9 May, 2024 <minato-nakazawa@people.kobe-u.ac.jp>
Medical Anthropology (5)Cultural competence in health care (source: Winkelman M, "Culture and Health", Chapter 3, pp.83-120, Jossey-Bass, 2009)•••

Differences between providers and clients may sometimes interfere with clinical consultation and treatment, program
development and disease prevention.
How can the barriers and problems produced by such difference be addressed with the development of cultural competence(based in the abilities to apply cultural knowledge and intercultural skills to effectively address the impacts of culture onsocial relations)?
• Effective adaptation to other cultures' health realities requires personal development by:• Developing awareness of the impact of cultural values and social processes on personal characteristics• Improving intercultural interactions• Acquiring models of culture for analysis of culture and health relations
Personal/Interpersonal skills related to intercultural encounters• Personal cultural awareness (shown as Exhibit 3.1) is a prerequisite for managing cross-cultural differences
Cited from Winkelman M (2009) Chapter 3, EXHIBIT 3.1. “Values Assessment Exercise” Assess how important each of the following factors is to you on the following scale: 1=Veryimportant, 2=Important, 3=Little importance, 4=Not important
Importance of values
HighLow
Cleanliness
1234
Satisfying others' needs
1234
Respect for elderly
1234
Past traditions
1234
Premarital virginity
1234
Social equality
1234
Family honor
1234
Education
12
34
Self-interest
1234
Independence from authority
1234
Personal relationships
1234
Directions in communication
1234
Having many children
1234
Punctuality
1234Being loyal to my manager
1234
Being given orders by managers
1234
Close friendships with coworkers
1234
Having independent responsibility
1234
Being liked by subordinates
123
4
Planning well in advance
123
4
Noncompetitive work environment
1234
Sharing ideas with superiors
1234
Separate roles for men and women123
4
Formal standards for behavior
1234
Improving social status
1234
Which of these values produce conflict for you at work? Why?
Which of these values are emphasized in your workplace?
Which of these values are rejected in your workplace?
Which of these values do you associate with specific cultural groups?
How do values affect health and health behaviors?
How do values affect the way providers interact with clients?

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Intercultural skills help overcome cultural communication gaps and facilitate adaptations to cultural factors that affectclient's reality.
Cultural awareness, sensitivity, competence, responsiveness and proficiency• Cultural awareness: an understanding of the importance of cultural differences• Cultural sensitivity: going beyond awareness to provide an appropriate response to cultural differences: eg, knowingthat people from some cultures don't like to look directly into another's eyes
• Cultural competence: having further capabilities to deal with differences effectively: the ability or function effectively
in the context of everyday life of a culture. Involving personal, interpersonal, organizational skills including behaviors,
attitudes, policies that enable people to work effectively with the various cultural groups• Composed of several dimensions like knowledge of general dynamics of culture and cross-cultural relations, generalskills in intercultural relations, specialty-specific skills for professional relations, and culture-specific knowledge ofbehaviors and beliefs of specific groups• Cultural responsiveness: falling between sensitivity and competence. In nursing care, the ability to respond to apatient's care needs in a way that is congruent with the patient's cultural expectations• Cultural proficiency: the ability to transfer cultural knowledge and skills to others, providing others with the skills toeffectively manage cultural differences.
Levels of cross-cultural competence (dislike and misunderstanding of out-groups => varying levels of appreciation of thenature and significance of cultural differences)• Ethnocentrism: People begin in an ethnocentric condition, ignorant of the relation of culture to behavior and self, nocompetency in understanding cross-cultural issues, no appreciation of the effects of historical and contemporary racism.

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Universalism: It rejects fundamental differences across cultures and emphasizes human similarities. "Everybody'sbasically same" view. It's naive regarding cultural differences (ignores the fact that one's perspective about human
universality is based on the one's own cultural assumptions). Often embodied in religious universalism: A single god isbelieved to have created all humans (thus equality under the god is assumed). Conventional biomedical view is a kindof universalism because it applies standard dose per body weight or normal ranges of weight for height to all humans
regardless with genetic and/or environmental conditions.
• Cultural awareness and acceptance: Awareness (incl. self-awareness of cultural values) of the "importance of culturaldifferences" and "knowledge of their influences on behavior" => Reduce cross-cultural misunderstanding• Adaptation (=cultural sensitivity): Ability to accommodate to cultural differences <= making appropriate adjustments forinteractions with people from other cultures by adjusting behavior and communication.
• Cultural competence: Ability to work effectively with clients from a different cultural group from one's own, based onunderstanding of cultural values, beliefs, behaviors. Incl. ability to use culturally relevant communication skills,
motivational strategies, organizational approaches.
• (Marginalization and biculturalism): Biculturalism refers an individual having internalized two different culture'sexpectations. Some bicultural persons are marginalized (feeling a lack of cultural identity), some others areintermediaries, functioning effectively in two cultural groups.
• Integration: Transcedenting the limitations of the previous cultural self, producing a new identity that incorporates theother culture. In other words, redefining one's identity in relation to multicultural contexts.
• Cultural proficiency: The ability to teach and direct others effectively in their development of culturally sensitive andcompetent approaches.
Concepts of culture• Culture and emic perspectives: "Culture" as a fundamental tool to overcome cross-cultural conflicts, requiring "emic"
perspectives to understand that members of a culture have about themselves – insider's view (eg. Kansai-jin's
characteristics identified by Kansai area natives)• Cultural relativism （文化相対主義）: According to the emic perspective, behavior is related to an actor's culture; thecontext in which that behavior is meaningful and rational. Knowledge of cultural patterns and values enables providers
to transform problems, conflicts, and paradoxes into meaningful behavior.
• Cross-cultural or etic perspectives: Specific pattern of human behavior is one of the general patterns of cross-culturalvariation. eg. We recognize specific cultural behaviors such as possession as the cultural manifestation of illness
behavior and the sick role, rather than a psychotic delusion.
• Cultural characterizations versus stereotypes: Cultural features <= member's of specific groups? Or it's stereotyping (All
who belong to one culture are same) ? Cultures provide common patterns of behavior that characterize their membersand intracultural variation in self, personality, and social roles. Complex societies have greater variation within theculture.
• Racial concepts: The application of the "race" concept to inter-group differences is misleading. Racial concepts reflect
racist traditions rather than genetic differences.
• Social versus cultural effects: Social influences are different from cultural influences. Characteristics of minority groups
in a multicultural society may be the consequence of economic and political relationships with other groups.
Effective cross-cultural adaptations• Culture shock adaptation: Cross-cultural contact => stress, emotional reactions, resistance to learning and accepting.
• Personal change and transformation: Developing cultural competence requires an effort to change personality.
• Cultural self-awareness: Recognize one's own cultural characteristics and influences (particularly values, prejudices,beliefs and their effects on behaviors and attitudes). Start from knowledge on one's own culture and its effects on one's
self, identity, preferences, patterns of behavior, and characteristics of one's professional practice (eg. nursing
professional cultures may differ by countries).
• Cognitive reorganization: Cross-cultural effectiveness requires cognitive changes ~ reconsider habitual culturalassumptions about what is normal, and so on ("self-reference criteria"). => interpersonal intercultural skills
Interpersonal skills for intercultural relations• Achieving communication competence: overcoming language barriers, listening and attending(see, language barrier for EPA nurses [http://ajw.asahi.com/article/behind_news/social_affairs/AJ201303220086])• Adjusting to another culture's behavioral expectations (eg. bedside manners, good will, compassion)• Developing and maintaining interpersonal relationships• Developing interpersonal skills for expressing empathy and cultural understanding (eg. nonverbal cultural norms likeeye contact, interpersonal space, tone of voice, timing).
=> eg. What is necessary for EPA nurses to adapt Japanese culture besides language barriers?

<No debate on 16 May 2024, instead, 5 minutes-talks (so-called "lightening talks") with 1 page presentation, one by one>• Please explain your experience of cultural gap in health-related issue and how to adapt.