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Local Cultural Sensitivities With Respect to Health Care Print E-mail
The Quarterly 2012

Colleagues at RACMA have recently produced a draft position paper on this important topic—you can check it out on the RACMA website. Linked to this initiative is a current series of webinars, looking at the complex issues raised from various perspectives, with contributions from RACMA Fellows in Australia, New Zealand and also Hong Kong, where I am based.

There are many definitions of cultural competency - the one developed by Australia's National Health and Medical Research Council (NHMRC) in December 2005 states:

"Behaviours, attitudes and policies that enable systems, organisations, professions and individuals, to work effectively in cross cultural situations"

I have no special training or qualifications in this field and it may make more sense for one of my Chinese colleagues to share their perspectives on Chinese culture and health care. However when invited to contribute to one of the webinars on this topic in June 2012, I found myself reflecting in some depth about what this meant to me as a westerner, who has lived and worked in Hong Kong for a long time, first as a clinician paediatrician, then health care manager in our public hospital system, and latterly as a teacher / trainer of health care management.

Hong Kong is essentially a Chinese city of 7 million people, but we have our own ethnic minority groups, which include Westerners --- and yes, Australians and New Zealanders are included in this group, Indians, Pakistanis, Nepalis( many of these have long-standing roots here because of Hong Kong’s 150 + years of British colonial history, which is regarded as a mere blip on the landscape when taken in the context of China’s 5000 year history!),African traders, and very large groups of domestic helpers on short term contracts from Philippines, Thailand, Indonesia and Sri Lanka. We also have a very large number of visitors – last year there were >40 million, of which 27 million were Putonghua speaking visitors from mainland PRC, many of these with very different value systems from our own local Cantonese speaking residents, especially when requiring health care.

As a health care manager, there are many different perspectives on cultural competency, moving from personal experience, awareness and training, to encouraging staff, as individuals, team members and at governance level to develop relevant sensitivities and skills. Then we have a duty to listen to patient views on how their cultural beliefs can be respected, as well as the cultural values of the rich diversity of ethnic communities which we serve, when we provide their health care. It is a complex and dynamic listening and learning process on all sides.

The model for action to improve and strengthen cultural competency is adapted from the 2005 NHMRC report which has identified 4 expanding domains, starting with the individual, then professional, organisational and systematic approaches. The parameters for success at the moment tend to be largely measures of process, but I am sure good outcome measures will develop in time.

As a Westerner in a Chinese community, my learning was essentially experiential and I covered some of this cultural awareness in my webinar presentation, along with some references which may be helpful.

When I first came to Hong Kong, as an individual I was fortunate to receive some very good advice from a couple of kind friends and colleagues about the importance of ‘face’ and how to work around it to still make a point, how not to lose one’s temper, the importance of building trust in relationships, respect for the authority of elders, teachers, family and social networks, and food. There is also a very powerful work ethic. My first year working in Hong Kong was spent with my eyes and ears open, not saying very much and I still made lots of mistakes. I learnt that 'yes' sometimes does not mean 'yes' and 'no' may not mean 'no' --- but may be just the start of a negotiation process to be relished on both sides.

As a professional, I learnt that Confucian values and beliefs surrounding birth, illness and death were very real. Local disease profiles were very different from what I had been used to diagnosing and treating in UK – for example very little type 1 diabetes and inflammatory bowel disease. Infectious diseases such as TB, Hepatitis B were common, as is G6PD deficiency; cancer and genetic disease profiles are very different. There were very late presentations of chronic disease; drug metabolism is different, as are attitudes to mental illness and mental handicap. Somatisation of symptoms is common.

Attitudes to organ donation and adoption were very different from mine. I remember well one child with complex special needs but of normal intelligence, who was rejected by his mother at birth. It was hard to find adoptive parents locally, but the story had a happy ending. After several years he was adopted by an overseas family, did well at school, graduated from university and now is an enthusiastic contributor to Facebook. In the past, many children with delayed development became wards of the HK Social Welfare Department or had parents who sadly did not have sufficient support to cope with stigma/caring at home and required long term institutional care, though attitudes have changed somewhat in recent years. Because of local lack of kidney donors in the past, many of our adult renal failure patients in their despair sought donations for renal transplants over the border in PRC, often from executed prisoners, although this practice is now under review. Widespread patterns of ‘doctor shopping’ and the importance of Chinese medicine cannot be underestimated. Children with broken bones and other illness were often taken to a local bonesetter or herbalist first for treatment before coming to hospital.

At an organisational level, there is much that can be done as a manager to integrate cultural competency into our core business--- such as staff training, timely access to interpreters, employment of ethnically diverse staff, inclusion of family members in care planning and recognition of the role of traditional healers.

But it is often the stories that people remember and have the power to change attitudes and then behaviour. I once took a call from a senior orthopedic surgeon. He was upset. One of his elderly and mentally competent patients was refusing lower limb amputation surgery for severe and progressive gangrene, because of her really strongly held belief in whole body burial. She eventually agreed to lifesaving amputation only after negotiation, when we promised that our kind hospital pathologist would safely preserve the amputated limb for her in his laboratory until her demise at some time in the future and her family promised to make sure that she was buried as a whole person with her reunited limb. One of my surgical colleagues, as a matter of professional principle, refused to perform circumcision requested for religious reasons for a newborn Muslim boy. To defuse an escalating row with the father we asked our local imam for his advice, and the message came back that circumcision was important but need not be performed immediately --still our surgeon declined. In the end, the case went to the hospital ethics committee, who advised respecting the surgeon’s views but referral of the patient to a surgeon in another hospital who was willing to perform circumcision within the time frame advised by the imam. It was another Muslim patient who, when we checked if he was receiving 'halal' food as requested, smiled gently and said yes, but it was always exactly the same meal (fish).

At a systematic level, it takes time, determination and commitment to develop, introduce and monitor effective policies and procedures, as well as ensuring that there are sufficient resources available for implementation. Involvement of diverse consumers and community engagement in the process is critical for success. Development of effective communication channels, both formal and informal with local opinion leaders can be very helpful, especially when development or restructuring opportunities arise and also in crisis situations. Needs analysis of the health care required for certain vulnerable groups can be very useful in service modeling. Many local elderly Chinese ladies have limited literacy and understanding of health care, so verbal instructions (with appropriate style of words and body language) as well as functioning hearing aids can be very important. Sometimes policy and procedures founded in widely accepted western based ethics and values can be a real source of potential conflict, such as patient autonomy versus family opinion, when dealing with issues of confidentiality and consent. This is particularly evident for services at the beginning and end of life, as well as mental health.

As our world becomes increasingly connected, health care professionals, managers and patients will be more and more mobile. Skills in managing cultural diversity will become more important as we strive to provide really good health care, whatever our roles and our own cultural backgrounds. I still make mistakes and get teased about them, but the effort to engage is well worth while and frequently enriching. Insight into one's own cultural behaviour helps. Different and deeply held beliefs /values deserve our respect, and it often takes time and effort to find grounds for compromise. Grief and joy are common to all. In summary hard work, trust, sincerity and patience can go a long way towards bridging some of the gaps.

Dr Helen Tinsley
FRACMA, FHKCCM, FHKCPaed