Ricardo C. Carrasco, PhD, OTR/L

The Medical College of Georgia Department of Occupational Therapy School of Allied Health Sciences Augusta, Georgia

Cultural diversity is a recognized phenomenon in the delivery of health care and in the education of health care professionals. This article is dedicated to this recognition and highlights how health professions recognize the importance of and apply cross-cultural studies to practice. Recognition is given to the following: examples of cultural differences, cross-cultural collaboration and recognition in practice, and incidence of crosscultural components in the education of health professionals. Cross-cultural differences are discussed by drawing attention to documented blending of Eastern and Western philosophies in theory application, such as neurodevelopmental treatment and traditional Chinese medicine. Aphasia and other neuropsychological studies are cited to

illustrate the effect of culture on measurable behaviors, as well as to point out the impact of the characteristics of native languages to syntactic or morphological impairments resulting from brain injury. Exam pies of ethnospecific variations in health beliefs and social practices within American culture are cited to remind the reader of cultural diversity within the United States. Cross-cultural collaboration and recognition of cultural diversity is illustrated by citing the educational guidelines of the occupational therapy profession, providing examples of institutional and individual collaborations, and describing how grassroots and scientific information are exchanged. A close look at the cross-cultural components in the education of health professionals reveals what has already been done as well as what needs to be done. Information about cross-cultural components in continuing education courses is also provided.

EXAMPLES OF CROSS-CULTURAL DIFFERENCES IN RESEARCH AND PRACTIC E East Meets West in Clinical Practice The blending of East and West in theory application has been reported in the literature. With the establishment of an open-door policy in China in 1979, communication between China and the West led to the merging of traditional Chinese medicine with the medical practices of the West. In a recent professional on-site visit, Boardman (1991) compared models of practice used in the WORK 1993; 3(1):2-9 Copyright © 1993 by Andover Medical

Health Care Delivery Across Cultures

United States with those used in the People's Republic of China. The comparison showed that there were indeed similarities, especially in the effort to obtain measurable results for patients with neuromotor problems such as stroke or cerebral palsy. However, in China, education in Bobath or neurodevelopmental treatment techniques was limited to those clinicians working at the newest rehabilitation centers. Likewise, traditional medical practices, such as acupuncture, were incorporated with newly acquired treatment techniques. However, Schnell (1987) cautions proponents of the blending of health care practices to be aware of fundamental conflicts between cultures, such as the Chinese taboo against the Western practice of blood transfusion. Cross-cultural blending or conflicts in mental health care delivery cannot be better exemplified than through mental health conceptions in Malaysia. The mixture of people of Malay, Chinese, and Indian origin in the Malaysian population comprise a sociocultural and religious diversity that is only complicated by the superimposition of British culture. Although services for mental health were spurred by the inception of medical psychiatric training in 1966 and counselor education in 1976, the shortage oft rained mental health personnel persisted. At the same time, a sophisticated framework of folk healers for both physical and mental illnesses thrived. What arises, Mohammed (1988) suggests, is a culture-specific application of traditional medicine or folk therapies combined with Western applications of psychotherapy. In Korea, Kang (1990) suggests that the philosophical goal of training and development of psychotherapy is to unify and integrate Western philosophy with the traditional Eastern Tao (Confucianism, Buddhism, and Taoism). The blending results in a sophisticated and culturally relevant form of psychotherapy. Rhee (1990) compared the Tao, psychoanalysis, and existential thought, and concluded that the goals of Tao practice are consistent with those of Western psychoanalysis, humanistic psychology, and trans personal psychotherapy: the goals are the same, but the names are different.


Cross-Cultural Perspectives in Health Sciences and Education Literature Neuropsychology, medical, and education literatures also have addressed cross-cultural differences. Recognizing the importance in psychiatric practice of considering cultural factors, including language, Thompson and Thompson (1990) presented cultural examples to help psychiatrists performing ethnosensitive differential diagnosis and treatment procedures. Sensitivity about differences in family communication patterns also can help the health professional in making decisions about tactfully recommending appropriate support systems and health service referrals. Fitzpatrick and Barry (1990) compared patterns of communication and use of professional support systems among Irish and American families who had sons with Duchenne muscular dystrophy; their findings showed that significantly less communication with the children and fewer contacts with professionals occurred among Irish families. To investigate whether cultural differences affect children's performance on subtests of an American neuropsychological test, Saeki, Clark, and Azen (1985) compared the performance of Japanese-born and Japanese-American children. The Japanese-American subjects performed better on design copying and motor accuracy subtests of the Southern California Sensory Integration Tests compared with the American normative sample; Japanese-born children performed the best. Cross-linguistic aphasia studies show that certain characteristics of an individual's native language may be important in understanding syntactic and/or morphological impairment. When subjected to stress-related limitations such as noise, normal speakers of morphologically rich, semantic information-processing systems, such as German, tended to compensate by relying on word orders - a strategy not used in a morphologically impoverished system such as English (Kilborn, 1991). A cross-linguistic study of people with Broca's and Wernicke's aphasias showed that in Chinese aphasia, morphological deficits and action naming could not be related. Bates et al. (1991) suggested that this is probably true because



in the Chinese language, there are no verb conjugations and no declensions. Furthermore, another cross-linguistic study suggested that the Chinese language is exceptional in that articles, numerals, and other modifiers cannot directly precede their associated names, but instead are followed by an intervening phoneme called a classifier. Based on the results of the study, Tzeng, Chen, and Hung (1991) suggested that Chinese people with aphasia experience difficulties in the production of nominal classifiers. Similar cross-linguistic comparisons have been conducted among Turkish and Italian subjects, thus contributing to the growing literature on cross-linguistic differences among the aphasic population (Slobin, 1991; Wulfeck, Bates, and Capasso, 1991).

Meeting Cross-Cultural Needs in the American Clinic Similar to the Malaysia mental health study (Mohammed, 1988) cited earlier, educators and health care providers face the challenge of meeting the needs of various cultures and subcultures in the United States. Understanding traditional health beliefs, such as folk-healing among MexicanAmerican families, can pave the way to identifying culture-sensitive approaches to education and heal th care deli very (Krajewski -J aime, 1991). Sometimes, the variable for the helping professional is not as much the cultural blueprint, but also the process and the length of time involved in acculturation. Rosenthal and Feldman (1990), for example, reported a family-functioning difference between families of first- and second-generation Chinese immigrants and their host culture counterparts of Anglo-Australian and Euro-American families in Australia and the United States. Parent-imposed structure and control over the children's participation in social acitivities was a predominant feature among the immigrant groups, particularly with first-generation immigrant families. Failure to recognize these culturally sensitive family dynamics may result in failure to elicit cooperation in therapeutic activities. Awareness of premorbid cultural orientation and level of acculturation, especially in cases of traumatic brain in-

jury, can influence rehabilitation approaches and treatment outcome (Vilaubi, 1990). Culture-sensitive treatment planning is crucial in providing health services to ethnic minorities, culturally different, or regionally isolated health care consumers. McCormack (1987) provided information on characteristics, health beliefs, and practices of Hispanic, Indochinese, and Asian (J apanese, Chinese, and Filipino) peoples, as well as strategies for intercultural communication during service provision. To call attention to the needs of a geographically distinct culture, Blakeney (1987) highlighted paradoxical behaviors toward work among Appalachian inhabitants; while work is highly valued within the culture, a person may fail to identify all work-related skills during an interview because of personal modesty. Failure to probe beyond the cultural constraints can result in less-than-optimal service provision.

RECOGNITION AND COLLABORATIONS OFINTERCULTURALSCOPE Recognition of Cross-Cultural Diversity by Occupational Therapy: A Case in Point The occupational therapy profession implicitly recognizes cross-cultural diversity in various ways. For example, recognition is expressed through educational guidelines, called Essentials, which prescribe minimum standards by which educational programs for occupational therapists and occupational therapy assistants are accredited and held accountable (American Occupational Therapy Association, 1991a, 1991b). In both program levels, required course content includes the study of human behavior from an ecological perspective, that is, viewed with an understanding of the effects of sociocultural and environmental factors on human occupation. Policies of the American Occupational Therapy Association (AOTA) ensure that issues of cross-cultural diversity and equal rights are included in all appropriate AOTA documents and publications (American Occupational Therapy Association, 1991c). Through its Minority Affairs

Health Care Delivery Across Cultures

Division, the AOTA also recognizes cultural diversity. This division manages cross-cultural issues such as recruitment and retention of minority American manpower and is also continually alert to international issues. Collaboration with and representation at the World Federation of Occupational Therapists, as well as the coordination of international affairs through the AOTA International Steering Committee, provide mechanisms for cross-cultural association activities.

Institutional and Individual Collaborations of International Scope Collaboration between health care professionals has crossed cultural and geographic boundaries through institutional and individual accomplishments. For example, the Exceptional Family Member Program (EFMP), administered through the Office of the Army Surgeon General in Washington, D.C., is implemented in overseas American military bases in the Atlantic and Pacific regions. Through interdisciplinary teams, EFMP delivers health care services to military families with handicapped family members and to paying residents of its host country at the United States Department of Defense Dependents Schools or at military medical centers in the area. The program also provides continuing education not only to EFMP health care and education providers, but also, in many cases, to host country professionals through periodic interdisciplinary conferences and selected continuing education seminars and workshops. An interdisciplinary - and, in many cases, a cross-cultural- roster of faculty is selected to present practice-related topics requested by EFMP staff. An overseas program of health care is not new to the United States military. In tracing the history of work in physical dysfunction, Hanson and Walker (1992) reviewed the experiences ofC, D. Myers, an occupational therapist in Europe during World War 1. Myers (1948) emphasized the importance of work produced by occupational therapy clients. While the soldiers might have produced furniture, souvenirs, and decorative items


to sell for the incentive of money, or simply for recognition, the therapeutic intervention can be viewed also as a prescription to provide meaningful activities that helped convert the barren barracks into livable quarters. The therapist unwittingly, through the use of purposeful activity, facilitated the adjustment offellow Americans who were in unfamiliar and possibly hostile cultural surroundings in the middle of a foreign war. Another institution involved in cross-cultural collaboration is the United Nations Development Program (UNDP). Through its Transfer of Knowledge and Technology by Expatriate Nationals program (TOKTEN), the UNDP facilitates international exchange by providing funds for teaching, research, and/or clinically relevant projects. The expatriate national spends a minimum of four weeks in his or her country of birth or national origin to teach, initiate research or action projects, and/or provide direct health care services. The project is multidisciplinary and certainly multicultural. A current cross-cultural interdisciplinary project that evolved out of a UNDP-TOKTEN grant is being implemented at the Philippine General Hospital Pediatric Neurology Section (Ilagan, S., and Villegas, S., unpublished communication). Through the guidance of a UNDP-TOKTEN consultant, faculty of the University of the Philippines College of Allied Medical Professions and the chief pediatric neurologist at Philippine General Hospital designed a double-blind research study to investigate the concurrent validity of a test instrument and measure the efficacy of a treatment protocol. The project will use two research instruments: a Philippine-designed at-risk infant scale and an American test, the Movement Assessment of Infants. Drawing on the neurodevelopmental approach, the treatment efficacy study will measure clinical change at the end of a period of treatment. The project uses cross-cultural technology, is being implemented by a cross-cultural team, and will be beneficial for cross-cultural validation of intervention models of health care delivery. Two nonprofit teaching and research institu-



tions that have actively spearheaded cross-cultural collaborations include Sensory Integration International (SII) and the Foundation of Knowledge in Development (KID Foundation). SIl has maintained its leadership in promoting sensory integration theory and practice. Administered at its headquarters in Southern California, SII urges practitioners to adhere to classic conceptual foundations, proposed by A.JeanAyres, Ph.D., when studying the theory, utilizing the assessment technology, and applying the treatment approach to appropriate populations. SII strongly encourages American and intercultural researchers to adhere to rigorous research designs, use psychometrically acceptable evaluation tools, and measure and document clinical change. Through its faculty, the organization has provided courses both in the United States and overseas. Currently, interest in and practice of sensory integration continues to grow throughout Europe, the Middle East, South America, and the Pacific. Based in the outskirts of Denver , Colorado, the KID Foundation, under the leadership of Lucy Jane Miller, Ph.D., has developed assessment tools for the infant, toddler, and preschooler client. Recognizing the need for translating one of these instruments for use in another culture, the KID Foundation collaborated with Japanese scholars in the standardization of the Miller Assessment for Preschoolers (MAP), called the JMAP in Japan. While the MAP is used widely in the United States, it is also widely accepted in other parts of the world, such as England, Germany, the Netherlands, Israel, Japan, Taiwan, and the Philippines. In an attempt to communicate the need to introduce the importance of cultural diversity to the individual who delivers the health care service, Merrill (1992) edited a monograph that highlights the experiences of occupational therapists who have worked in cultural environments different from those in which they were educated or have worked. The monograph describes cross-cultural practice in countries such as Ecuador, Finland, Zanzibar, and Cambodia. Through their personal experiences, the contributing authors share the challenges that they experienced in reassessing basic personal and professional assumptions when

faced with the challenges of applying theories that may not necessarily translate within their crosscultural practice surround.

Cross-Cultural Exchange of Grassroots and Scientific Information Invitational or juried conferences or publications of national or international scope facilitate the exchange of technical and applied information as well as more investigative, empirical studies of health services. The NDTA Newsletter, the official publication of the Neurodevelopmental Treatment Association in the United States, publishes papers of historical or practical use for American and international physical, occupational, and speech therapists. In 1986, for example, Bohman (1986) described the philosophy and traced the evolution of the NDT approach, beginning with its inception by Bobath and Bobath in England in 1943. As cited earlier, Boardman's (1991) impression of the blending of Western and Eastern technologies is consistent with the cross-cultural collaboration in the Chinese rehabilitation arena, especially from a financial standpoint. The China Rehabilitation Center, for example, a 260-bed facility, was constructed with financial assistance from Hong Kong, the former West Germany, J apan, Canada, and the United States. Likewise, staff training used imported experts for on-site education. Other publications of national and international scope include the WFOT Bulletin, the International Section Bulletin of the Council for Exceptional Children, Sensory Integration Quarterly, as well as computer data bases such as PsycLit, ERIC, and Dissertation Abstracts International. One publication devoted to the promotion of mutual understanding, if not a total blending of Eastern and Western practice, is the Joumal of Traditional Chinese Medicine, founded in 1981.

ADDRESSING CROSS-CU LTU RAL COMPONENTS IN THE EDUCATION OF HEALTH PROFESSIONALS Health care delivery across cultures can be interpreted, probably erroneously, as merely a phe-

Health Care Delivery Across Cultures

nomenon that occurs outside the geographical boundaries of the United States. A more intense review will show that cross-cultural diversity is implicit in the United States since all American citizens can claim at least one cultural heritage in addition to their American heritage.

Weaving Cross-Cultural Threads into the Curriculum Differences between health care provider and consumer can arise because of cultural disparity even if the provider has the most sophisticated set of job skills (Saltz, 1990). A successful clinical scenario includes meaningful activities that assess the consumer's social and cultural needs as well as assets and liabilities (Cromwell, 1985). Cross-cultural perspectives in the training of educators and health professionals have become part of some curriculum-related courses or conference themes. For example, Eastern Michigan University includes cultural sensitivity training in its curriculum through simulated activities (Sayles-Falks, 1990). Howard, Tuskegee, and Chicago State universities, on the other hand, serve a higher portion of minority students, thus providing education for the underrepresented segments of the population in the health care profession Ooe, 1990). While recognizing the importance of crosscultural medicine as a natural and important part offamily medicine, Borkan and Neher (1991) bemoaned its exclusion from family practice training programs. They then suggested a developmental model of ethnosensitivity that can be used in designing strategies to improve cross-cultural communication and practice skills. For example, courses in pharmaceutical education were designed to examine health beliefs and practices of Third World and other cultures (Kilwein, 1985; Appelt, 1984). The courses covered information on health-relevant behavior, the role of drugs in folk medicine systems, and an ethnosensitive introduction to modern health programs for nonindustrial societies. The courses were designed to enhance understanding of the influence of culture in a patient's health care decisions.


Recognizing the need to train culturally sensitive professionals and paraprofessionals, the University of Minnesota's Mental Health Technical Assistance Center has designed models of culturally sensitive training programs for personnel who provide mental health services to refugees. Target trainees were social workers, psychiatrists, psychologists, nurses, allied health professionals, and other human service providers (Hoshino and Bamford, 1990). Graduate programs in Spanish and bilingual studies at La Salle University have included intensive training not only in the Spanish and English languages, but also in dealing with facets of Hispanic culture and adjustment problems in the United States. The program provides a five-week immersion seminar in Spanish language and development of cross-cultural skills (Brownstein, 1985).

SUMMARY This article has attempted to reflect on the recognition and application of cross-cultural studies in health care delivery. Using occupational therapy as a case in point, recognition of cross-cultural diversity was illustrated by citing the use of basic guidelines and policies of a professional organization. Careful study and reflection revealed current or past projects cited in the literature that crossed geographical boundaries through grant- or privately-funded teaching, research, and education endeavors. These cross-cultural collaborations have resulted in a much smaller world where the blending of Eastern and Western philosophies was rendered inevitable. This blending has resulted in information sharing, expansion of knowledge, consideration of "other" cultures, and ultimately the personalization of education and health care services. The review of medical, educational, and psychological literatures reminds us that one need not leave the United States to encounter the need for cross-cultural health care practice. Evident in the literature were attempts at developing ethnosensitive programs at institutions of higher education and continuing education courses that foster



cultural sensitivity among educators and health service providers. Ideally, such concerted efforts will result in better understanding of the education

and health service recipient from the context of his or her own culture while functioning adaptively in a multicultural society.

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Health Care Delivery Across Cultures

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