Excerpt from a Chinese herbal medicine guide.

Anthropology: Primary Care Accessibility Influenced by Cultural Factors

The United States faces a rise in coronavirus cases of the new Delta variant of the virus. Almost every news station invited healthcare professionals to discuss the origins of the variant and how unvaccinated individuals are the medium for further mutations of the novel virus. This information is just the latest push for citizens to get vaccinated, but many are still wary of vaccination. Vaccines and primary care, in general, are accessible for much of the suburban and urban populations in the United States. Yet, many individuals do not seek primary care because their cultural values and beliefs do not align with the healthcare system.

Cultural Factors Limiting Access to Primary Care

Culture is often associated with a geographic region or place considered the center of the culture. For example, an ethnic enclave can exist in space (a specific location). Culture may also organize around a place, such as a church, restaurant, or community center. However, culture usually does not organize around a healthcare facility, such as a hospital. Therefore, hospitals can see a variety of different backgrounds within their patients. In many cities, urban planning attempts to eliminate disparities an individual may face in seeking primary care. Accordingly, cultural factors are one of the few factors that limit primary care access. In this post, I will discuss some of the various cultural factors that may cause deferral seeking and accessing primary care. 

A healthcare professional providing care to a child.
Image source: yoair.com

Cultural Distance in Primary Care

Historical interactions between different races have effects transcending time and contemporary movements for social justice. As a result, it is more likely that minority patients have dysfunctional interactions with nonminority health professionals (Saha, S., 2006). Many of the misunderstandings between minority patients and nonminority practitioners arise from a cultural distance or the vast differences between their cultural values. Consequently, differences in communication are not uncommon; the entirety of the culture of the patient does not influence the diagnosis process.

This image shows a person of color recieving care from a white primary care provider.
In this image, a white female doctor administers a vaccine to a patient, who is a person of color. Race alone is a big enough factor, producing some cultural distance. This cultural distance might make the man of color skeptical of the vaccine he is receiving. Image source: https://mississippitoday.org/2021/02/11/were-failing-minority-communities-why-black-mississippians-are-receiving-fewer-covid-19-vaccines-than-white-mississippians/

Overestimations and Underestimations

Overestimations and underestimations of patient conditions are possible, especially for minority patients (Saha. S., 2006). This is especially the case in patient-physician relationships involving cultural distance. If a patient complains of headaches and exclaims they are experiencing high stress, and the physician is unaware of cultural factors, they might be diagnosed with migraines. But, socioeconomic factors, for example, may reveal that these headaches are a symptom of malnourishment. The EMR information on a patient’s chart may or may not indicate socioeconomic hardship. 

A patient gauges the value of the doctor with relevance to promoting their health, depending on the care received (Saha, S., 2006). The common goal, returning the patient to optimal health, is undermined, especially if a patient did not receive the most effective treatment for their condition (Saha, S., 2006). Consequently, such experiences impede patient motivation in seeking regular healthcare. 

Electronic medical record found at a healthcare location
In this EMR system, the demographic information only includes the patient’s name, age, home address, and contact information. In addition, the EMR shows the patient’s occupation, but no other information concerning culture or even socioeconomic status.  Image Source: https://extension.okstate.edu/fact-sheets/electronic-medical-records-what-are-they.html

Language Barriers in Primary Care

Language is one of the central elements of culture and can contribute to cultural distance. Vernacular and colloquialisms contribute to cultural distance, along with languages unknown to primary care providers. In a review of how language barriers affect healthcare, results said that a language barrier often creates miscommunications that decrease the quality of care provided, in addition to patient safety (Al Shamsi, H. et al., 2020). The review uses empirical data from one study and found that from the perspective of patients speaking a language besides the local language, 30% had difficulty understanding medical instructions (Al Shamsi, H. et al., 2020). Additionally, 30% of patients expressed a problem with the reliability of the information, and 50% attributed the language barrier (Al Shamsi, H. et al., 2020).

This image shows a typical label on a pharmaceutial drug, prescribed by a primary care provider. The label is usually only in one language, regardless of the patient's cultural nbackground.
This is an image of a typical label found on a pharmaceutical drug. These labels are often written in one language. A patient seeking care, who does not have the resources to properly translate and understand the recommended drug regimen, might be prone to misusing the medication. Image source: https://www.singlecare.com/blog/medication-management-for-people-with-disabilities/

Additional Issues as a result of a Language Barrier

Other issues a patient may face due to the language barrier include, but are not limited to: difficulty understanding a medical situation, confusion surrounding the use of medications, and misunderstanding of medication labels. Some patients have experienced adverse effects from medications due to them not understanding their dosage and regimen. Patients are more likely to miss scheduled appointments or neglect to schedule later appointments.

Like all other forms of cultural distance, language barriers can undermine the patient-physician relationship and deter a patient from seeking subsequent care. Around 37% of physicians in one studied infer that patients withhold information about their current condition due to the language barrier (Al Shamsi, H. et al., 2020).

How does the healthcare system work to minimize the effects of possible language barriers?

Medical providers must use interpreter services for proper communication with their patients. However, translation services and interpreters are costly. Therefore, these services increase the cost of appointments (Al Shamsi, H. et al., 2020). The need for an interpreter can increase the duration of critical care time provided to a patient, which directly influences how a patient bills for an appointment.

This image shows signage in a different language at a healthcare facility to accomodate a different culture and language when they recieve primary care.
Primary care facilities often have signage in languages popular in the surrounding area. This sign shows directions in both English and Spanish. These simple signs help to relieve some of the difficulties a patient and their family might have due to the language barrier. Image source: https://www.nicolsonassociates.com/hospital-wayfinding-signs

Effectiveness of Home Remedies in Relation to Primary Care

Common home remedies include using turmeric for inflammation and hot tea for flatulence. Many home remedies gain credibility with science and anecdotal evidence. In an article addressing home remedies in Pakistan, the authors describe the pluralistic healthcare systems unique to less developed countries. Pakistan has a range of homeopathic and spiritual healers, bone settlers, and herbalists who respond to various symptoms (Anwar, M. et al., 2015). To examine patient symptoms, their method of care, and the reason behind their method of care, researchers formed focus groups and conducted interviews.

This map of India shows spices in cultural Ayurvedic medicine.
Throughout India, there are a variety of spices that are used in Ayurvedic medicine, a cultural element in India. Ayurvedic medicine involves holism and a natural method of providing care. Spices are often Ayurvedic medicines. Many individuals of Indian culture may prefer visiting a traditional Ayurvedic healer, as opposed to a primary care physician. Image source: yoair.com

Results and Observations

Many patients seek out home remedies before seeking primary care. For example, one patient attributed nasal bleeding to the warm water and figured washing her head with cold water could counteract the symptoms (Anwar, M. et al., 2015). When the home remedy did not prove successful, the patient visited a doctor. Past experiences of receiving nasal drops from the doctor motivated this patient to seek the aid of a primary care professional (Anwar, M. et al., 2015).

Another patient preferred homeopathic remedies after paracetamol (an agent of western medicine) failed to relieve their headache (Anwar, M. et al., 2015). This patient prefers homeopathic medicine for two reasons. Firstly, the homeopathic practitioner is close in proximity to the patient’s home. Secondly, the practitioner is a family friend, strengthening the bond between the patient and the caregiver. A third patient describes an underestimation of their cough, which, upon a later visit to the hospital, was diagnosed with tuberculosis (Anwar, M. et al., 2015). This particular patient favors homeopathic medicine over allopathic medicine for minor medical inconveniences only (Anwar, M. et al., 2015). For more severe conditions, this patient prefers seeking allopathic primary care, as they feel that there are more diverse treatments.

How do home remedies relate to cultural distance?

Within Pakistan, the culture of citizens differs in many ways from the culture of doctors from whom they seek care. As a result, they may experience cultural distance when interacting with their primary care providers. Language barriers could be responsible for the underestimation of the condition of the tuberculosis patient. The patient with the nasal bleed demonstrates a positive patient-physician relationship that encourages further visits to the clinic. This patient’s experience contrasts with the tuberculosis patient’s experience to an extent. Their underestimated condition holds the potential to deter the patient from pursuing allopathic healthcare for other health issues. Like the patient with the nasal bleed, the patient with the headache demonstrates a positive patient-physician relationship, without seeking homeopathic remedies for their headache. A very short cultural distance between the patient and the homeopathic healer is likely the reason behind their relationship. 

Religious Beliefs in Relation to Primary Care

Religion is another cultural element that is important to understand or at least consider in healthcare. Historically, religious leaders doubled as primary care providers (Swihart, D. L. et al., 2021). It was not until the scientific revolutions did the spiritual aspects of medicine become questioned. People of different faiths have to consider religious values when making medical decisions.

Spirituality can influence decisions, especially those surrounding adopting a diet and taking prescribed medications. Many religions have dietary restrictions, such as the consumption of pork and its by-products in Islam. Therefore, many Muslims may be wary of receiving medications that contain gelatin. Individuals that follow Hinduism and Buddhism might decline conforming to a recommended diet that calls for them to consume meat. This is because both Hinduism and Buddhism promote vegetarianism. Some vaccines, such as the flu vaccine, are egg-based, meaning they contain proteins found in eggs, which also might cause a patient to refuse to receive the vaccine. 

This image shows doctors standing in a circle praying or performing a cultural ritual.
Doctors, as well as patients, may consult religion prior to performing surgery. Image Source: https://valerietarico.com/2014/02/20/its-time-for-religion-to-get-out-of-the-healthcare-business/

Abortions

Aside from skepticism surrounding medications, vaccines, and diets, religion is also influential in medical decision-making. For example, Buddhism, Roman Catholicism, and Jehova’s Witness do not permit the termination of an unborn child. On the other hand, Judaism, Hinduism, Islam, and the Church of Jesus Christ of Latter-day Saints permit abortion only if termination will save the mother (Swihart, D. L. et al., 2021). If the child was conceived through incest or as a result of rape, many religions allow a woman to have an abortion (Swihart, D. L. et al., 2021). 

Clinical Issues

Most religions are lenient with rules when a clinical situation arises. However, some religions have preferences for when a patient seeks care. For example, a Muslim should seek care from a practitioner of the same gender (Swihart, D. L. et al., 2021). Jehova’s Witnesses should not receive blood products (Swihart, D. L. et al., 2021). Many Sikhs hold religious beliefs against cutting their hair. Therefore, in surgical procedures, surgeons cannot trim the hair around the operating field. In Judaism and Roman Catholicism, religious law prefers the saving of amputated limbs (Swihart, D. L. et al., 2021). Buddhist laws favor that patients should not receive mind-altering drugs and medications (Swihart, D. L. et al., 2021). 

The Unique Case of Christian Science

Unbelievably, Christian Science is widely against healthcare. The religion, created by Mary Baker Eddy, argues that prayer is the only method of eradicating an illness (Swihart, D. L. et al., 2021). Therefore, followers are not encouraged to seek primary care unless necessary (Swihart, D. L. et al., 2021). Since seeking primary care is discouraged, followers of Christian Science are not allowed to receive vaccinations, nor are they permitted to consume medication. 

Should religious information be mandatory in Electronic Medical Records?

Electronic Medical Records, or EMR, are stored data that details information gathered when a patient visits a healthcare provider. EMR includes the social history of the patient, family background, and health history. If the patient wants their faith known to the provider, the physician or medical scribe notes it. There is no requirement for religious information, but disclosing this information can help providers be more considerate in their care. Awareness prevents any situations where a provider suggests something against religious beliefs. 

There are downsides to having religious information included in EMR. Physicians already spend a significant amount of time compiling EMR, even outside of their practice. More information equates to more work and also more discrete diagnoses and care processes. Though this is more work for healthcare providers, patients are more likely to receive impactful care. Besides, various studies prove that a more thorough EMR is associated with better health outcomes. 

Cultural Value of Disease in Relation to Primary Care

Different cultures have different conceptions of disease. During the Bubonic Plague, many religious individuals felt that the disease was a punishment from God. Other cultures outside of Europe have similar ideas towards disease that could discourage individuals from seeking care for the disease. In a study taking place in the United Kingdom, researchers examined religious beliefs surrounding epilepsy. The participants were all of South Asian origin, and researchers grouped patients based on their religion into groups. There were 20 Muslim participants, six Sikh participants, and four Hindu participants in the study (Ismail, H. et al., 2005). The participants’ ages ranged from 18 to 68 years old (Ismail, H. et al., 2005). 

This image shows the symptoms of epilepsy.
There is more than one symptom for epilepsy, yet the contraction and jerking of muscles is the only symptom that has more of a cultural significance in South Asian cultures. Image source: https://www.womenshealthmag.com/uk/health/conditions/a36462364/epilepsy-mental-health/

Results and Observations

From interviews conducted with the participants, a 43-year-old Muslim male and a 25-year-old Muslim male believe epilepsy comes from their God, Allah (Ismail, H. et al., 2005). They both feel that the health of a patient is in the hands of God after diagnosis. The 43-year-old even stated his belief that medication does not work since God is the only one able to provide a cure. A 46-year-old female and 19-year-old male Sikh have disbelief towards epilepsy being a punishment for sins, but the 46-year-old female mentioned the association of epilepsy and jinn, or the possession by spiritual beings (Ismail, H. et al., 2005). The opinion of a 28-year-old Muslim woman diverges from that of the 46-year-old Sikh since she believes the spiritual beings involved in jinn are evil spirits (Ismail, H. et al., 2005). 

A total of 30 people took part in the survey, and 16 sought a cure from a traditional South Asian healer, as opposed to a practitioner of western medicine. Their reasons for seeking a South Asian healer are because of continued seizures after therapy and skepticism towards the long-term effects of consuming anti-epileptic drugs (Ismail, H. et al., 2005).

Limitations of the Study

There were many limitations to this study, including location, sample size, unequal distribution of religion, and researchers identified participants from their medical histories. However, the findings support the view that illnesses with great cultural significance may not warrant care from western-style healthcare. Though the reasons for epilepsy are not necessarily positive, the idea that the disease one will face in their lifetime is predetermined is commonplace among the South Asian population. The predetermination of the diseases that one may face creates a sense of hopelessness that only God can cure them. Hence, the portion of the participant group seeks traditional treatment as opposed to western medicine. 

Cultural Significance in Anthropology

Various cultural factors can influence an individual’s plan of care for an ailment. Though primary care professionals do not consider every element of culture for a patient, the healthcare system attempts to make healthcare more accommodating for people of all cultures. These accommodations include healthcare information in multiple languages, intercultural literacy, and trying to eliminate cultural distance. Yet, patients may still be wary of receiving care, since more traditional, nonwestern paths of care may provide patients with desired results.

A doctor in a white coat holds an orange bottle of pills towards the camera
Image Source: https://www.peoplespharmacy.com/

Referenced Materials

Anwar, M., Green, J. A., Norris, P., Bukhari, N. I. (2015) Self-medication, home remedies, and spiritual healing: common responses to everyday symptoms in Pakistan, Health Psychology and Behavioral Medicine, 3:1, 281-295, DOI: 10.1080/21642850.2015.1088387

Al Shamsi, H., Almutairi, A. G., Al Mashrafi, S., & Al Kalbani, T. (2020). Implications of Language Barriers for Healthcare: A Systematic Review. Oman medical journal, 35(2), e122. https://doi.org/10.5001/omj.2020.40

Ismail, H., Wright, J., Rhodes, P., & Small, N. (2005). Religious beliefs about causes and treatment of epilepsy. The British journal of general practice : the journal of the Royal College of General Practitioners, 55(510), 26–31.

Saha S. (2006). The relevance of cultural distance between patients and physicians to racial disparities in health care. Journal of general internal medicine, 21(2), 203–205. https://doi.org/10.1111/j.1525-1497.2006.0345.

Swihart, D. L., Yarrarapu, S. N. S., Martin, R. L. (2021). Cultural Religious Competence In Clinical Practice. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493216/

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