Multicultural Health

I Introduction

A young girl was rushed to Mercer Community Medical Center in California with a seizure. The staff immediately recognized Lia Lee, a Hmong toddler who, after being diagnosed with epilepsy at 8 months old, had become a frequent guest to the emergency room. Her pediatricians were aware that Lia's family did not comply with the prescribed medication schedules, but instead altered dosages or discontinued medications altogether. A social worker and a public health nurse were sent to supervise Lia's treatment, but the seizures continued. Finally, seeing no other option, the pediatricians called Child Protective Services and Lia was removed to foster care (adapted from Fadiman 1997).

That it can be harmful not to culturally-adapt health services was a message driven home by Dr. Carlos Sterlin, an ethnopsychiatrist at Hôpital Jean Talon, Montreal, and a presenter at the 9th annual Health Promotion Summer School held in June 2002. Drawing on Dr. Sterlin's comments as well as anthropological and clinical examples, this feature introduces strategies to promote multicultural health.

II Why Practice Multicultural Health?

Young et al (1995:499) note that Canada advocates multicultural health, which is "the attempt to make orthodox medicine more sensitive to the beliefs and practices of its aboriginal and ethnic minorities by providing culturally appropriate health care and by incorporating specific therapeutic practices from minority healing traditions into the dominant system." But it is not simply enough to check our ethnocentrism at the door, to be sensitive in our client encounters and to incorporate indigenous traditions into our practices. We must be aware of the cultural base of health.

All health systems are cultural systems. Diet, hygienic practices and an understanding of the interaction between the person and the universe are shaped by culture. Beliefs about the cause or origin of a disorder are also culturally determined. For example, one culture may believe that an illness is caused by an immune dysfunction. Another may believe that the same illness is caused by a vengeful spirit. Thus, practitioners must be conscious of the cultural base that shapes both their own thoughts and actions and their clients'.

The case of Lia Lee is an excellent example of how cultural misunderstandings can negatively affect treatment. Her physicians diagnosed her with epilepsy and treated her accordingly. But not only could her family not speak English (and thus not understand how to administer the prescribed dosages), they maintained radically different beliefs about Lia's illness. The medication to treat the Western disease caused side effects, which seemed to harm their daughter. Lia's parents changed dosages because the medications that led to further complications were not curing their daughter of her "qaug dab peg" (soul loss). Maybe Lia's parents could have better adapted by learning to read English and attempting to understand Western medical theories, but responsibility also lies with the doctors who could have tried to understand the Hmong interpretation of Lia's illness.

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III Explanatory Models (EM) of Illness and Kleinman's Eight Questions

Medical anthropologist and psychiatrist Arthur Kleinman has devised eight questions to uncover a client's explanatory model of illness -- how a person understands their illness' causation, treatment and complications. These questions are open-ended and allow us to culturally adapt our services by compromising between different conceptions of health and treatment.

The questions are

1. What do you call the problem?

2. What do you think has caused the problem?

3. Why do you think it started when it did?

4. What do you think the sickness does? How does it work?

5. How severe is the sickness? Will it have a short or long course?

6. What kind of treatment do you think the patient should receive? What are the most important results you hope to receive from this treatment?

7. What are the chief problems the sickness has caused?

8. What do you fear most about the sickness?

Had Lia's physicians asked similar questions to her family, they may have learned that Lia's family believed that medication should only have been administered when she seemed sick and at other times would have liked to have treated Lia with Hmong rituals such as a pig sacrifice (Fadiman 1997:260-1). Thus, the pediatricians could have amended the treatment regimen to incorporate (or at least tolerate) Hmong treatments and would have understood why dosages were being altered or discontinued.

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IV Cultural Interpreters and South East Asian Refugees in Kitchener-Waterloo

In response to a major influx of refugees from Southeast Asia in the early 1980s, the Waterloo Region Health Unit organized clinics to accommodate the cultural and linguistic backgrounds of the refugees (Elgie and Montgomery 1985). These clinics distributed translated materials, and staff were trained about the refugees' cultural practices. Bilingual volunteer "cultural brokers" were also enlisted to mediate between clients and their Canadian caseworkers.

The Kitchener-Waterloo Multicultural Centre has expanded this cultural interpreter program into a comprehensive service. Bilingual and bi-cultural interpreters bridge gaps between client and service provider by facilitating clear and effective communication, translating technical language and figures of speech and mediating between different concepts of health and the body to ensure comprehension by all parties. These types of services are also being incorporated into other organizations across Ontario including the Centre for Addiction and Mental Health, Access Alliance Multicultural Community Health Centre in Toronto and the Sexual Assault Centre (Hamilton & Area).

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V Culture Brokering

Jezewski's (Jezewski and Sotnik 2001) model of culture brokering is similar to cultural interpretation but it does not require a third party interpreter. This problem-solving model has three stages. First the health care provider must recognize an existing or potential problem in the client's encounter with the health system and expose the causes (such as age, socio-political determinants and timing). Next is the intervention stage, which involves establishing trust and rapport, and then using

* mediation (between the client and the health care system),

* negotiation (conferring with the client to understand their perception of the need for specific services such as transportation to religious services from a long-term care facility),

* advocacy (informing and supporting clients so they can make decisions that meet their needs), and

* networking with other professionals who can provide the client with services to minimize conflict, reach compromises, redistribute power and resources to individuals and groups that lack them, and who link professionals and their services with potential clients.

Last is the "outcome stage," which evaluates the effectiveness of the interventions. If the problem has not been adequately resolved, the broker (health care provider) reverts to earlier stages to reassess the situation and try different strategies.

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VI Conclusion

This feature is only an introduction to multicultural health. Multicultural methods are complex, and there are many other strategies in addition to the ones presented here. Please consult the resource list and read in more detail about the various approaches if you are interested in incorporating these methods into your practice.

It is imperative that health promotion practitioners recognize and value different conceptions of health. For multicultural health to truly succeed, we must mediate between medical cultures. Canada lauds itself on being a multicultural nation; if this is the case, we need to ensure that our health promotion practices are suited to our clients' needs.

VII. References

Elgie, K. and Montgomery, H. 1985. "A Community Development Approach to Meeting the Resettlement Needs of Indochinese Refugees." Journal of the Community Development Society 16(1): 75-93.

Fadiman, A. 1997. The Spirit Catches You and You Fall Down. A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux: New York.

Jezewski, M.A. and Sotnik, P. 2001. "Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-Born Persons." Accessed from October 25, 2002.

*Kleinman, Arthur. 1988. The Illness Narratives: Suffering, Healing and the Human Condition. Basic Books: New York.

*Young, D., Ingram, G., Liu, M., and MacIntosh, C. 1995. "The Dilemma Posed by Minority Medical Traditions in Pluralistic Societies: the Case of China and Canada." Ethnic and Racial Studies 18(3): 494-514.