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6. COMMUNITY CULTURAL ASSESSMENT

Guide for Assessment of Cultural Manifestations

A cultural assessment can be directed toward individual clients to assess their cultural needs. On the other hand, with community health nursing, the community is considered the client, and the following schema has been proposed to help nurses assess the community as a whole. A community assessment requires gathering relevant data, interpreting the data base (including problem analysis and prioritization), and identifying and implementing intervention activities for community' health. Although the community nursing assessment focuses on a broader goal; such as improvement of the health status of a group of people, an important factor to remember is that it is the characteristics of people that give every community its uniqueness, and a great deal of variation may occur between individuals within the community'.

An example of a cultural assessment is the Guide for the Assessment of Cultural Manifestations published by Boyle and Andrews (1989). The model takes into account the following dimensions of a community: language, diet and food habits, dress, ethics, social patterns of behavior, religious and other customs, rituals and taboos, use of time and space, nonverbal communication, economic systems, attitudes toward change, health/illness belief systems and practices. Included in social patterns of behavior are such things as male/female roles, family orientations, work orientations, authority' and decision-making rules, and interpersonal relationships.

They note that even though nurses are usually most interested in their patients' beliefs and practices regarding health matters, it is equally important to assess and understand the other components of culture in order to assess the problem accurately in culturally diverse clients. This data can be used as a means of providing nursing care that is culturally relevant and meets the cultural needs of diverse populations.

Cultural Manifestations Assessment
  1. Brief history of the origins of the cultural group, including location.
  2. Value orientations
    1. World view
    2. Code of ethics
    3. Norms and standards of behavior (authority, responsibility, dependability, competition)
    4. Attitudes toward:
      1. Time
      2. Work vs. play/leisure
      3. Money
      4. Education
      5. Physical standards of beauty', strength
      6. Change
  3. Interpersonal relationships
    1. Family
      1. Courtship and marriage patterns
      2. Kinship patterns
      3. Child-rearing patterns
      4. Family function
        1. Organization
        2. Roles and activities (sex roles, division of labor)
        3. Special traditions, customs, ceremonies
        4. Authority' and decision making
      5. Relationship to community
    2. Demeanor
      1. Respect and courtesy
      2. Politeness, kindness
      3. Caring
      4. Assertiveness vs. submissiveness
      5. Independence vs. dependence
    3. Roles and relationships
      1. Number and types
      2. Functions
  4. Communication
    1. Language patterns
      1. Verbal
      2. Nonverbal
      3. Use of time
      4. Use of space
      5. Special usage: titles and epithets, forms of courtesy in speech, formality of greetings, degree of volubility vs. reticence, proper subjects of conversation, impolite speech.
    2. Arts and music
    3. Literature
  5. Religion and magic
    1. Type (modem vs. traditional)
    2. Tenets and practices
    3. Rituals and taboos (e.g., fertility, birth, death)
  6. Social systems
    1. Economics
      1. Occupational status and esteem
      2. Measures of success
      3. Value and use of material goods
    2. Politics
      1. Type of system
      2. Degree of influence in daily lives of populace
      3. Level of individual/group participation
    3. Education
      1. Structure
      2. Subjects
      3. Policies
  7. Diet and food habits
    1. Values (symbolism) and beliefs about foods
    2. Ritual and practices
  8. Health and illness belief systems
    1. Values, attitudes, and beliefs
    2. Use of health facilities (popular vs. folk vs. professional sectors)
    3. Effects of illness on the family
    4. Health/illness behaviors and decisions making
    5. Relationships with health practitioners
    6. Biological variations
Components of the Cultural Assessment

Adding the cultural component to a community nursing assessment strengthens the assessment base. The following is an overview of selected cultural components and questions to assess each area, as proposed by Andrews and Boyle (1995).

  1. Family and kinship systems
    Is the family nuclear, extended, or "blended"?
    Do family members live nearby?
    What are communication patterns among family members?
    What is the role and status of individual family members?
  2. Social life
    What is the daily routine of the group?
    What are the important life-cycle events such as birth, marriage, death, etc.?
    How are the educational systems organized?
    What are the social problems experienced by the group?
    How does the social environment contribute to a sense of belonging?
    What are the group's social interaction patterns?
    What are its commonly prescribed nutritional practices?
  3. Political systems
    Which factors in the political system influence the way die group perceives its status such as the dominant culture, i.e. laws, justice, and "cultural heroes"?
    How does the economic system influence control of resources such as land, water, housing, jobs, and opportunities?
  4. Language and traditions
    Are there differences in dialects or language spoken between health care professionals and the cultural group?
    How do major cultural traditions of history, art, dreams, etc. influence the cultural identity of the group?
    What are the common language patterns in regards to verbal and non-verbal communication?
    How is the use of personal space related to communication?
  5. Worldview, value orientations, and cultural norms
    What are the major cultural values about human nature and man's or woman's relationship to nature and to one another? How can the groups' ethical beliefs be described? What are the norms and standards of behavior such as authority, responsibility, dependability, and competition? What are the cultural attitudes about time, work, and leisure?
  6. Religion
    What are the religious beliefs and practices of the group? How do they relate to health practices? What are the rituals and taboos surrounding major life events such as birth and death?
  7. Health beliefs and practices
    What are the group's values, attitudes, and beliefs regarding health and illness?
    Does the cultural group seek care from indigenous health (or folk) practitioners?
    Who makes decisions about health care?
    Are there biological variations that are important to the health of this group?

RECOMMENDATIONS FOR PROMOTING EFFECTIVE MULTICULTURAL RELATIONS IN COMMUNITY HEALTH CARE CONTEXTS

  1. Be aware that although some of an individual's cultural influences may be readily apparent, others are hidden and may not be immediately recognized in initial interactions.
  2. Be aware that developing effective relationships between culturally unique participants and healthcare professionals in the modem health care system is a prerequisite to effective health care delivery.
  3. Be aware that attempts to force others to give up then-personal culturally approved beliefs and behaviors can lead to anger and resentment, non-compliance, and distrust. This behavior is a common reason for ineffective communication and culturally inappropriate care plans for diverse clients.
  4. Develop and express genuine interest and respect for different cultural orientations.
  5. Explore different cultures to learn about new ways of interpreting reality, increasing your understanding of other people, their experiences, and the world in which they live.
  6. Be aware that there are many different legitimate perspectives and interpretations of reality, as well as many different ways to solve problems.
  7. Be aware that to communicate effectively with those w ho are culturally dissimilar to us, we must be willing to endure the discomfort of unfamiliarity and uncertainty.
  8. Continue to develop communication attitudes and skills that demonstrate an appreciation and sensitivity to cultural diversity that will enable participants in the modem health care system to avoid the many physical and psychological perils associated with culture shock.
  9. Be aware that health care treatment must attend to both me physical and symbolic aspects of illness to be effective. Learn about different culturally based health beliefs, values, and attitudes that influence relevant others' interpretations of health and health care, eliciting information about symbolic interpretations of illness and providing relevant information to both consumers and providers.
  10. Do not limit examination and selection of health care treatments based on ethnocentric preference for traditional health care methods but endeavor to review the wide range of traditional and alternative courses of treatment available.
  11. When living or working in a culturally different environment, the nurse must be willing to undergo culture-specific training designed to increase understanding of that culture's lifeways (especially values and beliefs regarding illness and health care issues) and work towards gaining proficiency in multicultural communication.

COMMUNITY CAPACITY BUILDING MODEL

When attempting to educate, inform, and provide healthcare services in culturally diverse environments, it would be well to consider using a Community Capacity Building Model that recognizes community assets over a social services model that tends to concentrate on deficits. Although tills framework was originally developed to educate social workers, it can help the community healthcare professional as well. Below are the fundamental differences that can lead to empowering individuals to recognize the assets, skills, and resources inherent in their community and to build on them in order to provide effective healthcare services.
SOCIAL SERVICE MODEL COMMUNITY CAPACITY BUILDING MODEL
Deficits Assets
Problems Skills
Pathologies Resources
Problem response Opportunity identification
Charity orientation Investment orientation
Provide services Create community collaborations
High emphasis on agency support High emphasis on indigenous support
Focus on providing services to individuals Focus on providing services to the community

HEALTH PROMOTION ACROSS CULTURES

  1. Building on community assets, engage the community in the process of providing healthcare education to community members.
  2. Work towards helping social support groups cope with life stress by providing relevant information about health care methods and services, problem solving interaction, referral services, and assistance in making health care choices that are culturally sensitive.
  3. Be sure that health promotion efforts begin with a clear understanding of the cultural influences on health beliefs and practices of the target audiences.
  4. Be aware that effective health promotion strategies call for public health messages of prevention and treatment that are congruent with the messages of targeted cultural groups.
  5. Be aware that cultural variables influence responses to health and health care and require the development of culturally sensitive programs to educate relevant populations and influence health behaviors. Important health promotion goals can be achieved only when sensitive and strategic multicultural communication efforts that involve the larger community social systems are in place.