Concepts in Cross-Cultural Dental Hygiene

Consideration of individual value systems and lifestyles should be an integral part of delivering high-quality dental hygiene care. A firm understanding of the conceptual frameworks that underlie modern dental hygiene practice and the vocabulary of cross-cultural dental hygiene is essential for the delivery of high-quality care in any setting.

Melting Pot and Salad Bowl Social Concepts

In the past many sociologists advanced the proposition that people of different cultures in the United States assimilated into the mainstream white Anglo-Saxon Protestant culture. The idea of the “melting pot” suggests that people relinquish their previous cultural identity in favor of the predominant culture of the society in which they find themselves. Such intermingling of cultural diversity was thought to result in a blended culture with liberty, equality, and justice for everyone.

The melting pot theory has given way to the “salad bowl” approach to explaining cultural assimilation. Modern sociologists prefer to use the salad bowl metaphor because it recognizes cultural diversity as a separate and unique component that remains heterogeneous within society. As it relates to health, the salad bowl model recognizes that culture influences the health status, beliefs, and behaviors of individuals and that healthcare providers and managers must be prepared to accommodate these differences. Treatment, educational programs, and client-provider interactions must be culturally appropriate. Some work settings proactively encourage cultural awareness through employee-training programs that identify cultural biases and facilitate positive attitudes and behaviors such as valuing diversity and team building.

Race and Ethnicity as Barriers to Healthcare

Currently, over 25% of the population in the United States belongs to a racial minority or is of mixed race (Table 5-3).³ According to recent demographic trends, about 50% of the U.S. population is expected to be Asian, Black, Hispanic, Native American or Pacific Islander, or a combination of two or more races by 2050.⁴ Non-Hispanic blacks, Hispanics, Native Americans, and Alaskan Natives have the poorest oral and general health of any of the racial and ethnic groups in the United States. Strategies for improving the health status of racial and ethnic minorities are prominent features of Healthy People 2010, the goal-setting health agenda developed by the U.S. Department of Health and Human Services.⁵ Because of changing demographics, dental hygienists must understand local cultures and culturally influenced healthcare practices to communicate with, educate, and motivate people from diverse racial and ethnic groups so that they can achieve optimal health.

TABLE 5-3 Diversity of the Population of the United States, 2006⁴

∗ Defined as “American Indian and Alaskan Native” by the 2006 American Community Survey.

Non-Western Medical Philosophy

Although most Western therapies are based on research evidence, the vast majority of the world populations are non-Western. Depending on his or her cultural values, the client may feel good, bad, or indifferent to the products and procedures used in Western-based dental hygiene practice. Likewise, a dental hygienist may fail to recognize the client’s cultural frame of reference and erroneously label the client as difficult, unmotivated, uncooperative, noncommunicative, or noncompliant. Healthcare practices from Western medicine may be viewed as functional or dysfunctional depending on the cultural system of origin. For example, the practice of putting a loved one in a nursing home may be viewed by some cultures as ensuring the best possible care on a 24-hour basis, but other cultures might perceive this practice as irresponsible, insensitive, or inhumane.

A dental hygienist’s lack of familiarity with non-Western medical philosophies and traditions can create a barrier to effective care and communication. Dental hygienists may know how to assess clients clinically but may not know how to interpret the client’s behaviors or concerns because of cultural differences. For example, a Muslim client’s refusal to have his teeth polished and treated with topical fluoride on a day of fasting may be erroneously interpreted as a lack of interest in professional care. A client’s food preferences may result in an erroneous dental hygiene diagnosis of a need for a biologically sound and functional dentition. Multicultural clients may have different cultural definitions of human attractiveness, some of which may be misdiagnosed as a need for a more wholesome facial image. Dental hygienists who do not recognize the reason or purpose behind a client’s home remedy or product preference may incorrectly assume that the remedy or product causes harm and should unequivocally be discontinued. Oral health therapy and promotion strategies, including the planning of interventions and the implementation of the care plan, must be delivered in relation to the cultural environment of the client. Although not a comprehensive list, Table 5-4 provides some basic guidelines for working with people from various cultural groups, including many with non-Western medical philosophies.

TABLE 5-4 Guide to Working with People of Various Cultural Groups^∗

∗ It is important to remember that not all people from a given culture will act in a standard manner. Great variability exists within cultural groups based on socioeconomic status, level of education, and overall life experiences. This chart is not meant to be generalized to all people within a specific culture, but rather to serve as a beginning guide.

Socioeconomic Status

Socioeconomic status is defined by a person’s income, occupation, and level of education. Socioeconomic status permeates every aspect of a person’s life. It affects where one lives, how one spends money, what one chooses to eat, how one uses free time, where one receives healthcare, how one pays for that healthcare, and, ultimately, one’s general and oral health status.

Poverty is universal, but its definition is culturally determined. Poverty is relative based on the standards prevailing in the community (Figure 5-1). Poverty in one community might be regarded as wealth in another. The U.S. Bureau of the Census reported that in 2006 36.5 million persons, or 12.3% of the U.S. population, were living below the official government poverty level as defined by financial income and household size.⁶ This poverty definition is from the U.S. Office of Management and Budget and consists of a set of income thresholds that vary by family size and composition. Families or individuals with income below the predefined poverty threshold are classified as living below the poverty line (Table 5-5).

Figure 5-1 Extreme poverty in slum in Mumbai, India.

(Courtesy Devan Darby.)

TABLE 5-5 Poverty Thresholds in 2008 by Household Size

The burden of poverty in the United States is disproportionately distributed among racial minorities, women, and children under 18 years of age. Blacks and Hispanics are overrepresented in the segment of the population classified as poor. In 2006, 24.3% of all blacks and 20.6% of all Hispanics were living in poverty, compared with 8.2% of non-Hispanic whites. In addition, the average woman earned only 77% of the average man’s earnings. The unequal burden of poverty that falls on women is often referred to as the “feminization of poverty.” Factors contributing to the feminization of poverty include lower real median income than men, teenage pregnancy, pregnancy out of marriage, divorce, abandonment, and female longevity. Children under 18 had the highest rate of poverty (17.6%) out of any age group.⁶

Poverty is a key predictor of poor oral health. Children with the most advanced oral disease are found within minority, poor, homeless, and migrant populations and populations with human immunodeficiency virus (HIV) infection.⁷ Poverty is a culture, and as a culture it is often passed on from generation to generation. This can be observed in people on welfare rolls, the urban and rural poor, and migrant workers who may become trapped in an ongoing cycle of poverty. Persons living in poverty are at high risk for or are more likely to manifest the following:

Dependence on government assistance for survival

External locus of control (i.e., fatalistic attitude and/or lack of control)

Substance abuse

Mental and/or physical disability

Depression or feelings of despair

Domestic violence

Because these characteristics tend to cluster in the population living in poverty, a scenario is created in which those who can least “afford” to be sick and who have the worst access to healthcare are in fact the sickest. In other words, the unemployed and poor, who have the highest burden of oral disease and may need the most care, cannot access it. According to Healthy People 2010, poor people get sick more often, experience greater complications with their illnesses, take longer to recover, and are less likely to regain their previous level of functioning, as compared with people from higher-income groups. Individuals in poverty do not readily take advantage of preventive health services, nor do they perceive the long-term benefits of these services.⁵

One barrier to taking advantage of preventive healthcare services such as routine dental hygiene care may include insufficient or nonexistent medical insurance. In the United States, low socioeconomic status is correlated with the likelihood of having inadequate health insurance coverage. In households earning $75,000 per year or more, the uninsured rate is 8.5%, whereas the rate is nearly 25% in households earning less than $25,000.⁶ Those eligible for government-funded healthcare (e.g., Medicare, Medicaid, SCHIPS) may find that oral care is not covered or that healthcare providers are unwilling to accept them as clients.

Although access to medical care is important, poverty itself may be a more powerful determinant of health status. Canada’s experience with making healthcare accessible to all people presents an interesting model of the effects of poverty on health. In 1968 Canada initiated a national health insurance program to provide healthcare to people without regard to financial resources, age, ethnic origin, or creed. More than three decades later, health remains directly related to people’s economic status.

Poverty continues to be a major barrier to healthcare that prevents individuals from meeting their basic human need for general and oral health. Low health expectations within the culture of poverty may result in a fatalistic attitude (e.g., “No matter what I do, I’ll lose my teeth anyway”; “My mother and father have false teeth and so will I”). Those living in poverty are also more likely to have low healthcare literacy. Healthcare literacy is the ability to understand the healthcare system and how it works. Other barriers to healthcare are disenfranchisement, lack of transportation, homelessness, seasonal work, prejudice, low literacy, daily dress that clearly distinguishes a person from the mainstream culture, inadequate levels of education, and a lack of healthcare personnel from the individual’s own culture. Given these barriers, it is easier to understand why some people resort to self-therapy, home or herbal remedies, or the services of a folk or faith healer, all of which are more accessible, less expensive, and more familiar than the modern healthcare system.

Impoverished environments directly influence the health status of residents. Low-income communities are more likely to be in close proximity to dump sites and hazardous waste facilities compared with high-income communities. Low-income housing is usually associated with poor maintenance, inadequate light and ventilation, insufficient access to utilities such as heat, water, and electricity, crowded living conditions, infestation, and lead poisoning. People who experience inadequate, high-density housing are also at higher risk to experience crime, physical and emotional abuse, stress, psychologic problems, alienation, and transmission of infectious diseases.

Wealth and Its Relationship to Health

Wealth is usually associated with high levels of education, prestige, self-esteem, power, and internal locus of control. Because the wealthy are more likely to be currently or to ever have been employed, they benefit from healthcare insurance, which in the United States is primarily a third-party payment system, to finance large portions of their healthcare needs. Because the wealthy are more likely to be earning income, they are also more likely to able to afford clean, comfortable housing, recreational activities, healthy diets, and, of course, access to healthcare. Because of their higher levels of education, financially secure individuals are less intimidated by the healthcare system than poorer individuals. On average, they verbalize their concerns, assert their needs, determine their level of participation in care, seek second opinions, and are more often critical healthcare consumers than their less-wealthy counterparts. On average, people in the upper socioeconomic levels of society live longer and experience less disability than do those from low-income groups.⁵

Development Status and Access to Care

Access to high-quality care is often, but not always, related to the development status of a country. Nations of the world are grouped according to economic development as follows:

Developed countries are economically and industrially developed states that are characterized by relatively high standards of living, literacy rates, life expectancy rates, and income per person. Examples of developed countries include Australia, Canada, Great Britain, Germany, South Korea, Switzerland, and the United States.

Developing countries are the poorer nations of the world, compared with the developed countries, that lack well-developed economies and have lower standards of living, lower literacy rates, and score lower on the Human Development Index. Some developing countries include Afghanistan, Guatemala, Haiti, Lesotho, Somalia, and Yemen. The United Nation’s Millennium Development Goals were adopted to improve the standard of living in developing countries.

Ensuring access to high-quality healthcare is a major challenge for all countries, but it is especially difficult in developing countries because of weak health infrastructure (Figure 5-2). Health infrastructure refers to the supporting framework of a health system, which includes everything from the physical hospitals and clinic buildings to healthcare administration and financing systems. Because a health infrastructure is expensive to create and maintain, many developing countries have limited formal healthcare systems and must rely substantially on home remedies and traditional healers.

Figure 5-2 Hospital ward in a developing country.

Verbal Communication

People who speak different languages perceive the world differently. A healthcare provider’s ability to effectively communicate with culturally diverse people facilitates care. Language can portray an individual’s identity, mindset, and values. European languages, including English, denote the individual as a private, singular entity who has importance. This is exemplified by the pronoun “I.” In some Asian and African cultures, the group identity takes priority over the self (Figure 5-3). In Japanese the first-person pronoun is expressed differently, depending on the situation (e.g., gender of speaker and person being addressed, private or public) and whether the language is written or oral.

Figure 5-3 Group of Chinese schoolchildren learning to floss with the dental hygienist.

Language systems that are different should not be viewed as deficient. In fact, dental hygienists who are native English-speakers should know that individuals with a native language other than English may have difficulty comprehending and communicating with them because of the following characteristics of standard English:

Lacks certain language sounds

Has language sounds for which other sounds may serve as substitutes

Has multiple pronunciations for similar letter groupings

Drawls some of its vowel sounds in sequences that are difficult for non-Americans to imitate

Requires several grammatic indicators for tense, gender, and plurality

Does not mark negatives sufficiently for words to make optimally strong negative statements

Variations also exist in the ways members of diverse cultures typically think, prioritize, and communicate. One manifestation of this difference in thinking is how various cultures may place different values on time.

Polychronic is a term to describe individuals who do many things at the same time, who are repetitive in their speech, and who place a low value on time. Some African, Arab, and Asian cultures are polychronic. Individuals from polychronic traditions may not orient themselves to Western time standards (clock time) but instead abide by time standards in nature. Other clients may be consistently late for appointments because they are less time-oriented. A dental hygienist insensitive to the time orientation of such cultures may erroneously attribute this action to a low value placed on oral health or to anxiety about obtaining dental hygiene care. Dental hygiene interventions that require action on the part of the client at specific time intervals may be difficult for individuals from polychronic cultures.

Monochronic refers to cultures whose members are linear in their thinking, sequential in behavior, and clock-oriented. Western European cultures are characterized as being monochronic.

Manner of Speaking

Intensity of style and expression varies among different groups. According to Western culture, an emotional speaker is viewed as persuasive, self-assured, and tough-minded. A calm, objective speaker is seen as trustworthy and honest. In contrast, many Asian cultures respect silence and are hesitant toward spontaneity. In many non-Western cultures, a younger speaker must show respect when speaking to elders. Older clients from these non-Western traditions may feel disrespected if a younger dental hygienist speaks brusquely or dominantly. Culturally sensitive dental hygienists intentionally modify their manner of speaking to facilitate positive interactions.

Nonverbal Communication

Culture is important in determining the meaning and interpretation of nonverbal communication. Various ethnic groups possess culturally acceptable gestures, etiquette, eye contact, physical contact, and methods of effective listening.

Eye Contact

Culture dictates the appropriate amount of eye contact. In many countries, staring or continuously looking at another person is considered rude. Lack of eye contact may be interpreted as disinterest in Western cultures but as polite behavior in some East Asian countries. Indirect eye contact is acceptable and preferable within Muslim and Native American cultures. When working with clients of diverse cultural backgrounds, the dental hygienist should be cognizant of eye contact because it may be interpreted as disrespect (Figure 5-4).

Figure 5-4 Women from a village in Botswana avert their eyes when being photographed.

(Courtesy Devan Darby.)

Assessment, Diagnosis, and Care Planning

The culturally competent dental hygienist understands that values and experiences shape everyone’s perceptions, beliefs, and attitudes. Most dental hygiene data collection tools direct the hygienist to gather information about the client’s health; however, a complete evaluation of the client’s condition can only be obtained from assessment of the client’s values and beliefs of the culture, ethnic group, or subculture. Therefore, assessing clients to identify culture-specific information is essential.

An ethnic and cultural assessment guide is presented in Table 5-6. This guide need not be a separate form but may be incorporated into existing data collection documents, interactions, and procedures. The dental hygiene diagnosis should identify the client’s unmet human needs that can be fulfilled through dental hygiene care, the cause of disease, the client’s perception of the cause of disease, the evidence for the diagnosis, and related cultural factors. With this detailed focus, an individualized care plan can be developed and appropriate interventions selected. Using a nonjudgmental, nonethnocentric approach, the dental hygienist assesses the client’s level of acculturation, English language skills, cultural health practices, and home remedies. Factors such as language comprehension, dietary preferences, and attitudes about the predominant culture can provide important cues for assessing the influence of the client’s cultural background. By synthesizing this information, the dental hygienist can conduct more positive, culturally informed interactions with the patient (see Tables 5-2 and 5-4). The dental hygienist who is able to demonstrate acceptance of diversity can establish trust with the client and achieve improved outcomes.

TABLE 5-6 Dental Hygiene Cultural Assessment

Adapted from Bloch B: Bloch’s ethnic/cultural assessment guide. In Orgue MS, Bloch B, Monroy LA, eds: Ethnic nursing care: a multicultural approach, St Louis, 1983, Mosby; U.S. Department of Health and Human Services: Oral health in America: a report of the Surgeon General, Rockville, Md, 2000, U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health.

Implementation

Dental hygiene interventions, whether educational, technical, or interpersonal, must be congruent with cultural values. Client values and needs guide the selection of interventions. As demonstrated by the anecdote about the Liberian girl at the beginning of this chapter, oral hygiene interventions must be culturally acceptable if they are to result in successful uptake by the host culture. Successful dental hygiene programs are often given legitimacy by coupling them with culturally accepted values or respected figures. In Sri Lanka, “[o]ral hygiene exercises are performed in Sunday schools run by the monks to propagate the teachings of Buddha. The religious leadership provided in the village gives the needed credibility to the program, and the villagers adhere strictly to the oral hygiene practices taught by the monks because of the respect they command in the villages.”⁹ In predominantly Muslim countries, people are taught that prayers from a clean mouth are received more favorably by Allah; therefore oral hygiene self-care compliments prayer rituals.¹⁰

These vignettes underscore the need to understand different cultures if client oral health is to be achieved. As long as cultural beliefs or practices cause no harm, the dental hygienist can determine their importance to the client and recognize that their continued practice might assist in maintaining an effective client-provider relationship (Figure 5-5). Even if the behavior is ineffective, the client’s comfort with and belief in its effectiveness can support a situation in which the person might otherwise feel alienated. Go to the website at http://evolve.elsevier.com/Darby/Hygiene to view resources for understanding people within various cultures. Obviously, not all people within a culture will subscribe to these beliefs; however, this guide can serve as a starting point for understanding people of diverse cultures.

Figure 5-5. Asian man receiving acupuncture for pain control before dental treatment.

Evaluation

In cross-cultural interactions, the evaluation phase of care calls for an awareness of the client’s cultural perspective of success. Frequent solicitation of the client’s perspectives, level of understanding, psychomotor skill development, and self-care practices is particularly important. Evaluation should determine whether dental hygiene services are meeting the client’s needs. Urging clients to talk about their oral health practices and status helps with cross-cultural communication. In addition to clinical indicators of health, validation occurs via feedback from the client and client’s family that the client’s needs are being met.