software. Translate information
sheets of common medications and instructions on ophthalmic, vaginal, rectal and
inhaler use. Some organizations such as the
Canadian Diabetes Association or local cultural groups have literature available in other
languages. Have diagrams and pictures of
body parts to help discuss symptoms or
application of drugs.
Speak slowly and clearly (but not loudly)
when speaking English to patients whose
second language is English. Avoid using
detailed explanations, idioms or slang.
4. Be aware of nonverbal language.
Gestures and nonverbal language, such as
eye contact, speaking distance, pointing
and touching mean different things in different cultures. Smiling can signify more
than happiness, and silence may mean more
CE COMPLIANCE CENTRE • JUNE 2004
than having nothing to say. Nodding and
saying “yes” may not mean that a patient
understands and is responding in the affirmative. Use universal symbols such as those
found on auxiliary labels or used at airports.
5. Be empathetic. Be prepared to recognize or anticipate emotions caused by
health conditions, medications and interaction in an unfamiliar health care setting.
Look for anger, frustration, fear, confusion
and embarrassment and let the patient
know that you understand.
6. Be assertive. Let the patient know that
you want to understand. Don’t give up in
frustration. Tell the patient if you don’t
understand them and ask them to slowly
repeat what they have said, or say it in
another way. Ask them to help you understand their needs and concerns, but let
them know it is your problem, not theirs.
Even if you are unable to understand fully,
they will appreciate your attempt.
7. Encourage feedback. Offer ample
opportunity and time during counselling for
patients to acknowledge that they understand and ask questions. Ask the patient at
intervals if you are making yourself clear.
This puts the onus on you for any misunderstandings rather than on the patient.
8. Recognize poor literacy/health literacy
skills. People become experts at masking
their lack of oral or written literacy. Be sensitive to the embarrassment that poor literacy can cause by not making an issue of it.
Offer simple explanations and definitions
of health-related terms, written or video
information when possible, and review
written information to clarify words
patients don’t understand. Use compliance
reminders, such as charts and dosettes, to
clarify dosage regimens.
9. Treat each patient as an individual.
Avoid stereotyping based on skin colour,
accent, clothing or other visible differences.
Each patient has individual needs, and these
needs should be identified and addressed.
10. Be alert to atypical drug responses or poor
response to treatment. Do not discount a
patient’s report of unusual drug ineffectiveness
or adverse effects until cultural reasons have
been ruled out. Reasons may include genetics,
misunderstanding directions, noncompliance
for cultural reasons, or misdiagnosis due to
misunderstandings during diagnosing.
COUNSELLING TECHNIQUES AND
TOOLS TO ADDRESS LANGUAGE
AND CULTURAL DIFFERENCES
THE FOLLOWING LIST DESCRIBES TECHNIQUES
suitable for intercultural counselling:19
1. Recognize the issues. Recognize the
complexity of the situation and cultural
issues and be willing to address them. The
pharmacist must also recognize his or her
own cultural biases and ethnocentric views
CE COMPLIANCE CENTRE • JUNE 2004
and try to view things from the patient’s
point of view, i.e. although the idea of a
male family member speaking for the
female may be abhorrent to a North
American female, consider that this woman
is probably comfortable with it.
2. Use questions appropriately. Use openended questions to determine how well the
patient speaks English. Use closed questions
to get specific information, limiting language struggles.
3. Involve family as needed. In situations
where no other family member is present
and English is poorly spoken or non-existent, ask if there is a family member who
speaks English. Indicate to the family member that he should translate what is being
said and wait for him to do this after speaking, signaling this with nonverbal language.
Often a child can be enlisted. If so, this
should be accepted, but counselling should
be adjusted to avoid embarrassment to the
child or parent. Even if the other family
member is being the spokesperson or translating, the pharmacist should make it clear
that the conversation is with the patient, not
the translator, by looking at the patient as
well as the family member when speaking.
4. Address privacy. Ask the patient to
come to a private area along with family
members as needed.
5. Use counselling aids. Pictures demonstrate where the problem is and where the
medication is to be applied. Other helpful
aids include dosing charts, dosettes and
instructions in foreign languages.
6. Speak slowly and clearly; avoid health
jargon or colloquialisms. Use simple explanations, words and sign language.
7. Get feedback. Ask if you are speaking
clearly enough. Make sure everything is
understood.
8. Follow-up. Provide the patient with a
card with the pharmacist’s name and phone
number and ask them to call to let you
know everything is OK. Refer the patient to
COUNSELLING IN A MULTICULTURAL SOCIETY
local ethnic groups which may have health
programs to assist them in dealing with
their illness.
SUMMARY
THE CULTURAL ISSUES RAISED IN THIS LESSON
are endlessly complex and present, perhaps
the biggest challenges in patient counselling
and compliance facing pharmacists in
Canada today. Being aware of the issues,
familiar with the neighbourhood surrounding the pharmacy, and employing the techniques discussed will, hopefully, make the
task less daunting. Rather than being
viewed as a chore, it should be seen as an
interesting adventure into the larger world.
REFERENCES
1. Burroughs V, Maxey R, Crawley L, Levy R.
Cultural and genetic diversity in America: The
need for individualized pharmaceutical treatment. National Pharmaceutical Council, National
Pharmaceutical Association. Available online at:
www.npcnow.org/issues_productlist/PDF/culturaldiversity.pdf. Accessed November 3, 2003.
2. Immigration population by place of birth,
provinces and territories. Available online at:
www.statcan.ca/english/Pgdb/demo35a.htm.
Accessed February 2, 2004.
3. Applied Research and Analysis Directorate - Working Paper Series: Immigration and
Health. Available online at: www.hc-sc.gc.ca/
iacb-dgiac/arad-draa/english/rmdd/wpapers/
immigration02. Accessed November 3, 2003.
4. Proportion of foreign-born population, census metropolitan areas. Statistics Canada, 2001
Census data. Available online at: www.statcan.ca/
englishPgdb/demo46b.htm. Accessed February
2, 2004.
5. Aboriginal identity (8) Age Groups (11B),
Sex (3) and Area of Residence (7) for Population,
for Canada, Provincial and Territories, 2001
Census. Available online at: www12.statcan.ca/
English/Pdb/popula.htm#imm and follow links.
Accessed February 2, 2004.
6. Second diagnostic at the health of First
nations and Inuit people in Canada. Health
Canada. Available online at: www.hc-sc.gc.ca/fnihb/
7
cp/publications/second_diagnostic_fni.pdf.
Accessed November 3, 2003.
7. Population by mother tongue, census metropolitan area. Statistics Canada 2001. Census
data. Available online at: www.statcan.ca/english/
Pgdb/demo18e.htm. Accessed February 2, 2004.
8. Samovar L, Porter R. The Challenge of
Intercultural Communication. In: Communication
Between Cultures, 4th Edition. Wadsworth,
Belmont CA, 2001. p. 3-20.
9. Samovar L, Porter R. Communication and
culture. In: Communication Between Cultures, 4th
Edition. Wadsworth, Belmont CA, 2001. p. 21-50.
10. Samovar L, Porter R. Cultural diversity in perception. In: Communication Between Cultures, 4th
Edition. Wadsworth, Belmont CA, 2001. p. 52-80.
11. Samovar L, Porter R. Language and culture.
In: Communication Between Cultures, 4th Edition.
Wadsworth, Belmont CA, 2001. p. 136-60.
12. Samovar L, Porter R. Nonverbal communication. In: Communication Between Cultures, 4th
Edition. Wadsworth, Belmont CA, 2001. p. 164-95.
13. Lustig M, Koester J. Intercultural
Competence - Interpersonal Communication
Across Cultures, 3rd Edition. Addison Wesley
Longman Inc. New York, 1999. p. 219.
14. Burroughs V, Maxey R, Levy R. Racial and
ethnic differences in response to medicines:
Towards individualized pharmaceutical treatment.
J National Medical Association 2002;94(10)Suppl.
Available online at: www.npcnow.org/ issues_
productlist/PDF/SupplementFINAL.pdf. Accessed
February 4, 2004.
15. Samovar L, Porter R. Cultural influences
on context: The health care setting. In:
Communication Between Cultures, 4th Edition.
Wadsworth, Belmont CA, 2001. p. 241-58.
16. Anderssen, E. Aboriginal health far below
standard. The Globe and Mail, 9/25/2003, p. A10.
17. Fowler, N. Providing primary health care to
immigrants and refugees: The North Hamilton
experience. CMAJ 1998;159:388-91.
18. Samovar L, Porter R. Accepting and
appreciating similarities. In: Communication
Between Cultures, 4th Edition. Wadsworth,
Belmont CA, 2001. p. 262-96.
19. Rantucci M. Tailoring Counselling. In:
Rantucci M. Pharmacists Talking with Patients.
Williams & Wilkins. Baltimore. 1997:176.
QUESTIONS
1. Which statements about multiculturalism
in Canada is/are TRUE?
a) Origin of the majority of immigrants has
changed over the years.
b) Different cultural groups have different
feelings of need, fear, mistrust and hope.
c) Less than 25% of the Canadian population
is foreign-born.
d) Few immigrants settle in major cities.
e) a and c
2. Canada’s aboriginal population
a) consists of mostly Inuit.
b) live mostly in the metropolitan areas.
c) make up 3% of Canadian population.
d) Alberta has the largest aboriginal.
population
e) both a and c
CASE STUDY #1
D.G. is a Middle Eastern immigrant pharmacist dealing with F.L., an elderly Sikh man,
dressed in traditional costume.
3. In order to be “culturally competent”
when dealing with F.L., D.G. needs to
a) be aware of his own cultural values compared to Sikh’s.
b) learn about Sikh culture to predict this
patient’s behaviour.
c) minimize discussion of side effects in
case F.L. misunderstands.
d) avoid entering into a discussion about
health beliefs.
e) both a and c
4. F.L. is accompanied by several family
members, including his wife who hands D.G.
a prescription. D.G. would expect that
a) F.L. may be distrustful of his female
Canadian physician and the pharmacist.
b) F.L. will be uncomfortable using North
American medicines.
c) F.L. has family support.
d) F.L.’s wife is handling the prescription for
him because women are the spokespersons
for the family in his society.
e) both a and c
8
COUNSELLING IN A MULTICULTURAL SOCIETY
5. F.L. has a prescription for clomipramine.
He is more likely to be compliant if
a) he has trust in his physician.
b) on discovering clomipramine may cause a
higher incidence and severity of side effects
in Indian and Pakistani people, the pharmacist arranges to change his medication.
c) the pharmacist includes him in the counselling, regardless of need for translator.
d) his family is supporting him.
e) all of the above
6. If D.G. wants to improve communication
with F.L., he should
a) use a Canadian version of his name when
talking to him.
b) use media descriptions of Sikh immigrants as guides.
c) ask if F.L. speaks English or another common language such as French.
d) provide extensive written information
since all Sikh’s are well educated.
e) both a and c
7. When gathering information about F.L.,
the pharmacist should
a) assume F.L. believes his condition is
treatable.
b) be aware that environmental factors
should be explored.
c) ignore comments made by his wife that
his condition is self-induced.
d) speak directly to the wife to save time on
translation.
e) both a and c
CASE STUDY #2
L.L. is a Canadian-born pharmacist starting a new practice in a community with a
large Aboriginal population.
8. L.L. will probably find that
a) most patients are poorly educated.
b) all patients view poor health as inevitable.
c) there is a high incidence of certain
medical conditions in the population.
d) parents don’t seem to look after their kids.
e) all of the above
9. What techniques or tools could L.L. use
to improve communication with patients
in this community?
a) Nonverbal language such as direct eye
contact, touching and close physical distance.
b) Give lectures on the causes of illness
and need for medications.
c) Recognize that patients’ reports that
drugs are causing side effects or lack
effect are just superstition.
d) Learn about community issues and meet
with key representatives.
e) both a and c
Missed something?
10. D.B. is a young teenage female in this
community, recently diagnosed with diabetes. When counselling her about this
L.L. should
a) ascertain her level of literacy when
providing written information.
b) talk to her about birth control.
c) discuss her home situation regarding
meal preparation.
d) insist she bring her mother and father to
an education session on diabetes.
e) both a and c
11. Which statement is NOT a dimension
of cultural values?
a) belief in Western-style health care
b) how much male domination is in a society
c) how assertive people are
d) how formally people dress or conduct
themselves
e) large differences between powers of different members of society
CASE STUDY #3
F.F. is a female pharmacist in an urban
neighbourhood with a vast multicultural mix
of people.
12. How does culture affect F.F.’s delivery of
pharmaceutical care to this population?
a) She may find difficulty developing rapport
with patients.
b) Some patients may not have drug plans.
c) Drug-related problems may be related to
genetic differences.
d) Providing written information will be most
appropriate.
e) Both a and c
13. When F.F. is counselling patients from
different cultures, she should recognize that
a) there may be discomfort dealing with a
female pharmacist.
b) genetic differences may affect drug
efficacy or side effects.
c) patients may be distrustful of the health
care system.
d) symptoms may not be reported due to
health beliefs.
e) all of the above
14. When counselling, what cultural differences between herself and her patients
should F.F. consider?
a) perceptions and values
b) facial expressions of fear
c) beliefs about what causes illness
d) facial expression of sadness
e) both a and c
15. With regard to nonverbal language,
FF should be aware that
a) nonverbal language is believed over verbal
CE COMPLIANCE CENTRE • JUNE 2004
communication.
b) how people are dressed means nothing.
c) eye contact should be maintained with all
patients.
d) a loud, authoritative voice will sound
most sincere.
e) both a and c
16. F.F. needs to consider patients’ health
beliefs because
a) it affects people’s understanding of
what causes illness.
b) some cultures believe that illness is
caused by supernatural rather than
biological factors.
c) their goal of treatment may not involve
removing the biological cause.
d) folk medicine may be used that can
affect drug use.
e) all of the above
17. Cultural beliefs involving the family may
affect health care because
a) there may be someone other than the
patient who has authority for health decisions.
b) presence of extended family always
improves compliance.
c) males usually prevent females from
seeking treatment.
d) some cultures have practices and
attitudes involving pregnancy.
e) both a and c
18. To maintain credibility and trust, what
should F.F. pay attention to?
a) dressing to look like a professional
b) speaking with patients in the common
area of the pharmacy
c) speaking in a very quiet voice
d) using complicated medical jargon
e) a and c
19. F.F. may interact with patients from
different cultures who may believe that
a) luck, religion or taboos can affect their
health.
b) they need to create imbalance to be cured.
c) illness is to be accepted like birth or death.
d) you need to balance the three body
humours.
e) both a and c
20. J.J., a black African male wearing
traditional dress, is getting a new
prescription for captopril. F.F. should
a) persist in trying to make eye contact.
b) tell him to bring his wife to an information
session on hypertension.
c) discuss this choice with the physician
because of possible poor clinical effects as
a result of genetics.
d) assume he sees only his family doctor.
e) all of the above
Previous issues of CE Compliance Centre are available at www.pharmacyconnects.com and www.novopharm.com.
COUNSELLING IN A MULTICULTURAL SOCIETY
1.5 CEUs
1.5 CE UNIT IN QUEBEC
CCCEP #094-0204
JUNE 2004
Not valid for CE credits after February 28, 2007
1.
2.
3.
4.
5.
a
a
a
a
a
b
b
b
b
b
c
c
c
c
c
d
d
d
d
d
e
e
e
e
e
6.
7.
8.
9.
10.
Last Name
a
a
a
a
a
b
b
b
b
b
c
c
c
c
c
d
d
d
d
d
e
e
e
e
e
11.
12.
13.
14.
15.
First Name
Licensing Prov.
Licence #
a
a
a
a
a
b
b
b
b
b
c
c
c
c
c
d
d
d
d
d
e
e
e
e
e
16.
17.
18.
19.
20.
b
b
b
b
b
c
c
c
c
c
d
d
d
d
d
e
e
e
e
e
Email address
Licensing Prov.
Business name
a
a
a
a
a
Licence #
Business telephone
Address (❑ Home ❑ Business)
Type of practice
❑ Retail (chain)
❑ Retail (independent)
City
❑ Grocery
❑ Other (specify)
_______________
Province
Postal Code
❑ Owner
❑ Full-time employee
❑ Part-time employee
Year Graduated _______
Feedback on this CE lesson
1. Do you now better understand multicultural counselling?
❑ Yes ❑ No
2. Was the information in this lesson relevant to your practice?
❑ Yes ❑ No
3. Will you be able to incorporate the information from this lesson
into your practice?
❑ Yes ❑ No
4. Was the information in this lesson... ❑ Too basic
❑ Appropriate ❑ Too Difficult
5. Do you feel this lesson met its stated learning objectives?
❑ Yes ❑ No
6. What topic would you like to see covered in a future issue? _____________________
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