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Physiotherapy 93 (2007) 229–232

Discussion paper

Taking culture seriously: considerations for physiotherapists

Matthew Hunt ∗

Biomedical Ethics Unit, McGill University, 3647 Peel Street, Montreal, Quebec, Canada H3A 1X1

bstract

Cultural diversity is increasing in Western nations. The cultural plurality of these societies has important implications for the provisionf health care to patients. Physiotherapists need to be conscious of the ways in which cultural frameworks – their own and those of theiratients – are played out in the clinical encounter. Cultural frameworks play a significant role in how individuals experience health, illness andisability. Cultural perspectives also inform the expectations that patients have of health care providers and contribute to shaping patient goals

oncerning therapy. Clinicians should strive to provide culturally sensitive care that encompasses an awareness of this reality. This articleonsiders the influence of cultural frameworks on the provision of care to patients and suggests ways in which therapists can respond to theiverse cultural perspectives held by patients and their families.

2007 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

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eywords: Cultural diversity; Physical therapy; Professional Practice

ntroduction

Western societies are increasingly multicultural. Thisncrease in cultural diversity plays an important role in theelivery of health care to patients. Cultural frameworks havefar-reaching influence on how patients and health care

roviders understand health and illness, and the expectationsnd values that they bring to the clinical encounter. However,he role and function of culture in health care settings, andhe response of clinicians to different cultural frameworks,ometimes go unacknowledged. This paper seeks to stimulateiscussion regarding the ways that physiotherapists respondo, and interact with, the diversity of cultural perspectives thatre active during the provision of care to patients.

hat is culture?

There has been considerable discussion regarding theature and interpretation of culture. Culture is often con-

eived of as encompassing the pattern of learned values,ehaviour and beliefs that are shared within a group [1].rom an anthropological perspective, Kleinman and Benson

∗ Tel.: +1 514 398 7403; fax: +1 514 398 8349.E-mail address: matthew.r.hunt@mail.mcgill.ca.

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031-9406/$ – see front matter © 2007 Chartered Society of Physiotherapy. Publisoi:10.1016/j.physio.2007.01.007

escribe culture as a dynamic process ‘through which ordi-ary activities and conditions take on emotional and moralone and meaning for participants’ [2]. Other researchers alsouggest that the view of culture traditionally discussed inhe context of health care has not adequately accounted forhe social and political factors that have contributed to thisnderstanding of culture [3].

Culture may be conceived of as the lens through which weerceive and interpret the world around us. In this way, cul-ural perspectives influence how we experience all aspectsf life. Culture impacts on our experience of health caret a number of different levels. It influences our under-tanding and experience of health, illness and disability. Itmpacts on inter-personal communication and our expecta-ions of patient–clinician relationships. Culture also affectsur expectations of the role that families and communitiesill play in our experience of illness and shapes our under-

tanding of what it is to be a virtuous clinician, or a virtuousatient.

It is often difficult to identify all the cultural aspects thatre at play in the context of health care. Many researchersave pointed out that Western biomedicine itself is a cultural

ystem with its own intrinsic values and practices [4]. Cow-rd and Ratanakul describe how biomedicine has its ownbelief system, social structure, initiation rituals, language,ress, and educational system’ [5]. The way that health

hed by Elsevier Ltd. All rights reserved.

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30 M. Hunt / Physioth

are is organized, structured and implemented is far fromvalue-neutral process. The interface between the culture

f biomedicine, the cultural frameworks of health careroviders, and the cultures of patients and their families is ofentral importance to the successful outcome of the healthare encounter and the establishment of culturally sensitiveare.

ulture and the individual patient

It is important that the concept of culture is not treated aseing synonymous with ethnicity. The cultural frameworksf individual patients can rarely be reduced to a cataloguef ‘typical’ values and practices attributable to a particularthnic community. Patients are ‘specific historically, geo-raphically, and socially situated human beings’ [6]. As aesult, social categories of difference such as religion andthnicity should not be considered as narrow categories withlosed sets of values or characteristics. Clinicians shoulde wary of making assumptions about the patient’s under-tanding and values based on dress, appearance or accent.ctive engagement and dialogue with patients about theirnderstanding and experience of health and illness, functionnd dysfunction, will be helpful in promoting understand-ng of the particular concerns of patients. This deliberateialogue will allow therapists to better understand the cul-ural frameworks of patients and provide culturally sensitiveare.

ulturally sensitive care

The provision of care that takes into account the particularultural perspectives of an individual patient is an importantonsideration in physiotherapy. A central concern of cultur-lly sensitive care is to consider the views and values of theatient as important and worthy of attention and consider-tion. It is essential that therapists do not assume that theiratients share common values and understandings regardingealth and illness. Respecting culture entails taking seriouslyhe cultural perspectives expressed by patients even whenhese do not coincide with the perspectives of the therapist. Itlso suggests that clinicians should strive to be open to learn-ng from, and about, cultural perspectives different from theirwn and to approach cross-cultural encounters with humility7].

The obligation to provide care that is respectful of patientss captured in the codes of ethics of most professional asso-iations. The Chartered Society of Physiotherapists in theirules of Professional Conduct includes the requirement to

respect and uphold the rights, dignity and individual sensi-

ilities of every patient’ [8]. The American Physical Therapyssociation requires members to ‘respect the rights and dig-ity of all individuals and provide compassionate care’ [9].imilarly, the Canadian Physiotherapy Association’s Rules of

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onduct state that therapists are to respect the client’s ‘rights,ignity, needs, wishes and values’ [10]. The obligations setut in each of these codes support the need to be respectfulf a patient’s cultural perspective.

As physiotherapists consider the influence of culture onatient care they will also benefit from reflecting on their ownultural framework in relation to health care. By examiningheir own cultural assumptions they may gain greater insightnto the impact of culture on care delivery. Ells and Canianobserve that ‘when relating to anyone from another culture,ne must seek to understand one’s own culture, the other’sulture and the interaction between the two’ [11]. It is notnough to ask what is the culture of a specific patient but alsoo consider one’s own cultural framework, and the interactionetween these values and perspectives.

The locus for culturally sensitive care does not onlyie at the level of the individual patient and their thera-ist. Clinicians may reflect upon the way that culture isddressed on an organizational or systems level to considerow issues of culture are manifest in the clinical milieu.his attention may reveal ways in which the differences

hat exist between the worldview of biomedicine and otherultural frameworks have not been identified or adequatelyonsidered.

ultural competency

Many authors have discussed the need for clinicians toevelop competency in regards to culture [12]. The move-ent to foster and promote cultural competency skills for

tudent health workers and for clinicians is well developed.n addition to developing specific cross-cultural skills, theres also a focus on the importance of humility in cross-culturallinical encounters [7]. Clinicians who provide culturallyompetent care will have developed skills in inter-culturalommunication, acquired knowledge relating to the impactf sociocultural factors on health care, and will demonstraten attitude of humility and a willingness to learn from otherultural viewpoints. On a more theoretical level, cultural com-etency entails the acknowledgement of the importance ofulture in people’s lives, an attitude of respect towards dif-erent cultural perspectives, and a desire to minimize theotential negative consequences of cultural differences [13].he importance of developing culturally competent healthare organizations and health care systems has also beenmphasized [14].

ultural sensitivity in the physiotherapy department

The influence of culture in the physiotherapy depart-

ent may at times be subtle, while at other times it may

eem quite obvious. An awareness of cultural influences onealth care is an important aspect of competent and effec-ive patient care. Physiotherapy services that do not take

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nto account the cultures of recipients and providers are lessikely to lead to successful outcomes for those involved.

hen the role of culture in the clinical encounter has noteen considered communication and understanding may bempeded and goals of care risk being less relevant to theatient. Patient collaboration may also be more difficult tochieve.

An essential element of physiotherapy practice is thestablishment of goals for treatment. Therapists work withheir patients to identify goals that will guide the physiother-py intervention that is provided. Cultural frameworks willnfluence which goals will be meaningful for the patient. Inonsequence, the health care team needs to engage in activeialogue with patients to identify goals that are relevant tohem [15]. As they are able to negotiate goals and create anntervention plan that reflects the patient’s cultural perspec-ive they will provide patient-centered care. If the goals ofherapy do not reflect this perspective the intervention mayrove unsuccessful.

Cultural plurality is sometimes associated with the pres-nce of language differences between clinicians and patients.ven when language is not a barrier, there may be more subtlebstacles to communication [16]. Inter-cultural communica-ion requires specific skills. Clinicians may need to search forthe question behind the question’ [17]. The discussion of cer-ain subjects, such as the articulation of negative news, may beiewed as culturally inappropriate by some patients. Besideshe obvious need that may exist for translation when lan-uage barriers are present, there may be situations in which aultural mediator, or ‘culture-broker’, can assist in the com-unication between the health care team, the patient and their

amily. A cultural mediator may help identify cultural issues,nd negotiate towards improved understanding [18]. A per-aps under-recognized feature of cross-cultural clinical visitss that they often take more time. The assessment and treat-

ent of patients with whom there is a cultural or linguisticarrier will take more time for the therapist and schedulingay need to reflect this reality.The nature of how culture can influence physiotherapy

nterventions is quite diverse. Culture has a direct link toow individuals experience health, illness, function and dis-bility. Therapists should seek to understand how patientsonceive of, and live, their state of health or illness. Forome an amputation may provoke different responses dueo a cultural perspective that emphasizes the importance ofhe integrity of the body [18]. Other types of variation includehe well-described differences between patients regardingheir experience and description of pain [19]. Patients mayxpress different explanatory models relating to their expe-ience of illness [20]. For example, some patients may havespiritual or metaphysical explanation for their state of ill

ealth that contrasts with the rationalistic causality of Western

iomedicine [16]. Greater insight into the ways that patientsnderstand and experience illness or disability will assisthysiotherapists in providing culturally sensitive care to theiratients.

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onclusion

Individual patients bring to the clinical encounter aaried set of culturally informed values and perspectives.herapists need to engage their patients in discussion around

heir particular goals and perspectives, and be mindfulf the ways in which cultural frameworks influence theare provided to patients and the patient’s experience ofeing ill, having an injury, or living with a disability. Manyultural frameworks are active in the health care setting:hose of patients, families and health care providers, asell as the culture of biomedicine. As therapists are more

ware of the influence of these varied cultural frameworksithin the clinical encounter they will be better able torovide effective and appropriate care to their patients.y approaching clinical encounters with humility and aillingness to learn, therapists will be better able to respond

o the particular needs of their patients as cultural beings.

cknowledgement

The author would like to thank Mary Ellen Macdonald forer helpful comments on this manuscript.

thical approval: None required.

onflict of interest: None.

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