Cultural beliefs can silently erode compliance
July 1, 1999 5 minutes read
Cultural beliefs can silently erode compliance
As a medical anthropologist, our guest, Noel J. Chrisman, PhD, helps clinicians raise the probability of compliance by teaching them to identify and respect their patients’ cultural beliefs. Chrisman is adjunct professor of Anthropology, Family Medicine and Health Services at the University of Washington in Seattle.
He teaches workshops on managing diversity for nurse managers and health administrators throughout the United States. His other areas of expertise include child abuse, rural health problems, and community development. Chrisman is co-author of the chapter "Cultural Competence in Primary Care" in the book Adult Primary Care, scheduled for publication in October (Meredith P, Horan N, eds. Philadelphia: WB Saunders). This is part one of a two-part series.
Q. You’ve contributed a great deal to nursing and medical students’ understanding of the connections between sociocultural factors and compliance in lifestyle changes to lessen the burden of chronic disease. Will you explain some of those factors?
A. The first thing to recognize is the importance of beliefs. Beliefs are not something that somebody else has, but something that all of us have. The literature shows — and I see it in my own work — when the practitioner and patient have similar or roughly similar beliefs about what is going on, compliance is more likely. The more difference there is between practitioner and patient beliefs, the lesser likelihood of adherence or compliance. The reason is that the practitioner will make incorrect assumptions and offer suggestions that don’t make sense to the patient.
For example, recently in a teaching situation in Family Medicine we had the Mien family from Laos. The mother, who must be about 60, has stomach cancer, according to Western-style medicine. For the last couple of years, she has gone back and forth on whether or not she is going to have surgery. What she says now is that she’s not going to have surgery because it’s too much pain and distress.
The interpreter, who has been in Seattle since the late 1970s, stayed after our conference. I asked her about the woman’s beliefs about cancer. She said, first of all, the woman does not think she has cancer. When the doctor shows her the mass on the X-ray, the woman thinks it’s probably the opium she took, not long before the X-ray, to control the pain.
So there is a belief difference that makes it very difficult to talk the woman into surgery when she "doesn’t have cancer." One of the reasons that she does not have cancer is that she can’t have cancer, because if she does, she’s going to die. Like many other Asian ethnic groups, this woman believes that you are not supposed to discuss cancer because that will make it come true.
The belief that if you have cancer you are going to die is a real, and widespread, belief among Americans of all different ethnic groups. And it has strong effects. For example, some of the literature on this subject comes from black women in the South who don’t believe they have to get pap smears and clinical breast exams or mammograms. They believe that if they have cancer, they are going to die. If they don’t have cancer they are not going to die, so why fiddle around with it?
Here’s another example. We find it particularly in the South among older white people, but more frequently among African-Americans. It’s an illness called high blood. It means the blood is pooled high in your system. When health practitioners hear that, they simply translate it as high blood pressure, and systematically misunderstand the patient. Because of that belief difference, all of the teaching the practitioner does to the patient won’t make any sense if the patient’s got high blood, not high blood pressure.
Q. And what is high blood?
A. Too much blood. And it goes up high. It may pool by your heart, and you get a heart attack. Or it may pool in your head and you might get a stroke, or you may become mentally ill.
The way you get rid of high blood is to use astringents like vinegar or lemon to help you sweat out the excess fluid. And how you get high blood is by eating or drinking red things. Because of that belief difference, there is the likelihood of lower compliance.
One of my Master’s in Public Health students is a physician who did her thesis on Hispanic beliefs in New Mexico about diabetes. Of course, one of her concerns was that her patients change to a diabetic diet. But these Hispanic patients saw the diabetic diet as Anglo food — white people’s food. No. 1, it was too expensive for them, they believed. And, No. 2, it wasn’t what they ate. It wasn’t "good" food. So there was no reason for them to comply. They’d like to comply, but it’s hard to do when someone is recommending that you do something unreasonable.
Here’s an example to illustrate the dilemma: I ran a focus group when I worked with the Yakima Indian Nation in eastern Washington state. We had a discussion about diabetes. The women in the focus group said they really needed help with menus, preparation techniques, and new ways to shop. So they wanted to comply, but they were unable to because they didn’t have the wherewithal. That really is a second issue — the capability of complying. Those Native American women couldn’t because they didn’t know about the foods for a diabetic diet. It’s the same with the Hispanics in New Mexico. In contrast to the Hispanics, the Native American diet looks more like European-American, but those Native Americans needed some help.
Another example: Sometimes you hear a practitioner saying to a mom, "Make sure you watch your child’s temperature." There are households in the United States that don’t have a thermometer or other equipment, for that matter.
Q. Will you tell us how social factors affect compliance?
A. A colleague who was working on the rehabilitation floor in a Seattle hospital told me of an African-American man who had been shot in the back. He couldn’t walk, so, before he could go home to live with his mother, she had to put in a wheelchair ramp. The rehab staff were really upset with the woman because she hadn’t put the ramp in within the week or two time frame that the staff wanted. The mom didn’t have a lot of money. One of her friends, a carpenter, was going to build the ramp. But then there was a death in one of the families.
Among African-Americans, as among lots of other people, when there is a death in the family, the whole family gathers from across the country. And so it wasn’t possible for the carpenter to put the ramp up. The rehab staff simply did not see that there were other things going on in that person’s life. So, there was no compliance, but there couldn’t be compliance.
(For further information, contact Noel J. Chrisman, School of Nursing, University of Washington, Box 357263, Seattle, WA 98195-7263. E-mail: [email protected].
Next month, Chrisman explains how providers can move beyond their assumptions and enter the patient’s frame of reference to achieve better outcomes.)
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