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Module 1: Cross-Cultural Sensitivity

"The goal is understanding. In cross-cultural training and living, the goal is learning about yourself and others. Just as you want to learn another language so that you can communicate with local people and understand the new world around you, so you will want to learn the silent language of cultures--your own and your host country's--that are crossing" (Peace Corps, 2012).

Key Concepts:

  • Understanding culture shock can help you prepare for a more successful experience
  • Working with translators may be a part of your experience; learning the etiquette of working with a translator will be beneficial for you, the translator, and the community member you are communicating with
  • CRASH is a pneumonic device to help you remember cultural sensitivity

Learning about your host community's beliefs and values will be extremely beneficial. "There is good evidence that health professionals do not automatically have the attitudes or skills necessary to be effective in culturally diverse healthcare settings" (Rust et. al, 2006). "Cultural beliefs are built into our worldviews, providing a reference point for understanding what we observe and a guide for how to act. Those from different cultural backgrounds simply have a different frame of reference; what we perceive to be "normal" is a consequence of the culture we are raised in” (Unite for Sight, 2012).

Be prepared to experience a range of emotions; best practices for acknowledging and managing these emotions will be discussed in more detail in module four, which covers building relationships. Your trip leader will help guide you through these emotions before, during, and after your experience. This module will also prepare you for culture shock, ethnocentrism, social norms, cultural humility, and attitudes toward service.

Achieving 'cultural competence' is an elusive quest-as one can never really be fully 'culturally competent' in a setting in which you are not native. However, Dr. Debra Malina (2005) suggests a practical approach--building a base of cultural knowledge but refraining from using it as a template for interpreting the values, character, and needs of individual patients.

Culture Shock

Unite for Sight (2013) explains the what, when, and why of culture shock below:

What: Culture shock is the holistic reaction to displacement from one’s familiar environment. Suddenly, you find yourself unable to understand, communicate, and function effectively. Common symptoms of culture shock include:

  • Feelings of frustration, loneliness confusion, melancholy, irritability, insecurity, paranoia, and helplessness
  • Unstable temperament and hostility
  • Criticism of local people, culture, and customs
  • Excessive concern over drinking water, food dishes, and bedding
  • Fear of physical contact with locals
  • Oversensitivity and overreaction to minor difficulties
  • Loss of sense of humor

When: Sometimes, transitioning to a foreign culture can have an immediate impact. An American tourist traveling to a developing country might be instantly alarmed or disheartened by living conditions that are perfectly normal and acceptable to the locals – for instance, a lack of private bedrooms or toilet facilities, or the use of chewing sticks rather than toothbrushes. Much more common, however, is delayed culture shock.

Why: Although culture shock is a complex phenomenon, experts agree that the basic cause of culture shock is the "abrupt loss of the familiar, which in turn causes a sense of isolation and diminished self-importance."

Perhaps seeing conditions in which people live will elicit feelings of sadness or guilt. These feelings are normal. The best way to manage these feelings is to focus on being present, building relationships with members of the host community, and discussing your experience with others in your group (Unite for Sight, 2013). Although it may appear that your host community is living in poverty, they can be “rich” in other ways that are not apparent to the naked eye. Learn about and focus on strengths that you see within the community. Remember that you are on this experience to learn, grow, and help to build a sustainable future for this community. Journaling these emotions may also help you sort through these feelings after returning home.

The "Mzungu" Factor

Mzungu is the Swahili word for a white person, but is applicable to all Western foreigners (Unite for Sight, 2013). "Regardless of your status in your home country, you will be seen as wealthy; indeed, in this society you are. People may ask you for favors, money, and more, all because they see you not only as the solution to their health ailments, but as the solution to their poverty" (Unite for Sight, 2013).

Members of your host community may assume that you can help them beyond your means; for example, mistaking an education specialist for a medical doctor. You may also be quoted higher prices in the markets and shops. These particular interactions may leave you feeling taken advantage of, but it is important to remember that you are not the first person to experience these feelings, and it is important to reach out to others on your team, and to your leader for advice or scripts to politely decline requests for money or other services that you cannot provide. Instead, one solution might be to focus on building lasting relationships with others involved in the ongoing Global Partners projects.

Futility

"Because the challenges of poverty are so overwhelming, at some point you may feel helpless, or that your hard work isn’t making a difference. While feelings of powerlessness are disheartening, remember that big change is nearly always the aggregate of relatively small steps forward. It is important to focus your perspective on a localized set of goals. You will not solve global poverty in a period of weeks, but you can make an enormous impact on the lives of those in the community you work in" (Unite for Sight, 2013).

One solution to the feelings of futility is to continue to work on Global Partners projects upon returning from an experience. Share your experience with your family and friends, and encourage others to be aware of the problems faced in other parts of the world and within your own community. Continuing to be involved with Global Partners will help you stay connected with others that have had similar experiences. There will be ample opportunity to stay connected and volunteer with Global Partners upon your return. Check the Global Partners website frequently to learn about upcoming events and volunteer opportunities.

The Peace Corps addresses feelings of futility in their training manual and point out that over a volunteer’s service time (two years), a common shift occurs in the mindset:

"A trainee often arrives with idealistic notions of wanting to save the forest, find new ways to increase food production to decrease hunger and malnutrition, or develop new local products that will make a community or business owner rich. But then frustrations often arise over the difficulty of getting things accomplished, the lack of support from local counterparts, and the obstacles of poverty and poor education. But over time, your initial idealism is likely to be replaced by a sense of practicality. Saving the forest becomes planting a few trees to protect a watershed. Feeding a nation becomes feeding a family. Revolutionizing a business becomes helping a business run better. One hopes that you will not see this as a loss of idealism but, rather, a realization that development comes from small but significant steps taken in partnership with your community." (Peace Corps, 2012).

Although the Peace Corps volunteers serve for a period of two years and Global Partners volunteers serve for one week, it is important to understand your role as the volunteer in the big picture.

Below are some tips for coping with culture shock and emotions, found in Unite For Sight’s Cultural Competency Guide, (2013).

  • Travel in a spirit of humility and with a genuine desire to meet and talk with local people
  • Take care of yourself – eat well, exercise, and get enough sleep!
  • Do not take anything too seriously – an open mind is the beginning of a great international experience
  • Do not let others get on your nerves – you have come a long way to learn as much as you can, to enjoy the experience, and to be a good ambassador for your country
  • Set realistic, short-term goals, and realize that periodic failures are inevitable
  • Carefully review your preparation materials – those who have gone before you have invaluable advice
  • Do not judge the people of a country by stereotypes, or by the one person with whom you have had trouble – this is unfair to the people as a whole
  • Cultivate the habit of listening and observing, rather than merely seeing and hearing
  • Remember that other people’s different conceptions of time, manners, privacy, humor, and tact are just that - different, not inferior
  • Be aware of the feelings of local people to prevent what might be offensive behavior. For example, photography must be particularly respectful of persons.
  • Spend time reflecting on your day in order to deepen your understanding of your experiences.

Ethnocentrism

"Ethnocentrism is the belief that one’s own way of life or culture is superior to others. Ethnocentrism is the view that 'our' ways of doing things are ordinary and better and that other approaches are in some way inferior. One’s own group or society seems normal, while another might seem peculiar," (Unite for Sight, 2013).

It is important to set aside any ideas about 'best practices' from your own experience, particularly medical, when traveling to a host community. There may be factors that you are unaware of that dictate the 'best practice' for that community. It is important to keep an open mind, and remember that you are there to learn from the host community, just as the host community will learn from you.

Many Westerners view illness as a chance event or as a result of lifestyle choices, but it is important to realize that this way of thinking is not universal. A view commonly held abroad is that disease results from fate, punishment of sin, sorcery, or other supernatural causes (Unite for Sight, 2013). It is important to learn about the local traditions and healing practices, and to not automatically consider the differences as inferior.

Elastic Time

As a Western culture, we base our lives around the clock. As a culture, we tend to value timeliness and honor appointment times and other commitments very punctually. However, the importance of time is not universal. In other countries, time and appointments are considered to be flexible (Unite for Sight, 2013).

As a guest in the host community, it is important to adopt the value of elastic time. Please do not feel disrespected if a community member misses, or is late to an appointment.

Working with Translators

In some of our host communities, the local people will not know any or very little English. There will be translators available, but you might find it frustrating to not be able to speak directly with an individual. When a translator is unavailable, enjoy the power of non-verbal communication. You will find that although you do not speak the same language, there will be many universal gestures, such as a smile, that can speak volumes.

Protocol for interacting with patients

  1. Introduce yourself and the interpreter before beginning the interview.
  2. Speak directly to the patient, as if you were interviewing an English-speaking patient
  3. Pay attention to nonverbal cues
  4. Make an effort to learn basic phrases in the local language, such as greetings and introductions
  5. Regularly repeat back to the patient what he or she tells you. This will let them know you are engaged, and that you understand their complaints. You should also ask patients to repeat back to you any instructions you give to make sure they have understood. However, do not take this too far and act in a condescending or patronizing manner.

Protocol for interacting with the interpreter

  1. Speak more slowly than usual, and use simple language. Although they speak English, your interpreters may not be native speakers, so speaking extra clearly will ease communication. Clear communication, however, is not necessarily loud communication.
  2. Speak two to three sentences at a time, and then pause to allow the interpreter to translate. If the interpreter puts a hand up or signals you to stop, pause and let them translate what you have said.
  3. Avoid long conversations with the interpreter. If speaking directly to the interpreter is necessary, explain the nature of the conversation to the patient. For example, if you need to ask the interpreter about pertinent cultural differences, you should ask permission from the patient first.
  4. Maintain your role as the interviewer. After several interviews, interpreters may notice patterns in your questions. They may begin to "get ahead of you," and ask what they think will be your next question before you ask it. If this happens, politely ask your interpreter to wait for you to ask the question to the patient.
  5. Most importantly, treat the interpreter with respect.

Social Etiquette

Cultural norms will vary by community. You will find more information about the social etiquette of the communities that Global Partners is involved with in module two. It is important to acknowledge social etiquette and social norms to avoid embarrassing yourself or your host community. A good rule of thumb is to wear appropriate clothing; knees, shoulders and midriffs should be covered. Wearing fancy jewelry or expensive clothing can also send the wrong message. These items are better left at home.

Cultural Beliefs about Service

"Western society generally teaches that those who have plenty should help those who are less fortunate than they are. In many circumstances, people who dedicate time to serving others are praised for their moral fiber, or given tax exemptions. It may therefore come as a shock to many Westerners that not everyone shares this laudatory attitude toward community service" (Unite For Sight, 2013)

Trust and Humility

Cultural humility can "denote a willingness to accurately assess oneself and one’s limitations, the ability to acknowledge gaps in one’s knowledge, and openness to new ideas, contradictory information, and advice" (Unite for Sight, 2013).

It is important to treat each person as an individual, not as a representative of their culture. Many individuals will have similar cultural beliefs, wants, and wishes; however it is important to continue to treat each person as an individual. It is important that "care providers must always be aware of the fact that even extensive knowledge about a given culture is not the same as having assimilated oneself into that culture, and therefore one must be aware of the differences that will still exist between their own perspective and the perspective of the members of that culture" (Unite for Sight, 2013).

The previously mentioned challenges for understanding cultural sensitivity can be organized into the CRASH model for understanding. CRASH is a mnemonic for one model for providing culturally competent health care. Rust et. al (2006) states that "Learning and practicing these cultural principles will not instantly confer cultural competence on anyone, but they can provide specific measurable skill sets, behaviors, and strategies for increasing one’s effectiveness in providing health care for diverse populations while minimizing culturally dysfunctional behaviors." Rust et. al (2006) continues to elaborate "The purpose of the CRASH-Course in Cultural Competency is to teach public health and primary care health professionals a strategy for incorporating cross-cultural skills and values into their own practice."

Practice CRASH (Rust et. al, 2006)

C - Culture awareness: Recognizing the role of culture in health means an acknowledgement of the importance of shared values, perceptions, and connections in the experience of health, health care, and the interaction between patient and professional.

R- Respect: Understanding that demonstrations of respect are more important than gestures of affection or shallow intimacy, and finding ways to learn how to demonstrate respect in various cultural contexts. Ask questions such as "How would a doctor greet you in the community you grew up in?"

Individuals and cultural groups that have experienced oppression, consistent disrespect, or minority status may place a much higher priority on being treated with respect first, earning trust second, and only then perhaps allowing friendship or a personal relationship to develop. Often this means that the health professional should engage in a more formal style of communication.

A- Affirm, Assess Differences

  • Affirm: Recognizing each individual as the world’s expert on his or her own experience, being ready to listen and to affirm that experience. We do not always appreciate other people’s cultural differences. It is in these circumstances that we must be especially disciplined in not assuming negative motivations or values on the part of the individual behaving against the grain of our expectations.
  • Assess: Understanding that there are tremendous "within-group differences," ask about cultural identity, health preferences, beliefs, and understanding of health conditions. Assess language competency, acculturation-level, and health literacy to meet the individual’s needs.

S- Sensitivity, Self Awareness

  • Sensitivity: Developing an awareness of specific issues within each culture that might cause offense or lead to a breakdown in trust and communication between patient and professional.
  • Self-Awareness: Becoming aware of our own cultural norms, values, and “hot button” issues that lead us to misjudge or miscommunicate with others.

H- Humility: Recognizing that none of us ever fully attain "cultural competence," but instead making a commitment to a lifetime of learning, peeling back layers of the onion of our own perceptions and biases, being quick to apologize and accept responsibility for cultural mis-steps, and embracing the adventure of learning from others’ own experiences.

One of the quickest ways to move from arrogance or self-confidence to humility is to put ourselves in the role of student, and elevate our patient to the role of teacher.

Take Home Message:

  1. Prepare mentally and physically for experiencing a different culture. Before traveling, learn about the history and culture of the host community.
  2. Be prepared to experience reverse culture shock once returned, and stay involved with the organization and/or others that shared your experience.
  3. Be open to new ideas and new ways of completing tasks. Think of the members of the host community as the teacher and you are the student.
  4. Treat people from different cultures as individuals, not solely as representatives of a culture as a whole.

Additional Resources:

Unite for Sight has a similar mission to Global Partners; to create sustainable partnerships with communities outside of their own. With permission from Unite for Sight, we have provided you with pieces of their content.

References:

Krawcyzk, E. (2012). Cultural connectiveness within Native American communities. Presented at WHEN conference, 2012.

Malina, D. (2010). Compliance, Caricature, and Culturally Aware Care. The New England Journal of Medicine, 353,1317-1318.

Peace Corps. (2013). The Peace Corps welcomes you to Nicaragua: A Peace Corps publication for new volunteers. Retrieved from:files.peacecorps.gov/manuals/welcomebooks/niwb524.pdf

Rust, G., Kondwani, K., Martinez, R., Dansie, R., Wong, W., Fry-Johnson, Y., Del Milagro, Woody, R., Daniels, E.J., Herbert-Carter, J., Aponte, L., & Strothers, H. (2006). A CRASH-course in cultural competence. Ethnicity & Disease,16, S3-29-S3-36.

Unite for Sight. (2013). Unite for sight cultural competency module.  Retrieved from http://www.uniteforsight.org/cultural-competency/ 

Unite for Sight. (2013). Unite for Sight: ethics, quality, and equality: online global health course. Retrieved from http://www.uniteforsight.org/global-health-course/

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