Cultural Awareness

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					Cultural Awareness and

         Glenn H. Luedtke, NREMT/P
       Director, Sussex County Emergency Medical Services
                    Adjunct Assistant Professor
                    Emergency Health Program
  The George Washington University School of Medicine and Health
• Increase awareness of changing demographics
  in our communities
• Understand our own cultural identities
• Understand health traditions that vary from
  Western methodologies
• Respect religious laws honored by patients
• Develop new skills to assist in communicating
  with patients from other cultures
• Ensure all patients are treated with dignity and
                 Special Thanks

• Linda Honeycutt                 • Beth Adams
   – Executive Editor, Elsevier     – Quality Manager, Fairfax
     Publishers                       County Fire and Rescue
   – Past President, NAEMSE           Department
                                    – Faculty, GWU Health
                                      Sciences Program
United States has always been
a country of immigration

           “…give me your tired,
           your poor, your
           huddled masses
           yearning to breathe
    Immigration Law Milestones
• Naturalization Act of 1790

• 1820 – 1st immigration records law

• Chinese Exclusion Act of 1882

• 1924 – “national origins” quotas

• 1960 – “hemisphere” limits

• Title VI/Civil Rights Act of 1964

• 2001 National Standards for CLAS in Health Care
         Cultural Competence

"Cultural and linguistic competence is a set of
  congruent behaviors, attitudes & policies that
  come together in a system, agency, or among
  professionals that enable effective work in cross-
  cultural situations."

                   2001 National Standards for Cultural and
     Linguistically Appropriate Services in Health Care Act
 CLAS Standards: 3 Themes

1. Culturally competent care

2. Language access services

3. Organizational support for competence
            Organizational dimensions

                  External dimensions

                 Internal dimensions

               external dimensions

        4 Layers of Diversity
• Personality
• Internal Dimensions
  – Age
  – Sex
  – Ethnicity
  – Physical Ability
• External Dimensions
  – Life Experiences & Choices
• Organizational/Vocational Dimensions
  – EMS is a Culture
           Diversity in the US
• 106 ethnic groups       • Largest Arab-
• Minorities = majority     American population
  population in 6 of 8      outside Middle East =
  largest US metro          Dearborn, MI
  areas                   • Largest minority
• 20% of MD’s in US         population in US =
  are foreign trained       Detroit, MI (80%)
                  Pop Quiz
•   What is the most popular condiment in
    the U.S.?
    A.   Ketchup
    B.   Mustard
    C.   Mayonnaise
    D.   Salsa

•   Answer: D
According to self reports* to NREMT in 2001….

• 83% majority … 14% minority … 3% other
• 23.37% respondents did not specify

• 69% male … 31% female
• 0.03% respondents did not specify

             * = 133, 526             (Hunter, 2002)
How have we adapted?
    Adapting To New Cultures
• Assimilation
  – Americanization
  – Conformity
    Adapting to New Cultures
• Amalgamation
  – Melting Pot
  – Blending best of
    old and new
   Adapting To New Cultures
• Anglo-Saxon
  – “American” = WASP
    Adapting To New Cultures
• Cultural Pluralism
  – Strength in variety
Ways Cultures Differ
         Cultural Awareness
• Culture is not overt
• We are all ethnocentric
• We observe, interpret, then act based on our
  own cultural programming
• We may not know when we are offending others
• Awareness and knowledge increase our choices
• Understanding one’s own culture is a first step
           The Culture of Age
•   The “Greatest” generation
•   The “Baby Boomers”
•   The “Me” generation
•   Generation “X”
•   Generation “Next”
       The Greatest Generation
•   Lived through the Great Depression
•   Value stability, loyalty to employer
•   Stick with relationships no matter what
•   Don’t take risks
•   Fear for their future
    – Health insurance
    – Continuance of promised pensions
    – Being “put away” in a nursing home
• Wanted something “better” for their
        The Baby Boomers
• Increased value for education
• Witnessed greatest strides in technical
• Loyalty to employers
• Trusted government in youth, later more
• Vietnam war a major part of their
          The “Me” Generation
• Were young during Vietnam War, but remember it
• Distrustful towards government
• Personal agenda supercedes employer loyalty
  – Employers less loyal to employees?
• Value home and family, but more likely to
  abandon a relationship that “isn’t working”
• Not as “volunteer oriented” as their predecessors
             Generation X
• Until recently, war has not been a part of
  their lives
• The first “technology oriented” generation
• Job is a means to an end, not an end itself
• More loyal to relationships than “Me”
                 Generation Next
Today‟s Teens – Tomorrow‟s Providers!
• 58% have visited or lived in a foreign
• 57% have a friend who is openly gay
• 48% have known someone who is in a
• 21% have a friend who was killed or
  injured by gun violence
• 19% have been the victim of a crime or
    Source: Washington Post Magazine, Kaiser Family Foundation, Harvard
                     University poll, 570 respondents, published 10/23/05
              Generation Next
Today‟s Teens – Tomorrow‟s Employees!
• 57% think there will be another terrorist attack
  like 9/11
• 54% think this country is headed in the wrong
• 54% think our country’s best years lie ahead

“ It‟s a confusing time, rather than bad or good.
   I‟m stuck in the middle of so many things –
   college things, the war, the economy, other
   things that are going on.”
      Generations and EMS
• “Greatest” and “Boomer” now reliant on
  “Me” and “X” for emergency care
• “Boomers” as administrators
• “Boomers” and “Me” experienced the AIDS
• “Me” and “X” as supervisors and
  experienced providers
• “X” and “Next” as new generation of
               Sex and EMS
• Fire Service and Volunteer EMS were
  traditionally male-dominated
  – Although women often ran calls during daytime while
    men worked
• Fire/ EMS tradition re homosexuality &
  transgender generally mirrored societal view of
  the times
  – Often slower than society at large to change views
• Changes over last 20 years have resulted in
  more women in leadership & command positions
    Gay and Transgender Issues
•   Alternative lifestyles more common
•   More gay people “out of the closet”
•   Legalization of “same sex” marriage
•   Increased efficacy of transgender surgery
•   Accepted by some
•   Resistance by others
         Ethnicity Characteristics:
          Mainstream American
•   Individualism
•   Independence/freedom
•   Competition/achievement
•   Materialism
•   Technology dependant
•   Instant time/actions
•   Youth/beauty
•   Equal sex rights
        Ethnicity Characteristics:
         Mainstream American
• Leisure time highly valued
• Reliant on scientific facts/numbers
• Less respect for authority/elder
• Generosity in crisis
• Self esteem issues during illness or
• Believe there is cause and cure for any
• Expect health care professionals to “fix” the
•   Not all African-Americans are black
•   Not all Blacks are African-American
•   Extended family networks
•   Religion valued
•   Interdependence
•   Daily survival
•   Technology valued
•   Folk foods
•   Folk healing modalities
•   Matriarchal family structure common
• Music is central
• Inquiry re personal info may be seen as
• 1 in 400 suffer from Sickle Cell Anemia
• “High Blood” and “Low Blood”
• Common diseases
  – Hypertension
  – Diabetes
  – High cholesterol
  – CAD
•   Extended family values
•   Interdependence with kin
•   Patriarchal
•   Exact time less valued
•   High respect for authority, elders
•   Religion valued
•   Same-sex medical staff preferred
•   Native foods for well-being
•   Very ill/dying pt may wish to say last
    words to each family member
• Tradition highly valued
• Family/extended family extremely
• Patriarchal/elder obligations & respect
• Group compliance, not self-care
• Holistic approach to medicine
• Harmony and balance
• Medical interventions may interfere with
  one’s spirit
• Religious & spiritual values
• Folk care practices
• Non-aggressive, non-confrontational
• Eye contact a sign of disrespect
• Touching stranger considered rude, intrusive
  – Same-sex touch preferred
• Area of body below waist almost never exposed
• NEVER touch the head
• Feet should not be pointed at another person
  – Soles of feet should not face another person
• Smile & nod = not understanding, or not wishing
  to disagree with authority to their face
• Snickering = embarrassment & confusion
• Silence = strong disagreement
• “Yes” may mean “I hear you”, not “I agree”
  – Do NOT like to say “no”
• Blood is the source of life (Chinese, Vietnamese)
• May expect to receive medication
• Name is private; prefer to be addressed by
  – “teacher”
  – “mother”
            Native American
• Harmony between land, people,
• Reciprocity with “Mother Earth”
• Spiritual inspiration/guidance
• Folk healers/medicine men
    – Do not heal; aid in journey
•   Cultural rituals & taboos (cleansing)
•   Authority of tribal elders
•   Pride in cultural heritage & “nations”
•   Respect and value for children
              Native American
• No direct eye contact
• Silence valued
  – Offended if rushed, interrupted, not listened to
  – May be viewed as non-compliant, stubborn by
• Note-taking may be considered rude
• High incidence of disease
  –   Diabetes
  –   Gallstones
  –   Ischemic heart disease
  –   Rheumatic conditions
  –   Arthritis
  –   Alcoholism
• Christians & Muslims
• Male-dominated; often demanding
    – Head of family given medical info, determines disposition
    – Male responsible for sexual purity of female
    – Sexual discussions not tolerated
•   Extended family
•   Passivity in presence of authority figure
•   Look down on female medical personnel
•   Illness is God’s will
•   “Evil Eye”
•   Food deprivation or bad news = illness
•   Right hand only offered for dx/tx
•   Left hand used for cleaning, going to bathroom
•   Male-female eye contact = sexual invitation
•   Time is “servant” not “master”
•   Mourning may be emotional
•   Shoes may be left @ door of home
•   Complimenting woman’s beauty offensive
•   Avoid admiring object in home
    – May feel obligated to make it a gift
    – Rejection of gift is a tremendous insult
               Pacific Islanders
• Extended family, interdependent
• Spiritual bond between family and nature
   – Living family members may interact w/deceased
   – May be inappropriately viewed as “bizarre”
   – Herbal remedies may be used
• Avoid conflict, social disruption
• Heirarchical system
   – Females defer to males
   – Young defer to old
   – Medical decisions made by eldest male or church leader
• Sitting while talking w/pt, family a sign of respect

• Christian Science
  – Blood & blood products not ordinarily used
  – No medical surgeries generally practiced
• Church of Jesus Christ of Latter Day Saints
  – 24-hour fast required once a month
  – Sacred undergarment (do not touch, remove or
    cut without explaining need)
• Hinduism
  – Shoes never worn indoors (@ home)
  – Shoes never pointed at elders
• Jehovah’s Witnesses
  – Blood & blood products forbidden
  – Medications acceptable if not derived from blood
• Judaism
  – No pork or shellfish (includes pork-based
  – Sabbath & Festival Days, Orthodox Jews may
    •   Work
    •   Fill out paperwork
    •   Turn electricity on or off
    •   Answer a phone
    •   Travel, except on foot (unless life or death
  – Opposite sex touching should be avoided with
    Orthodox Jews
• Islam
  – Pork & alcohol prohibited
    • Includes pork-based insulin
    • Alcohol wipes may be unacceptable
  – Opposite-sex touching should be avoided
  – Deceased person’s body turned to face east
    • Allow only Muslims to touch body
  – Ramadan (9th month of lunar calendar)
    • Month of fasting from sunrise to sunset
• No medical restrictions for EMS for
  – Baha’i
  – Buddhist
  – Roman Catholic
  – Seventh Day Adventist
  – Unitarian/Universalist
       Other Cultural Concerns
• Homeopathic
  –   Dermabrasion
  –   Acupuncture
  –   Coining
  –   Cupping
  –   Herbal remedies
What was done before
 you arrived?
      Other Cultural Concerns
• Cleanliness
  – More valued where water is plentiful
  – Body odor as sign of “being alive”
  – Layer of dirt = layer of protection
• Personal space
  – Mainstream American = arm’s length
  – Middle Eastern, Latin American = close enough to
    feel breath
• Modesty
  – Opposite gender touching
  – Disrobing
     Other Cultural Concerns
• Gestures
  – “OK” sign – obscene in S. America,
  – Smile
    • Korea – stupidity
    • Middle East – sexual come-on
  – “Come here” gesture w/index finger used in
    Asia ONLY to call animals
  – “Thumbs Up” sign = “FU” sign in Middle East
      Other Cultural Concerns
• Pain
  – Stoic cultures (“true feelings never revealed”)
  – Emotional cultures (free expression of feelings)
• Language
  – English very difficult to learn
  – Non-English Speaking feel they are assumed to be
    less intelligent, less competent
  – Children as interpreters
     • Confidentiality?
     • Role within the family
  – ATT Language Line
      Other Cultural Concerns
• Time
  – Agricultural groups have no need to keep time
  – No word for “time” in many Native American
  – Orientation may be difficult for peds, elders, homeless
• Relationships
  – Family a necessary part of healing in many cultures
  – Show respect by addressing family (eldest first)
• Death & Dying
  – Family may be expected to make decisions for
    gravely ill patients
  – Some pts not told they have terminal illness
• Awareness of our attitudes
• Awareness of attitudes of others on
  the scene
• Educational support for
        Beth Adams„ “Rules”

• Every person deserves to be treated with
  respect, and as an individual.

• In truly life-threatening situations, most
  “rules” are ignored, but asking first will
  offend no one.
  LEARN to Communicate
 empathy & understanding to the patient’s problem
 your perception of the problem
 and discuss differences and similarities
 course of action/treatment
 agreement (go to ED or stay home)
         Communication Tips
• Start with a formal tone
• Introduce yourself by full name & title
• Address other person by name & title
  – Mr., Mrs., Ms., Dr., etc.
• Avoid yes-no questions- give choices
• Watch body language (yours & theirs)
  – Smile, laughter may indicate confusion,
        Communication Tips
• Avoid use of idioms
  – “Cold feet” may be perceived as circulation
  – “Fanny” means “Vagina” to Australians &
    South Africans
  – “Rubber” is an eraser in most places
• Plusses and Minuses of using children as
• You cannot be expected to remember all
  of the unique elements of every culture
• In life threatening situations, many rules
  are exempt
• Asking before assuming will offend no one
• Above all, treat everyone with respect

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