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Cultural Differences in Health Beliefs a
Elaine P Congress ACSW, DSW & Beverly P. Lyons MA
b
a
Assistant Professor, Graduate School of Social Service, Fordham University, New York, NY 10023 b
Doctoral Cand, Graduate School of Social Service, Fordham University Published online: 26 Oct 2008.
To cite this article: Elaine P Congress ACSW, DSW & Beverly P. Lyons MA (1992) Cultural Differences in Health Beliefs, Social Work in Health Care, 17:3, 81-96, DOI: 10.1300/ J010v17n03_06 To link to this article: http://dx.doi.org/10.1300/J010v17n03_06
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Cultural Differences in Health Beliefs: Implications for Social Work Practice in Health Care Settings Elaine P. Congress, ACSW, DSW Beverly P. Lyons, MA
ABSTRACT. Individuals of diverse ethnic backgrounds often have beliefs about health, disease and treatment which vary significantly from American scientific medical practice. Cultural and subcultural health beliefs also vary among blacks, Hispanics and Asians. Individual differences within cultural groups may be influenced by length of time in the United States, age and social economic status. Social work activities which can improve health care services to ethnic minorities are identified. Social workers in health care settings are concerned with improving their practice with clients of different cultural backgrounds. In recent years the population of some ethnic minorities has grown more rapidly than that of Europeans. ' There has been a greater increase in the general population of Asians (129%); Hispanic Americans (61%); and African Americans (17. 5%); as compared to 5.7% for European whites ( U . S Bureau of Census, 1983; U.S. Bureau of Census, 1990). Yet despite attempts to extend and improve medical care to other ethnic minorities, whites of European extraction have higher life expectancy rates at most ages (Cockerham, 1983; Devore & Schlesinger, 1991). Health differences by ethnic background span the life course and are particularly probElaine P. Congress is Assistant Professor, Fordham University Graduate School of Social Service, 113 West 60th Street, New York, NY 10023. Beverly P. Lyons is a doctoral candidate at Fordham University Graduate School of Social Service. She is also Adjunct Lecturer at Queens College. Social Work in Health Care, Vol. 17(3) 1992 Q 1992 by The Haworth Press, Inc. All rights reserved.
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lematic in later life (Gelfand, 1982; Trevino and Moss, 1984; National Center for Health Statistics, 1990). There is extensive documentation that many ethnic minorities have beliefs about illness and treatment that differ significantly from Western scientific medical practice (Angel & Thoits, 1987; Chrisman & Kleinman, 1983; Delgado, 1979; Devore & Schlesinger, 1990; Eisenberg, 1977; Giordano & Giordano, 1976; Green, 1982; Guendelman, 1984; Lorenzo & Adler, 1984; McGoldrick, Pearce, & Giordano, 1982; Snow, 1974; W a t k i i & Johnson, 1979; Wilk, 1985-1986; and Zola, 1972). This paper explores some of the diverse cultural and subcultural beliefs about health, disease, and treatment and the effect of specific factors such as time of immigration, age and social-economic status on individual differences within cultures and subcultures. Specific skills and activities needed by social workers in health care who work with culturally diverse clients are identified. Barker (1991) identifies social work's belief in cultural diversity as "the recognition of sociocultural differences and respect for an assortment of beliefs and values." Recently Lum (1991) notes the concern that the social work community has not directed sufficient attention to the study of cultural diversity. A social work focus on differing health beliefs of clients serves to promote the traditional social work value of client self determination (Biestek, 1957). That the NASW Code of Ethics urges social workers to strive to "ensure that all people have access to the resources (and) services. . . they require" (NASW, 198411990) means that social workers have a responsibility to make health care services more available and relevant to ethnic minorities. Greater understanding and respect for clients' health beliefs can lead to improved treatment outcomes and help to modify the sobering fact that ethnic minorities in the United States are more prone to serious illness and early death than those of European extraction.
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ETHNIC BELIEFS AND THE SCIENTIFIC MEDICAL MODEL In modem Western societies, most people attribute illness to physical causes such as bacteria, pollutants, degenerative processes,
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heredity, poor nutrition, chemical imbalance, lack of exercise, and other factors. As a result, many Westerners are receptive to diagnoses and treatment that match their expectations. Many Americans, for example, are familiar with and accept treatments with antibiotics, vitamins, hormones, multiple medications, as well as surgical interventions, radiation and chemotherapies. The majority of these Americans do not accept acupuncture, herbal therapy, and spiritualistic rituals as legitimate treatments (Chrisman & Kleinman, 1983; Hepworth and Larsen, 1986). The scientific medical model may be inadequate for understanding the perception of illness and the help-seeking behaviors of ethnic minorities in our society @enis, 1979.) Different ethnic groups, as well as subcultures within these groups, vary in their beliefs about health, sickness, and treatment (Devore & Schlesinger, 1991; McGoldrick, Peace, and Giordano, 1982; Watkii and Johnson, 1979.) Physical and mental health problems can not be correctly diagnosed or treated without understanding of these differences. Cultuml Health Beliefi of Blacks
People who describe themselves as black come from varied backgrounds which affect their health beliefs and practkes differently. Many blacks born in this country emigrated to northern cities from rural areas in the south after World War II, while much earlier other black people had been brought north as slaves or indentured servants. Some of their health beliefs originated in Africa and took root in ante-bellum plantation life. Illness was classified into three main types, natural, occult and spiritual (Grossman, 1979). The type of disease dictated the type of treatment pursued. Natural illness was often treated by herbal medicines, while occult curing involved witchcraft or rootwork. Spiritual illness was often treated through prayer and laying on hands to exorcise sin and make the person well. In reality these three disease categories are often merged and the sick individual may seek treatment from a variety of healers within the black community (Grossman, 1979). It is important to recognize that the reliance on informal folk healers by an American black population has roots in the fact that their access to more formalized American health care
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was denied first by slavery and then by segregation. Second and third generation blacks raised in northern urban areas since the civil rights legislation of the sixties may be less influenced by these traditional southern black beliefs. Many blacks in this country emigrated from parts of Africa, Great Britain, and Caribbean Islands such as Jamaica and Haiti. Because they arrived in the United States recently and may have had limited access to the formal health care system, if they are undocumented, Caribbean blacks may be especially influenced by the health beliefs and practices of their native countries. The beliefs of some Haitians about the causes of illness, treatment and prevention differ markedly from American health care practices. Diseases are often attributed to supernatural causes (Wilk, 1985-1986). A young Haitian mother whose one year old daughter was recently hospitalized for pneumonia told the hospital social worker that someone had "done something bad for my baby." She had taken her baby to a voodoo doctor for treatment before she came to the hospital, but had not brought her baby to the Well Baby Clinic because her child was not ill and she had not understood the value of regular post natal care.
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When Haitians' health beliefs about the supernatural causes of illness, voodoo treatment and need for medical care, when symptomatic, clash with American health beliefs and practices, social workers may find themselves in a dilemma. On the one hand, they are trained to understand and accept differing health beliefs. On the other hand, they may be legitimately concerned about the possible long term negative effects on children who do not receive primary or secondary preventive health care.
Cultural Health Belkfi of Hkpanics Traditionally, many Hispanics classify illness as either natural or unnatural. Natural illness is thought to be caused by God's will or fate, while unnatural illnesses originate from evil done by another (Grossman, 1979). Since causation is perceived as originating outside the person, the notion of prevention of illness through diet,
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exercise or regular examination may be foreign to the Hispanic client. In contrast to a medical model which promotes specialization in health care, many Hispanics have a holistic approach in which the mind and body are seen as one. Hispanic clients are likely to express emotiond reactions in somatic terms. The idea of mental health treatment may be foreign and many clients approach mental health clinics with physical complaints such as "dolor de cabeza," literally, "a pain in the head" (Congress, 1990). Consistent with this holistic view, many Hispanics think illness may signify that those who are sick are not in balance with their environment. Illnesses, medications and foods are placed along a hotlcold continuum. A hot disease needs to be treated with cold remedies and a cold disease with hot foods. The sick Puerto Rican may seek herbal treatment before or concurrently with attending a health care facility (Delgado, 1979). Herbs are distributed at botanicas and are believed to have positive effects in treating both natural and unnatural illness. A belief in spiritualism is often evident among Puerto Rican clients. The spiritualist (folk-healer) tries to help the Hispanic client cope with medical and social problems by negotiating with the spiritual world. Many Puerto Ricans are reluctant to discuss their experiences with spiritualists because they accurately perceive that these beliefs may be accepted by health care professionals. However, the value of accepting folk healers as part of the treatment process with Hispanic clients has been noted (Delgado, 1979-1980; Berthold, 1989). Since the health beliefs of some Hispanics seem so different from generally accepted medical beliefs, Hispanics may be misdiagnosed and incorrectly treated in our systems of care. A 28 ye& old Puerto Rican woman was referred to a social worker by her physician whom she had consulted because of physical symptoms including fatigue, headaches and insomnia. She told the doctor that she felt her boy friend's former girl friend had put a spell on her. First she had visited a botanica and taken special herbs in tea, but noticed no relief of symptoms. She then went to a spiritualist who put her in a trance during which she lost all awareness of who or where she was.
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Her symptoms seemed to disappear for a while, but. then had begun to reoccur. The physician's initial diagnosis was rule out Paranoid Schizophrenia.
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This illustrates how a health care professional not versed in Hispanic health beliefs can diagnose a client incorrectly and possibly begin treatment which is not indicated.
Cultuml HeaUh Beliefs of Asians There is considerable diversity in the health beliefs of Chinese, Japanese, Philippinos, Koreans and Indochinese. Many Asians depend on home remedies for illness and subscribe to a Yin-Yang classification of foods (Grossman, 1979). Those Asians who have remained within their own communities and do not speak English are more likely to retain their native health beliefs. Both physical and mental illnesses are often described in physical terms. The word depression does not exist in Chinese medical dictionaries. Mental illness is stigmatized in their culture so that depression is expressed somatically. When Chinese are depressed or under stress, they describe symptoms such as dizziness, headaches, lethargy, appetite and sleep disturbances (Kleinman, 1980; Tseng & McDermott, 1981). The majority of patients with psychological manifestations of depression are diagnosed in the Chinese culture as neurasthenic (Mechanic, 1980; Chrisman and Kleinman, 1983; Tseng and McDermott, 1981). This is how a Chinese family interpreted and dealt with a mother's mental illness: '
Mrs. A., a 55 year old Chinese woman, was brought to a community mental health center by her two adolescent daughters. This family had lived in the United States for about six years. Mrs. A. seemed to be almost catatonic and appeared to suffer from a severe depressive disorder. She spoke no English, but her daughters recounted that since the death of her husband and their father five years ago, Mrs. A. had experienced symptoms of headaches, insomnia and lethargy. She would sit in her room for hours without activity. The daughters interpreted these symptoms as related to physical changes
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which occur during middle age. It was only when the older daughter took a college course in human behavior and read about depression that she decided that her mother needed mental health treatment. This case illustrates how psychiatric symptoms can be interpreted as physical ones. Only with the daughter's exposure to Western concepts of mental health did she seek treatment for her mother. Since many Asians are not aware of or readily engaged in mental health treatment, it is especially important that staff be knowledgeable about and sensitive to cultural differences in servicing this population (Ho, 1987; Lorenzo and Adler, 1984).
DZVERSZTY WZrnZN
CULTUWSUBCULTURAL GROUPS There are also individual variations in beliefs within diverse ethnic groups (Harwood, 1981) which can be attributed to duration of stay in the United States, age and socioewnomic status. During the last decade, between seven and nine million new immigrants have entered this country, the largest increase since the 1920's (U.S.Bureau of Census, 1990). Recent immigrants are more likely to have health beliefs and practices reflective of their cultural background than those who have lived in the United States for many generations. The cultural beliefs of Asian and Hispanic immigrants influence greatly how both subjective (perceived) and objective (actual) health status is reported to health professionals (Angel & Thoits, 1987). Newcomers tend to have beliefs directly related to their homeland medical traditions, while those who have lived in the United States for some time begin to believe more in the scientific medical model of this country (Angel & Cleary, 1984; Angel & Thoits, 1987; Keefe, 1980). Although some assimilation of health beliefs does occur, it is erroneous to apply a melting pot theory to culturally diverse clients when providing health care. It is important for social workers to recognize, accept and support cultural diversity (Handelman,
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1983). Even those who have lived in the United States for generations still have ties to both the prevailing and to their own specific cultures (DeAnda, 1984). The social worker can not assume that those who have lived in the United States for many years completely adopt the beliefs of the larger community. Although sensitivity to cultural factors are more significant in work with the newly arrived immigrant (Longres, 1991), it is important to understand how cultural differences affect the use of health care services for several generations. Because of the high incidence of acute and chronic illness in older pwple, the elderly need health care services frequently. It is usually assumed that the elderly are more likely to retain their culturally influenced health beliefs and practices than younger people who tend to become acculturated to American practices through their exposure to educational, work and other societal systems. Yet the elderly ethnic population can not be regarded as homogeneous. Some ethnic elderly were born in this country, some came here as children or young adults and some immigrated as older people (Gelfand & Yee, 1991). Since being a new immigrant is positively correlated with diverse cultural beliefs about health, illness and treatment, it follows that the older, recently arrived immigrants will be much more likely to adhere to the health beliefs and practices of their original culture than those who have lived in this country all their lives. Elderly individuals of ethnic minorities tend to utilize family support systems more than formal ones (Brody, 1985; Harel, 1986; and Stone, Cafferty, and Sangel, 1987). The elderly may be distrustful of formal health services and this contributes to their continued reliance on previously acquired cultural beliefs on health and treatment. Yet there is some evidence that family social supports may not continue to be as readily available to the ethnic elderly as before (Cantor, 1979 and Rosenthal, 1986). As the ethnic elderly then begin to turn to formal health care and support systems, it is important for social workers to explore and understand their cultural health beliefs and practices. Socioeconomic status is a significarit factor in diverse cultural beliefs on health and treatment. The economically deprived are more likely to retain the beliefs and values of their country of
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origin than their middle class counterparts from the same culture (Chrisman & Kleinman, 1983). A study of Mexican immigrants demonstrated that the poorest, especially the most recent undocumented immigrants retained more of their ethnic health beliefs (Angel & Cleary, 1984). A contributing factor, however, may be their difficulty in obtaining access to health services because of their undocumented status and low incomes. It has been suggested that socioeconomic differences and resultant status differences have greater influence on ethnic minority experiences with social service systems including the health care system than differing health beliefs, especially for those who have been in this country for many years (Longres,l991). This makes it important for the social worker to understand the effect of socioeconomic factors on clients' health beliefs and their ability to use health care services. The poor, and especially the ethnic poor, are particularly vulnerable to paternalistic interventions. Social workers must understand and support the health beliefs of their poorest clients and know that they have liinited choices even as they are helped to maximize their ability to make choices.
Bioethics and Autonomy The highly sophisticated increased technologies in medical care over the past decade has raised bioethical concerns (Reamer, 1985) about conflicts between patients and their physicians, particularly around issues of client autonomy, self determination, limitations of practitioners, threats posed by professional paternalism and the impact of organizational interests (Callopy, Dubler & Zuckerman, 1990). This has heightened sensitivity to those situations in the delivery of health care services which may threaten client autonomy and self determination. Culturally diverse clients are particularly vulnerable in this respect and their autonomy in making health care decisions are frequently at risk or jeopardized. Many health professions reared in the scientific medical model are critical of ethnic minorities' underutilization of the health care system. Social workers may experience conflict when minority clients and their families are committed to their health beliefs and trust their efficacy. The social worker may think that these clients make
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poor choices and this way of exercising their autonomy may be damaging to them. They may feel conflict in being advocates for good quality client care and at the same time negotiators for client autonomy. Although these may feel. like polarities and may be legitimate professional concerns, good practice requires that competent clients are ultimate decisionmakers and that they are helped to exercise this right (Callopy, Dubler & Zuckerman, 1990). IMPLICATIONS FOR SOCIAL WORK PRACTICE
What, then, can social workers do to improve their services to clients with culturally conditioned reactions to our health care systems?
increase their sensitivity to culturally diverse beliefs A central value of social work is that each person's uniqueness be respected (Lowy, 1985). It follows that social workers are required to be sensitive to the differing health beliefs of their clients. Social workers in a health care setting can use an ethnic-sensitive inventory to enhance their skills in working with culturally diverse populations and to refine their practice skills with ethnic minorities (Ho, 1991). Social workers need to become aware of how their own biases toward ethnic minorities may subtly and not so subtly affect their ability to be helpful to clients of cultures different from their own.
learn more about clients' beliefs about health, disease and treatment As they help clients, social workers as a matter of course explore with them how they perceive their illnesses and how they have experienced treatment. With minority clients social workers need to take special care to monitor themselves for any possible criticism or judgments about clients' beliefs and behaviors, as they deal with serious illness and receive treatment in our organized health care systems (Cook & Jenkins, 1982; MacLean & Sakadakis, 1989).
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Social workers can supplement what they learn from clients about their health beliefs by developing and participating in cultural education training programs with other health care professionals (Lefley, 1984; Collins, Mathura and Risher, 1984). Employing staff of similar cultural backgrounds can help with this learning as can interpreters.
avoid stereotyping and emphasize individual difjerences in diagnostic assessments It can not be assumed that all people from the same cultural and subcultural group share the same belief system about health and illness, even when they have been in the United States for a similar period of time, are about the same age and of the same socialeconomic status. Clients have multiple, often seemingly conflicting belief systems. Different factors influence their reliance on one system or another at any given time (Ell, Mantell, & Hamovitch, 1988). Individuals may use the organized medical system, as well as their own ethnic treatments and healers, but also may turn to religion, self-help groups, yoga, and chiropractors and to remedies recommended by their mothers and their friends (McGoldrick, Pearce, & Giordano, 1982). The social worker should anticipate considerable diversity in exploring health care beliefs, whether clients are poor recent immigrants or well educated middle class long-time Americans and learn how their beliefs affect their ability to use health care services.
increase the ability of culturally diverse clients to make choices All clients have the right to pursue health care of their choice. Many culturally diverse clients can not even consider alternatives because of fmancial constraints. Social workers have an important role in advocating for equity within the health care system so that culturally diverse clients, especially those who are poor, can make valid choices among health care models.
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enlarge other health care professionals' understanding of cultural diperences in the health beliefs of clients Social work practice aims to establish linkages between individuals and their environments which allow for multiple comections between them (Gordon, 1969). Health care social workers can facilitate these linkages between scientific medicine and clients' ethnic health beliefs about illness and treatment. Interdisciplinary exchanges with other health care practitioners provide social workers the opportunity to broaden the understanding of other disciplines about culturally diverse clients whose health beliefs seem to be in conflict with scientific medical practice. The important role of the social worker in interdisciplinary ethics conferences has been acknowledged (Joseph and Conrad, 1989). Social workers can use their skills to humanize and demystify advanced medical technology for their clients (Abramson, 1990). As social workers enlarge the knowledge of other members of the health care team about the various beliefs of their clients, they can encourage the development of modified andlor alternative courses of treatment which incorporate the health beliefs of many ethnic minority clients.
advocate for understanding and acceptance of differing health beliefs in the health care facility and in the larger community An important role for social workers in health care settings is that of culture mediator (Fandetti and Goldner, 1988). Social workers can function as client advocates on both micro and macro levels. Because of their professional knowledge and understanding of clients' culturally conditioned beliefs, social workers in the health care field are positioned. to advocate that cultural beliefs be incorporated and used in treatment plans. This role is congruent with social work's commitment to client self determination and autonomy. They can also advocate on macro levels for needed modifications withimhealth care treatment teams, the development of more sensitive hospital and clinic policies and in the larger political and policy making systems. These activities will help social workers fulfill their responsibili-
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ty to provide and improve health care services for their clients. Increased understanding of diverse cultural health beliefs has the additional benefit of helping clients of different backgrounds develop more trust in health professionals and thus make better use of their services. The promotion of ethnic sensitive health care is significant in realizing social work's goal of improving the health care their ethnic minority clients receive. NOTE 1. The term minority is used to refer to individuals from ethnic backgrounds, such as African Americans, Hispanics, Native Americans, and Asian Americans. In prior years white ethnic immigrants of European origin were defmed as minorities (Markides, 1987).
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Reamer, F. (1985). The emergence of bioethics in social work. Health and Social Work, IS, 271-281. Rosenthal, C. (1986). Family supports in later life: Does ethnicity make a difference? Gerontologitt 26, 19-24. Snow, L. P. (1974). Folk medical beliefs and their implications for care of patients. Annals of Internal Medicine. 81, 82-96. Stone, R., Cafferata, G., & Sangel, J. (1987). Caregivers of the frail elderly: A national profile. Gerontologitt, 27, 616-626. Trevino, F. & Moss, A. (1984). Health indicators for Hispanic, Black, and White Americans. Vital and Health Statistics Series 10, no. 148. Washington, D.C.: U. S. Public Health Service, National Center for Health Statistics. Tseng, W. S. & McDermott, J. F. (1981). Culture, mind, and therapy: An introduction ro cultural psychiatry. New York: Brunner-Mazel. US. Bureau of the Census. (1983). 1980 C e n w of Popularion: General Social and Economic Characteristics , U. S. Summary. Washington, D. C.: Government hinting Office. U S . Bureau of the Census. (1990). StotFFtical Abstract of the United States, 1990. Washington, D. C.: U S . Department of Commerce, Government Printing Office. Watkins, E. and Johnson, A. (1979). Removing culrural and ethnic bam'ers to heaDh care. Proceedings from a national conference. Chapel Hill,Nofih Carolina: University of North Carolina. Wdk, R. (1985-1986). The Haitian refugees: Concerns for health care providers. Social Work in Health Care, 11(2), 61-74. Zola, I. K. (1972). Culture and symptoms: An analysis of patients' presenting complaints. American Sociological Review, 5, 141-155.
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
Cultural Differences in Health Beliefs a
Elaine P Congress ACSW, DSW & Beverly P. Lyons MA
b
a
Assistant Professor, Graduate School of Social Service, Fordham University, New York, NY 10023 b
Doctoral Cand, Graduate School of Social Service, Fordham University Published online: 26 Oct 2008.
To cite this article: Elaine P Congress ACSW, DSW & Beverly P. Lyons MA (1992) Cultural Differences in Health Beliefs, Social Work in Health Care, 17:3, 81-96, DOI: 10.1300/ J010v17n03_06 To link to this article: http://dx.doi.org/10.1300/J010v17n03_06
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Cultural Differences in Health Beliefs: Implications for Social Work Practice in Health Care Settings Elaine P. Congress, ACSW, DSW Beverly P. Lyons, MA
ABSTRACT. Individuals of diverse ethnic backgrounds often have beliefs about health, disease and treatment which vary significantly from American scientific medical practice. Cultural and subcultural health beliefs also vary among blacks, Hispanics and Asians. Individual differences within cultural groups may be influenced by length of time in the United States, age and social economic status. Social work activities which can improve health care services to ethnic minorities are identified. Social workers in health care settings are concerned with improving their practice with clients of different cultural backgrounds. In recent years the population of some ethnic minorities has grown more rapidly than that of Europeans. ' There has been a greater increase in the general population of Asians (129%); Hispanic Americans (61%); and African Americans (17. 5%); as compared to 5.7% for European whites ( U . S Bureau of Census, 1983; U.S. Bureau of Census, 1990). Yet despite attempts to extend and improve medical care to other ethnic minorities, whites of European extraction have higher life expectancy rates at most ages (Cockerham, 1983; Devore & Schlesinger, 1991). Health differences by ethnic background span the life course and are particularly probElaine P. Congress is Assistant Professor, Fordham University Graduate School of Social Service, 113 West 60th Street, New York, NY 10023. Beverly P. Lyons is a doctoral candidate at Fordham University Graduate School of Social Service. She is also Adjunct Lecturer at Queens College. Social Work in Health Care, Vol. 17(3) 1992 Q 1992 by The Haworth Press, Inc. All rights reserved.
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lematic in later life (Gelfand, 1982; Trevino and Moss, 1984; National Center for Health Statistics, 1990). There is extensive documentation that many ethnic minorities have beliefs about illness and treatment that differ significantly from Western scientific medical practice (Angel & Thoits, 1987; Chrisman & Kleinman, 1983; Delgado, 1979; Devore & Schlesinger, 1990; Eisenberg, 1977; Giordano & Giordano, 1976; Green, 1982; Guendelman, 1984; Lorenzo & Adler, 1984; McGoldrick, Pearce, & Giordano, 1982; Snow, 1974; W a t k i i & Johnson, 1979; Wilk, 1985-1986; and Zola, 1972). This paper explores some of the diverse cultural and subcultural beliefs about health, disease, and treatment and the effect of specific factors such as time of immigration, age and social-economic status on individual differences within cultures and subcultures. Specific skills and activities needed by social workers in health care who work with culturally diverse clients are identified. Barker (1991) identifies social work's belief in cultural diversity as "the recognition of sociocultural differences and respect for an assortment of beliefs and values." Recently Lum (1991) notes the concern that the social work community has not directed sufficient attention to the study of cultural diversity. A social work focus on differing health beliefs of clients serves to promote the traditional social work value of client self determination (Biestek, 1957). That the NASW Code of Ethics urges social workers to strive to "ensure that all people have access to the resources (and) services. . . they require" (NASW, 198411990) means that social workers have a responsibility to make health care services more available and relevant to ethnic minorities. Greater understanding and respect for clients' health beliefs can lead to improved treatment outcomes and help to modify the sobering fact that ethnic minorities in the United States are more prone to serious illness and early death than those of European extraction.
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ETHNIC BELIEFS AND THE SCIENTIFIC MEDICAL MODEL In modem Western societies, most people attribute illness to physical causes such as bacteria, pollutants, degenerative processes,
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heredity, poor nutrition, chemical imbalance, lack of exercise, and other factors. As a result, many Westerners are receptive to diagnoses and treatment that match their expectations. Many Americans, for example, are familiar with and accept treatments with antibiotics, vitamins, hormones, multiple medications, as well as surgical interventions, radiation and chemotherapies. The majority of these Americans do not accept acupuncture, herbal therapy, and spiritualistic rituals as legitimate treatments (Chrisman & Kleinman, 1983; Hepworth and Larsen, 1986). The scientific medical model may be inadequate for understanding the perception of illness and the help-seeking behaviors of ethnic minorities in our society @enis, 1979.) Different ethnic groups, as well as subcultures within these groups, vary in their beliefs about health, sickness, and treatment (Devore & Schlesinger, 1991; McGoldrick, Peace, and Giordano, 1982; Watkii and Johnson, 1979.) Physical and mental health problems can not be correctly diagnosed or treated without understanding of these differences. Cultuml Health Beliefi of Blacks
People who describe themselves as black come from varied backgrounds which affect their health beliefs and practkes differently. Many blacks born in this country emigrated to northern cities from rural areas in the south after World War II, while much earlier other black people had been brought north as slaves or indentured servants. Some of their health beliefs originated in Africa and took root in ante-bellum plantation life. Illness was classified into three main types, natural, occult and spiritual (Grossman, 1979). The type of disease dictated the type of treatment pursued. Natural illness was often treated by herbal medicines, while occult curing involved witchcraft or rootwork. Spiritual illness was often treated through prayer and laying on hands to exorcise sin and make the person well. In reality these three disease categories are often merged and the sick individual may seek treatment from a variety of healers within the black community (Grossman, 1979). It is important to recognize that the reliance on informal folk healers by an American black population has roots in the fact that their access to more formalized American health care
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was denied first by slavery and then by segregation. Second and third generation blacks raised in northern urban areas since the civil rights legislation of the sixties may be less influenced by these traditional southern black beliefs. Many blacks in this country emigrated from parts of Africa, Great Britain, and Caribbean Islands such as Jamaica and Haiti. Because they arrived in the United States recently and may have had limited access to the formal health care system, if they are undocumented, Caribbean blacks may be especially influenced by the health beliefs and practices of their native countries. The beliefs of some Haitians about the causes of illness, treatment and prevention differ markedly from American health care practices. Diseases are often attributed to supernatural causes (Wilk, 1985-1986). A young Haitian mother whose one year old daughter was recently hospitalized for pneumonia told the hospital social worker that someone had "done something bad for my baby." She had taken her baby to a voodoo doctor for treatment before she came to the hospital, but had not brought her baby to the Well Baby Clinic because her child was not ill and she had not understood the value of regular post natal care.
'
When Haitians' health beliefs about the supernatural causes of illness, voodoo treatment and need for medical care, when symptomatic, clash with American health beliefs and practices, social workers may find themselves in a dilemma. On the one hand, they are trained to understand and accept differing health beliefs. On the other hand, they may be legitimately concerned about the possible long term negative effects on children who do not receive primary or secondary preventive health care.
Cultural Health Belkfi of Hkpanics Traditionally, many Hispanics classify illness as either natural or unnatural. Natural illness is thought to be caused by God's will or fate, while unnatural illnesses originate from evil done by another (Grossman, 1979). Since causation is perceived as originating outside the person, the notion of prevention of illness through diet,
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exercise or regular examination may be foreign to the Hispanic client. In contrast to a medical model which promotes specialization in health care, many Hispanics have a holistic approach in which the mind and body are seen as one. Hispanic clients are likely to express emotiond reactions in somatic terms. The idea of mental health treatment may be foreign and many clients approach mental health clinics with physical complaints such as "dolor de cabeza," literally, "a pain in the head" (Congress, 1990). Consistent with this holistic view, many Hispanics think illness may signify that those who are sick are not in balance with their environment. Illnesses, medications and foods are placed along a hotlcold continuum. A hot disease needs to be treated with cold remedies and a cold disease with hot foods. The sick Puerto Rican may seek herbal treatment before or concurrently with attending a health care facility (Delgado, 1979). Herbs are distributed at botanicas and are believed to have positive effects in treating both natural and unnatural illness. A belief in spiritualism is often evident among Puerto Rican clients. The spiritualist (folk-healer) tries to help the Hispanic client cope with medical and social problems by negotiating with the spiritual world. Many Puerto Ricans are reluctant to discuss their experiences with spiritualists because they accurately perceive that these beliefs may be accepted by health care professionals. However, the value of accepting folk healers as part of the treatment process with Hispanic clients has been noted (Delgado, 1979-1980; Berthold, 1989). Since the health beliefs of some Hispanics seem so different from generally accepted medical beliefs, Hispanics may be misdiagnosed and incorrectly treated in our systems of care. A 28 ye& old Puerto Rican woman was referred to a social worker by her physician whom she had consulted because of physical symptoms including fatigue, headaches and insomnia. She told the doctor that she felt her boy friend's former girl friend had put a spell on her. First she had visited a botanica and taken special herbs in tea, but noticed no relief of symptoms. She then went to a spiritualist who put her in a trance during which she lost all awareness of who or where she was.
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Her symptoms seemed to disappear for a while, but. then had begun to reoccur. The physician's initial diagnosis was rule out Paranoid Schizophrenia.
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This illustrates how a health care professional not versed in Hispanic health beliefs can diagnose a client incorrectly and possibly begin treatment which is not indicated.
Cultuml HeaUh Beliefs of Asians There is considerable diversity in the health beliefs of Chinese, Japanese, Philippinos, Koreans and Indochinese. Many Asians depend on home remedies for illness and subscribe to a Yin-Yang classification of foods (Grossman, 1979). Those Asians who have remained within their own communities and do not speak English are more likely to retain their native health beliefs. Both physical and mental illnesses are often described in physical terms. The word depression does not exist in Chinese medical dictionaries. Mental illness is stigmatized in their culture so that depression is expressed somatically. When Chinese are depressed or under stress, they describe symptoms such as dizziness, headaches, lethargy, appetite and sleep disturbances (Kleinman, 1980; Tseng & McDermott, 1981). The majority of patients with psychological manifestations of depression are diagnosed in the Chinese culture as neurasthenic (Mechanic, 1980; Chrisman and Kleinman, 1983; Tseng and McDermott, 1981). This is how a Chinese family interpreted and dealt with a mother's mental illness: '
Mrs. A., a 55 year old Chinese woman, was brought to a community mental health center by her two adolescent daughters. This family had lived in the United States for about six years. Mrs. A. seemed to be almost catatonic and appeared to suffer from a severe depressive disorder. She spoke no English, but her daughters recounted that since the death of her husband and their father five years ago, Mrs. A. had experienced symptoms of headaches, insomnia and lethargy. She would sit in her room for hours without activity. The daughters interpreted these symptoms as related to physical changes
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which occur during middle age. It was only when the older daughter took a college course in human behavior and read about depression that she decided that her mother needed mental health treatment. This case illustrates how psychiatric symptoms can be interpreted as physical ones. Only with the daughter's exposure to Western concepts of mental health did she seek treatment for her mother. Since many Asians are not aware of or readily engaged in mental health treatment, it is especially important that staff be knowledgeable about and sensitive to cultural differences in servicing this population (Ho, 1987; Lorenzo and Adler, 1984).
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CULTUWSUBCULTURAL GROUPS There are also individual variations in beliefs within diverse ethnic groups (Harwood, 1981) which can be attributed to duration of stay in the United States, age and socioewnomic status. During the last decade, between seven and nine million new immigrants have entered this country, the largest increase since the 1920's (U.S.Bureau of Census, 1990). Recent immigrants are more likely to have health beliefs and practices reflective of their cultural background than those who have lived in the United States for many generations. The cultural beliefs of Asian and Hispanic immigrants influence greatly how both subjective (perceived) and objective (actual) health status is reported to health professionals (Angel & Thoits, 1987). Newcomers tend to have beliefs directly related to their homeland medical traditions, while those who have lived in the United States for some time begin to believe more in the scientific medical model of this country (Angel & Cleary, 1984; Angel & Thoits, 1987; Keefe, 1980). Although some assimilation of health beliefs does occur, it is erroneous to apply a melting pot theory to culturally diverse clients when providing health care. It is important for social workers to recognize, accept and support cultural diversity (Handelman,
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1983). Even those who have lived in the United States for generations still have ties to both the prevailing and to their own specific cultures (DeAnda, 1984). The social worker can not assume that those who have lived in the United States for many years completely adopt the beliefs of the larger community. Although sensitivity to cultural factors are more significant in work with the newly arrived immigrant (Longres, 1991), it is important to understand how cultural differences affect the use of health care services for several generations. Because of the high incidence of acute and chronic illness in older pwple, the elderly need health care services frequently. It is usually assumed that the elderly are more likely to retain their culturally influenced health beliefs and practices than younger people who tend to become acculturated to American practices through their exposure to educational, work and other societal systems. Yet the elderly ethnic population can not be regarded as homogeneous. Some ethnic elderly were born in this country, some came here as children or young adults and some immigrated as older people (Gelfand & Yee, 1991). Since being a new immigrant is positively correlated with diverse cultural beliefs about health, illness and treatment, it follows that the older, recently arrived immigrants will be much more likely to adhere to the health beliefs and practices of their original culture than those who have lived in this country all their lives. Elderly individuals of ethnic minorities tend to utilize family support systems more than formal ones (Brody, 1985; Harel, 1986; and Stone, Cafferty, and Sangel, 1987). The elderly may be distrustful of formal health services and this contributes to their continued reliance on previously acquired cultural beliefs on health and treatment. Yet there is some evidence that family social supports may not continue to be as readily available to the ethnic elderly as before (Cantor, 1979 and Rosenthal, 1986). As the ethnic elderly then begin to turn to formal health care and support systems, it is important for social workers to explore and understand their cultural health beliefs and practices. Socioeconomic status is a significarit factor in diverse cultural beliefs on health and treatment. The economically deprived are more likely to retain the beliefs and values of their country of
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origin than their middle class counterparts from the same culture (Chrisman & Kleinman, 1983). A study of Mexican immigrants demonstrated that the poorest, especially the most recent undocumented immigrants retained more of their ethnic health beliefs (Angel & Cleary, 1984). A contributing factor, however, may be their difficulty in obtaining access to health services because of their undocumented status and low incomes. It has been suggested that socioeconomic differences and resultant status differences have greater influence on ethnic minority experiences with social service systems including the health care system than differing health beliefs, especially for those who have been in this country for many years (Longres,l991). This makes it important for the social worker to understand the effect of socioeconomic factors on clients' health beliefs and their ability to use health care services. The poor, and especially the ethnic poor, are particularly vulnerable to paternalistic interventions. Social workers must understand and support the health beliefs of their poorest clients and know that they have liinited choices even as they are helped to maximize their ability to make choices.
Bioethics and Autonomy The highly sophisticated increased technologies in medical care over the past decade has raised bioethical concerns (Reamer, 1985) about conflicts between patients and their physicians, particularly around issues of client autonomy, self determination, limitations of practitioners, threats posed by professional paternalism and the impact of organizational interests (Callopy, Dubler & Zuckerman, 1990). This has heightened sensitivity to those situations in the delivery of health care services which may threaten client autonomy and self determination. Culturally diverse clients are particularly vulnerable in this respect and their autonomy in making health care decisions are frequently at risk or jeopardized. Many health professions reared in the scientific medical model are critical of ethnic minorities' underutilization of the health care system. Social workers may experience conflict when minority clients and their families are committed to their health beliefs and trust their efficacy. The social worker may think that these clients make
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poor choices and this way of exercising their autonomy may be damaging to them. They may feel conflict in being advocates for good quality client care and at the same time negotiators for client autonomy. Although these may feel. like polarities and may be legitimate professional concerns, good practice requires that competent clients are ultimate decisionmakers and that they are helped to exercise this right (Callopy, Dubler & Zuckerman, 1990). IMPLICATIONS FOR SOCIAL WORK PRACTICE
What, then, can social workers do to improve their services to clients with culturally conditioned reactions to our health care systems?
increase their sensitivity to culturally diverse beliefs A central value of social work is that each person's uniqueness be respected (Lowy, 1985). It follows that social workers are required to be sensitive to the differing health beliefs of their clients. Social workers in a health care setting can use an ethnic-sensitive inventory to enhance their skills in working with culturally diverse populations and to refine their practice skills with ethnic minorities (Ho, 1991). Social workers need to become aware of how their own biases toward ethnic minorities may subtly and not so subtly affect their ability to be helpful to clients of cultures different from their own.
learn more about clients' beliefs about health, disease and treatment As they help clients, social workers as a matter of course explore with them how they perceive their illnesses and how they have experienced treatment. With minority clients social workers need to take special care to monitor themselves for any possible criticism or judgments about clients' beliefs and behaviors, as they deal with serious illness and receive treatment in our organized health care systems (Cook & Jenkins, 1982; MacLean & Sakadakis, 1989).
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Social workers can supplement what they learn from clients about their health beliefs by developing and participating in cultural education training programs with other health care professionals (Lefley, 1984; Collins, Mathura and Risher, 1984). Employing staff of similar cultural backgrounds can help with this learning as can interpreters.
avoid stereotyping and emphasize individual difjerences in diagnostic assessments It can not be assumed that all people from the same cultural and subcultural group share the same belief system about health and illness, even when they have been in the United States for a similar period of time, are about the same age and of the same socialeconomic status. Clients have multiple, often seemingly conflicting belief systems. Different factors influence their reliance on one system or another at any given time (Ell, Mantell, & Hamovitch, 1988). Individuals may use the organized medical system, as well as their own ethnic treatments and healers, but also may turn to religion, self-help groups, yoga, and chiropractors and to remedies recommended by their mothers and their friends (McGoldrick, Pearce, & Giordano, 1982). The social worker should anticipate considerable diversity in exploring health care beliefs, whether clients are poor recent immigrants or well educated middle class long-time Americans and learn how their beliefs affect their ability to use health care services.
increase the ability of culturally diverse clients to make choices All clients have the right to pursue health care of their choice. Many culturally diverse clients can not even consider alternatives because of fmancial constraints. Social workers have an important role in advocating for equity within the health care system so that culturally diverse clients, especially those who are poor, can make valid choices among health care models.
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enlarge other health care professionals' understanding of cultural diperences in the health beliefs of clients Social work practice aims to establish linkages between individuals and their environments which allow for multiple comections between them (Gordon, 1969). Health care social workers can facilitate these linkages between scientific medicine and clients' ethnic health beliefs about illness and treatment. Interdisciplinary exchanges with other health care practitioners provide social workers the opportunity to broaden the understanding of other disciplines about culturally diverse clients whose health beliefs seem to be in conflict with scientific medical practice. The important role of the social worker in interdisciplinary ethics conferences has been acknowledged (Joseph and Conrad, 1989). Social workers can use their skills to humanize and demystify advanced medical technology for their clients (Abramson, 1990). As social workers enlarge the knowledge of other members of the health care team about the various beliefs of their clients, they can encourage the development of modified andlor alternative courses of treatment which incorporate the health beliefs of many ethnic minority clients.
advocate for understanding and acceptance of differing health beliefs in the health care facility and in the larger community An important role for social workers in health care settings is that of culture mediator (Fandetti and Goldner, 1988). Social workers can function as client advocates on both micro and macro levels. Because of their professional knowledge and understanding of clients' culturally conditioned beliefs, social workers in the health care field are positioned. to advocate that cultural beliefs be incorporated and used in treatment plans. This role is congruent with social work's commitment to client self determination and autonomy. They can also advocate on macro levels for needed modifications withimhealth care treatment teams, the development of more sensitive hospital and clinic policies and in the larger political and policy making systems. These activities will help social workers fulfill their responsibili-
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ty to provide and improve health care services for their clients. Increased understanding of diverse cultural health beliefs has the additional benefit of helping clients of different backgrounds develop more trust in health professionals and thus make better use of their services. The promotion of ethnic sensitive health care is significant in realizing social work's goal of improving the health care their ethnic minority clients receive. NOTE 1. The term minority is used to refer to individuals from ethnic backgrounds, such as African Americans, Hispanics, Native Americans, and Asian Americans. In prior years white ethnic immigrants of European origin were defmed as minorities (Markides, 1987).
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