Cultural Awareness in Healthcare: A Checklist

Culture is a complex concept. It includes people’s beliefs, values, behaviors, and ways of understanding their world. In medicine, managing cultural differences—including customs—is essential to providing high-quality health care.

Managing cultural differences in healthcare

One challenge is that patients may not realize they have customs that could jeopardize their wellness. Culture is largely invisible to people who share it. But to outsiders, the customs and ways of life of different cultures are often obvious—and sometimes strange. Here's an example from my own experience:

I’m in Japan for a conference and I arrive at the house of my hosts. I knock on the door and they open it, greet me with short bows and smiles, and invite me in to the entry area. We stand and exchange pleasantries for quite a while. Eventually, it seems to me we should be making our way into the living room, but for some reason we aren’t. I notice people glance at my feet occasionally and look uncomfortable. It finally dawns on me that I have my shoes on and everyone else is wearing indoor slippers. How strange to them that I would walk off the street into a house without removing my dirty-soled shoes.

What is cultural awareness?

Cultural awareness is the ability to perceive our own cultural beliefs, values, and customs, and to understand how they shape our decisions and behavior. Cultural awareness requires us to step back and look at ourselves as if through a stranger’s eyes, and to open our minds to different ways of doing things. Margaret Mead described it best when she explained the core value of anthropology: “to make the familiar strange, and the strange familiar.”

Cultural awareness—on the part of both practitioner and patient—is key to identifying cultural barriers to medical care.

The impact of customs on healthcare

Culture influences patients' responses to illness and treatment. In our multicultural society, different customs can lead to confusion and misunderstanding, which erode trust and patient adherence. Here are three examples from my career that show how deeply culture impacts medical care:

1. I once had a patient from Morocco who had to be hospitalized for pneumonia. When I arrived at the unit, several nurses, nursing assistants, and the ward clerk were engaged in a loud argument with a group of Moroccan friends and family members. The staff were trying to escort the visitors out of the patient’s room. Back in Morocco, they wouldn’t consider leaving a sick relative alone in a hospital room. The notion of ‘visiting hours,’ which is so normal for us, was completely foreign to them.
   
   
2. When I practiced in New York, Orthodox and Hasidic Jewish traditions helped shape our policies and procedures. The hospital had a Sabbath elevator (so no one had to do the work of running the elevator on the Holy Day), and healthcare professionals and patients were not supposed to make physical contact across gender lines. We also observed plenty of dietary customs from various cultures: Kosher, Halal, and vegetarian menus, seaweed soup being served to Korean women after giving birth, and attention paid to the hot and cold properties assigned to various foods in traditional Chinese healthcare.
   
   
3.  One of my most memorable patients was Grace, an African-American Jehovah’s Witness. Grace was in her late 70’s and very sick. One of her heart valves wasn’t working and she needed major cardiac surgery to replace it. Grace also had a bleeding tendency and would require blood transfusions during the operation. Jehovah’s Witnesses usually decline transfusion of whole blood or blood components. This choice is not due to perceived risk but is based on interpretation of biblical texts. Grace refused to have the surgery. After a lot of introspection and discussion with her family and religious community, it became clear this really was her fully informed wish, so the medical team respected her decision.     

Cultural Awareness Checklist

Communication and ongoing education are essential to promoting cultural awareness and providing culturally sensitive care. As you work to develop cultural awareness for yourself and your patients, use this checklist to make sure you’re able to understand and negotiate any cultural differences that may directly impact care.

1. Establish clear communication
   
Make sure you know your patient’s preferred method of communicating and arrange professional interpretation if necessary.
2. Be aware of non-verbal cues without jumping to conclusions
   
Non-verbal communication conveys a lot of critical information—but it may differ dramatically across cultures. Don’t make any assumptions without knowing the person's customs.
3. Ask openly about potentially relevant traditions and customs
   
This includes exploring potential spiritual/religious practices, dietary considerations, and cultural norms that may be particularly important to the patient’s clinical situation.
4. Use normalizing statements
   A respectful way to ask about sensitive issues like cultural or religious customs is to first explain that they are very common. (e.g. “A lot of my patients have customs or practices that are important for me to know about so I can make sure to give you the best possible care.”)
5. Examine your own biases

   We all have unconscious biases and prejudices that impact our relationships with patients. Identifying and understanding these biases helps to control them, and is essential to achieving cultural awareness.