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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? _____________________ Brought to you by: Please allow 6-8 weeks for notification of score. 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