Cross-cultural Healthcare Quality Quiz

(Answer: c. The only assured similarity among people from around the world who come to you for care is the fact that they are your patients and they hope to be treated with respect and with concern for their individual health needs. As a health care practitioner, it is important to have a basic understanding of your patients’ cultures—and to recognize the similarities and differences among people from the same region of the world and the same country. Differences in cultures within a region can be pronounced. Each patient is the product of many cultural forces. People from the same continent, the same country, the same part of the country, and even the same city, may have major differences in cultural heritage, traditions, and language, as well as differences in socioeconomic status, education, religion, and sexual orientation. It is the combination of all of these factors that make up a person’s “culture.”)

(True: A growing number of people from majority U.S. cultures are turning to traditional medicines as part of their health care strategies. Providers should be aware of any such practices that may affect their patients’ health.)

(True: In many cultures, men are not involved in the activities surrounding pregnancy or childbirth. Yet they maintain the responsibility for making decisions and giving permission for treatment, medication, and hospital stays. A female relative may have to intervene between the provider and the husband.

(False: In addition to exploring payment options with the patient, it is important for the provider to inquire about cultural and psychological factors that may impede adherence to the prescribed treatment regimen.)

(Answer: b. Non-adherence can be the result of many different factors that may require a variety of interventions. Simply repeating the instructions may not address the real issues that are keeping the patient from adhering to the regimen. In fact, repetition of instructions may be inappropriate and quite offensive if the patient has a communication disability. Family members can provide valuable support. It may also be necessary to set small, realistic goals in order to achieve long-term behavioral change. Finally, an understanding of the patient's beliefs about other remedies may offer valuable clues to her/his reluctance to adhere to treatment.)

(False: Despite the lower rate of breast, oral cavity, colorectal, and urinary bladder cancers among Hispanics, their mortality rate from these cancers is just as high as that of the rest of the population.)

(Answer: c. Health and healing has been a part of Arab tradition since the earliest historical recordings. Not only has Arab medicine been in existence for over one thousand years, but Arab medical texts and practices were very influential in the development of Western medical tradition.)

(False: Low levels of cultural competence can impede the process of making an accurate diagnosis, cause the provider to order contraindicated medication, and reduce patient adherence to recommended treatment.)

(True: Because of language and cultural barriers, the patient may not understand the questions or may be reluctant to report symptoms; in turn, the provider may misunderstand the patient’s description of symptoms.)

(Answer: d. Even the most conscientious, committed staff who have been trained in cultural competence may need periodic reminders. In a busy practice, it is easy for providers to seek shortcuts, slipping into assumptions about the diverse populations they serve and failing to take the time needed to fully understand the health beliefs and values of each patient.)

(False: This is an inappropriate responsibility for families to take on and may actually place the provider in violation of the Civil Rights Act of 1964 and the August 30, 2000 Office for Civil Rights (OCR) Policy Guidance. The rationale for using professional interpreters is clear. Professional interpreters have been trained to provide accurate, sensitive two-way communication and uncover areas of uncertainty or discomfort. Family members are often too emotionally involved to tell the patient’s story fully and objectively, or lack the technical knowledge to convey the provider’s message accurately.)

(Answer: c. Modesty is a very important aspect of a Muslim's life. Handshakes between unrelated men and women are inappropriate according to Islamic norms. In addition, eye contact will often be avoided, especially in mixed-gender situations.)

(False: Each of these symbols has a very different meaning in different cultures, and may be offensive.)

(Answer: c. A large percentage of Africans are Muslims, most of them living in North and West Africa, but there are also many Muslims in East Africa.)

(Answer: b. The longitudinal NI-HON-SAN study and Honolulu Heart Program showed that dietary changes contributed to a significant increase in coronary heart disease among Japanese men who migrated to Hawaii and California. It highlighted the role that environmental factors can play in counteracting predispositions to disease.)

(True: This is an adaptation of the “Pygmalion theory” which has proven that students generally live up—or down—to the expectations of their teachers. (Rosenthal and Jacobson 1968).

(False: In the US, some individuals from minority and immigrant groups use traditional treatments before turning to conventional Western medicine, or use both concurrently.)

(False: Most of us harbor some assumptions about patients, based on race, ethnicity, culture, age, social and language skills, educational and economic status, gender, sexual orientation, disability/ability, and a host of other characteristics. These assumptions are often unconscious and so deeply rooted that even when an individual patient behaves contrary to the assumptions, the provider views this as the exception to the rule. A conscientious provider will not allow prejudices to interfere with making an accurate diagnosis and designing an appropriate treatment plan.)

(Answer: b. Although the provider may be tempted to correct the patient’s different beliefs about illness, this may lead the patient to simply withhold his/her thoughts in the future and interfere with building a trusting relationship. It is more effective to be nonjudgmental about differences in beliefs. The provider should keep in mind two goals: 1) the patient should reveal her/his medical history and symptoms to help the provider make an accurate diagnosis, and 2) the patient should develop trust in the provider’s medical advice and be willing and able to adhere to that advice. To accomplish these goals, it is essential to treat the patient with respect, openly discussing differences in health beliefs without specifying “correctness” or “incorrectness.”

(Answer: a. Although smiling is an expression of happiness in most cultures, it can also signify other emotions. Some Britishers, for example, may smile when they are discussing something sad or uncomfortable. The other pieces of advice are incorrect. The use and interpretation of body language depend entirely on the patient’s culture and personal preferences. What is appropriate in one culture may be embarrassing or offensive in another culture. Interpersonal greeting behaviors, for example, vary widely from one culture to another. Beliefs about touching are also highly variable, with some cultures placing a high value on physical contact, and others believing that physical contact of any kind is a sign of intimacy. Similarly, some cultures perceive direct eye contact as a sign of respect, while in other cultures, eye contact with elders and authority figures is to be avoided. Hand gestures in particular can lead to serious misunderstandings. For example, the “ok” sign, widely used in the US, is the symbol for coins or money in Japan. In several other cultures, the gesture represents a bodily orifice and is highly offensive.)

(False: In many of the world’s cultures, an individual’s health problems are also considered the family’s problems, and it is considered threatening to exclude family members from any medical interaction. The provider should ask the patient whether she/he would prefer to be seen alone or with the family. It should be the provider's goal to help the patient to express her/his true preference about this - without offending any family members. The provider might ease any tension around this issue by assuring family members that they will be asked to return to the examining room in a short time.)

(Answer: d. Although it may seem natural to look at the interpreter when you are speaking, you want the patient to feel that you are speaking to her/him, so you should look directly at her/him, just as you would if you were able to speak her/his language. It is best to speak in a normal tone of voice, at a normal pace, rather than pausing between words. Because of differences in grammar and syntax, the interpreter may have to wait until the end of your sentence before beginning to interpret. Do pause after one or two sentences to allow the interpreter to speak. When you need further information, or need to clarify what the patient has said, clearly tell the interpreter what you want asked of the patient. Although you may ask the interpreter to add his or her opinion of what the patient really meant, try to get as close as possible to the patient’s actual words and intent.

(Answer: a. While it may seem easier to ask questions that require a simple “yes” or “no” answer, this technique seriously limits the ability of the patient to communicate information that may be essential for an accurate history and diagnosis. The most effective way to put the patient at ease and to ensure that the patient provides essential information about his or her symptoms is to combine two types of questions: 1) open-ended questions such as “Tell me about the pain in your knee” and 2) more directed questions, such as “What makes the pain get better or worse?” Always get a qualified interpreter when possible.)