4.7 Cultural specificity

In considering any aspect of health care management and planning, it is necessary to remember that health-related behaviours and expectations may be highly culturally specific. Thus interpretations of personal health and expectations of treatment may vary widely between cultural groups, both between and within countries. Recognition of these differences presents significant challenges to the health care planner, who needs to be able to develop appropriate representations of the cultural diversity (in many dimensions) of the population to be served.

The provision of culturally-sensitive health care services may take the form of adaptation of existing service provision so that it better meets the requirements of identifiable population sub-groups or may require the provision of services designed specifically for use by sub-groups. We can explore these examples with reference, firstly, to primary health care for refugees in the UK and, secondly, to the provision of reproductive healthcare services targeted specifically at adolescents in both Zimbabwe and the USA.
 

‘Many refugees have health problems but experience difficulty in having their needs met’

Jones and Gill (1998: 1444)

 
Jones and Gill (1998) consider the very large and diverse refugee population of the UK, with a high concentration in London. Many of these refugees have health problems but experience difficulty in having their needs met, despite their entitlement to state-funded health care in the UK. Refugees are a particularly needy group who are likely to have left their home country involuntarily and may experience language difficulties and hostility in a strange country and may additionally be particularly prone to diseases specific to their country of origin and to illness associated with their circumstances and experiences, particularly mental illness. Although these refugees are entitled to registration with a general practitioner (GP) in the UK many GPs will have little contact with refugees and were found to be unsure about the services that they should offer. Medical records for refugees are likely to be poor, as is their immunization status. Language barriers may be significant – both in seeking registration with a GP and in presenting medical needs once registered. Further, many GPs in the UK will have little familiarity with the diagnosis and management specific medical conditions prevalent elsewhere in the world. Jones and Gill recommend a strategic approach to the provision of primary care for refugees. Hall (2006) comments on a further aspect to this challenge, whereby failed asylum seekers are not entitled to free health care in the UK, which presents physicians with a dilemma of whether or not to offer treatment to individuals who present with clear health needs but are not entitled to care. This scenario presents strong tensions and contradictions in a state-funded health care system designed to offer care to all which is free at the point of use.

Mashamba and Robson (2002) discuss the use of reproductive healthcare services by young people in Bulawayo, Zimbabwe. In particular, they sought to investigate why teenagers do not use existing health services. This is very much a cultural challenge as services, even when aimed at younger people will often suffer an ‘adultist’ bias which makes them unattractive or inaccessible to the very groups that they were intended to help. In a context of high rates of AIDS/HIV and other sexually transmitted diseases (STDs) the importance of educating and empowering young people to engage in less risky sexual behaviour is critical. Further, adolescent pregnancies present a particular challenge to healthcare systems in both the developed and developing world and in the Zimbabwean context may present severe challenges associated with attempted illegal abortions leading to high risks of medical complications and maternal mortality. The Mashamba and Robson study demonstrates that young people may not use clinic services even when they are geographically accessible. This is due to a range of non-geographical factors which fall under the general area of the cultural relevance and accessibility of the services. These include cultural taboos, ‘fear, ignorance, stigma and embarrassment’ (p. 279). Barriers to the use of the services available included the inconvenient opening hours (largely coincident with school hours) and the fear of being seen using the services. A satisfaction survey frequently highlighted the suggestion that the use of younger counsellors would make the service more attractive to young people as would the creation of a more welcoming atmosphere. In this context, the cultural relevance of the facility is a barrier to access, despite the fact that in geographical terms access was relatively good, and the service had been focused clearly on the needs of a target group. Brindis et al. (2004) address a very similar set of issues in relation to teenage access to reproductive health services in the USA. They focus explicitly on the ‘teen friendliness’ of such services . Despite the enormous wealth differential between Zimbabwe and the USA, the parallels between the two studies are notable: again, STDs and HIV infection are a primary concern affecting teenagers and targeted services are intended to improve the reproductive health of this core adolescent group. The Brindis et al. study was based in San Francisco and again interviewed users of services. The team attempted to develop a metric for ‘teen-friendliness’ which included suitability of opening times, geographical accessibility, confidentiality and the demographic characteristics of the service provider. It is clear that across very different national settings health service managers face many common challenges in providing culturally appropriate reproductive health services for young people.
 

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