Skillfulness in cross-cultural communication with patients can be demonstrated by a provider’s comfort with asking key questions so that he or she may discover the broader context in which a patient is operating. This broader context includes the patient’s cultural-religious beliefs which have a tremendous impact on health behavior. Our beliefs about what helps restore us to health can be amazingly powerful.
Culture, Religion & Spirituality
Participants in cross-cultural presentations often ask how to separate an individual’s cultural beliefs and behaviors from those that are based on the person’s religion. The best answer to this very complex question is to think of culture and religion as being two sides of the same coin – it may not be very useful to struggle with separating them (unless you are a theologian or philosopher). When interacting with patients and their families, religion can be a touchy subject. It isn’t always exactly clear where health care and religious practices intersect. According to Brick Johnstone, professor of health psychology at the MU School of Health Professions, “Some professionals may feel uncomfortable obtaining information about patients’ religious beliefs, (but) it is no different than inquiring about their sexual or psychological beliefs, substance abuse, etc…” (See MU Center Link below) In this Dimensions of Culture article, and as part of the cross-cultural communications “toolkit” we have developed for providers and other health care professionals, we suggest six key areas of intersection between a patient’s health care and cultural-religious beliefs. We also delineate five health events of particular interest in cross-cultural health care, suggesting examples of associated cultural-religious tenets from various faiths. Finally, resources for more specific in-depth cultural-religious information appear at the end of the article.
Six Key Areas Where Health Care and Cultural-Religious Beliefs Intersect
Communication with Spiritual Leaders: The need for adequate language interpreters in health care settings is uniformly addressed, but it is also imperative for people to be able to communicate with leaders of their faith community. These influential figures can help interpret what is happening on a spiritual level during a health crisis for patients and their families. For example, in the Catholic faith, a person may gain great strength and peace from the sacrament of the sick being administered by a priest. In Judaism, it is important to know the variations in practice among Orthodox, Conservative, and Reformed traditions. Religious leaders can clarify which tenets cut across the branches of their faith in matters ranging from birth control to life support. In the Muslim faith, it is considered a taboo topic to talk about death with a patient; a religious leader may be a crucial intermediary in conversations between doctors and second-degree male relatives deciding to whether to immediate family members about a terminal illness. Religious leaders assist individuals in making connections between their “inner life or spirit” and their communal, social, and cultural reasons for practicing a formal religion. ” Collaboration with the leaders of a faith community can result in strongly positive outcomes for a patient and family.
Gender: It is ethically egregious not to be aware of gender-specific rules for patient care that are extremely important in many faith traditions – for example, among Orthodox Jews and Muslims. It may be forbidden to be touched by someone of the opposite gender. Male Muslims should be examined by men and only female nurses and doctors should examine Muslim women.
Modesty: Nakedness is anathema to members of some faiths, notably Muslims. Health care situations, including hospitalization, do not lessen this sensitivity, especially for women and elderly people. Requirements for putting on a hospital gown may be met with opposition. Studies indicate that concerns about modesty contribute to health disparities among certain segments of the population. Asian women, in particular, if they are very traditional, may often avoid seeking care if a physical examination is necessary.
Diet: Concerns about dietary restrictions are most important in hospital settings where patients have little control over what they are served. Still, general awareness of food taboos predicated by culture/religion is important for all health care providers. Doctors in private practice settings and clinics need to be aware of how dietary restrictions affect patient compliance and should know to ask, for example, if a Hindu patient is vegetarian. Some do eat meat, but do NOT eat pork or beef. Eggs may not be allowed. Hindus and Muslims may both observe strict fasting. Mormons follow a dietary code that prohibits tea, coffee, and cola drinks. It is not as important to try to memorize specific dietary rules as it is to understand something about the beliefs driving the rules. For example, where fasting is practiced, it is related to a widely-held belief that physical cleansing is associated with spiritual cleansing.
Sacred objects: Be they amulets, figurines, portraits of saints, crosses, intaglios – sacred object should be allowed in a patient’s physical space and on the body. All caution should be taken to safeguard them. They should not be removed (or even moved) without talking with the patient/family. Evil eye pendants or charms are common worldwide. In Mexico they are very common, and should never be removed, especially from babies, without permission of family members. Similarly, Sikhs wear a steel bracelet on the right wrist that – like a wedding ring – should not be removed unless absolutely necessary. Called a Kara, this bracelet is a symbol of unbreakable attachment to God. It is in the shape of a circle which has no beginning and no end.
Sacred Time: In our Dimensions of Culture trainings we talk a great deal about how people’s concepts of time vary by culture. In addition to differences between clock time and “fluid” time, health care providers should be aware of sacred time. What day does the patient and family observe as a day of rest? It is Friday for Muslims, Friday at sunset until Saturday at sunset for Jews and Seventh-day Adventists, and Sunday for Christians. Institutions should post calendars that note the holidays for all traditions served. Meetings with families should not be scheduled on these dates, and office appointments should be offered on days other than sacred days. Clergy within certain faith traditions can provide the dates for holidays, like Ramadan, that shift year to year.
Possible Health Events and Associated Cultural-Religious Tenets
(Based on Table 5-1 presented in Rachel Spector’s “Cultural Diversity in Health and Illness” listed in resources below. )
- Use of Birth Control– Sterilization may be forbidden. In some circumstances, Jews may seek rabbinical consultation before deciding about the use of birth control. People of some other faiths may only use natural means of preventing pregnancy.
- Circumcision – Male: In some cultures, males must be circumcised after birth, during childhood, or around puberty as part of a rite of passage. Jewish law states circumcision is mandatory. In Islam it is either recommended or obligatory – worldwide 70% of circumcised males are from the Muslim world. It is also prevalent in parts of Southeast Asia, Africa,the United States, the Phillipines, Israel, and South Korea. Female: While individual Muslims, Christians, and Jews practise FGM, it is not a requirement of any religious observance. Judaism requires circumcision for boys, but does not allow it for girls. Islamic scholars have said that, while male circumcision is a sunna, or religious obligation, female circumcision is preferable but not required, and several have issued a fatwa against Type III FGM.
- Surgery (including Cesarian) In some faiths surgery is acceptable with the exception of abortion. In others, all invasive procedures are avoided. In the Hmong culture people fear soul loss during surgery. A Muslim woman may avoid a cesarian because she believes only Allah can decide whether a baby is born. Jehovah’s witnesses are not opposed to surgery but the administration of blood during surgery is strictly prohibited.
- Use of Blood and Blood Products – Typically no restriction except for Jehovah Witnesses and possibly Christian Scientists
- Autopsy – Tenets about autopsy range from being permitted for medical or legal purposes only to actually being required by law.
- Organ Donation – Forbidden by Jehovah’s Witnesses. For many who follow Judaism this is a complex issue requiring rabbinic consultation.
Health care providers may sometimes be uncomfortable talking about cultural-religious health beliefs and behaviors with patients and families. This article has suggested six key areas of intersection between a patient’s health care and their cultural-religious beliefs to assist in these important conversations. In addition, five health events of particular interest in cross-cultural health care were presented. Discovering the broader context of a patient’s life is critical to providing responsive care and assuring good health outcomes. Resources for more specific in-depth cultural-religious information appears below.