Journal of Cancer Education

ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20

Understanding cultural differences through family assessment Patricia Boston RN, MA To cite this article: Patricia Boston RN, MA (1992) Understanding cultural differences through family assessment, Journal of Cancer Education, 7:3, 261-266 To link to this article: http://dx.doi.org/10.1080/08858199209528177

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J. Cancer Education. Vol. 7, No. 3, pp. 261-266,1992 Printed in the U.S.A. Pcrgamon Press Ltd.

0885-8195/92 $5.00 + .00 © 1992 American Association for Cancer Education

UNDERSTANDING CULTURAL DIFFERENCES THROUGH FAMILY ASSESSMENT

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PATRICIA BOSTON, RN,

MA*

Abstract—While much has been documented with regard to the role of the family in managing the stress of a diagnosis of cancer, there has been a paucity of attention devoted to cultural differences, which are vital factors in the family's unique ability to cope. Health care professionals in large urban settings are often required to assess families that are unfamiliar to them. This paper focuses on the need to educate health care professionals in order that they can more clearly conceptualize the structure, function, and health-related needs of families from differing cultural backgrounds. Nine interviews with Greek, Chinese, and Italian immigrant families were analyzed retrospectively with regard to family perceptions of hospitalization and experiences surrounding coping and problem solving with respect to a diagnosis of cancer. Findings revealed that fear and loneliness were predominant emotions at the onset of hospitalization. Coping strategies and the management of stress frequency differed from the suggestions of health personnel. This paper concludes that the content of health education curricula needs to be broadened to include attention to cultural considerations.

INTRODUCTION Culture influences health beliefs and behaviour. It shapes one's understanding of health and illness and the way this understanding is expressed.1 The experiences of immigrant patients and families facing a crisis of cancer in a western health care system are affected by differences in values, beliefs, and ways of doing things, as well as by language difficulties. These variables are likely to influence levels of satisfaction with care and adherence to treatment.2 The purpose of this paper is to demonstrate that knowledge of the way immigrant patients and their families experience hospitalization following a diagnosis of cancer, and subsequently cope with treatment, is necessary for providing effective care. The problems of many immigrants, facing hospitalization for cancer in a foreign society in which cultural values are antithetical to those of their native country, tend to create *Department of Nursing, Consultant for Family Nursing, Royal Victoria Hospital, Faculty Lecturer, School of Nursing, McGill University, Montreal, Canada. Reprint requests to: Patricia Boston, RN, MA, Department of Nursing, Royal Victoria Hospital, 687 Avenue des Pins Ouest, Montreal, Quebec H3A 1A1, Canada.

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tremendous stress on individuals and their families. Thus health care givers working is hospital and hospice settings need to be keenly aware of the social, cultural, and environmental factors, as well as of the family dynamics that underlie the family's unique coping skills during the illness crisis. Cultural diversity is a common characteristic in many of our encounters with patients and their families. A major challenge is to understand how culture ultimately affects our treatment planning and overall care. Many health care givers lack knowledge of treatment approaches other than those of a western health care system. There is a tendency to see cultural perceptions of medicine—traditional healing methods—as belonging to the "uneducated" or in opposition to the efficiency of modern medicine. There is also the problem of the lack of availability of learning resources about cultural differences for western health care givers. LITERATURE REVIEW Examination of the literature pertaining to culture in the management of cancer indicates that very little attention is given to caring for families from differing cultural backgrounds. The importance of understanding the unique-

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ness of culture relative to illness has been emphasized by Madeleine Leininger, one of the earliest writers in the field of transcultural nursing. She defines culture thus:

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culture is the group's design for living and includes every facet that surrounds the person: the physical and social world, values, attitudes, roles, goals in life, knowledge, beliefs, customs, morals, laws, skills, acquired habits and capabilities that help the group survive and live together.3

Solutions for understanding the culture of immigrant families and its impact on health and illness behaviour have not been studied extensively. There have been studies that identified the relevance of culture in behavioural responses to illness, and Garcia and Lee have made recommendations for services based on those findings.4 There is a paucity of literature on coping and decision making among immigrant families. The studies, which exist with regard to immigrants and the health care system, have primarily focused upon utilisation of health services and reporting of symptoms.5 Interpretation of illness varies in meaning in different cultures. It is influenced by the patient's family's previous social environment as well as his daily physical experience.1 It has been observed that Italian patients were reluctant to enter a hospital out of "a deepseated fear of doctors and a belief that a hospital is a place to die."6 Discussing western treatment modalities for Chinese families, M. Jung wrote "the degree to which any minority group has been acculturated into American society can never be answered accurately or satisfactorily because the variables by which acculturation is assessed are so complex." He observes also that "individual growth and development are not within the accepted norm of the traditional Chinese culture, for the individual is always responsible to the family whether in the past, present, or future."7

Lee observed that working with Chinese families requires taking a holistic view of health and an interactive and contextual perspective on behaviour. The separation of social, psychological, physical, and cultural phenomena has limited meaning for the Chinese.8

Family case studies In order to determine appropriate and effective family interventions, clinical assessment routinely involves the necessity of understanding the family's perception of the patient's hospitalization and their overall ability to cope with a diagnosis of cancer. The following family cases are drawn from the clinical experiences of the author. All of the families were interviewed during a stressful period when a family member had been admitted to hospital with a diagnosis of cancer. All of the families were from immigrant parents. The fathers' ages ranged from 32-85. The language spoken at home was the family's mother tongue. Nine families were interviewed: three Italian families, three Greek families, and three Chinese families. METHODS The content of nine open-ended exploratory interviews which had been process-recorded was analyzed retrospectively. The interviews had been conducted during the course of the author's clinical work over a 2year period. Themes and concepts were identified from each interview and compared with themes and concepts from the literature. In reviewing the clinical content of the cases the following questions were addressed: 1. How do family members perceive the hospital situation? 2. What is the interactive experience surrounding coping and problem solving? RESULTS The conceptual categories presented here are family perceptions of the hospital crisis and family responses surrounding coping strategies. Family perceptions of hospitalization Italian families. Many Italian family members perceived the hospital as a "place to die." Some expressed feelings of helplessness with the hospitalization of their ill member. In

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cases where a relative had undergone surgery, return for a visit, despite instructions from his there was a prevailing fear that the patient family to do so. would not survive, despite a hopeful prognoFrom these observations of three Italian sis. One elderly mother had spent the night in families it seemed that, in general, they had a hospital waiting room "praying for a mira- difficulty perceiving the hospital as a place to cle" even though a positive operable outcome help and care for their ill relatives. There aphad been predicted. peared to be a deep rooted fear of doctors and In another family a large number of rela- much rationale of illness appeared rooted in tives kept vigil at the patient's bedside even fatalism and magic, especially in older family though a discharge was imminent for the pa- members. tient. They saw it as their duty to remain close Greek families. Among the Greek families to the bedside, even though a positive progno- interviewed, some family members perceived sis had been given. None of the families inter- the illness of cancer as a "punishment." Even viewed perceived the need for an assessment a strong religious belief did not appear to alby health personnel of their own ability to leviate fear that the sick relative would be cope. harmed. One mother stated "I believe in God, There was an inherent expectation that im- my son's life is in his hands, I am afraid he mediate treatment and relief could be gained will be punished, I hope not, he is a good by bargaining at the family interview. There son." There was the inherent belief that the was an expressed fear of doctors, and, in one patient was ill as a result of punishment or case, a father felt that bargaining with health some form of external malice. Generally, personnel would obtain different results. these families expressed loneliness and helpForming a relationship with these interviews lessness in the face of the hospital experience. was difficult as these were the first family as- In all of the Greek families there was an imsessment interviews these groups had experi- plicit expectation, expressed by the father, for enced. While there was some ability to discuss immediate relief of suffering for their ill relfear of hospitalization by younger members, ative. There was also the expectation that the there was reluctance to openly discuss this health care team had the power to provide inwithin the family session. Sometimes mistrust stant relief of the illness and often, an exand fear pervaded much of the response to pressed difficulty in trusting or accepting treatment planning, and one elder son insisted advice that was in contrast to the family's own that the health team was purposely withhold- health beliefs. ing information and was using the interview Chinese families. Among the Chinese famas a means of finding out the truth about his ilies there was also a demonstrated cautiousmother, who had undergone surgery for ness with respect to health personnel. One breast cancer. older patient felt, following diagnosis, that Another family member, the grandfather "returning to my country will help me get of a young male patient hospitalized for well." He also perceived a lack of caring in Hodgkin's disease, had explicitly forbidden North America, stating: "In this country there the health personnel to perform diagnostic is no heart, it is a big machine. In my counprocedures on his grandson. In the family ses- try everyone helps you." This patient and his sion, the more the grandfather verbally rein- wife wanted an immediate "cure for the sickforced his refusal, the more the family members ness." Neither was willing to wait for the resupported this behaviour. This man also saw sults of diagnostic tests and indicated that hospitalisation as a form of punishment for health professionals should provide a specific his grandson. In a later interview, family medication or treatment which would immemembers explained that the grandson's illness diately alleviate symptoms. was seen as a direct result of wrongdoing. ApThese families looked for practical guidparently when an uncle was dying in Sicily ance and had difficulty understanding a health two years earlier, the patient had declined to care system that had differing roles and tasks.

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The system was viewed as large and impersonal, and there was a pervasive sense of loneliness. It was apparent to the interviewer that the ability to cope and manage the stress of hospitalisation was of utmost importance to these families. Family experiences surrounding coping, problem solving Although the interviews involved three different cultures and although the nature of cancer diagnosis differed, the families had similar reactions to coping and problem solving. Italian families. In the Italian families there was sometimes an incompatibility between the family's beliefs and values and those of the interviewer. In one family, the issue of coping with fatigue was raised by the wife of a patient. She had spent long periods at her husband's bedside and expressed the desire to see "another place" other than the hospital, which was "dark and full of sick people." Thinking she could spend some time for leisure and recreation with extended family, it was suggested she go out shopping or to see a movie. From the family's point of view, this did not fit their style of life. The wife appeared embarrassed and her husband quickly reiterated that his wife had "much to do to care for the house and children." His wife also pointed to the differences between North American culture and her own, saying, "in my culture, we do not go out without our husbands." In another Italian family there was the issue of large numbers of relatives who could not be accommodated within the physical space available at the patient's bedside. Discussion about the reorganization of family visiting was initiated by the older son. Attempts by the health team to reorganize were unsuccessful and it became evident that visiting arrangements would be authorised by the father and elder son. In this respect, assessment lay in the area of recognizing the father's wisdom and competency in reorganizing his family's visiting habits, while at the same time reinforcing the strength of his fam-

ily as a source of solidarity at the present time of crisis. If role flexibility existed, it appeared to be between fathers and sons. There was very little observed negotiation or compromise between husband and wife. Fathers emerged as decision-makers and family managers and mothers were nurturers and comforters. In these families neither the patient nor the family defined emotional issues as problematic. Problems were perceived as practical and even though anxiety was expressed in the interview, it was of paramount importance that the patient receive good physical care. Greek families. In Greek families efforts to explore feelings of fear and loneliness were met with refusal. In one family the wife of a patient suffering from cancer of the stomach began to complain of pains in her stomach, and despite a physical examination with negative results, she continued to complain of pain. This patient's wife could not accept or talk about her own fear and anxiety and continued to account for her concern as being physiological in origin. In another family a husband and wife were asked to discuss how they might handle the children while the father was in the hospital. This request was ignored and the father then proceeded to tell his family how things could be organized. The wife would help with the business (a small restaurant), and the son would manage it, along with his uncle. In the same session, during a conflict between the husband and wife over the issue of the daughter's absences from school, an attempt to mediate and problem-solve by the interviewer was met with a unilateral decision by the father that the daughter would continue periods of absence to help her mother. This action was supported by the other family members. In the Greek families, roles of husband and wife were clearly defined. Males saw themselves as working and providing, and female members would help at home or in the family business. Even when one father was the patient, he saw himself as making decisions for the protection of his family, and, in remis-

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Understanding cultural differences

sion periods, earning a living and caring for his elderly mother. Chinese families. In the Chinese families, talking about feelings or conflict was unacceptable. If conflict existed, a son deferred to his father's decisions and the wife respected her husband's decisions. In cases where the father was absent, it became the son's decision. In one family, conflict arose over the issue of how much extra work the wife should do outside the home during her husband's hospitalisation. The conflict was resolved following the patient's instructions that his wife would remain at home with the children (despite financial difficulty), to which she openly agreed. It was later learned that the family borrowed money from the wife's parents at the husband's request. The Chinese families, in general, did not respond to exploratory attempts to problemsolve. They wanted concrete direction with regard to treatment and care, such as financial assistance or child care. These issues took precedence over emotional support, expression of feelings, and exploration of family communication. One wife expressed unhappiness over her husband's pain but acceded to her husband's wishes not to discuss it in the interview. It was apparent that while the health care giver was an important source in the area of information and practical help, she was not crucial to the family's own coping process. Direct concrete help was more important than emotional support and counselling.

DISCUSSION

From these preliminary clinical observations, some major themes common to all three groups have been identified. First, there was a perceived fear with varying levels of mistrust directed towards hospital personnel. All demonstrated fear and loneliness in the initial interview and the "engagement" process was difficult. In the Italian and Greek families the hospital crisis was often attributed to a "wrong doing" or associated with superstition. In the Greek and Italian families the

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hospital was perceived as a means of punishment and was sometimes coupled with fear that the patient would not survive. Some interviewees questioned treatment procedures and were uncomfortable with the coping strategies suggested by nursing personnel. Second, other interesting similarities in terms of family experiences surrounding coping and problem solving were noted. Families looked for specific concrete directions from nursing personnel rather than emotional support or suggestions on how to elicit interfamilial support. And finally, roles in the parental marriage were clearly defined and problem solving related specifically to the culturally defined role. In these observations, there was minimal evidence of intrarole or inter-role conflict. Rather, the hospital crisis appeared to reinforce traditional coping strategies, and family members enacted their roles dutifully and willingly. Fathers and elder sons emerged as decision makers for the family with relatively little conflict between husband and wife. In many cases the behaviour of family members was consistent with roles and status and if some role flexibility occurred, it was precipitated by the father as the recognized head of the household. Family expectations of health personnel were more directly concerned with specific treatments, medications, and concrete issues. Attempts to explore emotional issues in these initial interviews were unsuccessful. These families did not want a psychological explanation of their grief, fear of loss, or loneliness. In all cases family loyalty was perceived as a source of solidarity, and specific expectations were related to assigned family tasks relative to the crisis. It must be noted that a limitation to this work has been due to language barriers and it was sometimes necessary to rely on an interpreter for clarification purposes. These families were seen for the purpose of a routine assessment and it must be emphasized that these clinical observations are retrospective. The objective here is to provide direction for a more extensive study in order to gain a com-

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prehensive understanding of cultural perceptions of cancer and the hospital experience. Due to the small sample size and the retrospective nature of the study, caution must be exercised when attempting to make generalizations regarding the cultures here discussed.

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CONCLUSIONS The preceding results raise important questions with regard to methods of treatment and care planning, especially if this reflects differences in perceptions of cultural values and mores between health caregivers and patients. Health professionals need to consider the family's cultural beliefs, values, and culturally perceived system of support relative to a diagnosis of cancer. Rules for behaviour during illness and the family's own understanding of treatment planning need to be understood if a collaborative approach to treatment is to be successful. It may be necessary to assess cultural perceptions of coping and problem solving and the ways in which illness has been managed in the past. Views of treatment planning and the way the family perceives "caring" must also be considered, if communication between the health professional and the family is to be effective and conducive to collaborative outcomes. If, following a family assessment, it is concluded that the family can effectively utilise its traditional ways of coping, then interventions can be based on the family's own accomplishments and will perhaps be more successful. The use of culturally traditional

ways of coping can be effectively utilised if they are understood to contribute to greater caregiver effectiveness in the realm of psychosocial interventions. The concluding issue is the education of health care professionals, which often neglects to take into account the health and illness experiences of a diverse immigrant population. Initiatives need to be taken whereby cultural content is systematically incorporated into cancer education programs, so that culturally sensitive care is effectively practiced. REFERENCES 1. Good B, Good M: Cultural influences on illness behaviour: a cultural hermeneutic model for clinical practice. In: Eisenberg L, Kleinman A (eds): The Relevance of Social Science for Medicine. New York: Reidal Publishing, 1981. 2. Dyck I: The immigrant client: Issues in developing culturally sensitive practice. Canadian Journal of Occupational Therapy 56(5):248-255, 1989. 3. Leininger M: The cultural concept and its relevance to nursing. J Nurs Educ 6:27-37, 1967. 4. Garcia HB, Lee PC: Knowledge about cancer & use of health care services among Hispanic and AsianAmerican older adults. Journal of Psychosocial Oncology 6(3/4):157-177, 1988. 5. Pang K: The practice of traditional Korean medicine in Washington D.C. Soc Sci Med 28(8):875-884, 1989. 6. Robert B, Myers JK: Religion, national origin, immigration and mental illness. Am J Psychiatry 1100:758764, 1954. 7. Jung M: Structural family therapy: Its application to Chinese families. Family Process 23(3):365-388, 1984. 8. Lee E: A social systems approach to assessment and treatment for Chinese American families. In: McGoldrick M (ed.): Ethnicity and family therapy. New York: Guildford Press, 1982, pp 527-551.

Understanding cultural differences through family assessment.

While much has been documented with regard to the role of the family in managing the stress of a diagnosis of cancer, there has been a paucity of atte...
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