CULTURAL APPROPRIATENESS

Sensitivity to other cultures refers to the awareness of how other ethnic, racial, and/or linguistic groups differ from one's own. Sensitivity can be manifested through knowledge of different languages or manners of speech, norms, and mores, religious beliefs and practices, family structures and dynamics, community decision-making patterns, and class consciousness and socioeconomic realities. Cultural appropriateness puts this sensitivity in action through the tailoring of public health interventions to specific cultures or subcultures. Thus, public-and clinical-health services, health behavior change interventions and social marketing, community organization and empowerment, and even environmental and occupational health approaches are adapted according to the target population to which they will be applied.

HISTORY OF IMPLEMENTATION IN PUBLIC HEALTH

Many countries, including the United States, Canada, Australia, New Zealand, and Argentina, are almost entirely populated by immigrants and their descendants, which juxtaposed with the surviving indigenous populations make them highly diverse. Since World War II, European nations have become far more heterogeneous as well. Yet dominant groups are highly ambivalent about diversity. This ambivalence may contribute to negative health and social impacts on minority populations.

Concerns about diversity in the United States date from colonial time. As the new nation evolved, the founding fathers saw a need to populate the region with more Europeans (and their African slaves). Hence, the number of immigrants gradually accelerated until the beginning of the Civil War, when over 150,000 newcomers arrived each year. Nevertheless, public health efforts continued to emphasize the needs of the dominant population. Efforts directed toward disadvantaged and diverse groups were based more in controlling the spread of diseases that they might have had rather than in promoting their health itself. In the twenty-first century, immigrants continue to arrive in the United States and other industrialized countries at a record pace. Moreover they are now far more likely to come from Latin America, Asia, or Africa. Together these phenomena make the issues of cultural sensitivity and appropriateness more relevant than ever.

RELATIONSHIP TO HEALTH

Cultural sensitivity (or the inability to achieve it) may impact the health of individuals and populations in many ways. Social isolation—low or poor interaction with the surrounding society—may result in underutilization of health care. Social isolation may stem from a variety of factors such as a lack of transportation or financial resources, fear of being deported due to documentation status, or physical distance from the community. As a whole, social isolation, poverty, and lack of health care coverage may encourage individuals to postpone professional treatment in the hopes that the illness will resolve itself.

Even when care to the disadvantaged population is provided, it may be inadequate. Cultural and linguistic barriers may contribute to inadequate health care by limiting the ability of the provider to understand the patient and his or her symptoms, and result in an inappropriate course of treatment.

When considering various models of health behavior among immigrants, the ethnic context of their origin must be addressed. In most cases, theories of behavior change are normalized on stable, English-speaking middle-class populations. But these models of individuals as relatively autonomous beings who weigh potential personal outcomes, their own "self" efficacy, and their personal readiness to change, while at the same time choosing whether to listen to or ignore pressure from peers, may have little relevance to diverse communities, who often have a strong sense of identification with and attachment to their families, both nuclear and extended. The design of health messages must acknowledge this attachment. Dramatic differences among ethnic and racial minorities in terms of language and literacy, religion and family orientation, acculturation and experience with the dominant culture, and socioeconomic and legal status must also be considered.

Health officials and providers may be ignored as message sources, perceived to be unaware of the patient's culture, or even perceived as siding with hostile law enforcement. Formal health promotion programs typically rely on broadcast and print channels intended for non-English-speaking or immigrant communities. Many of these barriers can be surmounted by the use of community health advisors (CHAs) who come from the communities they serve and yet are sufficiently comfortable with the host culture to be able to understand and redirect health messages to their communities.

Cultural appropriateness is often manifested through attention to the literacy needs of a population. Current health instructional approaches and materials are typically designed for relatively educated individuals highly literate in English. Materials in non-English languages are largely direct translations from English and are often not culturally or even linguistically appropriate. Health communication messages aimed at immigrant or minority communities will often specify the audience's ethnicity in an attempt to render the communication more interesting, attractive, and acceptable to the audience.

Attention to religious beliefs in health communication efforts may be especially important given the central role that these beliefs and related practices may play in the concepts of illness, recovery, and wellness (received characteristics) as well as the potential for using the place of worship as a source for the message itself. Providers must also determine the specific roles of the family members and incorporate this knowledge into any treatment regimen. Adherence to the regimen is unlikely to occur unless the family trusts the provider and thinks that his or her recommendations are valuable and important.

John P. Elder

(see also: Anthropology in Public Health; Cross-Cultural Communication, Competence; Cultural Factors; Lay Concepts of Health and Illness )

Bibliography

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Castro, F.; Elder, J.; Coe, K.; Tafoy-Barraza, H.; Moratto, S; Campbell, N.; and Talavera, G. (1995). "Mobilizing Churches for Health Promotion in Latino Communities: Compañeros en la Salud." Journal of the National Cancer Institute Monograms 18:127–135.

Horowitz, C. (1998). "The Role of the Family and the Community in the Clinical Setting." In Handbook of Immigrant Health, ed. S. Love. New York: Plenum.

Nickel, J. (1986). "Should Undocumented Aliens Be Entitled to Healthcare?" Hastings Center Report December:19–23.

Ohmans, P.; Garrett, C.; and Treichel, C. (1996). "Cultural Barriers to Health Care for Refugees and Immigrants: Providers' Perceptions." Minnesota Medicine 79:26–30.

Waddell, B. (1998). "United States Immigration: A Historical Perspective." In Handbook of Immigrant Health, ed. S. Love. New York: Plenum.