The UN's World Day for Cultural Diversity promotes the crucial role of culture in bridging the gap to achieve the sustainable development goals. The World Health Organization advocates for 'adaptive, equitable, sustainable health care for all'.
Culture is a critical variable because it influences individuals' and communities' health status and health-seeking behavior. Here are the top 4 considerations to cultivate cultural intelligence beyond the boardroom to ensure health care better meets patient's needs around the globe.
1. Dig deep to uncover unstated assumptions
We are all cultural beings with value systems, institutions included. Culture is about more than what meets the eye; it includes learned values, beliefs, and attitudes, which shape behaviors. Social groups have distinct but non-monolithic cultures which change over time, as do institutions. For instance, nutritionism contains more than just biological views of diet:
“As an ideology, nutritionism is a cultural phenomenon...that has transformed not only the way we experience food, but also the kind of research that is valued, funded and referred to in policy decision-making. Nutritionism’s implicit emphasis on biological functionalism also reinforces social values related to personal responsibility and the perfectibility of the body, rather than the myriad ways in which food acts as a medium for caring, social connectivity and memory. In doing so, it replaces a culture of sharing with one of individual action.” (WHO 2017)
By acknowledging cultural diversity, you will reveal the internal logics driving processes, politics and people. The following tips will help you uncover these unstated assumptions:
• Question your own organization's assumptions, beliefs and value systems. It may take an outsider's perspective to see the implicit bias that pervades the fabric of a health care system designed with the status quo in mind.
• Imagine how might treatment regimens, clinical encounters, and service provision change if the rationale behind them was understood and designed differently to account for cultural differences
Take a look at what happens in an instance where culture is not taken into consideration:
"A diabetes education session that told patients they are conditioned to turn to foods in times of emotional need fell flat with Russian Jewish emigres because food for them was a scarcity and a vital need for survival and functioning; emotional fulfillment in day-to-day eating wasn't a thing but was only sentimental for ethnic foods with national pride/celebration/tradition.
The American emphasis on conscious control fell flat in the face of structural constraints and bigger problems of sadness for homeland and worries of children. Health care workers and educators labelled emigres as depressed, which psychologized and individualized the contradictions embedded in American health care and life in the US as new immigrants." (Borovoy and Hine, 2008).
2. Acknowledge diverse cultural perspectives to improve communication and health outcomes
Illness is seldom confined to a compartmentalized physical body; rather, illness is tied to broader notions of morality, identity, and the social order. Cultural values thus influence the awareness and interpretation of symptoms, manifestation and root cause of the condition, the diagnosis, treatment decision-making and compliance. For instance, somatization, or psychological symptoms manifesting as physical aches and complaints, may cause conditions to be missed in the check-up and diagnosis phase.
“Viewing care in purely clinical terms leaves health systems ill-equipped to understand the psychological, social and cultural drivers of illness and health.”
“A middle-aged Vietnamese woman attributed her chronic pain, fatigue, and depression to her husband's infidelity, to her position within her household, to her inability to express her anger and resentment, to her imprisonment under the communists, and to her concern for the relatives she left behind. In giving her account, she moves back and forth among these seemingly disparate elements. Eventually she provides the missing element, which is that her mother-in-law is a member of the household and she is constrained, both by cultural convention and self-interest, from expressing her anger and frustration that she associates with her husband. Her traumatic confinement in Vietnam and the continued persecution of her relatives have become a medium for articulating physical distress, dysphoric emotions (which she consciously recognizes as emotions), and her oppressive life circumstances.” (Kirmayer and Young, 1998).
To increase awareness in the clinical practice, you can follow these three tips:
• Train providers to probe for a patient's explanatory model of their health and illness.
• Compare and communicate differences to the provider's model.
• Reconcile the two to negotiate a treatment approach that will realistically work for both stakeholders. Keep in mind that explanatory models do not account for systemic factors like structural constraints.
“Psychological talk about emotions tends to situate problems entirely within the individual and may distract the patient, his or her family, and the clinician from the social and situational problems and inequities that are signaled by the emotion. Fostering individualism through psychotherapy may put people from such cultures more at odds with their families and local worlds and so undermine both social support and their own sense of self-worth. As a result, solutions that make sense from the perspective of Euro-American psychiatry and health psychology may involve tradeoffs for some ethnocultural groups that negate even the presumptively universal mechanisms of catharsis and healing.” (Kirmayer and Young, 1998).
3. Design for cultural diversity to reduce inequalities
Intentionally design systems and train providers for diversity of the population served to bridge the needs and accessibility gap. Immigrants face health disparities and declining health outcomes after coming to a new country that individuals in their home country do not experience. In studies of hypertension in Black individuals, genetics and socioeconomic status can not explain the worse health status – instead, the stress of perceived racism, a social factor, is at play (Poston et al., 2001).
“When they get here [USA], immigrants are on average healthier than their native-born American counterparts. But the longer they stay, the worse they fare on measures such as heart disease, hypertension, diabetes and mental health. Research has consistently found associations between people’s reports of discrimination and a variety of health problems. In a study of Asian-American immigrants, clinical depression was more likely to be predicted by experiences of discrimination than by standard measures of acculturation.” (Dolezsar et al. 2014)
So, what can you do about it?
• Train practitioners and design informational products to cater to differing perspectives and needs.
• Ensure patients have access to health care practitioners who look like and understand the population they serve.
• Accurately include diverse populations in clinical trial design – not as demographic boxes to check off, which often conflate categories of identity and external factors in analyses, but rather to ensure diverse data is generated and accurately interpreted, for the safer development of solutions.
• Utilize human-centered research and design to:
- ensure culture is at the forefront of a product roadmap and end-to-end strategy or service to meet and exceed patient needs
- ensure systemic racism is not perpetuated / built into new solutions.
"The U.S. health care system uses commercial algorithms to guide health decisions. Obermeyer et al. find evidence of racial bias in one widely used algorithm, such that Black patients assigned the same level of risk by the algorithm are sicker than White patients. The authors estimated that this racial bias reduces the number of Black patients identified for extra care by more than half. Bias occurs because the algorithm uses health costs as a proxy for health needs. Less money is spent on Black patients who have the same level of need, and the algorithm thus falsely concludes that Black patients are healthier than equally sick White patients. Reformulating the algorithm so that it no longer uses costs as a proxy for needs eliminates the racial bias in predicting who needs extra care." (Obermeyer et al. 2019)
When designing trials, go beyond the traditional economic cost-saving view of easing the patient experience to reduce recruitment time or to enhance retention, by instead committing to including diverse patients, which fosters safer, more effective, and more generalizable drug development in the real world. How diverse groups experience conditions differently provides insight into what their primary needs are on not only an emotional level but on a biological level as well, which has implications for the usage of drugs in populations they were not tested in.
For example, in cross-cultural research on kōnenki (menopause) in Japan, diseases thought to universally affect everyone are experienced differently in certain populations:
"Dr. Mori Ichirō has spent the greater part of his career doing research on kōnenki. He thinks that neither its definition nor its symptoms coincide with the current Western concept of menopause. He distributed questionnaires among his patients several times over the past ten years and consistently found that shoulder stiffness, backache, headaches, fatigue, forgetfulness, a “heavy” head, constipation, eye problems, dizziness, and low blood pressure are the most frequently reported symptoms. Dr. Mori notes that perspiration and hoteri (hot flashes) occur to some extent in the two years immediately after the end of menstruation, but he emphasizes that they are apparently less frequent than in the “West” and cause few problems for most Japanese women." (Lock, 1993).
4. Leverage cultural diversity to drive innovation
Accelerate new ways of thinking and innovative solutions by Viewing diversity as an asset. Cultural diversity is important for innovation in two ways:
i) People with varied beliefs, perspectives, and experiences breathe fresh air into strategy and design; and
ii) Diverse beliefs, perspectives, and experiences warrant different products and services to meet different needs.
“Cultural intelligence could be a win/win for our [pharma] industry, our talent pipeline, and our people; creating teams who accurately represent our customers and our patients, who offer new thinking and who don’t bring “one-size-fits-all” cultural attitudes and opinions could be a critical part of the solution as we look to innovate and succeed. A strong correlation between CQ [cultural intelligence] and performance has been demonstrated whereby organizations with inclusive, culturally intelligent environments were six times more likely to be innovative and agile, eight times more likely to achieve better business outcomes and twice as likely to meet or exceed financial targets.” (Sánchez, Mexico Business News).
To achieve this, we recommend to engage with social scientists in more expansive, culturally-situated ways of thinking about illness and health across different populations to uncover unmet needs and spur new products and services.
“The [pharma] industry needs to recognize the crucial importance of establishing a workforce reflective of its customers and the ultimate end users of their products – a diverse population of patients. Patients that come from every culture, race, nation, and socio-economic level worldwide and represent every type of religion, sexual orientation, and political group.” (Sánchez, Mexico Business News).
Cultural intelligence must go beyond the boardroom; it is about much more than how well employees communicate with one another across multinational workplaces. Taking an introspective look at your institution’s core cultural values and reimagining how they can coalesce with the diverse values of all stakeholders is necessary to catalyze a transformation capable of humanizing health care across the globe.