Transcultural Geriatrics

Alexander Lapin

Introduction

Our modern world is subjected to profound changes as never seen before in human history. Globalization of economics and communication and worldwide migration in all its forms bring new cultural confrontations during various moments of our daily lives. Moreover, extension of lifetime expectancy as a result of the achievements of modern medicine has produced the demographic phenomenon of population aging, which is not restricted to the developed countries but is recognized as an incipient global phenomenon. From the point of view of geriatric medicine, it means that situations of transcultural (or cross-cultural) confrontation, which would occur during an encounter between the physician and patient, can be expected to be occur more often and therefore should be considered with increased attention and competence.

This is particularly important in view of the current situation in Europe, which is characterized by the largest immigration movement since the Second World War. Most of these refugees are coming from Syria, Afghanistan and other Middle Eastern countries. They belong to different traditions of Islam, but also to various denominations of Eastern Christianity. Some of them are followers of the ancient religions of the Orient such as Yezidis or Druze.

In this chapter, general aspects of such transcultural encounters will be discussed. The focus will be on communication, acceptance, and medical compliance, especially when dealing with patients from another cultural background. Moreover, specific aspects of transcultural nursing will be presented, with examples from selected cultures.

Demographics

Worldwide migration is a steadily growing phenomenon, especially in political, economic, social, and intercultural contexts. Refugees, seasonal workers, migrants with higher professional qualifications, and even short-time visitors such as tourists, transportation workers, and sometimes military personnel with their families. All these categories of migrants illustrate the complexity of the phenomenon, which is so characteristic for today’s world.

At the same time, distinguishing between political and economic reasons for leaving one’s homeland appears no longer to be valid, because both these aspects can play a role in any migrant’s fate (Table 133-1). Even the type of integration into a new country has changed. The situation of a giving up one’s own culture (e.g., language, customs, religion) is no longer required. This is also true for so-called multiculturalism, which for a long time has been considered as a promising model for coexistence of self-sufficient but mutually isolated cultural communities living in the same country.

TABLE 133-1

Push-Pull Factors Affecting the Decision for Emigration

Push	Pull
Political or religious persecution	Political stability
Persecution	Democratic social culture
Economic crisis	Economic prosperity
Civil war	Better education
Natural catastrophe	Perspective for work and salary

What we find today is the transcultural type of coexistence, especially in the workplace, where people of different ethnic or cultural origins have to act together because of the same interests and goals. In the private sector, by contrast, the same people may maintain intensive contacts with their cultural community and even their home country. This is especially possible because of modern communication abilities and facile mobility. This is enabled by the Internet, cell phones and smartphones, tablets, and other technologic advances, as well as affordable long-distance flights. Incidentally, the best example of this transcultural coexistence can be observed among medical and nursing professions in many countries of today’s world.

Dilemma of the Physician-Patient Encounter

Migrants especially know well from their own personal experience how bitter it can be if one is in a situation of illness and helplessness in a foreign country and in the middle of unfamiliar surroundings. For older adults, such a situation is particularly unpleasant—the hospital, room, bed, personnel, medical facilities—everything is new and unexpected. The misfortune of illness leads a person to think about the worst possible scenario regarding the immediate future. The patient is concerned about family and friends. At the same time, due to restriction of mobility and interference with privacy and intimacy, the person’s mood can be changing between despair and hope.¹ All these aspects depend on the cultural and religious background of the patient and therefore affect the quality of life.

Despite actual demands for patient autonomy and consent for therapy, the encounter between the patient and physician still remains asymmetrical. Compared to the patient, the position of the physician during this encounter is quite different. Being in healthy condition, standing, and not being recumbent, as is the patient, the physician is in possession of medical knowledge; the patient depends on the physician’s decision. Moreover, in contrast to the patient, the physician has to exclude any private interests from the work. Primary interest has to be focused on determining the right diagnosis and implementation of the most efficacious therapy. Often, such work has to be done under stress because of lack of time and sometimes limited material resources.

Finally, despite the distant positions of the physician and patient, there is an imperative to recognize the common interest of both. For this common aim—the improvement of the situation of the patient—complete understanding is indispensable. However, the transcultural aspect as a complication of this endeavor represents a special type of challenge here.

Culture Shock: Three Steps

The encounter with a person of apparently foreign origin leads to a psychological reaction, which is termed cultural shock and consists of three steps. The first is marked by curiosity and usually a positive euphoric attitude toward the unknown foreigner. The primary communication is initiated from preexisting assumptions and stereotypes concerning the not yet well-known culture or nation. The second step is the phase in which not only positive experiences have been made. It is the phase where a certain disillusionment, frustration, anxiety, and rejection take place. Under such a condition, stereotypes can easily turn into prejudices, with a negative emotional tint. Finally, the third step is marked by acquisition of some concrete knowledge about the individual and by confrontation with his or her problems. This in turn enables a more participative, and usually more objective, neutral and rational adjustment of the mutual relationship (Box 133-1). In this analogy, the encounter between the physician and patient is also a gradual process.

Box 133-1

Acquiring Knowledge About a Person

A confrontation between cultures can be characterized by the following terms:

• Enculturation—learning and acquisition of elements of another culture

• Acculturation—changing one’s cultural elements as a result of a meeting between cultures

• Socialization—adoption of the moral views and behavior of the majority society

• Assimilation—giving up one’s own culture in favor of another one

From the perspective of the physician, the first step is dominated by the question of personal motivation for becoming a geriatrician. This can be done individually—by professional interest, one’s moral duty, religious background, or simply by the desire to help older adults. What is always important is the empathy (if not to say love) toward the patient. Even this positive attitude, independently from the cultural and social background of the patient, is necessary to overcome negative prejudices. The second step is dedicated to the concrete acquisition of knowledge about the patient and her or his background. It is the evaluation of cultural status and the search for a common denominator of communication and cooperation. Finally, the third step is the phase of concrete integration of culture-specific measures and experiences into medical care and therapy.

Nonverbal and Formal Communication

The first contact of the physician with the patient is usually on a nonverbal level. There is abundant literature on this topic, which states that in this situation only 10% of the information is transmitted in textual form. The rest of the communication is done by body language and how one uses the voice. A major factor on which such a situation depends is also the ambiance and timing of the communication. The cultural and education level of both parts of the dialogue are equally decisive. In sum, because emotions play such a substantial role here, this situation is important for future understanding, confidence, and empathy between the physician and patient. It is therefore important to recognize the nonverbal signals during such a conversation correctly.²

Mimicking seems to be that part of body language that cannot be suppressed entirely by one’s own will. Nevertheless, in a cultural context, there are some precautions that have to be considered. Direct eye contact in a Western context signals attention and sincerity. In the Middle East, the same attitude can be interpreted as overreaching and arrogance. When it happens between a man and woman, it can be interpreted ambiguously. Similarly, a smile in Europe or the United States signals friendship or a friendly attitude but, in the context of Chinese culture, it is rather an expression of uncertainty and defensive politeness.

Haptic refers to the type of bodily contact during a communication. In medicine and nursing, it includes so-called therapeutic touch, which is meant as a positive gesture of solace. Generally, in cultures of temperamental Mediterranean people, this approach is quite common and welcome. However, in the context of Islamic culture, it could be an understood as an offense, especially when ignoring the man-man and woman-woman principle.

The term proxemic refers to the distance between two individuals involved in a dialogue. Based on human anatomy, one can determine different proxemic zones:

• Intimate zone (hands): 15-30 cm

• Personal zone (talking): 120-210 cm

• Social zone (office): 210-360 cm

• Public zone (teacher): 360-760 cm

However, the cultural context here involves some corrections. In general, more temperamental Southern European cultures prefer shorter distances, whereas in Northern European cultures, these distances are longer.

Paralinguistics

This involves using the voice for the emotional part of communication—the fluency of the language and the loudness of the voice. In different cultures, such as Scandinavian (but not exclusively), slow speaking with pauses is not unusual. In other cultures, such as Hispanics or Italians, loud and fast language is quite normal. By contrast, for Vietnamese, loud speaking is considered to be rude.

Salutation

This is an important part of every communication. In different countries and cultures, it follows specific rituals. In Asian and Far Eastern cultural contexts, it is common to greet by prevention, but also by shaking hands longer. In Islamic countries, it is inappropriate for a man to shake the hand of a woman. Conversely, it is common that younger family members greet the grandfather, the head of the family, by kissing his hand. In Poland, it is still usual to greet an older lady by kissing her hand. In other middle European countries, especially for older adults, this requires a polite and noticeable greeting. Two cheek kisses are usual in France between two relatives or close girlfriends and three cheek kisses are done during at Easter between Orthodox Christians.

Address

In Europe, this is especially of considerable importance. In Central Europe (Germany, Austria) it is usual to greet someone using Mr., Mrs., or Miss with the family name—Herr Schmidt, Mrs. Robinson. It is also customary to use academic titles, such as Frau Doktor or Mr. President. The use of just a professional title is practiced in France and Italy—Commissario. In northern European countries, by contrast, it is customary to use only the family name—Johansson. In Anglo-Saxon cultures, it is common to address people only by their first name or nickname—Dick. In some countries, it is an expression of politeness to use the first name together with the father’s name (so-called patronym). In Russia or Ukraine, for example, one uses the form Alexy Vladimirovich or Lydia Ivanovna. On the other hand, in Iceland, the patronym is generally used instead of the family name—Gunnar Petersen (son of Peter), Anna Pálsdóttir (daughter of Paul).

Another consideration is the use of “you” for familiar addressing. More precisely, in most languages, it is the second person singular: “Toi, tu dois faire cela!” (French). In English, by contrast, this aspect is not relevant, because one uses “you” in a general context. In southern European countries, to switch into the address by second-person singular is seen as harmless and regarded as a friendly offer of ease and friendship. However, especially in Middle European countries, when talking to older adults, it can be considered impolite, especially if the person is not asked if it’s all right to be addressed in this way.

Not without interest is that in several languages, the family name of the woman has a special female form. This is the case especially in Slavonic languages—Jan Novák–Marie Nováková, Jacek Kowalski–Danuta Kowalska, Lev Tolstoy–Tatiana Tolstaya. In South America, it is the custom of a married woman to use both family names, that of the husband and her own maiden one—Isabella Rodríguez-Sanches–Miguel Rodríguez.

In this context, it has to be said that not only correct spelling of the name is important, but also the correct pronunciation, which usually has to be asked about. In any case, this signals interest and respect to the older patient.

Language as a Source of Information

How somebody uses language can reveal a lot of information—the history of the concerned person, original ethnicity, culture, sociologic and psychological status, and educational level. For this purpose, it is necessary to be aware of different forms of spoken language. In principle, one can distinguish three types of spoken language: