Culture+and+Behavior

=**Culture and Behavior**=


 * 1. Define the terms: culture, ethnicity, and race; define terms relative to misperception of groups.**

Culture is a collection of meanings, values, and behavioral norms that are learned and transmitted within a social group through a complex system of symbols possessing subjective dimensions such as ideals, feelings, and attitudes. Culture may be transmitted through social learning and reinforcing behavior. All cultures define a spectrum of normal and abnormal behavior.

Race originally denotes human groupings that are biologically determined, implying a biological basis for certain characteristics. However, with the completion of the human genome project, it appears that genetic variation between people of different races is not sufficient to suggest such a biological basis exists. Currently, it is thought that geographic ancestry is a greater influence on genetic risk factors that genetic ancestry. e.g., Asian Americans living in America are more similar in genetic risk factors than Asians living in Asia, even though both are of Asian decent.

Ethnicity is a sense of feeling of belonging to a group that shares a common origin and history. Ethnicity involves shared patterns of behavior, providing a lens through which an individual sees the world.

Misconceptions of groups can lead to prejudice, a cognitive misperception of negative beliefs and attitudes about a group. Behavioral misperceptions can result in discrimination, where individuals are excluded based on differences. Ethnocentrism, where an individual uses one’s own beliefs and vales to judge people of other cultures, is especially dangerous in the medical profession.


 * 2. Explain the effects of culture on risk, morbidity and mortality in the U.S. population.**

Different groups in the US population experience health disparities in risk, morbidity, and mortality. For example, African Americans are at a greater risk of congestive heart failure, hypertension, diabetes and cancer while Native Americans have a higher risk for substance abuse. Some studies have suggested a link between perceived racism and somatic symptoms, such as high blood pressure. Life expectancy for white females is 15 years higher than for black males. It is suggested that these health differences are rooted in the different cultural effects in different populations.


 * 3. Compare world views of people from different cultural groups regarding time, tradition, family, as these relate to the practice of medicine.**

Attitudes between the US population and other cultural groups differ. Time is viewed in terms of promptness, and time-equals-money attitude in the US, while other cultures view time as more relative, tending to enjoy the moment. The US population has a tradition placing value on youth, while other cultures respect elders and age. Decision making in the US is giving the patient more autonomy to decide his or her treatment options; other cultures place the family as an important part of the decision making process. The US places equality of gender roles while other cultures place different roles for men and women. The learning style of the US is based on problem-solving, where the patient is a partner in decision making with the physician; other cultures are more accepting, placing complete decision making power with the physian.


 * **Attitudes** || **USA** || **Other** ||
 * Time || Promptness, time equals money || relative, enjoy the moment ||
 * Tradition || Value on youth || Respect Age ||
 * Decision making || Autonomy || Family is part of the process ||
 * Gender roles || Equality || Different roles for men and women ||
 * Learning style || Problem-solving || Acceptance ||


 * 4. Differentiate between assimilation and separatism.**

Assimilation refers to when an individual decides to engage in acculturation and absorb themselves into a new culture. See Objective 8 for the phases of acculturation.

Separatism refers to when individuals decide to retain the culture of their origin and remain separate from the new culture within which they are residing. Separatism depends on the degree of support systems available to an individual and often results in forming Chinatowns and Little Italy’s.


 * 5. Summarize the effects of culture on the provider-patient relationship, the medical encounter, psychiatic symptom reporting and on sick role behavior.**

Because culture defines normal and abnormal behavior, culture influences the duration, course, and outcome of mental illness. Mental illness may have different perceptions in different cultures such as severe stigma, personal privacy issues impeding disclosure, less concern with internalizing problems (e.g., depression) vs. externalizing problems (e.g., conduct disorder), and attribution of the illness (e.g., biological, social, psychological, or supernatural).

The US tends to protect patient privacy but patients themselves are usually open to talking about illness. Other cultures place high respect on privacy and the condition of the patient may be kept within the family to the extent of the family requesting information be withheld from the patient.

Additionally, patients not proficient in English are less likely to receive empathy from physicians, establish rapport, receive information, and participate in medical decision making.

Cultural emotion-display rules may influence what is socially acceptable symptom reporting. That is, the kinds of problems reported, expressions of illness, meaning of symptoms, stigma associated with symptoms, and world-views may be affected by cultural attitudes. Cultural attitudes toward the role of the physician (authority figure vs. health partner) can also influence symptom reporting as well as treatment compliance and reporting of treatment progress.

Cultural issues can also affect hospitalization of a patient. Clothing and ornamentation may be related to decoration or health reasons that the patient may not allow to remove. Patients may have dieting preferences (e.g. fasting, vegetarian, etc.) as well as health practices (e.g. herbal remedies, “healers,” etc.) that physicians should be made aware of. The patient’s perception of blood, blood loss, and transfusions can also affect hospitalization (e.g., perception of blood can be affected by religious beliefs).


 * 6. Discuss the use of interpreters in the clinical encounter.**

When taking a history with an interpreter, it is important to elicit the patient’s model of illness to acquire the patient’s perspective and also assess the patient’s goals and expectations of treatment. During the mental status exam, it is important to take into account that the patient’s culture may not place much importance in certain information (e.g., the last few US presidents, etc.) and, therefore, not know such information; this should not be confused with true impairments.

The type of interpreter has varying satisfactory outcomes in an interview. A family member interpreter makes the patient more comfortable, but risk information distortion. Telephone interpretation makes patients feel disconnected, but may be more accurate. The best interpreter available would be a professional either on-site or at a remote location.


 * 7. Predict common emotional problems in refugees and those that have immigrated to the U.S. List typical questions in an immigration history.**

Refugees are individuals who flee or are forced out of their country while immigrants are individuals who left their country voluntarily. Refuges are more likely to suffer from culture shock and emotional illness.

Factors important to assimilation or separatism after relocations involve how long an individual has relocated, their reasons for leaving, the experience of relocation, the degree of loss they feel, and the availability of support systems for that individual (ethnic communities, etc.).

Culture shock is a reaction to a sudden change in cultural setting. It is a condition of anxiety or depression, feelings of isolation, de-realization, and de-personalization. The shock is lessened when the person attempting to adapt is accompanied by another family member.


 * 8. Describe the phases of acculturation. Explain the major stressors in the acculturation process.**

There are 4 phases of acculturation: traditional, transitional, bicultural, and assimilated.

Traditional phase refers to individuals raised in a native country who relocate as adults. These people live in ethnic neighborhoods and speak very little English because they retain their identity with their country of origin. They do not attempt full assimilation because it would cause significant stress.

Transitional phase refers to relocated adults that have children born in the relocated country such as the US. These children think of themselves as American and as different from their parents. They may or may not accept the traditions of the native country because peer group influences are strong. Struggle with acceptance of traditions may cause stress to both the children and the parents.

Bicultural phase refers to second generation US children who have learned to function in both cultures. They take on the immigrated country’s identity and have less pressure to take on the native country’s traditions, allowing better bicultural function.

Assimilated phase refers to individuals several generations removed from the initial relocation. These individuals are totally absorbed in the new society and may have lost some of their native customs.

Stress from acculturation is proportional to the distance/difference between the two cultures and increases when rapid change is necessary. The need to obtain a job rapidly and when resources are minimal also increase the stress. Parent-child stress is highest in the transitional phase.


 * 9. Describe the culture bound syndromes of amok, ataque de nervios, susto, rootwork, koro, and piblokto.**

__Amok__ A dissociative disorder (psychotic) characterized by brooding followed by violent behavior directed against people/objects.

__Ataque de nervios__ A nervous panic attack with aggressive behavior characterized with shouting, crying, trembling, and aggression. It is often brought on by stress and has an element of feeling out of control.

__Susto__ Also called soul loss. Similar to massive depressive disorder, mood disorder, and post-traumatic stress disorder but without re-experience symptoms. Symptoms include sleep problems, somatic complaints, and loss of appetite that can occur even after a long period of time since traumatic event. Symptoms are attributed to a frightening event that causes the soul to leave the body.

__Rootwork__ Anxiety,nausea, vomiting, dizziness, and fear similar to a type of anxiety disorder but imposed by another person. Symptoms are attributed to hexing, witchcraft evil, voodoo death, and spells. It is important to identify co-“healers” and have them contribute to treatment.

__Koro__ A somatoform disorder where there is somatic manifestation of psychiatric disorder. Koro is characterized by sudden and intense anxiety focused on the loss of the penis, vulva, or nipples receding into the body and causing death. Weirdness.

__Piblokto__ Also called artic hysteria. A brief psychotic disorder with 1-2 hour episodes followed by amnesia. It is characterized by tremors, anxiety, screaming, running into the snow, and imitation of animal screaming. It is more common in women (Native Americans from the artic region) and often triggered by stress.


 * 10. Demonstrate ways to improve cross cultural communication in a clinical setting, using the LEARN model.**


 * LEARN || What you’re supposed to do ||
 * Listen || Listen to the person’s explanation ||
 * Explain || Obtain the patient’s perspective on the medical information ||
 * Acknowledge || Acknowledge that there are similarities and differences between what the patient thinks and what the doctor thinks ||
 * Recommend || Recommend a treatment plan ||
 * Negotiate || Negotiate an agreement to follow the treatment plan and make sure the patient has the resources/capability to follow through ||