Study Guide 001 (Both) For HSE3701

# 2008 University of South Africa
All rights received
Printed and published by the

University of South Africa
Muckleneuk, Pretoria
HSE3701/1/2009-2011
98332805
Page
OVERVIEW vi
STUDY UNIT 1
Models for culturally competent care 1
1.1 Introduction 1
1.2 Leininger's theory: culture care diversity and universality 1
1.3 Ramsden's cultural safety theory 4
1.4 Giger and Davidhizar's cultural assessment model 5
1.5 Campinha-Bacote's model 6
1.6 Ubuntu 8
1.7 Cultural competence 9
1.8 Summary 11
1.9 Self-testing questions 11
STUDY UNIT 2
Cultural encounters in health care 12
2.1 Introduction 12
2.2 Intercultural communication 13
2.3 The process of communication 13
2.4 Verbal and nonverbal communication 14
2.5 Other cultural phenomena which might influence cultural encounters 15
2.6 Ethnicity and ethnic identity 17
2.7 Social class 17
2.8 Urbanisation 19
2.9 Conclusion 21
HSE3701/1/2009-2011 (iii)
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STUDY UNIT 3
Cultural awareness in health care 22
3.1 Introduction 22
3.2 Cultural sensitivity and awareness 23
3.3 Ethnocentrism 24
3.4 Prejudice 25
3.5 Race and racism 25
3.6 Stereotyping 27
3.7 Cultural imposition 27
3.8 Discrimination 28
3.9 Values clarification 28
3.10 Conclusion 28
STUDY UNIT 4
Cultural knowledge in health care 30
4.1 Introduction 30
4.2 Historical perspective 31
4.3 Health, disease and illness 32
4.4 Knowledge about health, disease and illness 36
4.5 Natural causation of disease 48
4.6 Supernatural causation of disease 50
4.7 The traditional structure of African medicine 51
4.8 Diagnosis and treatment 54
4.9 Worldviews 61
4.10 Religion, culture and health care 66
4.11 Conclusion 67
STUDY UNIT 5
Cultural skills in health care 68
5.1 Introduction 68
5.2 Cultural assessment 69
5.3 Teaching and learning in a multicultural milieu 80
(iv)
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5.4 Recommended practices: culturally responsive teaching 98
5.5 Preparing and selecting instructional material for use
in a multicultural context 104
5.6 Assessment and examination guidelines 109
5.7 Developing multicultural lesson plans 111
5.8 Conclusion 112
5.9 LIST OF SOURCES 113
HSE3701/1 (v)
OVERVIEW
Dear Student
Welcome to HSE3701, the health sciences education module that focuses on teaching and
learning in a transcultural health milieu. The condition set by the process of democratisation in
South Africa is equal education for all South Africans as well as caring for all the people of
South Africa in the health care sector. The result is that, in educational circles, educational
reform has become an urgent need because of the increasingly diverse composition of our
students and clients in the health care sector. In the future, health sciences educators, both
practising and aspiring, will be expected to reflect the cultural diversity of their students in their
teaching methods, attitudes and behaviour. This module will give you the opportunity to apply
the knowledge you have gained from other health sciences education modules and from your
study of the content of this module to teaching and learning in a transcultural health milieu.
Multicultural education is an approach to education which aims at taking account of the

diversity of the student population. This module is an attempt to prepare you for the challenge
that awaits you as an educator in a multicultural situation.
Please do not study this module in isolation. We want you to view health sciences education
holistically. This means we want you to integrate everything you know about the health
sciences into a ``whole''. The content of other health sciences learning areas, as well as general
education learning areas, is an integral part of this module and your teaching plans must reflect
this.
Purpose of the module

In this module, which constitutes various topics from the field of transcultural nursing and
multicultural education, we shall examine certain methods used by people from both western,
or modern, and indigenous societies, to perceive, interpret, explain and classify culturally
diverse nursing education.
Through your studies of culturally diverse education, we also wish to develop your ability to
evaluate information critically and to promote your awareness of the diversity in health issues
around the world. We also intend to develop your perception of your surroundings and
increase your sensitivity toward the beliefs and patterns of health behaviour of those people
whose sociocultural background differs from your own.
This module deals with the following issues.
In this module we focus on a conceptual framework of cultural competence for health sciences
educators, adapted from Campinha-Bacote's cultural competency model of care (1994). Health
professionals are waking up to the critical need to become more knowledgeable and culturally
competent in order to work with individuals from diverse cultures. This awareness in health
sciences education presents a major professional challenge.
We start by giving an overview of cultural competence, after which you will be introduced to a
conceptual model or conceptual models of culturally competent care. The rest of the study
guide will guide you through the main aspects of the adapted model. This model can provide
health care educators with a framework for teaching students how to deliver culturally
competent care/teaching.
This study guide for HSE3701 is divided into five study units.
(vi)
Study unit 1 focuses on models and theories for culturally competent health care; in study unit
2 we discuss cultural encounters in health care; study unit 3 deals with cultural awareness in
health care; in study unit 4 we discuss cultural knowledge in health care; and in study unit 5
(the last study unit), we shall guide you through cultural skills in health care.
Although you have two books prescribed for this study unit, we would urge you to do further
reading. There are many articles available on these topics. You could also look out for relevant
articles in newspapers and magasines.
We hope that you will find this module enriching and that it will stimulate you to become a
culturally competent health sciences educator.
As stated earlier, this module is structured according to Campinha-Bacote's (1996) adapted

model of cultural competence.
C
U
L
T
Cultural encounters U Cultural knowledge
R
A
L
C
O
M
P
E
T
Cultural sensitivity E
and awareness N Cultural skill
C
E
Culturally competent nursing care

(adapted from Campinha-Bacote 1996)
The process of cultural competence in the delivery of health sciences education is a framework
of cultural competence that identifies cultural encounters, cultural awareness, cultural
knowledge and cultural skill as constructs of cultural competence.
These four constructs are interrelated, and no matter where health sciences education comes
into the picture, all four constructs must be dealt with. However, it is the interplay of these four
constructs that reflects true cultural competence.
HSE3701/1 (vii)
To help you work through this study guide we have used a number of icons. The following is a
key to the way the icons are used:
When you see this symbol it means you must do the given activity. We may ask you to
use given information, think about topics not yet introduced, find your own
information or ask for information from other people. Please read the instructions
carefully.
This symbol indicates feedback on the activity. It may be reinforcement of information

given previously or pointers to direct you to information that is still to be given. Use
the feedback to evaluate your activity.
This symbol indicates the learning outcomes you should be able to achieve.
When you see this symbol, use your prescribed book to read the pages you are
referred to. Do this before you carry on with the next section of the work.
After having worked through this module you should be able to
& describe the foundations of transcultural nursing

& apply transcultural nursing concepts to health sciences education in diverse settings
& identify the challenges in transcultural health sciences education
& demonstrate an awareness of and sensitivity to all cultural components necessary for
health sciences education
& demonstrate your insight into cultural knowledge gained
& successfully plan teaching for culturally diverse students
& develop teaching strategies for a diverse class
& analyse various teaching strategies which can be used in a multicultural health setting
Composition of the study package

The tutorial matter for this module includes this study guide, and various tutorial letters which
you will receive from time to time. If you wish to read more about the field and scope of
culturally diverse education, you can consult the list of literature cited at the back of this study
guide to help you choose suitable references. Whenever you read something in other sources
you should question it and relate it to the discussion in the study guide.
The recommended learning process

The following points are important to our recommended learning process:
& Time management. To deal with this module effectively, you should spend at least 120
hours on it. Work on this module includes 40 hours of reading and studying the tutorial
(viii)
material, 40 hours of activities and assignments and 40 hours of preparation for the
examination. The examination will require you to draw on knowledge, and to express
your ideas clearly and concisely in written answers to questions. You should plan your
study programme now and keep to it. Without careful planning, you are unlikely to
succeed in the examination.
& Mastering academic skills. Besides mastering the content of this module, you will also
have to acquire certain skills which are explained in the HEAALA/301 tutorial letter, in
the course of your studies. The assignments are designed to help you develop these
skills, and the extent to which you have acquired them will be tested in the examination.
Acquiring the necessary skills is also closely linked to the self-testing questions and
activities included in each study unit it is therefore in your best interest to pay careful
attention to these exercises. Keep a list of skills handy and check regularly which skills
are involved before you answer an activity or assignment. As a university graduate, it is
likely that your ability to summarise, synthesise, compare, criticise and integrate
information from various sources will stand you in good stead in your work situation.
& The study guide. Sometimes this study guide actually provides you with the full text of
information needed, because some of this required information is not covered in your
prescribed book. It also includes guidelines on how to tackle your studies. If you want to
succeed in this module, you should follow the instructions and guidelines in the study
guide very carefully.
& The table of contents. The comprehensive table of contents of the study guide
constitutes the syllabus framework. Use the table of contents to orient yourself when you
approach a particular study unit, or when you want to locate a particular idea, principle,
theory or concepts in your tutorial matter.
& Learning outcomes. At the beginning of each study unit there is a list of learning
outcomes to focus your attention on certain important matters. At the same time, these
learning outcomes will help you direct your study of the particular study unit and remind
you of details that are presented as part of the broader topic.
& Cross-references. Pay attention to cross-references in different study units. Where we
refer you to work that has already been done in another study guide, read the reference
both to refresh your memory and to improve your understanding of the subject. What is
important in a study guide on culturally diverse education is the fact that basic ideas or
principles are mentioned again and again; therefore, unless you master these ideas or
principles when they are first dealt with, you will have difficulty understanding the work
later on. This means that, to a large extent, the discussion builds on information which
has already been dealt with. Reading cross-references may be rather awkward, but doing
this will make it easier for you to master the work, especially concerning your first-year
and second-year health sciences education modules.
& Activities. Study is an active process which requires you to get involved or to interact
with the information. At various places in the text, therefore, we have included activities.
These are exercises that will require you to reflect on work covered, test your own
understanding and, finally, assess your work. Always write down your response to an
activity. The activities are clearly marked and numbered. Self-assessment is an essential
part of self-study, so keep a notebook handy in which you write down your responses to
the activities.
& Self-testing questions. Most study units conclude with some self-testing questions. You
can use these self-testing questions to determine how well you have mastered a
particular study unit and achieved the learning outcomes. You don't have to submit the
answers to the questions for evaluation and correction. The questions should not be
regarded as the only ones that can be set on a particular study unit, but they are typical
of the type of questions you can expect in the examination.
HSE3701/1 (ix)
& Learning ± not the same as memorising. We expect you to understand and apply the
basic principles of what is taught in the module, not just memorise them. Also keep in
mind that you must accept responsibility for your own studies.
& Assignments.. Assignments for this module are provided in Tutorial letter 101.
Completing assignments is crucial if you want to achieve the learning outcomes. By
completing the assignments you can develop a feel for the type of question you can
expect in the examination and obtain first-hand feedback from your lecturer. The
assignment questions might, for instance, give you the opportunity to apply theory in the
classroom and/or teach patients in the clinical setting. It is important that you give of
your best in each assignment as the mark of each assignment counts toward your year
mark.
Assessment of the module

During the year you will be assessed on the basis of your assignments against criteria linked
directly to the module outcomes. All the assignment marks will be taken into account in the
final assessment of your total mark. You will receive a full mark guide with every assignment
submitted. Further details of the assessment and examination requirements of this module are
provided in Tutorial letters 101 and 102.
We hope that you will find this module challenging and that you will be able to use what you
gain from it in the classroom and in the clinical field.
Prescribed reading for this module

Andrews, MM & Boyle, JS. 2003. Transcultural concepts in nursing care. 4th edition. New
York: Lippincott.
Tjale, A & De Villiers, L. 2004. Cultural issues in health and health care. Cape Town: Juta.
Recommended reading for this module

Billings, DM & Halstead, JA. 2005. Teaching in nursing: a guide for faculty. 2nd edition. St
Louis: Elsevier (already in your possession).
Campinha-Bacote, J, Yahle T & Langenkamp, M. 1996.The challenge of Cultural Diversity for

Nurse educators. The Journal of Continuing Education in Nursing 27(2): 59±64.
Giger, JN & Davidhizar, RE. 2004. Transcultural nursing assessment and intervention. 4th
edition. St Louis: Mosby.
Helman, CG. 2007. Culture, health and illness. 5th edition. New York: Hodder Arnold.
MunÄoz, C & Luckmann, J. 2005. Transcultural communication in nursing. 2nd edition. New
York: Thomson Delmar.
(x)
1
m
1.1 Introduction
Models for culturally
competent care
(Louise de Villiers)
Any field of study has theoretical foundations, because theories and models which have been
developed by scholars are continuously tested and developed, resulting in an ever-expanding
body of knowledge. Similarly, to grasp the essence of a field of study, it is necessary to
understand its theoretical foundations. Therefore, in this study unit we are about to introduce
you to some theories and models that underlie culturally competent care.
After you have worked through this study unit you will be able to
& apply knowledge about the theoretical foundations of culturally competent care to health
sciences education
1.2 Leininger's theory: culture care diversity and universality

We start off this study unit by discussing Leininger's theory on culture care diversity and
universality. Although reference is made to nursing in this theory, the principles are applicable
to other health sciences as well. You have to keep your own profession in mind while studying
this theory.
Please study the prescribed book (Tjale & De Villiers 2004:21± 23) and the
recommended book by Andrews and Boyle (2003:3±4,6±11,257,265). Combine the
discussions on Leininger's theory in your prescribed book with the discussions below
to get an overview of the theory. Use the sunrise model as a frame of reference to help
you understand the structure of the theory.
HSE3701/1 1
Leininger's theory on culture care diversity and universality focuses on transcultural nursing as
a formal field of study. The theoretical aim is to contribute towards rendering culturally
congruent care to individuals, groups, communities and institutions by creatively combining
the professional and generic health care systems. The central theme of Leininger's theory is
culture care, which is described by Leininger (1991:44) as the broadest holistic means to
know, explain, interpret and predict nursing care phenomena to guide nursing care practices.
Culture care refers to the values, beliefs and patterned life ways that enable us to maintain our
wellbeing and to deal with illness, handicaps or death. To Leininger, care is the essence of
nursing. It is culturally learnt and defined. Care is essential for wellbeing, curing and healing,
as there can be no curing without caring. Caring is regarded as the actions and activities that
people engage in to help others to improve a human condition or to face death.
Leininger (1991:49) identifies seven cultural and social structure dimensions that influence
humankind's perception of health, illness and care. These seven cultural and social structure
dimensions are cultural universals because they are inherent in each and every culture.
However, the characteristics of each dimension may vary from culture to culture. The seven
cultural and social structure dimensions, or cultural universals, are
& technological
& religious and philosophical
& kinship and social
& political and legal
& economic and educational
& cultural
& life ways
These cultural universals are shaped by the broader worldview of a particular culture, and are
therefore also culturally diverse. For instance, the nature of the kinship structure varies from
culture to culture. In some cultures the nuclear family is the basic family unit, while the
extended family or even broader kinship structure is found in other cultures. The seven cultural
and social structure dimensions should be understood within the context of the environment in
which a particular cultural group lives, their ethno-history and their language. The position of
nursing (and other health professions) relative to the professional and generic (folk) health care
systems, as stated by Leininger (1991b:37-38), could be utilised to conceptualise the role that
health professionals need to fulfil in their attempt to render culturally congruent care. The
worldview, cultural universals, history and environment of a particular culture influence the
views and expectations, of its members, about health and care. The professional health care
system represents the biomedical (or scientific) approach to health, sickness and health care.
The generic health care system represents the sociocultural perspectives. Health professionals
are trained according to the biomedical perspective.
However, training in transcultural nursing (or anthropology of health) could give our students
insight into cultural differences with regard to health and sickness, and enable health
professionals to achieve the aim of the theory, namely to render culturally congruent care to
individuals, families, groups, communities and institutions. Culturally congruent care is
provided by combining the professional and generic health care systems creatively through
three modes of judgment, decisionmaking and action:
1 culture care preservation/maintenance
2 culture care accommodation/negotiation
3 culture care repatterning/restructuring
in order to preserve, adapt and restructure care values, life ways and practices.
2
Culture care preservation is focused on maintaining those cultural practices that are harmless
and incorporating them into the care plan of a client. An example of a harmless practice is the
utilisation of the wider kinship structure for social support. Culture care accommodation refers
to negotiating, with clients, some adaptations to cultural practices in the interest of their
wellbeing, especially if there is a possibility that safe health care delivery could be
compromised. An example is the use of traditional remedies which, if taken together with
prescribed medication, could place the lives of clients in danger. Health professionals should
negotiate with clients who use such remedies, to stop taking them until the prescribed course
of medication has been completed. Culture care repatterning refers to helping clients to change
harmful cultural practices and to replace them with less harmful ones in the interest of their
own wellbeing. An example is the practice of treating diarrhoea by administering an enema.
Culturally congruent care is described by Leininger as acts and decisions that are tailor-made
to fit in with the values, beliefs and life ways of clients and are certain to lead to service delivery
which is meaningful, beneficial and satisfactory to clients.
1.1
Reflect on Leininger's theory. Make notes about its influence on health sciences
education.
Leininger's theory highlights the importance of teaching students how to render

culturally congruent care by combining the biomedical and the sociocultural health
care perspectives. Educators must therefore teach students to look at health and
sickness from both these perspectives. These different perspectives about health and
sickness are discussed in full in study units 4 and 5. It is also necessary to
understand the manifestations of the cultural universals within the context of the
worldview, environment, history and language of a particular culture. Educators must
therefore include anthropology in the curriculum in order to allow students to acquire
this understanding. Because educators are specifically dealing with health care they
must teach students that there are cultural differences with regard to beliefs and
practices related to health, sickness and care. It would therefore also be appropriate to
include courses such as transcultural nursing (or anthropology of health) in the
curriculum. The tools that health professionals need to apply in order to render
culturally congruent care are the three modes of judgment, decisionmaking and action.
This implies that educators must develop the skills of critical thinking,
decisionmaking, clinical judgment and negotiation in students that would enable
them to use the three modalities appropriately. Have you thought about including a
local language in the curriculum? It would be much easier for your students to
understand those to whom they render care if they were able to speak the language of
the health care recipient.
Apart from teaching students the principles of anthropology and transcultural nursing
(or anthropology of health), it is also necessary to provide them with culturally
congruent learning experiences. Educators could do so by, for instance, assessing
each student's learning style and preferences and using different teaching strategies to
ensure that each student's preferences are accommodated at some point in time.
Students could also be exposed to multicultural learning experiences, both in the
classroom and in clinical settings. This is to ensure interaction with clients of diverse
cultures.
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1.3 Ramsden's cultural safety theory
The next theory that we will share with you is a theory that is widely used in New Zealand,
namely Ramsden's cultural safety theory. This theory is also applicable to the African
continent, for reasons that will become apparent to you as you read through this section.
In New Zealand, the concept of cultural safety is entrenched in nursing education and nursing
practice, and health professionals strive to render culturally safe care (New Zealand Nursing
Council 1996).
Cultural safety is seen from the perspective of the recipients of health care, with specific
reference to how they experience the care that they receive. Health professionals who render
culturally safe care are able to understand the power relations between the health care provider
and the recipient of health care. Because the biomedical perspective is dominant in the health
care setting, there is always a possibility that clients who belong to non-western cultures may
feel powerless and alienated. Remember that health professionals are socialised according to
the biomedical perspective during their training. To render culturally safe care, health
professionals ought to recognise their own cultural mindsets and the influence of these
mindsets on the therapeutic relationship. They must also recognise cultural differences that
could jeopardise culturally safe health care. Health professionals who render culturally safe
care are able to engage in actions which recognise, respect and nurture the unique cultural
identities of the recipients of health care, and safely meet their needs, expectations and rights.
Culturally competent health professionals are able to enter into partnerships with clients, which
enable the clients to comment on care. This should lead to reinforcement of positive
experiences and opportunities to be involved in changes to those services that were negatively
experienced by clients.
The process associated with culturally safe care is characterised by three stages:
& cultural awareness
& cultural sensitivity
& cultural safety
The first stage is that of cultural awareness, which means appreciating that there are cultural
differences to overcome. Health care providers involved in a multicultural encounter should
also recognise any negative attitudes on their part towards stereotyping individuals from a
different culture. During the stage of cultural sensitivity, health care providers learn to
understand the legitimacy of cultural differences. They reflect on the impact that their own
attitudes, metaphors, beliefs and values may have on the therapeutic relationship. The cultural
safety stage is characterised by a willingness to translate cultural awareness and sensitivity
into health care delivery which will satisfy the health care recipient.
1.2
Reflect up the cultural safety theory and write notes on its influence on health sciences
education. Use the feedback to the activity in which the application of Leininger's
theory is explained to guide you.
4
We have given comprehensive feedback on the application of Leininger's theory. Here,
we will merely list some key ideas that you could use to guide you in the application
of Ramsden's theory.
Principles to teach students are

& equal partnerships and shared power in health care
& respect for cultural differences
& empowerment of the community to participate in their own health care
Principles to apply in the teaching-learning environment:

& creating a democratic learning environment for students
& creating learning opportunities that promote active student involvement
& empowering students to participate in decisionmaking pertaining to their training
& providing learning opportunities to take students through the stages of cultural
awareness, cultural sensitivity and cultural safety
1.4 Giger and Davidhizar's cultural assessment model

We now introduce you to the cultural assessment model designed by Giger and Davidhizar.
Before we do so, we need to make some introductory remarks to explain the importance of
cultural assessments, be it in educational or clinical settings.
Spector (1991:xv-xvi) acknowledges the fact that we are all culturally unique individuals and
that this uniqueness is due to our cultural heritage. This applies to educators, students and the
clients to whom students render health care in the health care setting. Spector states that each
person enters the health professions with culture-bound definitions of health and sickness, and
of health practices. This, of course, also applies to educators' views about education and
educational or learning practices. However, professionals' ideas change as they are socialised
into the health care professions, and into the field of health sciences education. It is important
that we, as health professionals and educators, become more sensitive to how our views have
changed and the differences that may exist between ourselves and our clients, whether they are
students or health care consumers. This is to prevent a schism from developing between the
health care provider (or educator) and health care consumer (or student).
1.3
Read Ramsden's theory again and make notes on similarities in the thinking of
Ramsden and Spector.
Both theorists recognise the fact that the training that health professionals receive
results in changed views on matters such as health and health care. According to
Spector there is a potential schism between the health care provider and the client.
Ramsden concentrates on the experiences of the client and states that clients may
have a sense of powerlessness in the health care setting as a result of the differing
views of the health professionals and clients. This underscores the importance of
HSE3701/1 5
developing cultural competence in health professionals.
The uniqueness of each client requires that health professionals conduct culturalogical
assessments in an attempt to determine the culturally determined views and needs of
those whom they are caring for. Health professionals must also be sensitive to the fact
that the perspectives of their clients may differ from theirs, and that such differences
are mostly acceptable and need to be accommodated in health professionals'
interactions with clients. This brings us to the next model: Giger and Davidhizar's
cultural assessment model.
Study Giger and Davidhizar's cultural assessment model in Tjale and De Villiers
(2004:25±26,159±174).
Giger and Davidhizar's model provides a theoretical framework for cultural assessments as it
spells out what health professionals have to include in such assessments. Note that the
prescribed book by Giger and Davidhizar, and study unit 5 of this study guide, are structured
according to this model. Substance will be given to this model in study unit 5 where we
discuss culturalogical assessment.
1.4
Reflect on Spector's thoughts and Giger and Davidhizar's cultural assessment model
and make notes on how their principles could be applied to health sciences education.
You could have included points such as exposing students to self-knowledge

exercises to encourage them to reflect upon their own ideas and beliefs on health care.
Giger and Davidhizar's cultural assessment model could form part of the curriculum
content and could serve as a framework for teaching students how to do culturalogical
assessments.
Next, we will shift the focus of our discussions to the issue of dealing competently
with culturally diverse clients.
1.5 Campinha-Bacote's model

Let us consider what we have discussed so far. Firstly, we said that health professionals should
aim to render culturally congruent care by combining the professional and the generic health
systems. Health professionals do this by using the three modes of judgment, decisionmaking
and action as explained in our discussions about Leininger's theory. Then we discussed how
cultural safety could be promoted by recognising, respecting and nurturing the unique cultural
identities of the recipients of health care, and entering into partnerships with them, thus
empowering them to participate in their health care. The ability to do cultural assessments is
important as it enables us to recognise the needs and expectations of our clients. It is therefore
important that we understand how to do such assessments. Furthermore, we stated that
educators should be aware of changes in their views about education and that they must assist
students to become aware of how their views on health have changed as a result of completing
an educational programme.
6
All of the above bring the question of cultural competence to mind. What skills do students
require to enable them to function in culturally diverse settings? Educators have to understand
what cultural competence is and how they can go about developing it in students.
Study Tjale and De Villiers (2004:26±28,30±42) and Andrews and Boyle (2003:15±
21) and make notes about the nature of cultural competence, why health professionals
need to be culturally competent, and how cultural competence is developed. The
cultural competence theory is described very briefly in your prescribed book and we
will explain some aspects here. It is your task to integrate our discussions with those
in the prescribed book.
Cultural competence is the process in which the health care provider continuously strives to
achieve the ability to work effectively within the cultural context of a client. A client could be an
individual, family or community. The constructs of cultural competence are cultural awareness,
cultural knowledge, cultural skill, cultural encounters and cultural desire. If we are to be
culturally competent there must be an intersection of these constructs, which means that they
all must be present during our dealings with people from different cultures.
Cultural awareness is the deliberate cognitive process in which health professionals become
appreciative and sensitive to the values, beliefs, life ways, practices and problemsolving
strategies of clients' cultures. It also means that health professionals examine their own cultural
backgrounds, and their prejudices and biases towards other cultures. This is done in order to
minimise ethnocentrism on their part, and enable them to adopt an approach of ethno-
relativity. This can be done by developing a mutually acceptable care plan, based on data
gathered through cultural assessments, which incorporates the client's values, beliefs, life
ways and practices.
Cultural knowledge is the process of seeking and obtaining a sound educational foundation
concerning the worldviews of different cultures in order to gain an understanding of such
differences. Worldviews will be discussed in detail in study unit 4. To obtain cultural
knowledge, students must understand the relationship between culture and health practices.
This is explained further in study unit 4.
Cultural skill is the ability to collect relevant objective and subjective cultural data from
culturally diverse clients during a cultural assessment. How to do a cultural assessment is
discussed in full in study unit 5.
Cultural encounter is the process which encourages health professionals to engage directly in
cross-cultural interactions with clients from culturally diverse backgrounds. Face-to-face
experiential encounters with many clients give health professionals the opportunity to refine or
modify their existing beliefs about a particular cultural group. Such encounters help to
counteract any possible stereotyping that may have developed when academic knowledge was
obtained.
Cultural desire refers to motivation on the part of health professionals to engage in the process
of cultural competence. They must have the genuine desire to work with culturally diverse
clients in a caring manner. If health professionals are to be effective in rendering culturally
competent care, the client must have a positive experience of his or her encounter with the
health professional. When we speak of a positive experience we mean one which leads the
client to feel valued.
In the next activity we give you the opportunity to apply what you have learnt.
HSE3701/1 7
1.5
Explain the implications of Campinha-Bacote's model for health sciences education.
Again, you could have mentioned that educators have to include subjects such as
anthropology and transcultural nursing (or anthropology of health) in the curriculum.
This is to develop the knowledge component of cultural competence. Educators must
also provide learning experiences that could help to foster in students the attitudes
necessary for respecting and accommodating cultural differences. Here, cultural
awareness learning opportunities and learning opportunities aimed at developing
respect in students would be appropriate. Self-knowledge exercises and group
discussions involving culturally diverse groups would be appropriate here. Certain
skills have to be developed in students, an example of which is the ability to do
culturalogical assessments. It goes without saying that relevant knowledge and respect
are prerequisites for gathering and analysing cultural data. Students must be given
opportunities to function in culturally diverse settings, thus paving the way for
appropriate cultural encounters. The aim must be clinical placements of students, to
give them the opportunity to interact with culturally diverse individuals, families or
groups, and apply what they have learnt in these settings. This will also help them to
gain insight into the fact that not all members of any particular culture are exactly
alike, and that health professionals should be alert to the dangers of stereotyping.
Educators' accompaniment of students must foster the development in students of a
truly caring attitude towards their clients. Educators must create ample opportunities
for students to participate in follow-up discussions on what they have experienced in
clinical settings. These discussions will also be an opportunity for peers to suggest
other appropriate response options.
We have discussed a few models and theories that underlie the field of cultural
competence. Next we will contextualise our discussions by including Ubuntu.
Although Ubuntu is not a cultural competence theory or model, it represents a
particular way of looking at the world, which is especially relevant to the African
continent.
1.6 Ubuntu
Educators in the health sciences have to prepare their students to function in a specific context.
To most of you, this is an African context. It is therefore imperative that we include a study of
the main principles of Ubuntu. The main tenets of Ubuntu and their implications for heath
sciences education are found in Tjale and De Villiers (2004:19±21,165±166, 207±208).
1.6
Explain the main tenets of Ubuntu and their application in health care delivery and
health sciences education.
8
Refer to Tjale and De Villiers to refresh your knowledge.
The main tenets of Ubuntu are found in the prescribed reading. We shall, however, give you
some guidance on how to apply Ubuntu to health sciences education. We provide only some
key ideas and it is your responsibility to add substance to the suggested structure.Curriculum
content:
(1) Anthropology
(2) Transcultural nursing (or anthropology of health)
(3) Environmental studies
(4) Ethos and professional practice ± personal autonomy balanced with social responsibility
(5) Principles of community involvement, empowerment, social change
(6) Critical thinking skills, problemsolving skills
Role of the educator/student:
(1) Educator available, caring, respectful

(2) Student actively involved
Learning climate:
(1) Democratic, caring

(2) Open communication
Educational strategies:
(1) Problem-based learning

(2) Community-based education
(3) Cooperative learning, group work
(4) Strategies for learning on an individual basis ± complementary to cooperative learning
Evaluation of learning:
(1) Problem-based approach

(2) Focus on the ability to meet relevant social health needs
(3) Credit for individual achievement and contribution to the group or towards community
development
(4) Awarding of credits to groups for collaborative assignments as opposed to individual
credits
1.7 Cultural competence

Developing cultural competence is a professional expectation for all health sciences educators.
Because culture and communication are strongly linked and the population needing health care
services has become increasingly diverse, student nurses need to demonstrate core knowledge
and skills in providing care and education to clients with different backgrounds. It is important
that all health care providers respond with respect and sensitivity when interacting with
students, clients and families from different cultural backgrounds. We will discuss cultural
competence in this section and the actual competencies, that is cultural awareness, cultural
knowledge, cultural skill and cultural encounters, in ensuing study units.
HSE3701/1 9
1.7
1 Revise the term ``culture'' and cultural competence in chapter 3 in Tjale and De
Villiers (2004). Make sure that you understand the concept of culture as one of
the central concepts of multicultural education.
To sum up, ``culture'' may be defined as follows:
Culture is the sum total of a specific group's activities (represented by symbols
and artifacts in the material and non-material world) whereby the group behaves
in a creative, self-improving, self-caring and adaptive manner according to
traditional values and norms (historically cultivated and selected). Culture may be
viewed as either the result of a group's activities or the condition for further
activity.
2 For further reflection: Do you agree with the summary of culture given? Could you
add anything to it?
................................................................................................................................
................................................................................................................................
3 Select any two cultures in your country and compare them. Indicate the
differences and similarities in the table below:
Culture Differences Similarities
4 Select two other cultures and discuss the following aspects of their cultures:
& language
& religion
& clothing
& eating habits

& literature
& famous members

Do you think your knowledge of these cultures is sufficient? If not, how would you
supplement/increase it?
5 Define ``cultural competence'' and explain how a health sciences educator can
ensure culturally competent education to a class of culturally diverse nursing
students.
................................................................................................................................
6 How would you as a health sciences educator develop cultural competencies in
your students?
10
1.8 Summary
We have come to the end of the study unit on the theoretical foundations of cultural
competence. We will refer back to this section in other study units. Take note that one or a
combination of these theories and models will be used as points of departure for discussions
in the subsequent study units.
1.9 Self-testing questions

1 How would you as health sciences educator apply Leininger's sunrise model in your
classroom?
2 Explain how you would incorporate Ramsden's cultural safety theory when designing/
developing a curriculum.
3 Indicate how you as a health sciences educator will incorporate the knowledge found
after doing a cultural assessment with the students in your classroom.
4 Explain the implications of Camphina-Bacote's model for health sciences education.
5 Describe the main tenets of Ubuntu and their application in health sciences education.
6 Provide a framework in which a health sciences educator could instil culturally
competent education in the nursing curriculum.
HSE3701/1 11
2
c Cultural encounters in
health care
Prescribed reading material

Andrews, MM & Boyle, JS. 2003. Transcultural concepts in nursing care. 4th edition.
Philadelphia: Lippincott.
Recommended reading material

Giger, JN & Davidhizar, R. 2004. Transcultural nursing: assessment and intervention. 4th
2.1 Introduction
In the previous study unit you were introduced to models for culturally competent health care.
Culturally competent care is care that is sensitive to individual differences. These differences
may be ascribed to various factors: ethnicity, cultural background, sexual orientation or
socioeconomic status. A culturally competent health professional is able to recognise the
differences and to base care on understanding how those differences influence people's
behaviour. According to Meleis (1999:12), a culturally competent health professional will have
knowledge of diversity in communication patterns, of styles and protocols and of how language
and communication may influence the development of trust in relationships. This study unit
focuses on factors such as intercultural communication, ethnicity and ethnic identity, social
class and urbanisation. It is essential that the educator teaching in a multicultural milieu
should be knowledgeable about the influence of these factors on learning and include cultural
12
awareness in his or her teaching practices and, by using culturally competent teaching
practices, prepare students for cultural awareness in practice.
After you have worked through this study unit you should be able to
& demonstrate ability to apply cultural awareness in your teaching practices

& explain the role that culture plays in the understanding and perception of time and space
& communicate with a culturally different people, taking into account the verbal and
nonverbal attributes that might influence communication
2.1
Read/scan chapters 4 and 7 in Tjale and De Villiers, forming a broad idea of the
contents. While you are reading, ask yourself: What key terms occur in this section?
Mark them in your book.
2.2 Intercultural communication

Communication between individuals with the same cultural background can be full of pitfalls.
Therefore, when you communicate with people from cultural backgrounds that differ from your
own, or with those who have to communicate in a language other than their mother tongue, the
likelihood of misunderstanding increases significantly. In effective communication there is
mutual understanding between the people involved. Barriers to communication include
differences in language, worldview and values. In promoting effective intercultural
communication, you should also be aware that your own perceptions of time, space,
distance, touch and other nonverbal factors, as well as the perceptions of the student or client,
might influence communication.
According to Giger and Davidhizar (2004:22), health professionals require a thorough

awareness of racial, cultural and social factors that may affect communication with persons
from other cultures. They must also be aware that individuals, though speaking the same
language, may differ in communication patterns and understanding as a result of a unique
cultural orientation. They must also have the communication skills that would enable them to
relate to individuals who do not speak a familiar language.
2.2
Read chapter 2 in Giger and Davidhizar book and summarise it.
2.3 The process of communication

Although the process of communication is universal, styles and types of feedback may be
unique to certain cultural groups. Health professionals/educators/managers should be aware
HSE3701/1 13
not only of this position but also of the fact that many factors influence the way the message is
given and received. These factors include physical health and emotional wellbeing,
communicating skills, the environment in which the communication occurs and past
experiences that relate to the current situation.
2.4 Verbal and nonverbal communication

Communication can be described in terms of verbal and nonverbal behaviour.
2.4.1 Verbal communication

Verbal communication includes components such as vocabulary, grammatical structure,
pronunciation and intonation. In dealing with culturally diverse students or clients you should
begin with an assessment of the dialect, style and volume. The dialect differs among people
living in different parts of a country, while language styles often differ among and between
cultural groups. Persons in certain cultural groups amplify the volume of their voice when
talking, while others lower their voice. An educator/health professional who correlates
loudness with anger may misinterpret what should be perceived as a normal communication
pattern. People in other cultural groups may utilise silence as a mode of communication (Giger
& Davidhizar 2004:26±30).
2.3
Read and summarise chapter 7 in Tjale and De Villiers and chapter 2 in Giger and
Davidhizar in your prescribed books.
2.4.2 Nonverbal communication

Nonverbal messages are conveyed by touch, facial expression, eye movement and body
posture, for example. According to Giger and Davidhizar (2004:30), nonverbal communication
is powerful and honest, but its meaning and importance vary among and within cultures. They
conclude that health professionals should have an awareness and appreciation of the role that
body language may have in the communication process.
In some cultural groups, people communicate through touch as a vehicle to convey their
feelings and emotions. Other groups might, however, interpret touching as intrusive or having
a sexual connotation and therefore react negatively when touched. In some cultures
handshaking has cultural significance and symbolism and is learned behaviour, whereas
lengthy, vigorous handshaking is considered aggressive by others.
Giger and Davidhizar (2004:30) assert that a broad body of knowledge supports the premise
that through body movement a person may convey what is not verbalised. There are endless
expressions of body movement, such as finger pointing, head nodding, smiles and slaps on
the back, to name but a few. Kinesics refers to the use of gestures and eye behaviour when
people relate to each other. In some cultures the use of eyes is an important aspect of
communication, for example when eye contact is restricted or avoided.
14
2.5 Other cultural phenomena which might influence cultural
encounters
2.4
You have summarised chapter 3 in Giger and Davidhizar. Can you define the term
"personal space"? You may consult your prescribed book again.
2.5.1 Space
Space refers to distance and intimacy techniques that people use when relating verbally and
nonverbally to others. You should have noted in your prescribed book that space is divided
into inner and outer space. There are four distinct zones of interpersonal space (Giger &
Davidhizar 2004:45). These authors cite Hall (1966). These are the intimate, personal, social
consultative and public zones. The intimate zone is reserved for close personal relationships
such as comforting, protection and lovemaking. Invasion of the intimate zone during other
types of interaction is considered taboo in some cultures. The personal zone is the space where
touching is permitted by family members and friends, but may also be considered appropriate
during some counselling interactions. The social consultative zone is maintained in a work
environment or in casual social gatherings, and the public zone is outside the sphere of
personal involvement and verbal communication is formal. After you have summarised the
chapter on space in your prescribed book, do the following activity.
2.5
Explain what cultural universals are and indicate the difference between universals
within a culture and universals between cultures, by referring to specific examples.
2.6
Explain how ``time'' can influence nursing care chapter 5 in Giger and Davidhizar and
summarise it.
2.5.2 Time
Cultural groups can be oriented to either the past, the present or the future. Giger and
Davidhizar (2004:199) maintain that those who focus on the past strive to maintain tradition
and have little motivation to formulate future goals. People who are oriented to the present tend
to be unappreciative of the past and do not plan for the future. The present task is viewed as the
HSE3701/1 15
most important. People with a plan oriented to the future will organise present activities to
achieve future goals. According to Giger and Davidhizar (2004:202), people who are future
oriented tend to `ùse'' people, who are considered less important than their ultimate aims; thus
they are regarded as cold and heartless.
After you have read the prescribed chapter you should be aware of the differences between
social time and clock time. The most fundamental difference in the meaning of time occurs
when cultural groups measure time predominantly by either social events or the clock. When
measured by social activities, time has significance only in terms of the activities taking place.
When time is measured by the clock, it has significance only in terms of money, which is
perceived to be a scarce commodity: all activities take place in the shadow of the clock (time is
money) (Giger & Davidhizar 2004:105). You should remember that time and punctuality vary
considerably from place to place and region to region. It is important not to stereotype people
but to be aware of differences and accommodate them in the work environment. You should be
aware that time may be perceived differently by individuals from diverse ethnic, cultural, age
and socioeconomic groups and that the first step to increasing tolerance for time-related
cultural behaviours is to accept that there are different ways of perceiving time.
2.7
What, according to Giger and Davidhizar (2004), are the verbal and nonverbal
attributes that the health professional/educator must be aware of when communicating
with a culturally different client/student/colleague?
Did your answer include attributes such as vocabulary, voice qualities, rhythm, speed and
pronunciation? Nonverbal attributes which should have been included are touch, facial
expression, eye movement and body posture.
Health professionals, educators and managers commonly have to relate to people from
different cultures. Giger and Davidhizar (2004:34) present guidelines for relating to clients from
different cultures which might, if adhered to, increase the likelihood of ensuring a positive
relationship between people from different cultures.
2.8
1 Work through the ten guidelines presented in Giger and Davidhizar.
2 Describe approaches that you can use when relating to someone whose primary
language differs from yours.
3 Discuss these guidelines with a culturally different colleague.
2.9
Read chapter 4 in Giger and Davidhizar. Summarise the chapter for yourself.
16
2.6 Ethnicity and ethnic identity
Ethnicity is the condition of belonging to a specific ethnic group. Although the term `èthnicity''
is frequently used to mean race, it includes more than biological identification. In its broadest
sense it refers to groups whose members share a common social and cultural heritage passed
on to each successive generation. An important characteristic of ethnicity is that members of an
ethnic group feel a sense of identity (Giger & Davidhizar 2004:67). The difference between race
and ethnic group is explained in the following quotation from Henderson and Primeaux
(1981:xx):
Sometimes we tend to confuse race and ethnic groups within a culture. Great races do have
different cultures. Ethnic groups within races differ in cultural content. But, people of the same
racial origin and of the same ethnic groups differ in their cultural matrices. All browns, or
blacks, or whites, or yellows, or reds, are not alike in the cultures in which they live and have
their being. The understanding of the culture of another, or of groups other than your own,
demands a knowledge of varied elements within a culture or the variety of cultural matrix.
2.7 Social class

The previous two sections reveal that race and ethnicity are variables frequently associated with
low status and diminished access to power, which, in turn, is reflected in a trend toward poor
standards of health and marginality. Social class, as a further variable linked with both, is
defined as a stratum of people of similar position on a continuum of social status within a
society (Horton & Hunt 1989:2) that is organised into an overall hierarchical structure (Levine
& Havighurst 1989:2). The individual's position in the social class structure implies a certain
lifestyle, membership of particular groups, attitudes towards life chances, political affiliations,
health, child-rearing patterns and many other aspects of life. The beliefs, values, actions and
patterns of speech of social subgroups differ sufficiently to create difficulties in interactions
across and between social groups (Lemmer & Badenhorst 1997:200±201).
Social class as a structure of the dominant society has a direct influence on what services are
made available to groups. Whether knowingly or unknowingly, the middle classes dominate
the lower classes in many areas of everyday life. When basic services are made available, it is
the middle classes who mostly benefit. Community services, including health and formal and
informal education programmes, are more closely aligned with the values and activity patterns
of the middle classes. The reason is that the people most directly involved in the management
of these organisations are usually public officials, doctors, health professionals, health
educators and the like, who are drawn from the dominant ethnic and social classes. Either
consciously or unconsciously, they reflect the interests of the dominant group in the services
offered and in the way they teach (adapted from Arthur 1994:234±235).
It has been noted by Hollingstead and Redlich (Cockerham 1986:101) that the higher the
individual's socioeconomic position, the less `èthnic'' the person appears to be. They point to
the fact that black, Mexican and Asian Americans tend to acquire Anglo or white middle-class
norms and values as part of their participation in middle-class society. Socioeconomic status
as measured by education and income seems to be a much stronger predictor of health-related
behaviour than ethnicity. Ethnicity as a predictor of health-seeking behaviour is apparently
limited to the role of providing the cultural context for decisionmaking within social networks.
According to Northmore (1986:181), despite innovations and significant experimentation with
adult education, it is still the case that most adult education is associated with middle-class
value systems which the lower classes do not share. There is a need to ask whether a middle-
class ethos of adult education is the reason for a predominantly middle-class clientele or
HSE3701/1 17
whether the latter is the reason for the former. Frequently, in adult education, the mode of
knowledge presentation is biased towards the middle classes in terms of content and language.
Furthermore, the school experiences of adults discriminate between those who are labelled as
successes or failures in education.
Logically, it should be acknowledged that just because people have experienced education in
the past, there is no reason to believe that they will desire it again in the future. Ross-Gordon
(1990:7) points to the disproportionately low participation rates of Hispanic and African
Americans in adult education programmes, while Karkenwaled and Merriam (Ross-Gordon
1990:7) suggest that education is more important than race in predicting participation, since
well-educated blacks participate at similar levels to those of whites.
Such a point of view is in line with Bernstein's analysis (Jones 1992:20) of the lexical and
syntactical levels of speech, which reveals degrees of disparity between the various social
classes. He discusses the restricted code of speech of the working classes and the extended
code of the middle classes. Language is used differently at different ends of the social
spectrum, with the middle classes having the ability to control verbalised behaviour in a way
that facilitates high achievement and success in planning long-term goals. The degree of
language disparity, in turn, reflects the different social relationships which exist between
people of different social status. Not only do the beliefs, values, actions and patterns of speech
of the social classes differ sufficiently to create difficulties in interactions across and between
social groups (Le Compte 1985:112±113) but Jones (1992:19) refers to findings that different
life orientations are to be found between different classes. The lower classes are characterised,
for example, by an immediate time orientation to life in which the present, and its problems and
notions of immediate gratification, predominates. Conversely, the middle classes tend toward a
future orientation in which deferred gratification for the sake of future benefits constitutes a
cornerstone of life. Members of the middle class tend to view nature as capable of
manipulation, whereas the working classes tend to see themselves as being manipulated by
nature, rendering them more fatalistic in outlook.
It has been found that persisting social inequalities on many fronts in the United Kingdom.
Using occupation as an indicator of social position, the poorer health status of the socially
disadvantaged was revealed, not only in respect of mortality data but also in respect of
morbidity. These tendencies were evident throughout the lifecycle. Acknowledged problems,
associated with the use of occupational class as a standard, were checked against the
measures such as housing tenure and car ownership as indicators of people's command of
resources. Higher mortality rates were revealed in groups where the indicator represented a
proxy for poverty rather than for affluence. Unemployment, as another measure of social and
material disadvantage, highlighted differences in mental and physical ill-health between the
unemployed and those at work. In respect of gender, women were shown to experience lower
mortality rates, but higher morbidity rates than men. Lemmer and Badenhorst (1997:78)
reported on social class and life expectancy reinforce the importance of these socioeconomic
differentials. They suggest that on every measure, social class influences the individual's
chances of longevity.
Economic status is fundamental to health status. The links between poverty, lack of access to
facilities and services and high levels of mortality and morbidity are undisputed. Improvement
in social status among blacks in America has been related to significant improvement in health
status (Lemmer & Badenhorst 1997:79).
Hubley (1988:390) argues that health science educators in the western world have contributed
towards inequality in respect of health by using educational approaches that are inappropriate to
the poor, therefore reaching mainly the more affluent groups. Value systems prevailing in the
various classes are very different. The manner in which the poor live and perceive their
environment is not considered in the norms and organisation of western-oriented biomedical
18
health services. Assumptions are made by many health professionals that the lives of the poor in
some way reflect their own (Lemmer and Badenhorst 1997:80). People of lower socioeconomic
status are brought up sharply against the differing demands of home and of community and
health services, including that of nursing and health education, as they are called on to adjust to,
and comply with, the demands of an alien subculture which they cannot identify with. Breakdown
in communication is the inevitable result (Lemmer & Badenhorst 1997:80).
In these terms, it may be concluded that culture clash occurs not only between ethnic groups
and the dominant culture, but is also evident between the lower and middle classes of the
dominant culture. In similar vein it was noted almost three decades ago that health
professionals frequently have more in common with professionals from other cultures with
similar training and educational levels than with illiterates from their own culture.
In turn the question can be asked how many students from minority backgrounds manage to
``beat the system'', and ``make it'' successfully into the dominant group's world of employment
and future opportunity. Undoubtedly, many experience social disadvantage, but it is equally
true that an unexpectedly large number are successful, despite the socioeconomic and
ethnocultural strategies of social exclusion (closure) used by dominant groups to contain the
aspirations of minorities.
Social phenomena and aspects of human relationships cannot be ascribed to a single cause.
An examination of social class throws much light upon many aspects of health and education
in any complex society, including ethnically and racially heterogeneous societies. However, it
is unsatisfactory to accept that any one of these variables in isolation holds the answer to
problems associated with health status and learning outcomes. Doing so may lead to
incompetent cultural health care.
Integral to any discussion on ethnicity and social class in respect of health, health care and
health education is the matter of rural-urban drift and urbanisation in developing countries.
2.10
Discuss the reasons why an educator should consider the ``social class'' of her or his
students when planning teaching.
2.8 Urbanisation
Urbanisation is rapidly increasing in the southern hemisphere. Often it takes the form of
successive moves by individuals and extended family members. This results in new arrivals
joining family members who have already settled in the urban area. However, migration by
individuals, or the nuclear family, also occurs. These persons do not have a social support
system to help them to settle into the new surroundings, and adaptation to the realities of urban
life may be difficult. The motive for moving to an urban setting may be the hope of finding
employment and securing a good life, but political upheavals in rural areas also contribute to
this phenomenon.
Migrating to an urban setting has many financial and social implications. It is costly to move
one's belongings and to secure some form of housing or shelter in an urban area. The newly
urbanised are faced with dependence on a cash economy, which also requires adaptation on
their part. However, the job market is very competitive and it is hard to find suitable
employment, especially if newly urbanised people do not have the necessary skills. It is often
HSE3701/1 19
necessary to settle for a poorly paid job, and some individuals may find themselves in a
position of under-employment. This situation leads to personal hardships, and if the individual
relies on family members for support, the entire family is subjected to strain. Over time,
urbanisation also leads to a breakdown of the traditional extended kinship structure, as nuclear
and female-headed families are more prevalent in urban areas. This situation leads to a
decrease in social support during times of hardship.Urbanisation affects the health status of
communities. For instance, there is an increase in chronic, degenerative and cardiovascular
diseases. Especially in poorer urban areas, diseases and social problems associated with
overcrowding and pollution are prevalent. Urban dwellers may fear eviction, which leads to
stress-related health problems.
Given the heterogeneity and mobility of the urban community, individuals may have a
diminished sense of community. New migrants to the city may continue to identify with their
community of origin, but the identity of the new urban community will be adopted within one or
two generations. The urban community is, however, culturally diverse and the social affiliations
may not be as strong as they were in the rural setting. This may lead to loneliness and related
psychological problems.
Urbanisation inevitably leads to cultural change. Individuals and families who have moved to
an urban setting continue to identify with the traditional cultural value system that is deeply
entrenched, but they also come into contact with a blend of other cultures. People often create a
middle ground between the modern world of the urban setting and the traditional order that
they have left behind. Similarly, because of the influence of the new arrivals, the urban culture
also changes constantly.
Acculturation is a process leading to extensive cultural changes. The dominant culture in a
given situation has more influence on the less dominant culture. The result is that the less
dominant culture undergoes more drastic changes than the more dominant culture. For
instance, the dominant cultural orientation in the health care setting is the western, biomedical
perspective. Persons from traditional societies, who move to urban areas, will find that more
adaptation is required on their part than on the part of health professionals. This may lead to
conflict which is often associated with change, and to a tendency not to utilise health facilities
optimally.
In technologically advanced countries, cities have evolved in ways that have greatly
complicated the tasks of urban educators. The flight of the middle class from inner city areas
has left many cities with a high concentration of ``dependent'' individuals who have
extraordinary needs. This is reflected by high poverty rates, unemployment and low per-capita
income growth found in inner city areas. People migrating from rural areas tend to settle in
``squatter camps'' (informal housing) on the fringes of the bigger cities and towns.
Educators have to consider the fact that some of their students may come from rural areas and
have to adapt to an urban way of life. Apart from having to deal with the demands of the training
programme, students may also be faced with the realities of having to cope with the problems
associated with urbanisation. They may experience cultural conflict because of the differences
between their cultures and the biomedical perspective according to which professional
socialisation is approached. Students must also be equipped with the knowledge and skills to
render health care to communities who have to cope with the demands of urbanisation.
(Lemmer and Badenhorst 1997:80±90).
20
2.9 Conclusion
The discussion surrounding the variables associated with the circumstances within current
health, nursing and education systems clearly indicates the complexities of the issues involved
and their interrelatedness in terms of group access to opportunity, prestige and power. In areas
of health, nursing and education, perceptions of inequality and lack of opportunity related to
lifestyle developed from observations that minority groups, whether in terms of race, ethnicity
or social class, are underachievers. Such perceptions led to the conclusion that social forces
advantage some people but disadvantage others and, thereby, enable those who are already
advantaged to take further advantage of educational opportunities and health services.
This in turn led to theories of social and cultural deprivation resulting in compensatory forms
of social and health services, including nursing and health education and, ultimately, the
progressive health care movement and notions of empowerment of the disadvantaged.
It is also apparent that the more evident the physical characteristics of a group are, the more
readily identifiable the group is. Because there is a demonstrable connection between the
physical and social environment and the internalised, organised behaviour of human beings,
deductions concerning the cohesion, communality and unity of the diverse in relation to the
dominant culture are readily explained, as opposed to one that encompasses concepts of
cohesion or communality in diversity and particularly in multiculturality within society as a
whole.

1 Describe at least two problems encountered by the educator when teaching students who
do not speak English as their primary language.
2 Describe four communication approaches that the educator can use when teaching about
culturally appropriate care.
3 Explain the barriers to intercultural communication which a educator should take into
consideration when planning her or his teaching programme.
4 Write a few paragraphs about your language background and experiences that you may
have had with language in your nursing college or university. What language(s) were
spoken in your home?
5 How would you sensitise student nurses to the norms and values, and the sociocultural
complexities in general, that should be considered in classroom interaction?
HSE3701/1 21
3
c Cultural awareness in
health care


3.1 Introduction
In this study unit we deal with cultural awareness in health care and health sciences education.
In study unit 1 you were introduced to several models of cultural competence. Cultural safety is
seen from the perspective of recipients of health care, with specific reference to the way they
experience the care. According to Polaschek (1998:452), cultural safety is not merely cultural
sensitivity. It is a concept developed by Maori health professionals in New Zealand in order to
reflect on nursing practice from the Maori health care recipient's point of view as the
indigenous minority in their country. The process associated with culturally safe care is
characterised by three stages:
& cultural awareness

& cultural sensitivity
& cultural safety
22
You will also be given an overview of the role of introspection in facilitating multicultural
awareness. Furthermore you will become acquainted with cultural sensitivity and awareness,
prejudice, ethnocentrism, racism, stereotyping, cultural imposition, cultural blindness and
discrimination. While this study unit does not attempt to provide a detailed analysis of the
various concepts, it is important to define these terms, as most of them are often used in
literature dealing with culture and health care.
We view values clarification as a major strategy in helping us to become multiculturally aware.

This strategy is fundamental to our attaining self-knowledge and carrying our self-evaluation of
our attitudes towards diverse cultures. As such, these functions are imperative to our efforts to
become multiculturally aware.
& demonstrate how you have developed cultural sensitivity and awareness
& describe multicultural awareness
& implement experiential awareness strategies in multicultural health sciences education
& analyse your personal orientation about multicultural awareness
& distinguish between stereotyping and prejudice
& explain how ethnocentric beliefs, racism and cultural imposition may contribute to
problems when one deals with culturally diverse persons
3.1
1 Define and describe multicultural awareness.
2 How would you as health sciences educator ensure self-awareness? Read the
information and practise the exercises on pages 46±47 of Tjale and De Villiers
(2004). Do you have any other means of becoming self-aware? Please name
them.
3.2 Cultural sensitivity and awareness

Cultural awareness is the deliberate, cognitive process by which health care providers become
appreciative of and sensitive to the values, beliefs, life ways, practices and problemsolving
strategies of clients' cultures (Campinha-Bacote 1999:204). Because people tend to be
ethnocentric when it comes to their own values, beliefs and practices, this awareness process
must involve examination of one's own prejudices and biases toward other cultures and in-
depth exploration of one's own cultural background. Unless one is aware of the influence of
one's own cultural values, there is a risk that one might engage in cultural imposition.
However, awareness of one's prejudices and biases does not ensure culturally responsive
interventions. A culturally sensitive approach requires only an awareness of the values, beliefs
and life ways of an individual, whereas a culturally responsive approach incorporates the
individual's values, beliefs and life ways into a mutually acceptable treatment plan. Therefore,
Campinha-Bacote (1994:4) asserts that health professionals must go beyond cultural
sensitivity and awareness and develop other necessary components of cultural competency.
Analyse your own cultural sensitivity by doing the following activity.
HSE3701/1 23
3.2
Read the following statements and tick the appropriate column:
Yes No
1 I am knowledgeable about and sensitive to students' cultural backgrounds.
2 I show respect for cultures and backgrounds different from my own.
3 I provide a classroom atmosphere in which students' cultures are recognised,
shared and respected.
4 I use culturally appropriate curricular materials.
Yes No
5 I am willing to learn about other cultures from my students.
6 I involve cultural leaders and other community members in classroom activities.
3.3 Ethnocentrism
Ethnocentrism is a term which was first introduced and used by Sumner in 1906 in the sense of
``cultural narrowness'', a tendency of individuals to be `èthnically centered'', to be rigid in their
acceptance of the culturally `àlike'' and to reject the culturally `ùnlike'' (Ruiz 1981:177).
The presence of students/patients from multicultural backgrounds is a source of potential

problems. These problems are related to communication and cultural differences. Much of this
is a result of ethnocentrism, the belief that one's own culture is superior to all others. This can
be seen in the comparison of the values and behaviour of other cultures with those of one's
own culture, using one's own culture as the standard. It is important for educators/students to
be consciously aware of ethnic and cultural differences and to accept these as appropriate.
These differences should not be viewed as either good or bad (Kozier, Erb & Blais 1992:458).
Ethnocentrism may stem from a lack of exposure to or knowledge about other cultures. Most
people are gradually exposed to the beliefs, customs and values of their own culture over a
long period of time, starting at birth. In order to develop cultural sensitivity, one has to examine
one's own culture carefully and become aware that alternative viewpoints are possible (Eliason
1993:226).
3.3
In considering the influence of culture on health sciences education, educators should
note approaches in dealing with cultural diversity. One of the approaches is
`èthnocentrism'': the tendency to regard one's own culture as superior and thus as the
criterion for evaluating other cultural phenomena. Reflect on this definition and name a
few examples of when you have consciously or unconsciously regarded your culture
as superior.
24
3.4 Prejudice
The term ``prejudice'' refers to inaccurate perceptions of others and results in conclusions
drawn without adequate knowledge or evidence. All people are prejudiced for or against other
people (Andrews & Boyle 2003:478). Prejudice involves negative feelings about groups
different from one's own, regardless of how they are different. These attitudes are based on
limited knowledge, limited contact and emotional responses, rather than on careful observation
and thought. These beliefs or opinions are formed before the facts are known (Andrews &
Boyle 2003:235). It is now clear that ignorance is one of the primary causes of prejudice.
According to Spector (1996:67), prejudice occurs because the person making the judgment
generalises an experience of one individual from a culture to all members of that group.
Without understanding people's historical and cultural backgrounds, we cannot fully appreciate
their cultural backgrounds and contributions. However, ignorance is not the only cause of
prejudice. Some highly educated people are extremely prejudiced people. Their prejudices,
especially ethnic and racial prejudices, are deeply rooted in emotions (Henderson & Primeaux
1981:202). When prejudice is the result of ignorance or misinformation alone, the negative
attitudes may be overcome by education. But, when it is deeply rooted in the affective
components of socialisation, the process of overcoming prejudice is much more difficult.
Everyone has prejudices, but people in power should never allow prejudices to affect their
relationships with culturally different people (Eliason 1993:226).
Cultural understanding does not mean being culture-free or indifferent. Everyone should adopt
beliefs, values and attitudes that are consonant with their subgroup identities. Therefore we
should remember that not only are students and clients different from one another ± but also
that people are different. The following quotation from Henderson and Primeaux (1981:197)
illustrates the meaning of ``prejudice'':
Since people are different, considering people as being different is not prejudice.
The prejudiced are not those who insist that people are different in various respects
and by various reasons, but those who deny it. Insisting that people who are
different are not different means making propaganda for misunderstanding each
other. Since we are different, we can only understand each other if we admit and are
aware in what respects and why we are different. Prejudice comes only if we
misinterpret the existing differences in terms of inferiority and the like.
3.4
If you have formed a study group with one or more fellow students the following
activity can be done in this group. If you did not form a study group it should be done
in your work environment. The objective is to understand prejudice.
Talk about various groups of people who, through the ages, have been discriminated against.
Talk about the reasons for this. Examine and discuss the situation in your country. Let
members of the group share their own personal experiences and views on prejudice with other
members of the group.
3.5 Race and racism

As we pointed out in study unit 2, people often confuse race with ethnicity. ``Race'' is related to
biology. Members of a particular race share distinguishing physical features such as skin
HSE3701/1 25
colour, bone structure or blood group. Ethnic and racial groups can and do overlap because in
many cases the biological and cultural similarities reinforce one another. One should
remember that, regardless of race, all people have a cultural heritage which gives them an
ethnic identity (Giger & Davidhizar 2004:67).
Racism implies a belief that superior or inferior traits and behaviour are determined by race. It
includes prejudice and discrimination. Racism is caused by a complex web of factors that
include ignorance, apathy, poverty, historical patterns of discrimination against particular
groups, and social stratification. The expression of negative attitudes and behaviours by people
toward others according to their identification as members of a particular group is of particular
concern in the multicultural workplace (Andrews & Boyle 2003:188±189,355,370±371). This
is highly relevant to the current situation in South Africa, and may also be in other countries.
There are two kinds of racism: the individual and the institutional varieties. Individual racism
refers to the behaviour of individuals that supports the belief of racial superiority of one or
more groups over others. Institutional racism refers to the systematic oppression of people
through institutional policies and practices (Henderson & Primeaux 1981:5).
In the multicultural workplace, the expression of negative attitudes and behaviours by people
toward others, according to their identification as members of a particular group, is of
particular concern. These attitudes and behavioural patterns are learnt as part of the cultural
process.
Racism amounts to viewing one's own race as superior to other races. Given the foregoing, we
should refrain from making assumptions about people's abilities, potential and behaviour on
the basis of physical appearance. People may look different but that does not imply that they
are differently `àbled''. In the nursing college situation, in particular, educators should not
judge students on the basis of assumed characteristics linked to race but should, rather, value
each individual in her or his own right (Lemmer & Badenhorst 1997:190±191).
3.5
We learn about people who are different from ourselves by many methods. Stereotypes
are negative or positive attitudes which are transmitted by family members, friends,
religious institutions, schools, the media and popular culture. Usually we don't know
where our attitudes come from because they come from so many different sources.
The following is a list of groups for which stereotypes exist.
To complete each statement, write down the first word or phrase that you think of in connection
with the people mentioned in each of the following groups (whether or not you really do believe
it!).
Asian people tend to ..
Academics are
I am reluctant to talk to foreigners because ..
I feel ................................................................................................. toward black men.
Alcoholics deserve ................................................................................. in my opinion.
BMW drivers make me .............................................................................................................
26
I believe that Afrikaans women are ...........................................................................................
Gays should be .........................................................................................................................
The ANC is ................................................................................................................................
I believe the Sotho people are ..................................................................................................
I feel the AWB caused ..............................................................................................................
Hairdressers are ........................................................................................................................
3.6 Stereotyping
Stereotyping is the assumption that all people in a similar cultural, racial or ethnic group are
alike and share the same values and beliefs (Giger & Davidhizar 2004:68). According to
Andrews and Boyle (2003:297±298,299,411), stereotypes are simple links in one's memory
between a person and a particular trait. They often capture characteristics that are real and
common in the group, but stereotypes may also be out of date and dangerously limited. People
tend to see what they expect to see and stereotypes narrow vision, by ignoring variations that
occur naturally within groups. Stereotypes can be favourable as well as unfavourable. If an
individual from a specific background is expected to excel at academic work as a result of
stereotypes that associate his or her racial group with high academic achievements, this is not
a negative stereotype. But it is potentially harmful because it imposes expectations that are
unrealistic, just as negative stereotypes do. If one stereotypes all psychiatric clients as
dangerous, the generalisation does not accurately represent the high percentage of clients who
are not. When stereotypes involve negative beliefs about a group they lead to ``prejudgment'' (or
prejudice) that ignores actual evidence.
3.6
Explain how you as a health sciences educator will elicit stereotyping when teaching
students of diverse cultures.
3.7 Cultural imposition

According to Leininger (1984:43), a serious and largely unrecognised problem in health care
today is the problem of cultural imposition. This refers to the educator's tendency to impose
his or her values upon the student without being aware of the students' values, feelings and
beliefs. This phenomenon has serious ethical and professional implications because students
have the human and cultural rights that their own cultural values and life ways should be
considered in health care practices. As a professional health practitioner, educator or manager
you have to be aware of your ethnocentric tendencies and develop strategies to avoid cultural
imposition.
HSE3701/1 27
3.8 Discrimination
Where prejudice refers to attitudes, discrimination refers to behaviours and is defined as the act
of setting one individual or group apart from another, of demonstrating a difference or
favouritism. Discriminatory behaviours and not attitudes comprise the majority of intergroup
problems. Although laws protect people against discrimination, there are none against
prejudice (Andrews & Boyle 2003:369±370).
3.7
In this study unit we have discussed various concepts that you should be aware of
when teaching, learning, caring for or managing in a multicultural environment. Think
carefully about each of these concepts.
1 Have you been the target of racism, ethnocentrism, stereotyping, prejudice or
discrimination? Now reflect on times when you were guilty of making racist
remarks, being prejudiced, stereotyping people or discriminating against
someone.
2 Write a brief essay in which you explain a particular incident and also discuss
your feelings in relation to the incident.
3.9 Values clarification

Once you are in touch with yourself, or after you have become self-aware about cultural
diversity using values clarification as an approach to create a positive experiential field for your
students, you may use the following essential guidelines to further your multicultural
awareness.
3.8
Read Tjale and De Villiers (2004:48±53) to familiarise yourself with the approach. Pay
particular attention to the process of values clarification.
1 With knowledge of the above choose a small group of students and practise the
exercises on pages 55±62.
2 Ask the students to write about their individual experiences of the exercises.
3 Write down your own reflection of the exercises done.
3.10 Conclusion
In many countries, people are often targets of racism, discrimination, prejudice, stereotyping
and misunderstanding. That is why knowledge of factors that might influence cultural
encounters is essential. The secret of success when dealing with people of diverse cultures lies
in knowledge and willingness to be sensitive to the needs of these people. By using values
28
clarification exercises student nurses may improve their cultural awareness and so render
competent care.

1 Critically analyse the cultural origins of conflict that may arise in the health sciences
educational environment.
2 How would you as health sciences educator ensure that the conflict mentioned above
does not arise in the classroom?
3 Explain how you as health sciences educator will become self-aware. Write about your
experiences of how you have changed within yourself.
4 Reflect on the use of values clarification as a tool to enhance behavioural change in
clients concerning family planning services. Discuss this issue in a small group
discussion with your students. Write down the students' answers.
HSE3701/1 29
4
c Cultural knowledge in health

care


4.1 Introduction
Cultural knowledge is the process of seeking and obtaining a sound educational foundation
concerning the various worldviews of different cultures. One's worldview can be considered a
paradigm or way of viewing the world and the phenomena in it. Purnell (1998) defines
"worldview" as the way individuals or groups view the universe to form values about their lives
and the world around them.
The goal of cultural knowledge is to understand the student's/client's worldview (emic view).
One of the most important concepts for understanding students'/clients' behaviours is to
understand their worldviews.
In addition to seeking and obtaining a sound educational foundation concerning the various
30
worldviews of different cultures, the process of cultural knowledge also involves obtaining
knowledge regarding specific physical, biological and physiological variations among ethnic
groups. Purnell (1998:28) identifies this area of cultural knowledge as "biocultural ecology" and
goes on to say that these variations include skin colour and physical difference in body habitus;
genetic, hereditary, endemic and topographic diseases; psychological makeup of individuals;
and the biological differences that affect the way drugs are metabolised by the body.
To obtain cultural knowledge, the student must understand the relationship between culture
and health practices. Of the many factors that are known to determine health beliefs and
behaviours, culture is the most influential variable.
In this study unit we will concentrate on the cultural knowledge that you will need in your role
as educator as a basis for your teaching: knowledge of the historical perspective of culture and
health care systems in Southern Africa; metatheoretical and theoretical perspectives on cultural
studies; some African philosophies; culture; health, illness and disease; heritage and cultural
phenomena.
& identify and explain the historical perspectives of culture and health care systems in
southern Africa
& differentiate between western and African health care systems
& discuss the importance of understanding the concept of multiculturalism in health care
utilise the knowledge gained in this study unit in all teaching programmes
& incorporate the knowledge gained in all curricula
& demonstrate insight into the worldviews and cultures of students
& show an understanding of the different views on health, illness and disease
4.2 Historical perspective

Prior to the arrival of the first European people in southern Africa, indigenous people were
treating diseases and illness in accordance with their cultural belief systems. You will be
studying this part of the study unit in order to understand the health care systems in South
Africa. This knowledge forms the basis for educators in health sciences education for teaching
student nurses from different cultures.
4.1
Read through chapter 1 in Tjale and De Villiers (2004:1±11) and answer the following
questions:
& Write a short paragraph on the southern African health care system
& Differentiate between western and traditional views of health care systems.
Tabulate your answer.
& Discuss two examples from your experience in the clinical field where you think
that traditional medicine would be to the advantage of a patient.
& In which cases in the clinical field would you discourage patients to use
traditional medicine? Here you may have thought about the application of ash
and/or cow dung to the navel after a newborn baby's umbilical cord is severed.
HSE3701/1 31
4.3 Health, disease and illness
In study unit 3 you were introduced to cultural awareness in health care and education. You
may recall that a culturally sensitive approach requires only an awareness of the values, beliefs,
life ways and practices of an individual, whereas a culturally responsive approach incorporates
the individual's values, beliefs, life ways and practices into a mutually acceptable treatment
plan/education plan. Therefore, educators must go beyond cultural sensitivity and awareness
and develop other necessary components of cultural competency.
Cultural knowledge is the process by which the educator seeks and obtains a sound
educational foundation concerning the various worldviews of cultures. Most health care
providers have experienced situations in which they were aware of and sensitive to differences,
but lacked specific knowledge and a framework that would help them to understand the
experiences involved.
This section of the study unit will describe some of the main knowledge components an
educator should possess if he or she is to render culturally competent education. In providing
care across cultural boundaries, the educator must take into account the context in which the
student lives, attending to the total context of the student's/client's situation including
awareness of immigration, stress factors and cultural differences (Lipson, Dibble & Minarik
(1996:48±56).
The educator needs culture-specific information; culturally sensitive education depends on

educators at least possessing some basic knowledge of constructive attitudes toward each
cultural group in their locality (Rooda 1992:337±347).
Research done by McGee 1992 (24-34) shows that health professionals have a lack of cultural
knowledge, without which competent cultural education cannot take place.
Generally, theories of health and disease/illness causation are based on the prevailing
worldview held by a group. Each of the three major worldviews (magico-religious, holistic and
scientific) has its corresponding systems of health beliefs. In two of these worldviews, disease
is thought of as an entity separate from the self which is caused by an agent that is external to
the body but that is capable of getting in and causing damage. This causative agent has been
attributed to a variety of natural and supernatural phenomena.
Before we discuss the different worldviews we need to revise the term ``culture'' as this is
central to all cultural discussions.
4.3.1 Culture
As the life experiences of humankind are deeply embedded in the social reality of culture in
respect of both health and education, and as culture is at the root of the concept of the
transcultural encounter, it becomes important to arrive at a clear understanding of the concept
of ``culture'' and of any relationship it bears to conceptualisations of health and education.
Culture is a normative notion (Barrow & Woods 1988:155). The concept of culture is in no way
self-explanatory and is "itself a cultural construct" which has been defined and understood in
many ways over the years. These variations in meaning reflect the scope of human experience
under different historical circumstances.
32
4.3.2 Definitions of culture
Some definitions can be operational, where the concept defined is like "culture", which is
seldom so static that it cannot be reinterpreted, modified and developed in keeping with new
insights and information as revealed by science. Anthropological, sociological and dictionary
definitions of the term point to the holism and pervasiveness of the concept as it influences
humankind's relationship with their world, themselves, other human beings and their history.
Anthropologists have provided many definitions of the term "culture", perhaps the most
famous being Tyler's definition in 1871:
That complex whole which includes knowledge, belief, art, law, custom and any other
capabilities and habits acquired by humankind as a member of society.
Keesing, (1981:1±8) in his definition, stresses the ideational aspect of culture:

Culture comprises systems of shared ideas, systems of concepts and rules and
meanings that underlie and are expressed in the ways that humans live.
From these definitions it can be deduced that culture is a set of guidelines (both explicit and
implicit) which individuals inherit as members of a particular society, and which tell them how
to view the world, how to experience it emotionally, and how to behave in it in relation to other
people, to supernatural forces or gods, and to the natural environment. It also provides them
with a means of transmitting these guidelines to the next generation ± by the use of symbols,
language, art and rituals.
Helman (2007:2±5) states that ``culture'' is an inherited lens of shared concepts and rules of
meaning whereby society's members perceive the world, guide their behaviour and determine
their emotional reactions in daily living.
One aspect of this ``cultural lens'' is the division of the world, and the people in it, into different
categories, each with its own name. For example, all cultures classify their members into
different social categories, such as men and women, children or adults, young people or old
people, kinsfolk or strangers, upper class or lower class, able or disabled, normal or abnormal,
mad or bad, healthy or ill. And all cultures have elaborate ways of moving people from one
social category into another (such as from ill person to healthy person) and also of confining
people ± sometimes against their will ± to the categories into which they have been put (such
as mad, disabled or elderly).
Anthropologists such as Leach (1982:33±36) have pointed out that virtually all societies have
more than one culture within their borders. For example, most societies have some form of
social stratification into social classes, castes or ranks, and each stratum is marked by its own
distinctive cultural attributes, including linguistic usages, manners, styles of dress, dietary and
housing patterns, and so on. Rich or poor, powerful and powerless ± each will have its own
inherited cultural perspective. Most complex societies, such as those of the UK or the USA,
include students, political refugees, recent immigrants and migrant workers, as different social
strata ± each with its own distinctive culture. Many of these groups will undergo some degree
of acculturation, whereby they incorporate some of the cultural attributes of society at large. A
further subdivision of culture within a complex society is seen in the various professional
subcultures that exist, such as the medical and nursing, legal or military professions. In each
case, they form a group apart, with their own concepts, rules and social organisation. Although
each subculture is developed from the larger culture, and shares many of its concepts and
values, it also has unique, distinctive features of its own. Students in these professions
undergo a form of enculturation, as they slowly acquire the culture of their chosen career. In
doing so, they also acquire a different perspective on life from the perspective of those who are
outside the profession. In the case of the health professions, their subcultures also reflect many
HSE3701/1 33
of the social divisions and prejudices of the wider society, which could interfere with both
health care and health professional-patient and educator-student communication (Helman
2007:2±5).
4.2
1 Read through your prescribed book Tjale and De Villiers (2004:66±77) and/or any
other literature for more definitions of the term ``culture''. Summarise the
definitions and draw up a list of characteristics for a culture.
2 Ask the students in your classroom to evaluate their own culture against the
characteristics identified above.
3 Overall, therefore, cultural background has an important influence on many
aspects of people's lives, including their beliefs, behaviour, perceptions,
emotions, language, religion, rituals, family structure, diet, dress, body image,
concepts of space and of time, attitudes to illness, pain and other forms of
misfortune all of which may have important implications for health and health
care. However, the culture into which you are born, or in which you live, is never
the only such influence. It is only one of a number of influences on health-related
beliefs and behaviours. Read through all the information about the above
statement and name and describe the other influences on health-related beliefs
and behaviour. In the summary of your reading you may have found the following
factors:
& individual factors (such as age, gender, size, appearance, personality,
intelligence, experience, physical state and emotional state)
& educational factors (both formal and informal and including education into a
religious, ethnic or professional subculture)
& socioeconomic factors (such as poverty, social class, economic status,

occupation or unemployment, discrimination or racism, as well as the
networks of social support from other people)
& environmental factors (such as the weather, population density or pollution

of the habitat, but also including the types of infrastructure available, such as
housing, roads, bridges, public transport and health facilities)
4.3.3 Western versus African culture

Many authors have attempted to distinguish between social and structural conditions under
which socialisation of individuals takes place in western culture as compared with African
culture. These authors have also attempted to distinguish between the psychological and social
systems that result from such socialisation.
Prinsloo (2001:58±64) notes:
Africa consists of a wide range of diverse cultures and social organisations and thus any
attempt to isolate or discuss ``the African personality'' or any other such model concept will fail
to do justice to the complexity of the situation ... It would (however) appear that a number of
34
social, structural, and psychological dimensions do appear to occur frequently enough in (sub-
Saharan) Africa to be regarded as typically traditional.
In the same way, western societies tend to be structured along particular lines in such a way
that typically westernised or industrialised countries are very similar. Japan, the USA, Sweden
and Germany are very different. However, in the sense that these countries have certain modes
of production and values in common, they can be said to be industrialised, while many African
and other third world countries can be said to be underdeveloped, developing, or lesser
developed countries. Thus, although different countries are all unique, they can be grouped in
terms of a ``family likeness'' and it becomes meaningful to speak of traditional African cultures
and to compare these with typical western or industrialised cultures.
Helman (2007:160±163) and other authors wrote about the major and structural dimensions
that differentiate between typical western and typical African cultures (table 4.1) as well as
about the major psychological differences between western and African cultures (table 4.2).
This basic knowledge which the educator needs will enhance his or her skills and
understanding of students from diverse cultures. In turn this knowledge will also help the
student to become a culturally competent health professional.
Table 4.1: Social and structural differences
Dimension Western industrialised Traditional African

Subsistence mode Industrial/technological Agricultural
Use of technology Widespread Limited
Rate of technological change Rapid Slow
Family structure Nuclear Extended
Status achievement Earned Ascribed
Source of authority Ability Age/seniority
Affiliation and loyalty Larger unit-nation, employer Smaller unit ± family, tribe,
work team
Ambition Materialistic Religious, other-worldly
Social control Legal, written Traditional, cultural
Socialisation Benign, tolerant Harsh, authoritarian
Occupational mobility Relatively high Low
Table 4.2: Psychological and social value differences
Dimension Western industrialised Traditional African

Basic orientation Individualistic, inner-directed Communalistic, other direc-
ted
Motivation Achievement Affiliation
Intrinsic endorsement of Pro- Extrinsic non-endorsement of
testant work ethic Protestant work ethic
Self-actualisation Lower-order needs
Uncertainty Tolerates ambiguity and un- Intolerant
certainty
Locus of control Internal External
HSE3701/1 35
Interpersonal relations Machiavellian Highly principled
Exploitive Cooperative
Competitive Cooperative
Relation to authority Autonomous Conformist
Independent Dependent
Time orientation ``Linear'' ``Circular'', seasonal
Risk taking Willing to take calculated Unwilling to take any risk,
`èntrepreneurial'' risks and conservative
show initiative
Study chapter 8 in Tjale and De Villiers (2004:134-156). Add the information you gained to the
above description of the anthropology of health.
4.3
1 Conduct a survey in your classroom/unit/clinic using the two tables given to
gather information about the differences between your students/staff/colleagues.
Write down your findings.
2 Describe in table form the differences and similarities between health, illness and
sickness from a western perspective and from the traditional perspective.
3 When do you regard yourself as healthy and when do you regard yourself as sick?
Describe the universal indicators.
4 What is the difference between healing and curing?
5 Complete the table below by briefly explaining the key concepts as listed:
Concept Meaning Example
Health
Healing
Illness
Ill-health
Disease
Curing
4.4 Knowledge about health, disease and illness

So far you have gained insight into the concept of ``culture'' and you are now aware of the role
culture plays in the aetiology of folk illnesses. You would therefore be able to obtain relevant
cultural data. For it is data elicited in the history taking of clients'/students that usually enable
the health professional practitioner/educator to make an accurate diagnosis. Insight into what
people believe causes illness will help the health professional to understand client/student
behaviours, such as at what point during an illness episode a client will seek western health
care, with what treatments the client will or will not comply, and what influences whether or not
the client will return for follow-up care, if needed.
36
4.4.1 Health
Health professionals should be as knowledgeable about cultural factors that contribute to
illness and disease as they are about psychological, physiological and sociological causes.
Competent cultural care depends on the practitioner's consideration of the effect of each of
these factors on a client's health. The reason is that the body has only a limited repertoire of
reactions to illness, whether the cause is somatic or psychological Andrew and Boyle
(2003:79). Health professionals working in multicultural health care settings should be aware
of the role that culture plays in the aetiology of folk illnesses so that relevant cultural data can
be obtained in the history during assessments. As we said previously, the data elicited in the
history are usually what enables the health professional/student to make an accurate diagnosis
(Helman 2007:160±163).
4.4
Before reading the next section on health, make short notes on how you would define
health.
Definitions of what constitutes both health and sickness vary between individuals, cultural
groups and social classes. Usually health is seen as more than just an absence of unpleasant
symptoms (Helman 2007:126±128). The World Health Organization, for example, defined it in
1946 as a state of complete physical, mental and social wellbeing and not merely the absence
of disease or infirmity (Helman 2007:126). In many non-industrialised societies health is
conceived of as a balanced relationship between humankind and humankind, humankind and
nature, and humankind and the supernatural world. A disturbance of any of these may manifest
itself in physical or emotional symptoms. Among western communities, definitions of health
include physical, psychological and behavioural components. The definitions also vary
between social classes. For example, Fox (1968:90±96)(Helman 2007:110) quotes a study of
``Regionville'', a town in upper New York state, where members of the highest socioeconomic
class usually reported a persistent backache to their physician as an abnormal symptom, while
members of the lower socioeconomic class regarded it as an inevitable and innocuous part of
life and thus inappropriate for referral to a doctor.
Similarly, in Blaxter and Patersons's study (Helman 1994:92) in Aberdeen, working-class

mothers did not define their children as ill, even if they had abnormal physical symptoms,
provided that they continued to walk around and play normally. This functional definition of
health, common among poorer people, is probably based on the (economic) need to keep
working, however they feel, as well as on low expectations of medical care. Helman classes the
above as lay definitions of health, which would obviously differ from those of the medical
profession, which would be described later.
To substantiate the findings of the above studies Craig and Albino (1983:571±572) in Herman
1994:82 carried out a study on urban Zulu mothers' views on the health and health care of their
infants. Sixty-three percent of mothers described a healthy baby as one who eats and plays,
and a sick baby as one that does not eat or play. Urban mothers in this study accepted western
medicine (attended antenatal clinics, gave birth at a hospital, accepted health education by
medical personnel on matters such as childhood diseases and the importance of
breastfeeding) but at the same time they had not relinquished their belief in traditional
health care.
As is reflected in the above description, the concept of health has been defined in widely
HSE3701/1 37
divergent ways, ranging from those in which health is seen in unidimensional, static terms to
those that view health as a set of qualities involving the total person in personal encounter with
his or her human world. However, the description of health as an absolute state has not been
universally accepted, for it is viewed as unrealistic and difficult to use when trying to determine
who is or is not healthy. According to Spradley (1990:9±10), ``health is relative, not an absolute
concept because the term ... refers to a state of being'', which is affected by the many different
characteristics and qualities making up the world of individuals and communities. All the
dimensions of life that are embedded in physical, sociocultural, psychological, intellectual and
spiritual experience, and that affect everyday functioning, collectively determine individual and
community health. As a state of being which people define in relation to their own values,
health may not be regarded as a part of the body, a function or a thing, nor as an acquired piece
of scientific knowledge.
Spector (2004) in MunÄoz and Luckmann 2005:94 includes concepts such as homeostasis,
kinetic energy in balance, optional functioning and freedom from pain. This author states that it
may be difficult for experienced health care providers to give a comprehensive, acceptable
definition of the term ``health''.
Somatic health refers to the optimum capacity of the individual to perform the valued tasks of
society effectively and to fulfil role obligations. This definition, with its emphasis on social
performance alone, highlights the social dimension of health, but ignores a holistic perspective
(Tjale and de Villiers 2004:139).
Two conceptually distinct dimensions of equilibrium and actualisation in respect of the

concept of health exist. The idea of equilibrium ranges through disequilibrium, imbalance or
disease to balance ± balance being indicative of the optimal functioning of bodily systems.
Disease manifests as a result of the influence of multiple outside agents, such as germs and
stress, that act on the physiological and psychological systems and disrupt their equilibrium.
The actualisation component refers to any change or growth that occurs in order to deal
effectively with the environment, thereby denoting actualisation of potential. Health is balance;
integration and harmony are possibly the most prominent themes in holistic definitions of
health (the word ``health'' itself is derived from the Old English word for wholeness) (Lowenberg
1989:30).
The definition which most closely reflects the meaning of the term as used in study unit 1, and
which evolved from concepts embodying notions of holism, balance, integration and harmony
as outlined above, is the one given in The American heritage dictionary (Spector 20±21):
The state of an organism with respect to functioning, disease, and abnormality at any given
time.
1 The state of an organism functioning normally without disease or abnormality.

2 Optimal functioning with freedom from disease and abnormality.
3 Broadly, any state of optimal functioning, wellbeing, or progress.
4 A wish for someone's good health, expressed as a toast.
The World Health Organisation (1978:2) defines health as a state of complete Physical, mental
and social well-being, and not merely the absence of disease or infirmatory: (it) is a
fundamental human right and that the attainment of the highest possible level of health is a
most important level of worldwide social goal whose realisation requires action of many other
social and economic sectors in addition to the health sector.
These and the previously mentioned definitions ± varying in scope and context ± are
essentially those that convey the meaning of health, according to health professionals.
We can discern subtle variations in denotation when we analyse these definitions. If this occurs
38
in the denotation of the word, then what is the connotation? That is, are health care providers as
familiar with implicit meanings as they are with more explicit ones? Spector (1996:20±21)
makes the following comment:
Whereas health itself is in reality an elusive concept, in much of research, the stages involved
in seeking medical care are conceived as completely distinct. The health professions are
becoming increasingly aware of the lack of clarity in the definition of health.
If this comment is found to be accurate, it means that the educational process is deficient.
The framework of both education and research in the health professions continues to rely on
the more abstract definitions of the word health. In a broader context, health can be regarded
not only as the absence of disease but also as a reward for good behaviour. A state of health is
regarded by many people as the reward one receives for good behaviour and illness as
punishment for bad behaviour. People are often heard to say things like: ``She is so good: no
wonder she is so healthy'', or (a mother admonishing her child), `Ìf you don't do such and
such, you'll get sick''. Situations and experiences may be avoided for the purpose of protecting
and maintaining one's health. On the other hand, some people seek out challenging, albeit
dangerous, situations in the hope that they will experience the thrill of a challenge and still
emerge in an intact state of health. One example of such behaviour is the practice of driving at
high speeds (Spector 1996:20±21).
Health can also be viewed as the freedom from and the absence of evil. In this context, health is
analogous to day, which equals good light. Conversely, illness is analogous to night, and evil,
and dark. Illness, to some, is seen as punishment for being bad or doing evil deeds; it is the
work of vindictive evil spirits. Students each enter the health care community with their own
culturally based concepts of health. During the educational and socialisation process in the
profession ± nursing, medicine or any other health-related work ± students are expected to
shed these beliefs and adopt the standard definitions. In addition to shedding the old beliefs,
they learn, if only by unspoken example, to view as deviant those who do not accept the
prevailing, institutional connotation of the word health (Spector 1996:21).
On the basis of the above, health or wellness may be described as a condition in which all the
variables or parts and subparts of the internal and external forces surrounding humankind
represent a state of harmony with the whole of humankind, in which social, psychological and
spiritual wellbeing are emphasised equally with physical wellbeing (Lowenberg 1989:30), and
where disharmony reduces the state of wellness, so that continuous adjustments to stressors
in both the internal and external environments are required, in order to make optimum use of
existing resources for the realisation of maximum potential for daily living.
Such a definition, which reflects health as a holistic and dynamic life experience, shows
humans to be in a state of reciprocal interaction with their internal and external environment
and, by implication, acknowledges the possibility of change in respect of health status.
In summary, this section has attempted to deal with the concept of health. The multiple
denotations and connotations of the word have been explored.
In the next section we explore the concept of illness.
HSE3701/1 39
4.5
After reading this section on health, take the notes you made on your views of health
at the beginning of the section and add anything that you may not have included to
your list.
4.4.2 Illness
4.6
Write down what you believe to be the definitions of illness and disease.
Health professionals should be as knowledgeable about the cultural factors that contribute to
illness and disease as they are about physiological, psychological and sociological causes.
Congruent cultural care depends on the student's consideration of the effect of each of these
factors on a client's health. Students working in transcultural health care settings should be
aware of the role that culture plays in the aetiology of folk illnesses so that relevant cultural data
can be obtained in the history taken during assessments in order to formulate an accurate
diagnosis.
The American heritage dictionary defines ILLNESS as ``Sickness of body or mind. B. Sickness.
2 obsolete. Evil; wickedness'' (Spector 1996:31).
At this point we need to distinguish between the concepts of disease and illness:
& Disease is a malfunction of the biological and/or psychological processes of the human
body. Disease is an abnormality of the body's structure or function which is revealed by
the presence of certain symptoms and characteristics. By implication western medicine
treats disease as having the same identity wherever it occurs.
occurs
& Illness, on the other hand, refers to an individual's experience of ill-health, that is his or
her perception of and response to disease and the way the disease is communicated to
and perceived by the individual's social group. It is created by personal, social and
cultural reactions to disease (Kleinman 1987:447). What is classified as illness,
therefore, may vary from society to society.
Kleinman (1978:252) amplifies the distinction between disease and illness as follows:
The distinction holds that the disease in the western medical paradigm is malfunctioning or
mal-adaptation of biological and psychophysiological processes in the individual; whereas
illness represents personal, interpersonal and cultural reactions to disease or discomfort.
Illness is shaped by cultural factors governing perception, labelling, explanation, and valuation
of the discomforting experience, processes embedded in a complex family, social and cultural
nexus. Because illness experience is an intimate part of social systems of meaning and rules
for behaviour, it is strongly influenced by culture: it is, as it were culturally constructed.
Illness is culturally shaped in the sense that the way we perceive, experience and cope with
40
disease is based on our explanations of sickness, explanations specific to the social positions
we occupy and systems of meaning we employ (Kleinman 1978; Helman 2007; Spector 1996).
These have been shown to influence our expectations and perceptions of symptoms, the way
we attach particular sickness labels to them, and the valuations and responses that flow from
those labels. How we communicate about health problems, the manner in which symptoms are
presented, when and to whom people go for care, how long they remain in care, and how they
evaluate that care are all affected by cultural beliefs (Chrisman 1986:358; Kleinman 1978:252).
Illness behaviour is a normative experience governed by cultural rules; we learn approved ways
of being ill. So there is marked cross-cultural and historical variation in how disorders are
defined and coped with. The variation may be equally great across ethnic, class and family
boundaries in our own society. And health professionals' explanations and activities, as those
of their patients, are culture-specific (Kleinman 1978:252).
Neither disease nor illness should be regarded as entities. Both concepts are explanatory
models mirroring multilevel relations between separate aspects of a complex, fluid, total
phenomenon: sickness. They derive from and help construct the special forms of clinical
reality. The dynamic interplay of biological, psychological and sociocultural levels of sickness
requires that a new framework for understanding and treating sickness be developed. The
disease/illness distinction is one conceptual means to meet this requirement (Spector 1996;
Cheetham & Griffiths 1982).
For patients, illness are problems ± the difficulties in living resulting from sickness ± are
usually viewed as constituting the entire disorder. Conversely, doctors and other health
professionals often disregard illness problems because they look upon the disease as the
disorder. According to Kleinman, both views are insufficient.
Medical anthropological studies show that traditional healing in developing societies and
popular health care in developed societies are principally concerned with illness, that is with
treating the human experience of sickness (Kleinman 1978). Healers seek to provide a
meaningful explanation for illness and to respond to the personal, family, and community
issues surrounding illness.
On the other hand, biomedicine is primarily interested in the recognition and treatment of
disease (curing). So paramount is this orientation that the professional training of doctors
tends to disregard illness and its treatment (Kleinman 1978). For the above reasons the present
South African government has emphasised primary health care and the training of health
professionals will follow suit.
Western medical doctors measure health in relation to certain physical and biochemical
parameters, for example weight, height, blood pressure, blood counts, heart size and rate, and
respiratory rate. An individual is considered healthy if such measurements fall within the range
regarded as normal (Helman 2007). Many other traditional societies, on the other hand, regard
health as a balanced relationship between humankind, nature and the supernatural and believe
that physical or emotional symptoms may arise if this relationship is disturbed. For instance,
among Xhosa-speaking people the term impilo, primarily referring to physical health, is also
defined as fullness of life. It also has a religious connotation in that it implies one's
relationships with the ancestors are harmonious (De Villiers and Van der Wal 1995:56-60).
In many societies of a more traditional nature illness is not distinguished from other forms of
misfortune, all of which are ascribable to similar causes. For instance, illness, crop failure and
loss of property may all be attributed to witchcraft. Helman (2007) argues, however, that illness
is nevertheless a distinctive form of misfortune since it has the outstanding characteristic that it
involves direct harm to an individual. The individual concerned thus experiences illness
HSE3701/1 41
differently from another misfortune, such as his house burning down, even though he may
ascribe the same cause to both incidents.
The emphasis on the disease rather than on the ill person is generally accepted in western
society. As such it is directly at variance with the approach of rural black peoples of Nguni
origin. The overall conceptual model of illness used by these peoples provides explanations of
illness in terms of biological, social, religious and magical factors. They regard the human
organism as a whole which is integrated with the total ecology of the environment and with the
interrelated spiritual, magical and mystical forces surrounding the person. Likewise, their
conceptual model of health is couched in terms of a balance between a healthy body and a
healthy situation and that set of circumstances which concerns them: good health means the
harmonious working and coordination of their universe (Tjale de Villiers 2004:137).
Most of the above authors have documented the most striking feature of the above conceptual
framework, which is the absence of the body-mind dichotomy which characterises the greater
part of western medicine and which has led to the disease orientation discussed above. In
contrast, the orientation of the African concept of illness is that of the group and the cosmos. A
study done by Uys (1986:28±32) supports the above statement. In this study, ``Perceptions of
health and illness, and related practices among the urban black population of Mangaung
(Bloemfontein)'', Uys found that the view of health-illness matters shows a strong tendency
towards a western model, with the impact of Christianity also clearly seen. Although magical
thinking and the use of the traditional health care system is still evident, it is augmented
strongly by the abovementioned two systems. In another study undertaken, ``Die vrou en haar
opvattinge oor gesondheidsbevordering onder die Suid-Sotho'', it was found that the South
Sotho informants did not make an absolute distinction between the stages of being well and
being ill. They were of the opinion that illness could be seen when medication needed to be
taken.
Cheetham and Griffiths (1982) agree with these authors, but they also describe the social
structure which is common in most African societies. In the structure they describe the Nguni,
who have strongly held beliefs, convictions and patterns of behaviour, as maintaining
individual and social homeostasis. Cardinal to social integration is strict adherence to ancestor
worship and allied beliefs, while systematised rituals, ceremonies and the observation of
taboos sustain social cohesion. In contradistinction to its function in the western world,
medicine in the African sense is global and is the focal point around which all life events,
illness, disaster, subsistence and the economy revolve. With this scenario, the roles of the
iSangoma/iSanusi/iGiri (traditional healers) are of paramount significance, for it is they, with
their capacity for divination and for mediation with the ancestors, who act as the final arbiters in
matters of sickness and health. The power of their arbitration and prescription derives from
their explicit knowledge of a particular worldview which is shared and accepted by their people
and, more importantly, from the community's awareness that they embrace this view.
So it is very important for the health professional to have knowledge of health/sickness

concepts as seen from a western medical perspective and from an African perspective. As we
said previously, problems may be expected where students in South Africa have received
unicultural western training which might lead them to diagnose patients incorrectly, simply
because these students lack appropriate cultural knowledge.
4.7
Correlate your notes on illness which you wrote down in the previous activity and
make additions where necessary.
42
4.4.2.1 The connection between culture and the interpretation of ill-health
We touched on the subject of this section in the previous section. Now we shall describe the
relationship between culture and ill-health in greater detail. Whether physical or emotional
symptoms are interpreted as illness largely depends on culture. Thus what would be classified
as a disease in western medicine may not be regarded as an illness in some societies. For
example, in certain parts of Africa where yaws is very common, people who have this disease
are not regarded as being ill. In Europe, in former times, a certain skin disease (eczema) was so
common among children that it was considered to be a sign of health. The Eskimo shaman
may pass through a stage of what would be regarded as mental disturbance by western medical
specialists before becoming a healer, and may indeed continue to show mental aberration.
However, he is not regarded as a deviant personality by his own society and is held in high
esteem (Ackernecht 1971:467±497).
Attitudes towards sickness vary widely. Sickness may be a major preoccupation to a society
regardless of the actual incidence of disease. The Navaho Indians of North America, for
instance, are reported to spend much of their time engaging in religious rituals dealing with the
prevention or healing of sickness. In contrast, other societies such as the Cheyenne Indians of
North America appear to be little concerned with sickness and its prevention. The Dobu of
Melanesia, on the other hand, place more emphasis on spells designed to make their
neighbours ill than on healing practices (Ackernect 1971:467). A symptom such as pain may
also be responded to differently. The Cheyenne, for instance, bear pain stoically and their
young men are expected to undergo ritual self-torture without complaint. Other societies may
consider it acceptable to be very vocal and emotional when in pain (Ackernect 1971:467±497).
The relation between culture and the interpretation of ill-health is illustrated by certain
disorders known as culture-bound syndromes. Culture strongly influences the ways in which
mental abnormality is recognised, explained and treated. Western specialists tend to regard
mental disorder as essentially the same in all societies. In anthropology the concern is less
with the objective definition of disease than with the way in which illness is interpreted by the
society concerned. The culture-bound syndromes, therefore, are certain illnesses which are
apparently unique to a particular culture or geographic area. Examples of such illnesses are
Arctic hysteria, windigo, amok and ufufunyana.
Arctic hysteria (pibloktog) is a mental disorder found among the Eskimo. It is thought that this
illness is partly due to a deficiency of calcium in the body because of certain environmental
factors such as the lack of sunlight. The long periods of darkness, and the long winters and
cold climate which necessitates that the body be covered, all limit the amount of sunlight
reaching the skin. Another reason given is that the illness is a way of dealing with feelings of
intense anxiety and helplessness and can be precipitated by sudden fright or unusual mental
shock (Gussow 1985:271±284). Pibloktog manifests itself as hysterical behaviour in adults. In
an attempt to discover whether mental disorders manifest differently in different societies,
Parker (1977:349±358) compares the Eskimo with their neighbours, the Ojibwa Indians of
northeastern Canada. Both groups experience similar environmental conditions and long
periods of isolation. However, mental abnormality among the Ojibwa, known as windigo, takes
the form of a belief that the ill person is possessed by a giant monster with a skeleton and heart
of ice who feeds on human beings. The person possessed develops a compulsion to eat
human flesh. Parker concludes that the differences in deviant behaviour between these groups
are linked to marked differences in beliefs, social organisation and personality development.
Amok is a phenomenon found among the Malay of Southeast Asia. This disorder affects males
and manifests itself in violent outbursts during which people and animals are attacked
indiscriminately and often killed. The expression to ``run amuck/amok'', meaning to rush
around in a frenzy, is derived from this phenomenon.
HSE3701/1 43
Ufufunyana is an illness found in the South African context. It made its appearance fairly
recently among the Nguni and was first noticed in Zululand in 1903. It is a form of hysteria or
aggression and the symptoms are fits, hysteria, progressive weakness and the presence in the
sufferer's stomach of ``voices'' speaking in Zulu. Untreated patients are in danger of dying.
Ngubane (1977:144) states that among the Zulu this condition is believed to indicate
possession by the spirits of different racial groups, including Indians and whites. She sees it as
an expression of the racial conflict in South Africa which has resulted in social deprivation for
black societies. It is possibly a manifestation of the problems which contemporary
communities face, and may be aggravated by the breakdown of traditional culture (De Villiers
1984:61±62,82).
These culture-bound conditions each have a specific set of symptoms which are responded to
in a standardised way by the people concerned. These symptoms may be linked to changes in
the environment, to the supernatural, or to social disharmony. Each society attributes a specific
cause to the illness in question and provides ways of preventing, diagnosing and treating it.
Such illnesses have a symbolic meaning for the people concerned and may play a role in
expressing and defusing social tensions and conflict in a culturally determined way. The
student providing health care in a multicultural setting should have the specific knowledge of
the culture-bound diseases in the health setting where he or she is situated, to render
congruent cultural care.
4.8
Read chapter 10 in Andrews and Boyle (2003) and Helman (2007) regarding pain.
Answer the questions at the end of the chapter.
4.4.2.2 Meaning of sickness

The experience of illness includes attaching meaning or significance to the sickness event.
Meaning or meanings are highly individual, and they are developed by the sick person in
relation to the sense of self, the cultural context (of beliefs, values and expected behaviours)
and relations with others (such as parents, children, spouse, companions, peers, co-workers,
or caregivers). In the USA today, for example, anorexia nervosa and bulimia nervosa, diseases
with serious physiological consequences, can be accounted for, in part, by the meaning
attached to being thin in contemporary American youth culture, that is ``thin is in'' or ``thin is
beautiful''. In other cultures being fat, rather than thin, has a positive value (Helman 2007:126±
143).
A person newly diagnosed with a serious disease may interpret its meaning as a death
sentence, an unlucky deal of the cards of life, an outrage that thwarts life goals, failure by the
government to control the polluted environment, the will of God, punishment for sins, self-
failure to stop smoking or avoid sun exposure, a challenge to accomplish certain goals, a curse
from a long-standing enemy, or possession by a spirit. For some, the onset of disease may
provoke, for the first time, contemplation about the ultimate philosophical questions: What is
the meaning of life, or death? Is life worth living, and why? The various meanings attached to
sickness events influence the way the person will go about coping with the experience (Helman
2007:150-151).
Sickness is accompanied by symptoms that have cultural meaning. For example, back pain,
one of the most frequent reasons for job absence in the USA, could be interpreted by the
employee as a reflection of poor working conditions or job injustice in the culture of the
44
workplace, whereas the employer could interpret the back pain as malingering behaviour. One
employee with job-related back pain may view it as an open door to entitlements, whereas
another may view it as a threat to an ability to provide for his or her family, and will continue to
work despite the pain. Employee health evaluation in such situations can be fraught with
difficulties.
The meaning attributed to sickness is also related to what an individual believes to be normal
or natural for the self in the context of the prevailing culture. In mainstream US society, for
example, injury to the face that would lead to scarring is a medical emergency, whereas in
other cultures, deliberate facial scarification is valued as a marker of a developmental
milestone, ritually celebrated with elders or others (Helman 2007:134±143).
When the label attached to a disease and/or its symptoms is regarded negatively in the culture,
the person with the disease becomes stigmatised. The cultural meaning can result in
discrimination, blaming of the victim, or irrational fears of pollution or contagion. Mere
mention of mental illness, leprosy, herpes, acquired immunodeficiency syndrome (AIDS) and
obesity can evoke a stereotypical stigmatising response in individuals and groups, even when
they have never knowingly been in person-to-person contact with an individual from a
stigmatised group (Chrisman 1986:358±359). For the person with the stigmatising disease or
symptoms, meanings may include shame, guilt, fear of disclosure, anger or resentment. So
persons in stigmatised groups may act to protect themselves, For example, a man who had
been transported from his job to an acute coronary care unit was in a dangerous, highly
anxious state not so much because of the myocardial infarction but because of fear that the
closely guarded secret of his epilepsy (another stigmatised condition) would be inadvertently
disclosed to his visiting employer, and that this disclosure would result in the loss of his job.
Although the epilepsy had been controlled with medication, the patient feared that the stress
might provoke a seizure; he wanted his medication at hand for his immediate use at the start of
an aura (Helman 2007:134±143).
The meaning of illness also embraces the suffering that accompanies many losses. This was
evident when Chrisman (1996a:45±54) visited a relative with other family members, in a bone
marrow transplant unit that provided a stark contrast between western biomedical disease
treatment and the accompanying illness experience. The contrast might not be evident to the
experienced professionals working there and who have adapted to its culture, though it may
provoke cultural shock in novice professionals as well as in patients and visitors who visit this
foreign territory for varying periods.
Here, immediately following total body irradiation and intensive chemotherapy, the sick patient
was placed in an enclosed, hospital-equipped isolation cubicle (with no bathroom) for weeks,
for protection from infection until blood cell counts indicated readiness for transfer. Disease
(cancer) treatment here is on the cutting edge of medical science and technology. The young
woman patient and her husband had consented to a ``pull-out-all-the-stops'' kind of attack on
the imminently life-threatening blood cell cancer.
The patient arrived, a highly active, multi-talented, upbeat, beautiful, witty, affectionate young
woman, recently graduated and launched in a career and recently married. In short order she
became bald, infertile, bloated by steroids, and anorexic but vomiting precipitously, especially
after attempting to eat autoclaved food; she lost self-esteem, body image, job and income,
hope of achieving valued life goals, and faith; she harboured fears of untimely death, disability
and dependence; she suffered through daily biomedical crises, including those related to graft
versus host (GVH) disease; she was untouched by human hands except those gloved for
medical procedures; she was responsible for special hygienic self-care and packaging of her
body wastes for disposal; she communicated with visitors through glass and an intercom; she
provided her visitors with her daily `'numbers'' of blood counts, to record on a wall chart
opposite her cubicle. Critically ill, though performing an extraordinary degree of self-care, she
HSE3701/1 45
suffered, when suffering is defined as experience of threat to self or personal identity often
brought on by pain, loss or psychological distress but not identical to these conditions loss of
self as the fundamental source of suffering in the chronically ill (Helman 2007:134±143).
Though her visitors (often anxious and always feeling inadequate) gave support by merely
being present and by providing diversions to make the long hours pass more quickly, the need
for that presence and support precluded the patient from sometimes saying what she needed
and wanted to say about the meaning of this experience for her. She needed a skilled
professional, unknown and uninvolved, to whom she could unburden her mind and soul.
Yet no specialised mental health professionals were available during the stay in isolation or
after transfer elsewhere in the hospital to help the patient with the multiple meanings of her
illness experiences and the powerful emotions attached to them. These were controlled by
drugs. Staff were highly competent, kindly, and given to personalising her care, but their high-
tech ministrations seemed to consume their energies. Moreover, the circular arrangement of
the unit, with a corridor for visitors on the outside periphery of the patients' rooms and the
professionals staffing the inner circle, controlled and limited the frequency and type of
interaction that could take place among families, staff and patients. An informational group
meeting of families was conducted by a physician once a week and doctors were available by
telephone. Staff could be seen working through the porthole gloves but were virtually
unavailable to families.
Even granting that without this advanced biomedical treatment system there would be no need
to consider an illness experience, care in such settings must be complemented by planned
attention to the illness response of the whole person. Costs for services to help patients cope
should be built in when such units are being planned, and students need to be advocates for
the full range of services for patients and families. Moreover, cancer is a chronic illness: the
illness experience continues even if there is remission from the disease (Germain 1992:5±6).
The condition of a patient can also have a spiritual or religious meaning that may be
experienced as distress, despair, alienation, resignation or transcendence. A shared culturally
linked religious or spiritual support system would be expected to help the person deal with
these dimensions of the illness experience. In traditional societies there were (and are) systems
of support, but these have waned in western society as society has become more secular.
Germain (1992:7) cites an example: Native American inpatients at the Tuba City (Arizona)
Indian Medical Centre can leave the hospital to see a native healer or medicine man, and the
patient's hospital bed is reserved for the length of the healing ceremony, which could take
several days. Thus, western biomedicine, with its focus on body parts, is complemented by
Navajo healing traditions in which the body is viewed as part of the whole of the universe, and
symptoms as a reflection of disharmony, which healing ceremonies focus on.
Therefore health professionals should be aware of and have knowledge on how clients perceive
the meaning of sickness. The significance of understanding how cultural knowledge mediates
an individual's experience of sickness lies in the goal of providing care that promotes comfort
and healing in an environment of trust. Many misunderstandings between clients and
professional health care providers can be attributed to the fact that each uses different
knowledge systems and reasoning processes to determine and manage health and sickness
states. For example, professional health care providers base their practices on a shared system
of scientific knowledge that provides evidence of disease states when objective data are
collected and measured against a logical and predictable standard. In contrast to professional
providers, clients typically express a subjective recognition of illness in the context of pre-
existing cultural standards used to determine degrees of wellness and illness (Helman
2007:139±143).
It has been implied that failing to understand how clients determine their health status and
46
interpret the meaning of their illness experiences may result in lost opportunities for
interventions such as early detection and screening programmes. The role of culture in
influencing health, sickness and healing is understood only when the meanings and
interpretations of behavioural standards are attached to social relationships and institutional
settings (Kleinman et al 1978:251±258).
4.4.3 The African conceptualisation of disease causation

The idea of ontological or cosmological balance, having reference to a state of harmony, is an
important theme found in African cultures. Ideally, balance exists between humankind and the
total environment: natural, supernatural and social. While balance prevails, all is well. Any
misfortune, including sickness, disturbs the balance, creating a situation of danger for all.
Therefore, every effort is directed toward restoring any loss of balance as soon as possible
(Jansen 1982:108).
In western medical systems disease is generally explained by means of empirically based

cause-and-effect sequences. For instance, an infected tsetse fly bites a man and he contracts
sleeping sickness. The disease manifests in certain symptoms according to which the medical
doctor diagnoses the disease. These medical systems do not attempt to explain why the fly bit
that particular man and not another. Their concern lies in discovering what is causing the
symptoms, that is what pathological process is at work. To the question ``Why has it happened
to me?'' western medical science would answer ``By chance'' (Hammond-Tooke 1974a:336).
Many belief systems that are more traditional, however, do not acknowledge the idea of chance
and their medical beliefs do provide an answer to the question ``Why me?''. In such systems the
cause of the illness is more important than the way in which it develops.
Africans generally recognise both natural and supernatural conditions as causes of disease.
Helman (2007:102±110) supports this view, but adds that illness is also caused from within:
within the individual patient, in the natural world, in the supernatural world and in the social
world. This is illustrated in figure 4.1.
The supernatural world

The social world
The natural world
The individual
FIGURE 4.1
4.4.4 Sites of illness aetiology

In some cases illness is ascribed to combinations of causes or to interactions between these
various worlds. Social and supernatural aetiologies tend to be a feature of some communities
in the non-industrialised world, while natural or patient-centred explanations of illness are
more common in the western industrialised world, though the division is by no means
HSE3701/1 47
absolute. For example, it has been stated that there are eight groups of lay aetiologies that are
common among patients in the USA, and that most of them are patient-centred.
For this section, we shall concentrate on the African conceptualisation of disease causation.
4.5 Natural causation of disease

Certain diseases are referred to as common or ordinary illness (mkhuhlane in Zulu; mokotlane
in Sotho). Such illnesses display a degree of overlapping and may be specific or nonspecific.
Specific causes are not necessarily attributed to all human ills in more traditional societies.
Many minor illnesses, such as colds, toothache or boils, may be regarded as `'natural'' and
require no explanation. Furthermore, death after a long and honoured life would generally be
regarded as normal. On the other hand, the idea of illness as a punishment for sin is not
completely unknown in western societies. It is therefore only possible to draw general rather
than rigid distinctions between the various ideas on the causation of illness (Helman
2007:134-143).
4.5.1 The ``hot-cold'' theory of illness causation

Societies in many parts of the world explain illness by means of the humoral or ``hot-cold''
theory. Ayurvedic medicine in India, and the traditional Chinese Yin-Yang system of medicine,
fall into this category. This theory is also common among Latin American societies and
particularly among the peasants in these societies. Briefly, it is believed that health can only be
maintained if the body's natural ``hot and cold'' balance is not disturbed. Temperature
imbalance occurs when the body is exposed to extremes of heat or cold, and illness or death
can result. The terms ``hot'' and ``cold'' do not refer to actual temperature conditions but to a
symbolic quality possessed by natural objects, food or illnesses which are all classified as
being either one or the other. These beliefs govern daily life since the entire natural
environment has these qualities and the body's equilibrium is constantly being threatened
(Helman 2007:126).
4.5.2 Illness as a sanction

In societies in which illness is regarded as a direct consequence of individual behaviour it is
linked with social and moral values and becomes an important social sanction. This role of
illness is more likely to be encountered in societies which lack or have few institutions for
ensuring social control. It is probably ± but not necessarily ± most characteristic of non-
centralised societies (Helman 2007:126).
The belief that illness is a punishment underlies the values that people regard as important. For
instance, in some circles, particularly among more religious persons, AIDS is regarded as a
punishment for sexual promiscuity. Among the South African black societies breaches in
social relations with living kin, neighbours or the ancestors are believed to result in ill-health.
Furthermore, someone who is surly, mean and inhospitable is more likely to be accused of
sorcery and witchcraft than one who exhibits approved social behaviour. Illness is thus
expressive of social tensions and underlines the norms of the group. For example, kin should
remain united, seniority of age and rank should be respected. To keep the family healthy the
person has to conform to acceptable social behaviour.
48
4.5.3 Other factors relating to the incidence of disease
The environment in which a society lives is a factor in health and each type of environment has
its particular hazards. Tropical regions have a large number of disease vectors (these are
organisms which transfer disease to other organisms) such as the anopheles mosquito which
carries malaria and the tsetse fly which carries sleeping sickness. Harsh climates such as those
of the subpolar regions create special problems for the human body, as do high altitude
environments. Urban environments, too, are associated with particular health problems such
as high levels of stress (Helman 2007:150±151).
Human populations adapt to their environments by means of biological mechanisms such as
physiological adaptations (eg bodies sweat to produce cooling) and genetic adaptation (eg
Africans have long limbs which dissipate heat whereas Arctic hunters have bulky bodies which
conserve heat). Chiefly, however, humans adapt to their natural environment by means of their
culture and more specifically by means of technology. Technology, of course, may also have
maladaptive consequences. For instance, the introduction of agriculture into West Africa and
the subsequent clearing of forests provided an ideal breeding ground for the malarial
mosquito. The building of the Aswan Dam in Egypt made it possible to expand irrigation, but at
the same time led to a drastic increase of the parasite which causes bilharzia. Highly developed
industry produces environmental pollutants which can cause health problems such as chronic
respiratory diseases and cancers (Helman 2007:150).
Economic factors may be directly related to the incidence of disease. The use of human
excrement for fertiliser has become almost an economic necessity in overpopulated parts of the
world and disease is spread in this way. A study of hookworm infestation in a Chinese village
revealed that the village rice-growers who stood in mud fertilised with human excrement while
planting rice were heavily infested, while villagers engaged in silkworm production, and who
spent their day on ladders tending mulberry trees, were relatively free of the disease.
Occupational health hazards in industrialised societies have been well documented, an
example being the miner's disease in South Africa, phthisis.
The unequal distribution of wealth in a society is another economic factor which relates to
health. Poorer sectors of society are generally less well nourished and, at the same time,
medical facilities may be less accessible to them (Spector 1996:192).
The availability and quality of food are important in the maintenance of health. While the
physical environment may be a limiting factor, what is considered to be food, how it is
produced, prepared and consumed, is largely dependent on culture. Some foods may be
available only to certain sections of the group. At times certain foods may be forbidden. This
can lead to malnutrition. For instance, the Zulu woman has to abstain from drinking amasi
(sour milk) during the period of isolation after childbirth and for about two months afterward
(Helman 2007:180). This deprives her of an important source of nutrition at a critical time.
Other customs may also have an effect on nutrition. In some societies women have to abstain
from sexual relations for some time after the birth of a baby and the baby is weaned late. This
helps to protect the baby from malnutrition.
Sex distinctions and the different roles assigned to men and women may also be factors in the
incidence of disease. For instance, Bedouin women often suffer from bone disease resulting
from a deficiency of vitamin D related to diet and to lack of sunlight, while men do not. The
reason is that while men and children may move about freely, women spend most of the day
inside their tents and when outside are covered by heavy black cloaks.
Sexual behaviour and marriage practices may also be factors in the distribution of diseases.
Promiscuous sexual behaviour may lead to a high incidence of venereal disease and is
regarded as the main cause of AIDS. Societies which practise endogamy may tend to have a
higher incidence of genetic diseases than exogamous groups.
HSE3701/1 49
Ritual practices involving food taboos, fasting, self-mutilation and funerary customs may have
an effect on health. A progressive fatal illness called kuru occurs among the ForeÂ of New
Guinea, and is particularly prevalent among women. It was found that the virus causing the
disease was transmitted during the ritual cannibal meal held to honour dead relatives. To show
their love and respect, close relatives cooked and ate portions of the deceased. A deceased
woman's parents, husband and children did not partake, nor did warriors since they believed
that eating human flesh made them vulnerable to enemy arrows. Women, therefore, were the
main participants in the ritual. Incidence of the disease has declined sharply since the practice
of cannibalism has practically disappeared (McElroy & Townsend 1979:43±48).
Political factors play a role in health. Disease and malnutrition are rife among the refugees from
Africa's various internecine conflicts. The most recent example here are the refugees from
Rwanda. Many who survived the carnage in their own country died from malnutrition and
cholera in the refugee camps in ZaõÈre. Denial of resources such as efficient medical care can
also result from political events. On the other hand, the provision of health care facilities,
education of medical personnel and the control of medical practices are usually the
responsibility of modern governments.
4.6 Supernatural causation of disease

The core belief system on which traditional African medicine rests constitutes "a metaphysical
article of faith" (Conco 1972:288), in that claims regarding its truth cannot be refuted or
verified empirically (Conco 1972:288). In order to explain the basic tenets of the supernatural
theory of disease causation, belief systems relating to the Supreme Being, ancestors and
pollution are significant.
& The Supreme Being. In traditional African society, God is a shadowy figure who made
the world, but toward whom no prayers or rituals are directed. His involvement in human
affairs functions as a residual explanatory concept much like that of "fate", "luck" or
"chance" (Hammond-Tooke 1980:46±47).
& Ancestors. The shadows or spirits of deceased ancestors constitute an important
religious entity. Ancestor belief provides a set of explanations for misfortune and
disease. Ancestors not only protect the interests of their descendants, but may also
punish them for failing to honour them appropriately, for not respecting senior members
of the group or for neglect of long-standing traditions and rituals. A close relationship is
forged between the integration of wider descent groups and morality (Jansen 1982:107-
108; Hammond-Tooke 1989:47).
Ancestor spirits who may feel neglected or wronged in some way may punish their
descendants by sending illness or other misfortune. Among many South African blacks
it is believed that ancestor spirits may communicate with their kin by punishing them in
this way. For example, the Zulu believe that the ancestors reveal themselves by seizing
on part of an individual's body and causing illness (Krige 1950:288). The South Sotho
have ascribed all illness to the ancestors in the belief that the ancestors are jealous of
the living. Presently, however, only a few disorders such as hysteria, insomnia and
epilepsy are ascribed to them (Hammond-Tooke 1974a:331). Generally, South African
blacks do not consider ancestor-sent illness as evil, and it is rarely fatal.
& Witchcraft/Sorcery. These terms denote a mystical ability possessed by certain
individuals enabling them to use their powers and forces of nature to bring harm to
others (Hammond-Tooke 1989:48).
50
Sometimes illness is caused unintentionally as in the case of the evil eye. Interpersonal
feelings of tension or conflict usually underlie accusations of witchcraft and sorcery.
Beliefs concerning witchcraft and sorcery are especially common throughout Africa, and
among many South African blacks are frequently regarded as causes of illness.
& The evil eye. This is recognised as a cause of misfortune in Europe, the Middle East and
North Africa. The person suspected of having the evil eye may be a stranger or someone
who is different in some way from the rest of the community. A jealous look is believed
to be sufficient to cause harm. The harm is, however, unintentional and the possessor of
the evil eye may be unaware of his or her powers.
& Pollution beliefs. These are beliefs concerning causation of disease and misfortune that
function independently of spiritual and human volition. People are inadvertently in a
dangerous state of ritual impurity stemming from certain life conditions such as
menstruation, the birth of twins, illness and death (Hammond-Tooke 1989:50,91).
& Taboos. These are the prohibitions or avoidance rules applied to particular persons,
objects or phenomena. The consequences of breaching a taboo may either follow
automatically or be inflicted by some god or spirit. Such consequences can take the
form of illness for the offender or even for his or her family. For instance, the Xhosa-
speaking people believe that a woman who breaks a taboo connected to her state of
ritual impurity during menstruation will bring illness on herself, her husband and
children, or on her husband's agnatic kin (De Villiers & van der Wal 1995:52).
Two comparatively new phenomena relate to the possession cults and to faith healing
(Hammond-Tooke 1989:51,126):
& Possession cults. This term refers to the possession of individuals by alien spirits or
individualised ancestral spirits which are clearly distinguishable from the ancestral
group descent pattern. By entering the body, these spirits cause illness, which presents
in a variety of symptoms. Because of their recent origin, cults only fit loosely into
traditional worldviews. Membership is restricted mainly to females (Hammond-Tooke
1989:51,127±129,134).
& Faith healing. Great emphasis is placed on the healing power of the Holy Spirit.
Introduced in 1908, Pentecostal teaching found echoes in African thought, giving rise to
the Zionist movement. Sects continue to proliferate. Belief centres on the ability of the
Holy Spirit to provide guidance and influence the minds of worshippers (Hammond-
Tooke 1989:51,136).
Inextricably linked with any social and cultural construct regarding disease causation is the
content and structure of the practice of medicine. Restoration of a state of balance or harmony
necessitates discovering the cause of the condition and, where relevant, the responsible agent.
The nature of the illness, in turn, determines the correct treatment and the means whereby a
recurrence may be prevented. Depending on the social context of aetiological decisionmaking,
illness episodes are channelled towards specific therapeutic options (Mills 1987:7).
4.7 The traditional structure of African medicine

As a generalisation, it is possible to state that Africans believe in the unity of nature as a vital
force directing and animating everything in the universe. Although God is the source and
ultimate controller, spirits also have access to this force. A few human beings may have the
knowledge and skill to tap, manipulate and use these powers (Tjale and de Villiers 2004:136).
It is within this construct of reality that the traditional medical and healing arts of African
HSE3701/1 51
medicine are practised. Traditional practitioners or healers, in their diagnostic and healing
capacity, act as mediators between the visible and invisible world to determine the forces at
work and how to restore harmony (Vontress 1991:243). Treatment and prevention of the
harmful event are inevitably and logically intertwined.
In African medicine, there are clearly distinguishable categories of specialists and healers,
although they are not necessarily watertight compartmentalised groupings. Sometimes
practitioners are seen as being endowed with variations of power and, in other instances, as
all-powerful (Jansen 1973:117). In the South African context, the following specialists are the
most clearly identifiable:
4.7.1 The diviner

The diviner is generally regarded as a friend of the community, and practises as a result of a
call by the ancestral spirits. In South African black societies the diviner therefore interprets the
will of the ancestors. A diviner is consulted in cases of misfortune such as illness and will
indicate whether an illness has been sent by the ancestors or is due to witchcraft or sorcery. He
or she will advise what actions should be taken to remedy the situation. Diviners may also refer
clients to herbalists for treatment. On the other hand, diviners may also be herbalists, and may
treat the patient themselves.
Divination is the process of obtaining knowledge of future events or secret things by means of
astrology, oracles or contact with divine or superhuman forces. The diviner (igqira in Xhosa;
isangoma in Zulu; ngako in North Sotho; selaodi in South Sotho) is usually female, and is
called to the profession by the ancestors. It is this affirmation that underpins the divination
process and bestows on it the authority derived from its sacred nature. The neophyte, prompted
to divination by a series of vague and variable symptoms, submits to the inevitable and is
apprenticed to an established diviner for a period of intense training (Hammond-Tooke
1989:104±107).
The role of the diviner is specifically that of controlling the forces of evil that constantly
threaten the wellbeing of the community (Hammond-Tooke 1989:103). They make possible the
fusion of human being and spirit, the seen and the unseen, the natural and the supernatural.
Whatever the source of power, the primary role of the diviner is to identify the agent causing the
illness and then to determine how to overcome or placate it. Therapy is believed to have little
effect until the causal agent has been identified. A complicated system of medical practice is
integral to the healing arts of traditional practitioners (Tjale & De Villiers 2004:82,156).
4.7.2 The herbalist

Herbalists are medicine men who have specialised knowledge of plants used to treat or prevent
illness. Herbalists are familiar with magical techniques but do not possess occult powers. They
may specialise in the use of certain herbs only or may utilise a wide selection of remedies.
Hammond-Tooke (1974a:342) points out that in the South African context herbalists and
diviners cooperate with one another in much the same way as do general practitioners and
specialists.
The herbalist (inyanga in Zulu; ixhwele in Xhosa; ngaka in Sotho) is usually male and is not
mystically called. Herbalists decide to specialise in the use of herbal medicines and apprentice
themselves to established herbalists (Hammond-Tooke 1989:104).
52
The herbalist is a master of his or her trade in pharmacopoeia and important to the wellbeing of
the community. He or she possesses knowledge of a vast array of roots, plants and other
substances. Some of these medicines may also be used to harm people, should the
practitioner become antisocial and operate like a witch (Hammond-Tooke 1989:104±105).
4.7.3 The shaman

The shaman is usually both a diviner and a medicine man (the term is used by anthropologists
for traditional practitioners who specialise in healing illness and in dealing with other
misfortunes) and has the ability to control spirits by means of ritual techniques. His function is
to heal those who are ill and to protect the community from danger. Shamanism is found
among the aboriginal groups of north and South America, and in parts of Africa. The shaman's
power to heal comes from an ability to communicate directly with supernatural beings from
whom he learns the healing techniques he uses (Tjale and de Villiers 2004:157).
4.7.4 The cult leader

Cult leaders appear to be women of commanding and strong personality. Characteristically,
women are inducted into a cult group where they regularly undergo a possession experience.
Afflictions are not treated by the exorcism of a possessing agent, but by arriving at a viable
accommodation with it. Sufferers, unlike the victims of ancestral displeasure, are not seen to
bear moral responsibility for their condition because the possessing spirits are perceived as
originating from outside the society (Lewis in Hammond-Tooke 1989:134±135).
4.7.5 The faith healer

Faith healers may belong to either mission or independent churches. Healing takes place in
three main modes: healing during church services, by immersion or in consultation with a
prophet. The first two derive from Pentecostal practice, while the third displays significant
parallels with indigenous methods of healing. Praying and the sacrament of laying on of hands
are the most common rites performed by prophets associated with the sect. Use of holy water
is widespread. The power to heal is believed to come from God and the Holy Spirit through the
agency of the prophets and the efforts of the congregation (Hammond-Tooke 1989:136±137).
Although the administration of the independent churches is almost entirely male-dominated,

the general importance of women is reflected in the role of the prophets, the majority of whom
are female (Hammond-Tooke 1989:137±138).
4.7.6 The sorcerer/witch

Sorcerers, wizards or witches (bathakathi in Zulu; baloi in Sotho) (Conco 1972:291) perform
their work by becoming invisible, changing shape or sending familiars to do their evil deeds.
They are sinister, highly ambiguous figures, both human and nonhuman, whose activities
transcend normal human powers. Their services may be used by those not endowed with
mystical powers, to the detriment of others (Hammond-Tooke 1989:73).
Sorcerers are able to place hexes on individuals, cast spells, inflict both physical and
psychological harm on people, cause them to commit suicide, plant suggestions in their
HSE3701/1 53
minds, kill them from a distance without leaving evidence of the deed, and send messages
through dreams announcing happy and unhappy events.
Finally, it is necessary to mention those people who do not practise medicine as such but who
have some skill in treating particular conditions.
4.7.7 Individuals with special knowledge and skills

Certain persons are known to have skill and knowledge in respect of treating conditions,
especially those of natural origin. Specific empirical treatments may be passed on via relatives,
dead or alive, be revealed by spirits in dreams or learnt from a traditional practitioner without
secrecy, mysticism or supernatural conceptualisations (Conco 1972:285,295). Bonesetters
and traditional midwives may be included in this group. In African medicine, the unity of cause,
practice and diagnosis is well demonstrated.
4.8 Diagnosis and treatment

Expectations of diagnosis and treatment will include `à generally accepted interpretive view of
sickness and its causes'' (Conco 1972:300).
In both western and traditional medical systems dealing with ill-health involves first diagnosis
and then treatment. As pointed out in the above section, in both western and traditional
systems a sick person has recourse to self-help or advice from non-specialists such as kin and
friends. Such self-help or advice includes diagnosis. Sometimes the patient may consult a
practitioner in order to have this diagnosis confirmed. The following discussion, however,
concerns diagnosis and treatment as practised by practitioners.
The difference between western and traditional systems lies in the purpose and methods of
diagnostic procedures. The western medical doctor attempts to establish what disease process
is causing the symptoms. This procedure relies on questioning, physical examination, and
sophisticated laboratory techniques. The concern of the doctor is chiefly with the patient, not
with his or her sociocultural environment. In traditional systems the purpose of the diagnosis
is usually to establish the ultimate cause of the illness and not the disease process causing the
symptoms. The client's entire social and environmental circumstances are taken into account
(Helman 2007:122±134).
4.8.1 Diagnostic techniques

Traditional practitioners use a variety of procedures to diagnose problems. Some arrange
elaborate ceremonies to invoke ancestral spirits to obtain answers to the problem, while others
go into trancelike states and yet others may take histories. Other procedures include the use of
divine objects: bone throwing where the configuration of bones indicates what is wrong,
divination methods in the form of studying the flight of birds or the reading of leaves,
clairvoyance and clairaudience (terms which refer to the seeing and hearing of things invisible
and inaudible to normal vision and hearing) and the use of ``mirrors'' to ``see'' problems and
interpret dreams. Rituals are generally conducted in group context so that the `àfflicted'' person
is not isolated from the community of which he or she is a member (Tjale and de Villiers
2004:92, 99±100).
Trance divination is a common form of divination. For example, the Zulu divining methods
54
include bone throwing, or the use of sticks which jump around to indicate the answer to
questions (Krige 1950:301).
The patient's kin and friends are usually witnesses to the divination process and may
participate in the consultation by verbal acknowledgment of stages in the procedure, for
example by indicating agreement with the diviner's pronouncements. The diviner attempts to
discover what troubled relationships with kin, neighbours or the supernatural are causing the
illness (Krige 1950:302).
Diagnostic and healing techniques are inextricably entwined and frequently overlap.
4.8.2 Treatment
Treatment involves restoring relationships (with kin, neighbours). The following example
illustrates these principles.
The Ndembu of Zambia ascribe illness to social causes and when someone becomes ill a
diviner is consulted. The diviner goes into a trance during which the assembled kin ask
questions of the spirit which has possessed the person. The spirit diagnoses the cause of the
illness and prescribes treatment. When the cause has been established the diviner calls the
relatives of the patient to assemble at a sacred ancestral shrine where they have to confess any
grudges they hold or any animosity they have towards one another or towards the patient. In
this way social tensions are resolved. The diviner also uses rituals of exorcism to draw evil
influences from the patient's body and may apply medicines or manipulation. Dances and
songs are performed to purify the patient and his or her group (Tjale & de Villiers 2004:82,
156) (Helman 2007:85±86, 238).
Treatment methods thus reflect ideas about illness. Where ill-health is defined on the ground of
objectively observed physical changes in the structure and function of the body, such as in
western systems, treatment concentrates on the disease itself. Where the illness is believed to
originate from supernatural beings such as the ancestor spirits, treatment may involve
propitiation of the spirits by means of prayers, invocations and sacrifices. Generally the action
recommended by a practitioner, for example a ritual sacrifice to appease the ancestors, may be
carried out by others such as the patient's kinship group. Among South African black societies
it is usually the senior male of the patient's agnatic group who performs such rituals. If the
illness is due to a malevolence agency such as witchcraft or sorcery, treatment may attempt
either to neutralise the evil power or to strengthen the patient against it. For instance, a healer
may magically retrieve and destroy an illness-inducing item hidden by a sorcerer or may
administer medicines to strengthen the patient.
Healing may, therefore, involve public confession of acts which are disapproved of, prayers,
sacrifices, the use of magical techniques and the use of medicines. The term ``medicine'' is
used here to refer to any substance that is given to patients in the belief that its power will
assist recovery from illness. Medicines can also be used in other ways, such as in the
protection of crops or even to cause illness. Plants are not the only source of medicine and
other sources such as flesh, blood or fat may also be used.
While magico-religious beliefs play an important role in the treatment of illness in traditional
medical systems, such systems also have many healing practices which have an objective
therapeutic value and demonstrate the application of empirical knowledge. Examples of such
techniques are bonesetting, obstetric procedures such as Caesarean section, inoculation,
administering of laxatives and applying ointments. Furthermore, these medical systems
embody a knowledge of a wide array of medicinal plants, many of which have become accepted
for use in western medical systems, such as quinine (for preventing and treating malaria) and
HSE3701/1 55
opium (which is used as a sedative). Traditional medicines are thus frequently therapeutically
effective. Often, however, no distinction is made between these curative medicines and magical
remedies. In the worldviews of many societies there is not the clear distinction between the
natural and the supernatural which is found in the western worldview. Magico-religious beliefs
about the efficacy of medicines are not unknown in western societies, although the medical
profession does not recognise them.
4.8.3 Other traditional African treatment methods

Note the following methods of treatment:
& Pharmacotherapy. Traditional practitioners are well versed in the prescription of
pharmacological agents. Directions for use are frequently phrased so that responsibility
for the medicine's working properly falls on the patient (Conco 1972:294) while
associated symbolic values are often as important as the healing properties of the
medication. For example, emetics and purgatives may be used to eject evil spirits or
poisons from the body or to effect thorough cleansing so that the medicine will have
maximum effect. Many people, especially the elderly, have some knowledge of common
roots and herbs (Conco 1972:285) (Helman 2007:369±370).
& Exorcism. This practice is as old as religion itself and remains a feature of orthodox
western religions. The expulsion of supposed evil spirits from people or places is
accomplished by means of specific incantations and ceremonies (Helman 2007:204,
285).
& Sacrifices. The sacrifice of domestic animals is a symbolic act intended to propitiate the
spirits of the ancestors. Harmony between the living and the ``living dead'', or recently
deceased, is hereby maintained or restored (Helman 2007:225).
& Possession dances. Magicians reveal predictions and councils of the spirits during
these ceremonies. In the emotionally charged environment, the sick and the group are
spiritually elevated and unconsciously reconciled and leave the event feeling physically,
psychologically and spiritually recharged. In a sense, such dances may be seen as
group psychotherapy (Helman 2007:225).
& Music as therapeutic accompaniment. Music is used as a key to the invisible world and
as an instrument of the inner dimensions. Music is necessary to induce spirits to leave
their domain and travel to the social world. Mediums usually require accompaniment to
induce the trances that allow ancestral spirits to inhabit their bodies. Music also serves
as a psychological tonic.
& Shock therapy. In certain types of mental disorder African-style shock therapy is used to
restore patients to wellness. Repeated dunking of patients in ice-cold streams or
submission to severe fear-inducing experiences may be used to effect a cure (Helman
2007:225).
& Preventive measures. Prevention of illness in western medical systems may involve
active measures such as inoculation against disease or the application of ideas
concerning hygiene, healthy eating habits, regular exercise and so on. More traditional
groups have customs which have the effect of preventing illness, although not
specifically intended as health measures. These would include keeping a living area
clean because of fear of pollution, or wearing clean clothes for ritual reasons (Worsley
1982:343±344).
Other measures may be consciously directed towards the avoidance of illness. These include
avoiding giving offence to others, carrying out rituals and observing taboos, the wearing of
56
protective amulets or charms or the administering of medicines. For example, Xhosa speakers
may ritually scarify the face or cut off the little finger at the joint, in order to prevent illness or
other misfortune. An attempt may be made to distract the attention of supernatural beings in
order to protect someone. The Lango of Uganda, for instance, give a baby a degrading name in
an effort to conceal its birth from their god, Jok, who is believed to be jealous of his creation
and may cause the baby's death. The Turks often protect their children against the evil eye by
hanging unattractive objects on their clothing.
Preventive medicines are obtained from traditional practitioners or persons with the necessary
skills. Measures cover all aspects of life ranging from pregnancy and childbirth to success in
business, lovemaking, crops, control of hail and lightning, as well as warfare and making the
home invincible (Conco 1972:293±294). Good health and fortune are rich rewards for good
behaviour and constant sacrifice to ancestral spirits.
Africans practise preventive health in the areas of maternal and child health; herbs seem to be
used more to prevent children from contracting specific diseases, especially newborn babies.
The use of lephekho as a preventive measure against those regarded as impure by the
community (eg the bereaved), its purpose being to keep them from entering a room in which
there is a newborn. There are indigenous healers who specialise in fields relating to the
treatment of children's diseases, as well as a variety of prophylactic measures taken against
certain diagnosed and undiagnosed paediatric conditions. The attitude of the African towards
health, be it preventive or curative, is sensible, even though the cause might be attributed to a
perturbed spirit. The role of the healer in preventive health among the Shona of Zimbabwe as a
specific concern with the prevention of pregnancy, the prevention of diseases in people likely
to come into close contact with a corpse, the creation of a pleasant social environment and the
protection of crops against thieves. (Helman 2007:138±139) (Tjale & de Villiers 2004:136±
137)
Two factors are involved in the protective ritual for children. First, accidents do not occur at
random and as a result individual protection is needed. Secondly, newborn babies die readily
and need protection. Health and illness depend on the `èquation of the spirit, the balance which
is forever to be maintained by propitiation and ritual''. There is also a strong avuncular-nepotic
relationship among blacks and the role of malome in the prevention of diseases among blacks
is the other important factor.
Indigenous African healing is frequently preventive and preventive measures are usually
initiated by the family. Since healers are commonly found within the family, they teach other
family members the art of healing.
The use of rituals remains one of the most important aspects of preventive medicine as used by
black South Africans. A missionary in Papua New Guinea found that traditional religious
practices, such as sacrifices, offered a means of coping, which the culture of the missionaries
did not offer. It is believed that unless the ceremony is blessed by the ancestors the whole
exercise is futile. In the case of illness it is important that a healing ritual be performed to
appease the ancestors.
It seems that indigenous healers undertake health education and counselling to prevent the
recurrence of certain diseases. States as a matter of fact that indigenous healers recognise the
existence of hereditary disorders and advise against marriages which would perpetuate them. It
was from indigenous healers that formal health practitioners learnt the use of oil of
chaulmoogra for leprosy and Ginchona bark (quinine) (from the pre-Colombian Indians of
Peru) for the treatment of fever. Digitalis is reported to have been stolen by Withering as a
secret remedy for dropsy from `àn old woman'' (Trotter 1975:38) who could not be
acknowledged by name.
Like formal health practitioners indigenous healers use consultation sessions before
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prescribing medications. They look for the cause of the health problem through divination and
then diagnose the condition before applying the correct treatment.
Please study the relevant chapters in Helman (2007) with regard to AIDS and culture.
4.9
1 Should exorcists treat sick people?
2 Where will you go when you die?
3 What are some of the principal differences between western and African medicine?
Put your answers in your portfolio.
4.10
Describe one cultural custom or practice with health assessment implications that you
have experienced in your professional or personal life. Answer the following
questions:
& What is the custom or practice?

& What country or culture does it represent?
& What implications does the custom have for health care professionals who are
practising in your country and caring for clients from the country or culture you
have identified?
It is not possible to consider the structure and content of traditional African medicine
without paying more attention to the family as the central unit within traditional African
societies.
4.8.4 The traditional African family

The family, as the pivotal group around which the social system is organised, constitutes a
cohesive structure. The relationship between the family and the medical system is outlined by
Jansen (1982:114±119).
Illness or misfortune affecting a single family member becomes a crisis for the whole family.
The family, as a unit, determines whether or not the affected member is to receive medical care
and whether health care should be provided by the family or the formal health system. The
family is involved in decisionmaking at every stage of illness from diagnosis, to treatment, to
rehabilitation (Ansersen in Gort 1987:18). Generally, family members escort the affected
person to the healer and remain with him or her until the treatment is complete.
Because of the clearly defined structured cohesiveness found in the family, illness involves the
extended family, other kinship groups and even classificatory kin. In the African social system,
kin are classified into broad categories in which there are accurate linguistic descriptions for
degrees of closeness and seniority. Status structures are strongly hierarchical, with each
person holding a specific position which is uniquely his or her own. Both seniority and respect
for age are integral aspects of traditional African cultures. Status hierarchies are different for
58
men and women, with males holding a generally dominant position. Significantly, specific
patterns of behaviour in respect of duties and responsibilities and privileges are codified within
the classificatory terminology. A distinguishing characteristic of the African social system is its
corporate nature. No African may lead an individual life out of self-interest as it is considered
self-indulgent. Whatever affects the individual involves the group and anything happening in
the group carries implications for the individual. What matters is the collective wellbeing of the
extended family, which usually comprises the eldest male, as head of the group, his wife or
wives, their children and other consanguineous relatives such as nephews, nieces,
grandchildren and grandnephews and nieces.
In order to provide a unifying framework to allow the reader to understand more clearly the
divide between traditional and western-based biomedicine, a description of the transcultural
context of health care in South Africa follows.
4.8.4.1 Health care in a transcultural context

Where different medical systems are found side by side, as in South Africa, patients have
different options available to them when they require medical treatment. In South Africa most
black patients may either consult a western-trained doctor or another health care professional
such as a clinic sister, or go to a traditional practitioner. With increasing urbanisation,
however, more black patients appear to be turning to western medicine (Hammond-Tooke
1989b:10). At the same time the provision of health care in South Africa is changing as the
technological approach to health care makes way for primary health care which emphasises
prevention and early diagnosis. The government's announcement in 1994 that pregnant women
and young children were to receive free medical care reflects this trend. In spite of this, many
patients retain ideas and beliefs of a more traditional nature which influence their health care
behaviour.
Behavioural and not ideological differences between people are emphasised in this study unit.
Being aware of and understanding such differences helps us to understand the culture of other
people, and why they behave in particular ways. As far as health care is concerned, health
professionals should essentially treat each patient with deference to his or her own
sociocultural background. It is only in this way that the health professional or the student will
be able to provide truly effective treatment (Tjale & De Villiers 2004:171).
4.8.4.2 The transcultural context

Colonisation, industrialisation and modern technology have introduced western medicine (or
biomedicine) to developing countries, producing changes in the local system of medicine. The
effect has been that in many countries, including South Africa, western and traditional medical
systems are found side by side. Therefore many black patients retain traditional health care
beliefs and behaviour but consult a doctor or other biomedical practitioner. For them
consultation takes place in a setting, either the hospital, clinic or consulting rooms, in which
doctor and patient may have different beliefs and ideas about health care, or may speak
different languages. Hence the contact between doctor and patient is transcultural, a term which
implies contact between persons of different sociocultural orientations, and hence contact
between western medicine and traditional medicine.
In this contact situation differences in the sociocultural orientation of doctors and patients are
obvious from the following with regard to
& differences in ideas and in value systems
& different perceptions of health care phenomena
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& diverse health-related beliefs and behaviour
& varying perceptions of the body and its functioning
& different ideas about causation and the treatment required to cure a particular condition
Generally, in spite of the differences, the encounter between doctor and patient goes off
smoothly and patients recover after treatment regardless of whether such differences are
acknowledged or not. However, it may become apparent that there are problems in the
encounter. These problems are manifest in miscommunication, delayed consultation, fear,
distrust, disregard of the health professional's instructions, noncompliance with treatment,
discrimination and excessive submissiveness among patients, all of which have implications
for patients' wellbeing and recovery. On the other hand, the problems could also be the result
of a patient's experience with poverty, unemployment, political factors, ignorance about
available health care facilities and the services they offer, distance from health care facilities
and lack of transport (De Villiers & Van der Wal 1995:286). It should also be borne in mind that
problems could be the result of the health professional's lack of awareness and understanding
of his or her patient's beliefs, perceptions and behaviour. It has been found for instance that few
white doctors are aware of anything other than the more obvious aspects of their patients'
health care beliefs and behaviour, such as ritual sacrificing, treatment by traditional
practitioners and ideas about witchcraft and sorcery.
Black students often share their patients' sociocultural orientation, or speak their languages.
Hence they generally recognise and understand their patients' beliefs and behaviour. The
relationship between students and patients is therefore often one between persons with the
same sociocultural background. This is important to communication between student and
patient and sharing of health care ideas and beliefs. At the same time the students have been
trained in western medicine. They therefore represent the western medical system and have
professional knowledge of its principles and functioning. So they are used to the multicultural
setting of the hospital, clinic or consulting rooms.
Many black students therefore have a foot in both camps as it were. They are in an ideal
position to mediate between doctor and patient in the health care setting. Such mediation is
evident when a student translates for a doctor who cannot speak the patient's language,
explains medical procedures to the patients, deals with their fears and insecurities in the
hospital, provides information when necessary, and acts as the link (as often happens) between
a patient in hospital and his or her family or community of origin (De Villiers & Van der Wal
1995).
Many black health professionals, even though they may be trained in and practising western
medicine, also retain the magico-religious beliefs of their sociocultural background.
Traditional and western medicine could be used to complement one another.
There may be dual consultation of both types of practitioners for the same condition, a
procedure known as medical pluralism, or dual consultation. Two patterns may be identified in
dual consultation:
& A patient may consult a medical doctor/health professional first and then a traditional
practitioner.
& A patient may consult a traditional practitioner first and then a health professional.
In order to understand the difference between western and traditional medicine, we proceed to
describe the different worldviews in order to explain the differences.
60
4.9 Worldviews
4.11
1 Read through chapter 2 in Tjale and De Villiers (2004:12±19) to familiarise
yourself with the concept ``worldview''.
2 Write down the definition and how you understand the concept.
3 Summarise the universals of worldview, as these universals form the basis of
teaching students of diverse cultures.
In the case of health and illness the following worldview is described. Generally, theories of
health and disease/illness causation are based on the prevailing worldview held by a group.
Each of the three major worldviews, magico-religious, holistic and scientific, has its
corresponding systems of health beliefs. In two of these worldviews, disease is thought of as
an entity separate from self caused by an agent that is external to the body but that is capable of
``getting in'' and causing damage. This causative agent has been attributed to a variety of
natural and supernatural phenomena.
4.9.1 Magico-religious health paradigm

In the magico-religious paradigm, the world is an arena in which supernatural forces dominate.
The fate of the world and those in it, including humans, depends on the actions of God, or the
gods, or supernatural forces for good or evil. In some cases the human individual is at the
mercy of such forces regardless of behaviour. In others humans are punished by the gods for
their transgressions (Andrews and Boyle 2003:76).
Ackernecht (1971) states that ``magic or religion seems to satisfy better than any other device a
certain eternal psychic or `metaphysical' need of [hu]mankind, sick and healthy, for integration
and harmony''. Magic and religion are logical in their own way, but not on the basis of
empirical premises; that is, they defy the demands of the physical world and the use of the
senses, particularly observation. In the magico-religious paradigm, disease is viewed as the
action and result of supernatural forces which cause the intrusion of disease-producing foreign
bodies or the entrance of a health-damaging spirit.
The categories of events that are believed to be responsible for illness in the magico-religious
paradigm have been discussed in a previous section.
In addition, in this paradigm, health and illness are viewed as belonging first to the community
and then to the individual. Therefore, one person's actions may directly or indirectly influence
the health or illness of another person. This sense of community is virtually absent from the
other paradigms.
4.9.2 Scientific or biomedical paradigm

The second paradigm, the scientific, is the newest and most removed from the interpersonal,
human arena of life. According to this worldview, life is controlled by a series of physical and
biochemical processes that can be studied and manipulated by humans. The scientific
paradigm is characterised by several specific forms of symbolic thought processes. The first
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form is determinism, which states that a cause-and-effect relationship exists for all natural
phenomena. The second form, mechanism, relates life to the structure and function of
machines; according to mechanism, it is possible to control the life processes through
mechanical and other engineered interventions. The third form is reductionism. According to
this all life can be reduced or divided into smaller parts; a study of the unique characteristics of
these isolated parts is thought to reveal properties of the whole. One of the ideas of
reductionism is Cartesian dualism, the idea that the mind and the body can be separated into
two distinct entities. The final thought process is objective materialism, according to which
what is real can be observed and measured. There is a further distinction between subjective
and objective realities in this paradigm (Andrews & Boyle 2003:75±79).
The scientific paradigm disavows the metaphysical. It usually ignores the holistic forces of the
universe as well, unless explanations for such forces fit into the symbolic forms discussed
above. Members of most western cultures subscribe to the scientific paradigm. When the
scientific paradigm is applied to matters of health, it is often referred to as the biomedical
model.
Biomedical beliefs and concepts dominate medical thought in western societies. In the
biomedical model, all aspects of human health can be understood in physical and chemical
terms. This fosters the belief that psychological processes can be reduced to the study of
biochemical exchanges. Only the organic is real and worthy of study. Effective treatment
consists of physical and chemical interventions, regardless of human relationships.
In this model, disease is viewed, metaphorically, as the breakdown of the human machine as a
result of wear and tear (stress), external trauma (injury, accident), external invasion
(pathogens) or internal damages (fluid and chemical imbalances or structural changes).
Disease is held to cause illness, to have a more or less specific cause, and to have a
predictable time course and set of treatment requirements. This paradigm is similar to the
magico-religious belief in external agents, except that germs replace supernatural forces.
Using the metaphor of the machine, western medicine uses specialists to take care of the
"parts"; ``fixing'' a part enables the machine to function. The computer is the analogy for the
brain; engineering is a task for a biomedical practitioner. The discovery of DNA has opened up
the field of ``genetic engineering'', an eloquent biomedical metaphor (Andrews & Boyle
2003:76).
The biomedical model defines health as the absence of disease or the signs and symptoms of
disease. Any search for cause and effect in the influences stemming from spiritual forces is
considered unscientific and unthinkable. Modern medicine is, therefore, quite separate from
religion (Hammond-Tooke 1989:145±146).
The entities postulated by medical science can generally be measured by sophisticated

instruments, and the theories and results of experiments can be tested and replicated. A critical
attitude and objective description, made possible by the separation of the material world from
that of reason, have become the ideal of scientific practice (Hammond-Tooke 1989:145).
4.9.3 The holistic health paradigm

The holistic paradigm is similar to the magico-religious worldview. In the holistic paradigm,
the forces of nature itself (or herself since when nature is personified she is usually seen as
belonging to the feminine gender) must be kept in a natural ``balance'' or ``harmony''. Human
life is only one aspect of nature and a part of the general order of the cosmos. Everything in the
universe has a place and a role to perform according to the natural laws that maintain that
62
order. Disturbing these laws creates imbalance, chaos and disease. Native American and Asian
cultures usually adopt a holistic worldview.
In the biomedical model, the cause of tuberculosis is defined as invasion by the

mycobacterium. In the holistic paradigm, according to which disease is the result of multiple
environment-host interactions, tuberculosis is caused by the interrelationship of poverty,
malnutrition, overcrowding and the mycobacterium. The holistic paradigm seeks to maintain a
sense of balance or harmony between humans and the universe at large. Explanations for
health and disease are based not so much on external agents as on the imbalance or
disharmony between the human, geophysical and metaphysical forces of the universe.
In this paradigm, health is viewed as a positive process that encompasses more than the
absence of the signs and symptoms of disease. It is not restricted to biological or somatic
wellness but rather involves broader environmental, sociocultural and behavioural
determinants. In this model ``diseases of civilisation'', such as unemployment, racial
discrimination, ghettos and suicide, are just as much illness as are biomedical diseases.
In the holistic health paradigm, because illness is inevitable, perfect health is not the goal.
Rather, the best possible adaptation to the environment by living according to society's rules
and caring appropriately for one's body is the ultimate aim. This places greater emphasis on
preventive and maintenance measures than does western medicine.
The hot/cold metaphor for health and illness in this paradigm was discussed in a previous
section.
It should thus be acknowledged that, whether traditional or modern, all healers have the same
goal. Their aim is to relieve pain and suffering, to cure the disease if they can and to comfort
the sufferer (Gumede 1990:153).
Now that health professionals in South Africa have been introduced to the western, the
traditional and the holistic approach to health care (training having been mainly in the
biomedical model), we shall discuss the general underlying principles of western versus
traditional African medicine.
Discussion of the general underlying principles which follow is derived from Coe (1978:130±
134). The medical system as an integral part of the culture of a specific society. Medical
cultural patterns do not occur in isolation, but are integrated within the complex network of
values and beliefs constituting part of the culture of any society. There can be no disputing this
fact; yet it is within the ontic fact of communality that the difference lies. What is the extent of
difference and to what extent are these differences mutually exclusive?
4.9.3.1 `Òpen'' versus ``closed'' systems

Traditional medicine has been viewed as a closed system and western medicine as an open
system. According to Horton (Haram 1991:167), the difference is that there is a highly
developed awareness of alternatives to established bodies of theocratic tenets (and
technological advances) in scientifically oriented cultures, which is not found in traditional
cultures. Haram (1991:167) demonstrates that Tswana medicine, through its traditional
practitioners, displays both an integrated approach (implying flexibility or `òpenness'') and a
``closedness'', when confronted with a new body of knowledge and practice. On exposure to
external cultural elements, new medical knowledge may either be fitted into existing categories
of knowledge, or be considered useful only for specific sorts of ailments. It can also merely be
rejected. In other words, Tswana medicine is an open or inclusive system to the extent that it
allows new external knowledge to be assimilated without replacing notions of ``reality'' and
``truth'', but is ``closed'' in so far as existing truths are monitored or new elements rejected.
HSE3701/1 63
Western medicine has already been shown to be a ``closed'' system in respect of
complementary or alternative medical systems (holistic worldview). It is however `òpen'' to
new elements from outside the system to the extent that the new knowledge is compatible with
the existing system.
It may, therefore, be deduced that traditional and western medicine are characterised by both
openness and closedness. The point of departure lies in definitions of ``truth'' and ``reality'' as
embodied in a particular worldview.
4.9.3.2 Scientific versus nonscientific systems of medical care

Western medicine is described as scientific, whereas traditional medicine is viewed as
empirical and nonscientific (Helman 2007:76±77). In contemporary industrial nations,
diseases are commonly viewed as natural phenomena which are subject to investigation by
scientific methods. Modern medicine is as scientifically and technologically based as
industrial society is. Conversely, traditional medicine tends to be built upon accumulated
evidence as opposed to scientific proof (Elling 1981:96).
Although the above generalisation holds good in most instances, it should be noted that,
according to Elling (1998:96), both modern medicine and traditional medicine share a
reverence for accumulated knowledge, especially in the area of folk medicine. Furthermore,
integration of medical beliefs and practices with other aspects of culture is never a perfect fit in
either first or third world societies. The implication is that the degree to which segments of any
population are aware of the totality of the medical belief system, much less accept it, will vary.
It is therefore possible for different systems to coexist and to overlap one with the other.
The dichotomy between modern and traditional medicine is understandable in view of the
historical foundations on which each is based (Edwards 1986:1273). In societies where
science and technology are poorly developed, human control over the environment is relatively
limited. Therefore, what cannot be described in relation to the regularities of the natural world
is attributed to supernatural forces.
4.9.3.3 Naturalistic versus magico-religious systems of medical care

Western medicine, based on logico-deductive procedures of diagnosis, excludes the mystical
and religious (Hammond-Tooke 1989:37,146). A worldview based on the supernatural and
other belief systems is incompatible with, alien and incomprehensible to, the modern sector
medical practitioner (Green 1988:1126).
At the same time, the esoteric qualities of biomedical definitions of disease are not always
understood by members of first world communities themselves. Acceptance of a medical
system under these circumstances becomes in itself an act of faith.
A mechanistic view of disease carries the implication that doctors treat physical symptoms
only and misunderstand or disregard causes of ill-health stemming from the social
environment, as well as the symbolic significance and meaning that people attach to illness
(Ferreira 1987:141). Nonetheless, all people continue to seek for the meaning of life events at
levels above those of mechanistic laws. (Andrews & Boyle 2003:75) states that both religion
and magic seem to satisfy an eternal ``psychic'' or ``metaphysical'' human need for integration
and harmony. Religion and magic are both logical in their own way, although not on the basis
of empirical premises. Religions remain a social reality, regardless of first or third world
affiliation.
64
Even in western cultures, evidence is found of magico-religious belief systems. For example,
Christian Scientists believe that physical healing can be affected by prayer alone (Andrews &
Boyle 2003:76). Laying on of hands and prayer, as an act of faith and healing, is commonly
practised in both the evangelical and the more orthodox Christian religions.
While characteristics of the traditional conception of illness include beliefs that humans are
integral parts of an ordered system and that illness is the consequence of some disharmony
within the cosmic order, traditional medicine includes many empirically successful treatments
that can be explained by western medicine in a rational and scientific way.
Not only do medical systems constitute an integral part of the culture of a society but in every
society the prevention of disease and treatment of illness follow, more or less logically, from
beliefs about causation.
4.9.3.4 Treatment regimes as an integral part of the belief system of disease causation
A mechanistic view of the human body precludes the incorporation of philosophical and
existential issues within the treatment regimes of contemporary medicine. Treatment is focused
on what is wrong. It is symptom-specific or disease-specific as a result of which modern
medicine achieves rational and scientific results more dependably than do other systems
(Hammond-Tooke 1989:15). Conversely, traditional healers focus on questions concerning
``why'' and address `ànxieties'' associated with ill-health in their effort to treat symptoms. The
traditional model incorporates a multiple-factor concept of disease causation and thus of
treatment. For these reasons, treatment in western medical systems is frequently regarded as
specific or limited in nature, while that of traditional practitioners as holistic in character.
The conclusion that traditional African healing is holistic is based on the fact that, in keeping
with traditional worldviews, little distinction is made between the body, mind and spirit. The
whole person is treated (Green 1988:1128). A patient's family and the healer often play a wider
social role in the sense of religious, political and legal adviser or marriage counsellor, social
worker and detective (Herman 2007:140±143). It is argued that because traditional
practitioners know their patients as people and understand their social milieu, their
ministrations are bound to be more effective (Hammond-Tooke 1989:15). However,
contemporary villages are modernising rapidly and rural-urban migration is reaching
cataclysmic proportions. In settings such as these, traditional practitioners may no longer be
said to possess intimate knowledge of the family and community background (adapted from
Fosrer 1983:23).
On the face of it, it seems clear that there is little similarity between western and traditional
systems of medicine. However, to view the treatment of the former as non-religious and the
latter as religious is problematic. In fact, many herbalists, bonesetters, midwives and so on
may operate in a very instrumental and purely functional fashion, while both divination and
related treatments could be analysed in terms of psychotherapeutic variables. A significant
body of research into biomedicine reveals the positive results of the placebo effect in which
inactive substances given to patients, with the false claim that they are active drugs, have
significant effects on making people better (Feierman 1985:106). It is an error to read religious
meanings into forms of healing that are not religious or to reduce the religious meaning of
sacred healing to mechanical or clinical significance.
Folk medicine is not the prerogative of traditional medicine. It has been widely practised
throughout the western world. Folk remedies, constituting the basis for prevention or treatment
of ailments, are to be found in household medicines and old-fashioned remedies. They remain
in common use. Today, ``popular medicine is in a sense, commercial folk medicine'' (Spector
1996:29).
HSE3701/1 65
The conventional distinction between the scientific and technological approach and the
nonscientific and nontechnological approach is particularly apparent in respect of diagnostic
and treatment procedures. At the same time, recognisable artifacts are as essential to the
western clinician as to the traditional practitioner. Symbols such as impressive consulting
rooms, stethoscopes, diplomas and white coats all constitute part of a scientific image of
power and authority. For the traditional practitioner, artifacts such as masks, animal horns,
bones and drums all serve to project the desired image of charisma. The perceived potency of
the medical practitioner, regardless of worldview, remains an essential part of the diagnostic
treatment model.
As a result of advances in the fields of sociology, psychology and psychiatry, western medicine
is increasingly paying attention to social and emotional variables in disease causation, while
social change is affecting the way traditional practitioners operate. Many traditional
practitioners are beginning to adopt the practices of modern health care. Such change reflects
change in the content of traditional health care and increasing competition for modern health
care providers. Traditional practitioners are also becoming increasingly professionalised
(Helman 2007:140±143).
Although biomedicine and traditional medicine are based on radically different paradigms, it is
important to understand that their practitioners do not constitute homogeneous groupings.
Each has many different specialities and treats different types of illness. Studies have revealed
that people are pragmatic in their health-seeking behaviour. They choose therapies which seem
to be best for them during stages of an illness (Good in Gesler 1989:129). Beliefs and values
underlie choices made in respect of a course of action.
4.9.3.5 Chains of referral as an integral part of human behaviour

Remarkably similar procedures are followed in both traditional and modern societies. It is in
the folk and lay, or popular, sector that illness is first experienced, labelled and treated within a
network of friends and/or family. Most health care takes place in this sector when symptoms
are minimal and self-limiting. Decisions regarding the seeking of help and compliance are also
made in this sector (Booyens 1991:484).
Remedies are closely linked to folklore and what is available. If symptoms become worse or
new ones develop that cannot be identified, the individual in a first world society will seek the
advice of close friends or family. He or she will make the ultimate decision concerning the
course of action to be taken. In third world societies, consensus is primarily sought within the
family and family support occurs automatically. Consultation with specialists then takes place,
either as an individual or in the family or community context (Helman 2007:84±93). If the
person is unresponsive, the diagnosis and treatment may be reviewed and alternative sources
sought in the areas of either biomedicine or complementary medicine.
An increasing number of authors refer to the pluralistic nature of all medical systems in the
world today (Hammond-Tooke 1989:151). There may be overlapping participation in different
medical systems, or systems may coincide or may be mutually exclusive.
4.10 Religion, culture and health care

As an integral component of culture, religious beliefs may influence a client's explanation of
the cause(s) of illness, perception of its severity and choice of healer(s). In times of crisis, such
as serious illness and impending death, religion may be a source of consolation for the client
and family and may influence the course of action believed to be appropriate.
The educator should take account of the different religions; to render competent health care, the
66
student needs to respect and show tolerance for the views and needs of clients from religions
other than the student's.
4.12
1 Study the chapter on the different religions in Tjale and De Villiers (2004:78±
105). In a table, summarise each religion under the headings given for each
religion in the chapter.
2 Read Andrews and Boyle (2003:433±437) on the dimensions of religion and add
the information to the above.
4.11 Conclusion
The process of attaining cultural knowledge is intended to provide the student with a general
overview of culture and worldviews. Students cannot rely solely on theoretical knowledge for
culturally specific knowledge. They have to develop the necessary skill to obtain cultural
knowledge directly from the client. This prevents stereotyping of a specific cultural group.

1 Explain what cultural universals are. Referring to specific examples, indicate the
difference between universals within a culture and universals between cultures.
2 Write down the content of a lesson plan for fourth-year nursing students, explaining the
universals of a culture in order to understand the nature of culture. Explain to the
students how to identify universals within their culture in order to satisfy the purpose of
meeting people's health needs.
3 In a lesson for third-year nursing students explain the case of a patient who complains
that she has been bewitched. They should answer the following questions:
& How should the nurse react in this situation?
& What should the nurse say to the person concerned?
& What form of behaviour should the nurse recommend to the patient?
4 If you believed in the hot/cold theory, which aspects should you apply?
To answer the question you may have thought about methods of reducing a temperature,
providing a sick person with warm foods such as soup, and keeping warm when you
have a cold.
5 Describe the different types of causes of ill-health.
6 Prepare a lesson plan on the main characteristics of the following religions and explain
how each religion influences the health care needs of its followers:
& African religions
& Christianity
& Hinduism
& Islam
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5
c Cultural skills in health care
Prescribed reading
Tjale A & De Villiers, L. 2004.Cultural issues in health and health care. Cape Town: Juta:25±
26,159±174.
Philadelphia: Lippincott:18,36±37,338b,340b±342b,533±539.
Recommended reading
Giger, JN & Davidhizar, RE. 2004. Cultural nursing: assessment and intervention. 4th edition.
St Louis: Mosby:21±159.
5.1 Introduction
For this part of the module you need to develop a portfolio (revise the relevant section in your
second-year study guide) on all the teaching strategies that will be discussed in this study unit
± as well as the new ones you will develop on your own.
The cultural features of educational and health care settings are very complex. Health
professionals, including educators, are faced with cultural differences between themselves and
their clients, and among themselves. The content of the previous study units serves as a frame
of reference for this study unit. It will benefit you to study the discussions and prescribed
readings in this study unit, and to revise the appropriate sections of the study guide. In this
study unit you will learn how to apply what you have learnt so far in the educational and clinical
settings.
68
The theoretical foundations of culturally competent care were discussed in study unit 1. This
was followed up by discussions on various aspects of culture. In this study unit, we discuss the
cultural competence that students have to obtain to be able to work in culturally diverse health
care settings. First, we will discuss culturalogical assessments, after which the focus will be on
culturally appropriate educational practices.
& integrate and apply your knowledge about culture and health in order to conduct
culturalogical assessments of students in a multicultural learning milieu
& integrate and apply your knowledge of transcultural nursing to teach students how to
conduct comprehensive culturalogical assessments in clinical settings
5.2 Cultural assessment

Before you proceed with this study unit, it is necessary to familiarise yourself with the term
``culturalogical assessment''. This term is explained in Andrews and Boyle (1999:24).
According to Leininger (1984:44), culturalogical assessment is an essential prerequisite for

rendering holistic, humanistic and meaningful health care to clients. Traditionally, health
professionals are taught how to gather biopsychosocial assessment data. However, it is
imperative that, once the necessary biopsychosocial assessment data have been gathered in
culturally diverse settings, the focus should shift towards cultural data.
Note that we will focus on two aspects of culturalogical assessment: assessing students in the
educational setting and teaching students how to conduct assessment in clinical settings.
Educators must get to know their students and must strive to plan their educational practices
according to their students' characteristics and needs. Similarly, we must teach students to
conduct culturalogical assessments in the clinical setting and plan their care delivery
according to the characteristics and needs of their clients.
Before we continue with culturalogical assessments, we must first remind you of what you have
learnt so far, because most of it is relevant to this section as well.
5.1
We introduced you to some theories and models pertaining to cultural competence in
study unit 1. Although these are nursing models, the principles are applicable to the
health sciences in general and you should approach them with your own profession in
mind. The models applicable for this study unit are Leininger's theory on cultural
universality and diversity, Spector's views about the client within a culturally unique
heritage, and Giger and Davidhizar's transcultural assessment model. You must revise
those models and use them to structure your own notes on culturalogical assessment.
We will now proceed with guidelines on how to integrate and apply your cultural knowledge to
culturalogical assessments. The discussions that follow provide explanations about what kinds
of data should be gathered and why such data are important.
5.2.1 Differences in ways of perceiving the world

Members of a particular culture share a worldview (mindset) that is the result of how they were
raised and the circumstances under which they grew up. This worldview represents a particular
HSE3701/1 69
logic according to which they look at the world and solve problems that they encounter. A
people's worldview remains intact for a longer time than some of the customs, beliefs and
features of their culture. It would be advisable to consider differences in worldview when you,
as educators, teach culturally diverse students, or teach those students how to function in
culturally diverse health care settings, for reasons that will become apparent as you work
through this section.
5.2
1 Revisit Leininger's theory, which was discussed in study unit 1, specifically the
sunrise model. Note that a worldview is described as influencing the cultural
universals and care beliefs and practices of any particular culture.
2 You learnt about worldviews in study unit 4. Integrate this information into our
discussions on culturalogical assessment. Note that this knowledge is important
to the conducting of culturalogical assessments, as each person's worldview
influences the way he or she responds to the questions asked during an
assessment interview.
Two major categories of worldview are the mechanistic and the supernatural perspectives.
The mechanistic perspective is typically held by those cultures that have adopted a scientific
approach to life. Members of such cultures typically believe that nature (and disease) can be
conquered through experimentation and by applying the principles of science. Principles such
as self-responsibility, self-reliance and proactive behaviour to prevent predictable problems
are valued. Members of these cultures typically value the use of analytical thought processes.
Health care delivery from a western perspective is in accordance with the mechanistic
worldview.
The supernatural perspective is typically held in cultures where people enjoy a more traditional
lifestyle. This perspective is characterised by a belief that one does not have much control over
one's destiny and therefore a more fatalistic approach is adopted. Life occurrences are
explained as being the result of supernatural forces or influences by ancestral spirits. This
perspective generally allows for a value system that supports looking for causes and solutions
outside the individual. Traditional healers and religious institutions are prominent in the lives
of people belonging to these cultures, especially in their quest to secure prosperity or to
recuperate from adversity. Holistic thought processes are typically practised. Many recipients
of health care hold a supernatural worldview, while some could also incorporate the
mechanistic perspective.
When conducting culturalogical assessments, health professionals should take differences in
worldview into consideration, as this knowledge will help them to interpret the cultural data that
they have obtained. It is also important to consider that the cultural values that people adopt
may be varied. Values, together with worldview, shape people's views about health and
sickness, and learning.
Study cultural values in Andrews and Boyle (2003:335). Note that these values also influence
educational and health care delivery and must therefore also be included in a culturalogical
assessment.
70
5.3
Let's consider issues inherent in the educational setting and the health care setting
respectively:
1 Which of the above worldviews supports the notion of personal responsibility for
learning in the educational setting?
2 Which of the above worldviews supports the principle of preventive health care?
The answer to both questions is the mechanistic worldview. It is believed that any individual
takes responsibility for matters such as learning and good health through self-reliance and
proactive behaviour either to prevent problems or to speedily solve problems that have
occurred. Students with a mechanistic worldview may flourish when teaching strategies that
promote independent learning are employed, while health education aimed at responsible,
preventive behaviour will have a greater effect on clients with a mechanistic worldview than on
those with a supernatural worldview. On the other hand, people who have adopted a
supernatural worldview believe that they have no control over their destinies, and are therefore
more fatalistic. To them a student's success depends rather on the efforts of the educator than
on their own efforts. Similarly, clients in health care settings may believe that the health
professional is primarily responsible for the client's health, as opposed to believing in self-
responsibility.
5.2.2 Communication
Intercultural communication was dealt with in study unit 2, so we will not discuss this issue
again. When we conduct culturalogical assessments, the issue of communication is relevant;
therefore you have to revise study unit 2 and do the activities in this section.
5.4
1 Revise the section on intercultural communication in study unit 2.
2 Explain the data on communication that you would gather during a culturalogical
assessment.
3 The clinical implications of cultural differences with regard to communication
have been spelt out in your prescribed book. Make notes on the implications.
4 Make notes about how educators should prepare students to deal with cultural
differences around communication in the health care setting.
One has to gather data pertaining to language, and verbal and nonverbal communication styles.
Also focus on meanings that are attached to matters such as physical touch. Other important
factors to assess include
& meanings and restrictions around gestures and eye contact

& the context of speech, such as the relationship between tone of voice and emotions
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& interaction etiquette, such as requirements for an initial conversation about general
matters before specific questions are asked
& appropriateness of questions about intimate matters
This is not an exhaustive list of the data that should be gathered. You must read through the
section on communication again and complete the list.
The educational implications of diversity around communication are numerous. Teaching and
learning are in essence processes involving interactions between educators and students, and
among students themselves. It is therefore necessary that educators and students note things
like communication patterns and the significance of some nonverbal behavioural patterns, to
prevent unnecessary misunderstandings and conflicts in the teaching-learning situation. Have
you thought about the fact that some students come from an oral communication tradition,
while others come from a written word tradition? The implication is that educators should
develop both written and oral tests and examinations to assess learning.
5.2.3 Space
Clients' perceptions of personal space are explored to enable health professionals to create a
therapeutic environment without inappropriately intruding on the space that is reserved for
intimate friends and family. It is important to recognise that there are cultural differences
regarding the physical and emotional space that is reserved for different people in different
situations.
Study Tjale and De Villiers (2004:164±165), Andrews and Boyle (2003:28±29) and Giger and
Davidhizar (2004:52±60), paying attention to the following:
& spatial behaviour and its cultural implications

& objects in the environment and their cultural implications
& body movement or position and its cultural implications
5.5
1 The clinical implications of cultural differences around space have been spelt out
in your prescribed book and you should make notes on these implications.
2 Reflect on and make notes about the educational implications of cultural
differences around space. What are the implications of cultural differences for
& making known students' test results?
& sharing books and notes?
& discussing personal issues?
& sharing physical space?
Educators should observe the nonverbal behaviour of students to identify their space
requirements. They must be careful not to transgress on the boundaries set by
students. Educators could also allow students to verbalise their preferences when they
are working in groups. For instance, some students may move their chairs farther
away from other students, and educators and students alike should recognise this as
72
an attempt to secure appropriate distance. Similarly, some students may be reluctant
to share their books and notes with others. Educators should refrain from forcing
students to share if they do not want to do so. If students misinterpret such behaviour
in their peers, the educator should allow them to talk about their different views to
prevent conflict situations. Educators should also refrain from inappropriately
verbalising matters that are private to students, such as marks obtained.
5.2.4 Social organisation

Here, the focus is on cultural group affiliations such as the nature of the family or kinship
networks. The nature of interpersonal relationships and power relationships should also be
determined during cultural assessments. For instance, clients and students who have a group
consciousness must be viewed and approached within the context of their kinship structure,
while others have to be approached on an individualised basis. This provides clues about the
social needs of clients and students, and how to utilise available social support systems.
Study Tjale and De Villiers (2004:165±167) and Giger and Davidhizar (2004:69±79).
Structure your notes according to the words in bold below. When you study the issue of social
organisation, note that some cultures have an individual orientation, while others have a group
orientation. There are also differences in family and kinship/family structures and
relationships. Furthermore, there are differences in beliefs about who is the primary
responsible person, as well as the cultural significance of gender.
5.6
Reflect on the implications of cultural differences in social organisation:
1 Why is knowledge about kinship structures and relationships important to the

delivery of culturally congruent health care?
2 What are the implications of social orientation for health sciences education?
3 Make notes about the clinical implications of cultural differences about social
organisation, as explained in your prescribed material. Integrate our feedback into
your discussions.
We can illustrate the importance of knowledge about kinship structures and

relationships in the health care setting with a simple example. Consider the issue of
obtaining permission for surgery. People who value lineal or collateral relationships
would make decisions about undergoing surgery in collaboration with a responsible
family member, various kinship members or even community members. Those with an
individualistic orientation would be quite happy to make such a decision alone. It is
imperative that educators find out about these matters while conducting culturalogical
assessments, to ensure that educators approach matters such as these in a culturally
congruent manner. It is important that educators teach their students about these
issues, as this knowledge is essential to interpreting culturalogical assessment data.
Students who have a group orientation will flourish in educational settings where the
principles of collaborative or cooperative learning are applied. Those with an
individualistic orientation may prefer educational strategies that require independent
work, such as doing assignments independently. It is therefore important that educators
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offer a variety of teaching strategies to their students to accommodate learning styles of
students, who will certainly be from various cultural backgrounds. Educators should also
consider different perspectives about what constitutes achievement. While some people
may regard individual achievement in competition with fellow students highly, others
may prefer to focus on the contribution towards effective group work or towards helping a
community improve their health status. It is also important to organise activities that
involve family members or the community of which students are a part. The family and
community may also be utilised to give social support to students who require such
support.
5.2.5 Cultural differences in the perception of time

The discussion by Giger and Davidhizar (2004:94-102) on different time perceptions highlights
the importance of assessing clients' views about time. Assessing time perceptions will
determine clients' conceptualisation of time: this is important because it influences how to
attach time frames to therapeutic interventions or what to expect from clients about honouring
appointments, for example.
Study Tjale and De Villiers (2004:167). Pay attention to the following matters:
& concept of time
& measurement of time (you need only read through this section)
& social versus clock time
& time and human interaction
& cultural perceptions of time
& implications for health care
5.7
1 The clinical implications of cultural differences about time have been spelt out in
your prescribed book. Make notes on these implications.
2 Reflect on the implications of cultural differences about time for educational
practice. We will assist you by asking some questions that you should attempt to
answer.
What possible conflicts could arise when an educator sets a firm date and time for
submission of an assignment, while a student with a present-time orientation is
experiencing a personal crisis?
What possible differences in orientation need to be considered by educators when they
have to terminate a group discussion session, for example because the designated
time is up?
The above two scenarios have been included to help you understand how you should
apply your newly acquired knowledge to the educational setting. Read through the
prescribed material again and make notes on other implications of cultural differences
about time for your educational practices.
74
Scenario 1 could lead to cultural conflicts in both the educator and the student.
Whereas the educator might expect that all students exercise time management and
submit their assignments on time, a student may find himself or herself in a situation
of crisis management. The student may be inclined to focus on the present personal
crisis first and ignore a future submission date until the very last minute. As a result,
he or she may attempt to complete the assignment in a rush and even submit it late,
resulting in penalties from the educator.
Students with a present-time orientation may also be late for classes or other
appointments in the event of a crisis at home. The educator should try to understand
these cultural differences, but must stress the importance of a clock-time orientation in
the health care setting, and guide students towards accepting this orientation in the
interests of safe health care. It is important to guide students towards cultivating time
management skills, which are important in health care settings where they will be
confronted with time limitations on a daily basis.
As for scenario 2, when terminating a session such as a group discussion, the
educator should bear in mind that this may be quite acceptable to students with a
clock-time orientation. However, those with a social time orientation may be
dissatisfied that a session has been terminated just because of time constraints, while
some outstanding issues have not been dealt with.
Moreover, have you considered the impact on education of differences in orientation
in the way one goes about satisfying one's needs? Some students would be happy to
wait for deferred rewards, while others may need rewards such as positive feedback on
a frequent basis to motivate them in their studies.
5.2.6 Environmental control

This topic provides insight into views about our relationship with nature. For instance, do we
control nature, do we live in harmony with nature, or is our destiny predetermined by forces
beyond our control? Those who believe that we are in control of nature generally have faith in
medical science, while those who believe that our destiny is predetermined may not be very
receptive to health education aimed at prevention of disease.
Study Andrews and Boyle (2003:22±23,257) and Tjale and De Villiers (2004:169±
170) and pay attention to the following:
& the explanation of what is meant by environmental control
& the distinction between illness and disease (also apply the knowledge that you
acquired in study unit 4)
& cultural health practices versus medical health practices
& people-to-nature orientation
& locus-of-control construct as a health care value
& folk medicine
& implications for nursing (health) care
The next activity is aimed at helping you to impose some structure on the material that you are
about to study. Therefore it is advisable to complete the activity before you proceed with this
section.
HSE3701/1 75
5.8
Revisit Leininger's theory in study unit 1. Pay particular attention to the sections in the
sunrise model that deal with the position of the nurse (health professional), relative to
the generic and professional health systems. Note that the health care provider who
does a culturalogical assessment can be visualised as being positioned in the middle
of the three circles of the sunrise model. Information about the views on health,
sickness and health practices that are generated through cultural assessments can be
structured according to the professional (biomedical) or the sociocultural (folk)
perspectives. Therefore, when you study this section you could also structure the
information in the prescribed reading material in the same way. In the following
section we will give you some guidance.
Explanatory model
Health/Sickness
Sociocultural explanation
Biomedical
explanation
Pathology/Germ Equilibrium Supernatural Sorcery

theory (holistic)
Figure 5.1: Explanatory model for health and sickness
As explained in your prescribed material, health and sickness are perceived within a
cultural context. Differences in conceptualising health and sickness are found among
health professionals, as well as between health professionals and clients. The two
main explanatory categories are the biomedical explanation and the sociocultural
explanation.
The biomedical explanation is an explanation of health in terms of normal
physiological processes in the body. Sickness is explained in terms of scientifically
proven, disease-causing pathological processes. Health care is based on scientifically
developed surgical procedures and medication. The health care practitioners are
professionally trained and render health care that is based on scientific principles.
The sociocultural explanation is divided into the equilibrium theory, the supernatural
explanation and the sorcery explanation. The term `ìllness'' is used to refer to the
subjective experience of being unwell.
The equilibrium theory attributes health and illness to an equilibrium (or the lack of)
inside the human body or between the human body and the environment. Prevention or
76
treatment is based on naturalistic principles such as rest, healthy food and the intake of
herbs. Alternative health care practitioners are consulted to restore equilibrium.
The supernatural explanation attributes health and illness to God/a god, or spirits such
as the ancestors. Faith healers or traditional healers are consulted to restore the
relationship with the supernatural. Treatment strategies include prayer, offerings and
other rituals.
The sorcery explanation relates health and illness to harmful spirits. Prevention and
treatment are aimed at protecting a person from sorcery or ridding him or her from evil
spirits.
Health professionals are trained to approach health and disease from a biomedical
perspective. This is sometimes in conflict with their own belief systems. Another
source of conflict is the health professional's biomedical perspective versus the client's
sociocultural perspective and related expectations.
5.9
Revise the discussions in this section and explain the implications for health sciences
education.
Educators have to remember that students come from specific cultural backgrounds
and may have adopted the sociocultural explanation for health and sickness. However,
the health sciences view health and sickness from a biomedical perspective. As
students' views change over time, they may experience alienation from their own
culture, which may negatively impact on their relationships with their clients in health
care settings. Revise Spector's views and Ramsden's theory in study unit 1. Some of
those discussions are relevant to this section.
Students must learn how to determine the client's explanatory model of sickness, as
well as associated beliefs and practices that would influence health care delivery by
the professional health system. These include preferences with regard to health care
institutions, health practitioners, and remedies and rituals. Health professionals ought
to determine the expectations of clients, for instance with regard to the utilisation of
cultural support systems and folk practices, which are often utilised to complement
the professional health care system.
5.2.7 Biological variations

The ability of the health professional to conduct objective assessments appropriately depends
on in-depth knowledge of biological differences between different cultural groups. Matters
such as the appearance of skin lesions or the criteria for physical growth differ from culture to
culture. The health professional should also focus on health problems that are associated with
particular cultures. For instance, race and ethnicity are regarded as risk factors in hypertension
and sickle cell anaemia.
Study Tjale and De Villiers (2004:159±174).
HSE3701/1 77
5.10
1 The clinical implications of biological differences have been spelt out in your
prescribed book. Make notes on these implications.
2 Reflect and make notes on the implications of biological variations for health
sciences education with regard to
& health problems to look out for among students
& nutritional needs of students
& protecting the psychological health of students
Note that biological differences may render some cultural groups more susceptible to
certain health problems. Students should be screened for specific health problems that
they may be susceptible to. Educators could look after students' interests at
residences/hostels to ensure that provision is made for their food preferences and
requirements. Note that behaviour that the educator may regard as abnormal may be
viewed as normal in the student's cultural context. Educators should refrain from
expecting students to demonstrate psychological characteristics that fit the educators'
own preconceived ideas of what constitutes a good student. It is imperative that
students feel that their uniqueness is accepted and respected by educators. Another
point to consider is that the practice of IQ testing is under criticism as being culturally
insensitive.
5.2.8 The assessment interview

We have discussed the content to be covered during a culturalogical assessment. At this point
it is appropriate to make a few comments about the assessment interview. Campinha-Bacote
(1995:22) suggests four techniques that could be applied during the assessment interview. The
author suggests that health professionals should listen with interest and remain nonjudgmental
about what they hear. Health professionals may have to develop alternative styles of enquiry to
elicit cultural content from a client in a culturally sensitive manner. For instance, it may be
necessary to adopt a less direct and more conversational approach to the assessment of the
client's background. This means that health professionals may have to talk about general
matters to the client and identify appropriate information from the client's responses. It is also
advisable to integrate questions about cultural content into the traditional assessment that is
gathered from clients, in contrast to having a separate cultural assessment tool. In this manner,
culture is not singled out and the client may be more inclined to answer the questions
truthfully.
5.11
Identify a student from another culture in your area of practice. Conduct a
culturalogical assessment, using Giger and Davidhizar's model. Record the student's
responses.
78
5.2.9 Analysing culturalogical assessment data
Once a culturalogical assessment has been done, it becomes necessary to analyse the data and
make a diagnosis. Depending on the diagnosis, a culturally acceptable intervention plan is then
developed. It is imperative that this process result in culturally congruent care and that the
client enjoys an experience of cultural safety.
Health educators should teach students negotiation skills that would enable them to make a
culturally acceptable diagnosis. This also applies to the care plan. Clinical judgment and
decisionmaking skills are applied to devise a culturally appropriate care plan. The outcome
should be a care plan aimed at culture care preservation/maintenance, culture care
accommodation/negotiation or culture care repatterning/restructuring. It is therefore also
necessary to develop, in students, clinical judgment and decisionmaking skills. The negotiated
care plan is implemented by creatively combining the biomedical (professional) and the
sociocultural (indigenous) health systems. The client's particular views will be known to the
health professional as a result of the culturalogical assessment, and these views have to be
incorporated into the care plan. This implies that creativity must be cultivated in students. After
the care plan has been implemented, the outcomes of care have to be determined. Evaluation
entails assessing the health care outcomes from the biomedical and sociocultural
perspectives.
At this point we must make a few comments about negotiation and negotiation skills. When we
analyse assessment data and develop a care plan, the issue of negotiation comes to the fore.
Negotiation entails listening, explaining, comparing and compromising. When negotiating, a
health professional carefully listens to the client's point of view. He or she then explains the
professional point of view to the client. The two perspectives are compared, emphasising the
areas of both agreement and disagreement. Then the parties arrive at a compromise that
changes the health professional's position while encouraging the client to make changes as
well, until a workable solution is found (Chrisman 1990:8,13). This implies that students have
to acquire social, communication and higher cognitive skills. Listening and explaining are
communication skills. Comparing involves critical and analytical thought processes and
compromising implies social skills. A health sciences curriculum should support the
development of the stated skills in students.
Study Tjale and De Villiers (2004:172±174) and Andrews and Boyle (2003:533±539).
You should cover the following paragraphs:
& Analysis of cultural data
& Clinical decisionmaking and nursing actions
5.12
1 At this point it is necessary to refer you back to Leininger's theory in study unit 1.
Take note of the three modalities of nursing care decisions and actions in the
sunrise model, as well as the explanations of each of these modalities. Remember
that these modalities come into play in analysis of data that were gathered during
a culturalogical assessment.
2 Analyse the cultural data that you obtained during the cultural assessment of the
student in your area of practice:
& What are the characteristics of the student's worldview? Is the student's
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worldview consistent with the mechanistic or the supernatural perspective?
How should the educator accommodate the student's perspective?
& How can the educator incorporate the student's communication style and
preferences in the teaching-learning setting?
& How can the educator accommodate the student's preferences about space in
the teaching-learning setting?
& Does the student have an individualistic or a group consciousness? How can
the educator accommodate the student's orientation in the teaching-learning
setting?
& What is the student's time orientation and what are the implications for the
educator?
& What are the student's views about environmental control and what are the
implications for the educator? What possible cultural conflicts could arise if
the student is introduced to the biomedical explanation of health and
sickness?
& What aspects of the student's cultural views could be preserved and utilised
in the educational setting?
& In what respects should the educator and student compromise to ensure that
educational aims and objectives are achieved without ignoring the student's
culture?
& What cultural changes should be negotiated with students to ensure that the
students' views and practices are consistent with the culture of your
profession?
Because each person is a unique cultural being, the cultural data that you obtain will
be unique. We will therefore not provide feedback. Compare your answers with our
explanations in the preceding text to determine whether you understand how
culturalogical assessment data influence the practice of the educator.
5.3 Teaching and learning in a multicultural milieu

Multicultural education is probably the most common form of education for diversity.
Multicultural education is about changing the nature of teaching and learning in order to create
a suitable learning environment for students from diverse cultural backgrounds.
Banks (2006:201) states as follows: ``Significant changes in the racial, ethnic, and language
groups that make up the nation's population creates [sic] a demographic imperative for
educators to respond to diversity. Diversity offers both opportunities and challenges to our
nation, to schools and to teachers.'' Banks furthermore states that diversity enriches a nation,
communities, educational institutions and classrooms. Diversity also provides the society with
many different and enriched ways to identify, describe and solve social, economic and political
problems.
80
Diversity also provides academic institutions with an opportunity to educate students in an
environment that reflects the reality of the nation and the world. A major goal of multicultural
education will be to reform the academic institutions so that students from diverse racial,
ethnic and social class groups will experience educational equality (Banks 2006:201±202).
It is important for the educator in the health sciences to note that multicultural education is not
an educational course or programme but rather a multiplicity of programmes and practices. It
can also have different meanings for different institutions and groups of people, according to
needs and circumstances.
Most of the information in this study guide prepares you with the knowledge you need to
deliver multicultural education.
Lemmer, Meier and Van Wyk (2006:4±5) identify some general guidelines for multicultural
education which you could use. Multicultural education
& recognises and accepts the rightful existence of different cultural groups
& encourages acculturation and cultural preservation
& encourages mutual interaction and cooperation
& views cultural diversity as a positive educational experience
& accepts that students from different cultural groups have equal rights and educational
opportunities
& acknowledges differences in each student
& expects that educational institutions for health care workers will reform
& sees itself as a process to approach education involving the whole teaching and learning
process
& is culturally competent teaching
After studying this section on learning and teaching in a diverse environment, you should be
able to
& discuss the dimensions of multicultural education

& adapt your teaching approach to students of diverse cultures
& explore and develop different teaching strategies to deal with the diversity of student
needs in the classroom
Read through chapter 10 of Tjale and De Villiers (2004) and do the following activity.
5.13
1 What do you understand by the term ``multicultural education''? Write down all the
points that come to mind.
2 Give reasons why you think multicultural education principles should be included
in curricula for students in the health sector.
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3 Is there a need for multicultural education in the institution where you are
teaching?
4 Explain the goals of multicultural education to your colleagues.
5.3.1 Competencies required by the educator in multicultural education

The classroom is a complex microculture, consisting of unique individuals and a variety of
cultures. Each individual brings with him or her a distinct set of beliefs, values and
experiences, which influences attitudes, behaviours and perceptions of the classroom as a
whole.
Having a variety of cultures in one classroom has definite implications for teaching and
learning. Lemmer and Squelch (1993) discuss some of the cultural factors that influence
education:
& Socialisation. This refers to the way in which the student is brought up to function in a
society: in other words, the process whereby he or she acquires values, language,
knowledge and social skills. This process is very much part of what we mean by the
word ``culture''.
& Communication. Students who have to learn through the medium of a foreign/second
language may well find learning difficult. It is worth remembering that nonverbal
communication is, to a large extent, culturally determined and could lead to
misunderstandings between educator and student.
& Learning preference. The way in which students learn is also closely associated with
culture. In other words, not all students will learn in the same way.
& Social values. Values differ from culture to culture, although all societies share certain
core values. Conflict can arise without proper knowledge, by both educators and
students, of value differences.
& Worldview. The ways in which different cultures perceive reality differ, which can also
lead to conflict and misunderstandings in society generally.
The closer a student's culture is to that of the educator, the greater his or her chances of
academic success. So the educator has an important role to play in bridging cultural gaps that
may exist in the classroom.
The educator in the health care professions needs certain competencies, to attain the goals
mentioned above. The self-awareness of the educator is an important component of effective
multicultural reaching
5.14
1 Use the cultural sensitivity and awareness self-test in Tjale and De Villiers
(2004:179) and do the test on yourself. Write down what you have experienced by
doing this test. What have you found out about yourself?
2 Which factors do you think are barriers to the teaching and learning process for
the educator? If you are unsure of this question, read pages 181±185 in Tjale and
82
De Villiers (2004) and summarise the barriers. You may have to go back to
previous study units where intercultural communication, and so on, is discussed.
3 You have students whose first language is not English in your class. How will you
reduce these barriers to effective communication in the classroom?
The educator has the important role of bridging possible gaps which may exist. In order to
achieve this the educator needs to acquire knowledge of the different cultures in his or her
classroom. According to Lemmer and Squelch (1993), this will involve
& speaking to community leaders

& arranging information days
& inviting members of the community to talk to the class
& collecting information about a specific culture
& arranging workshops for educators
As discussed in previous study units the educator's communication style has a definite impact
on his or her effectiveness. Without cultural sensitivity, awareness and knowledge of the
implications of cultural differences in interaction, the learning success rate could be very low.
Communication that segregates students and encourages competition hinders successful
teaching and learning in the culturally diverse classroom.
5.15
Read the following scenario and respond to the questions:
Themba, a first-year student, rarely makes a sound in class and seldom asks
questions. The standard of his work is not high. Whenever the educator, Mrs Sithole,
talks to Themba he never looks directly at her and this apparently rude behaviour
angers the educator and causes tension between them.
1 How can you explain Themba's behaviour?
2 Is the educator justified in getting angry?
3 How should the educator respond to Themba?
The educator must ensure that his or her instructions are clear, concise and consistent when
explaining certain content and be sure that feedback is also clear, concise and consistent.
Feedback, however, could be problematic without knowledge of cultural differences. Students
from collectivist cultures may give feedback which seems ambiguous to someone from a
western culture, because such students do not want to criticise their educator. Students from
these cultures will not, for instance, ask questions or interrupt when they do not understand
something. Educators who come from individualist cultures must not assume that a minimal
response or even silence means that an instruction has been understood ± educators should
check students' understanding and if necessary repeat instructions on a one-to-one basis. In
other words, the educator must respond to all feedback.
Troyna and Carrington (1990) claim that proponents of the anti-racist movement pay particular
attention to the structure of classroom relationships, teaching and learning styles. An
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authoritarian learning environment where the educator does all the talking and the students
lack the confidence or opportunity to express their views is at variance with the goals of anti-
racist education: `Às well as stressing the importance of a democratic ethos in classrooms and
underlining the need for strategies to promote discussion, we should also like to stress the
importance of teaching strategies which seek to develop co-operative skills'' (Troyna &
Carrington 1990:24).
5.3.2 Teaching strategies

The multicultural education approach entails reworking instructional processes in the
classroom so that they support high expectations, build on the strengths that diverse students
bring to the classroom, and actively engage students in working with and producing knowledge
(Sleeter & Grant 2007:166).
According to Hernandes (Lemmer & Squelch 1993), educators acquire a broad repertoire of
instructional methods and techniques, because one method will not work for all students. For
instance, the `ìnquiry method'', which involves questioning and problemsolving, is not
appropriate for students who are accustomed to rote learning.
There is, however, a need to move away from pure rote learning and the lecture method and
instead to move towards creative ways of learning and teaching. Active student participation is
now regarded as an important part of the learning process. Educators should gradually
introduce a variety of methods in the learning process, such as roleplay, games, independent
study, project and group work.
Revise your second-year study guide on the these teaching strategies as well as those
discussed in Tjale and De Villiers (2004:187±200).
5.16
Revise the above teaching strategies, especially in a class with students from diverse
cultures.
Mastery learning seems to be a good way of incorporating cultural and individual differences in
the learning process. Lemmer Squelch (1993) describes mastery learning as the breaking
down of subject matter into series of units to be learnt sequentially. It is important to achieve a
high level of competence in one unit before moving to the next. In this way students get a solid
foundation on which to build new content and also gain a sense of success and
accomplishment.
According to Jacobs, Gawe and Vakalisa (2000), cooperative learning is important in moving
from a competitive-individualistic ``mass manufacturing'' model to a high-performance team-
based organisational structure.
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5.17
Revise the section on cooperative learning and describe the benefits of this type of
learning and teaching for a classroom with diverse students.
Now we shall discuss some of the major teaching strategies concerned with cooperative
teaching and learning.
5.3.3 Storytelling as a teaching strategy

We have always told stories about our patients, ourselves and our profession. Informal
storytelling has always been part of the African culture.
The biopsychosocial conditions of humans are represented in novels, short stories, poetry,
music, paintings, and so on. Storytelling can be used as a tool to teach and to understand
health and illness. It has gained in interest and attention over the last decade.
As part of formalised educational programmes, sharing stories encourages a new level of

understanding. Using storytelling as a learning activity can be a powerful addition to
orientation of new staff, to seminars and workshops, or to use on caring rounds.
The use of stories has the potential to illuminate and inspire students in health care, bring new
insights into health care practice; it also has the potential to the person as a whole for whom we
care.
Through the use of storytelling, the health professional will be stimulated to consider new
methods of solving problems, making decisions and resolving personal and professional
conflicts.
5.3.3.1 Definitions
A story is an event or series of events, encompassed by temporal or spatial boundaries, which
is shared with others using an oral medium or sign language.
5.3.3.2 Storytelling
Storytelling involves the following:
& the process or interaction used to tell stories

& people sharing a story (storytellers)
& people listening to a story (storytakers)
5.3.3.3 Benefits
a Preserving the history
The importance of storytelling is recognised throughout the world. In Africa, storytelling has
been one of the most significant ways of preserving the history and culture of various groups. It
is also a vehicle for teaching values, strengthening community and family bonds and sharing
the practical information necessary for daily living. Storytelling not only serves these functions,
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but is also one of the most important ways of resisting domination of people from one culture
by those from another.
b Therapeutic benefits
Storytelling
& builds self-esteem and rapport

& extends care and support to all colleagues
& strengthens health professional-client relationships
& establishes connections between people and creates a shared history
c Scientific potential
By telling and listening to stories
& participants have the opportunity to give their naturalistic views

& participants can apply Heideggerian hermeneutics
& participants can explain auto-ethnography
& participants can share their birthing stories
d Benefits for health care education

Storytelling has the following benefits for health care education:
& is a way of introducing humanities in curricula

& stimulates critical thinking.
& serves to enhance a student's capacity for compassion and empathy
& equips the student to live within current society and expands the student's perception of
self and the world he or she lives in
& promotes collegiality and collaboration
& gives students a voice
& exposes students to the potential of language and expression, and to further
development of listening skills
& makes nursing practice visible
& addresses diversity
& facilitates self-help groups
5.3.3.4 Written story

Short stories, written for children or adults, may be integrated into a health care programme.
For example, students who have paediatric clinical experience may find ``Curious George goes
to the hospital'' helpful in understanding children's perceptions of the hospital experience.
Terminally ill children and nursing students may both be helped to understand death and dying
and the purpose of life through the short story ``The fall of Freddie the leaf''.
Spencer's ``Seasons'' may be used during discussions of life-span development. As students

are introduced to various developmental stages and tasks, this short novel will illustrate a
character's development through the backdrop of the changing seasons. Issues of mental
illness also can be dealt with through short stories. Melvill's ``Bartleby the scrivener'' concerns
itself with the passive resistance of a depressed patient. Through this short story, nursing
86
students may gain insight into issues of mental health. These, as well as a multitude of other
short stories, may be used as a foundation for students to learn particular concepts, investigate
issues and explore human behaviour and development.
5.3.3.5 Contextual grounding

In this instance stories serve as a means of locating one's self. Storytelling also clarifies the
lens one uses to look out at the world and consequently provides a foundation on which to
build our understanding of the world and our place in it. It not only influences how we see
ourselves and others, but also the choices we make and the way in which we behave.
Storytelling and thinking aloud could thus also serve to clarify one's values. This is exactly
what education in the health sciences should aim for, to put students in touch with themselves
and with others as caring beings.
5.3.3.6 Bonding
Bonding with other group members appears to be the most important function of storytelling.
Even when there is disagreement, stories could foster connection. In a broader perspective,
such bonding through the common denominator of caring, whether at the experiential or the
descriptive level, could only serve to enhance group cohesion and the advancement of the
caring concern.
5.3.3.7 Validation and affirmation

Stories are also a means for the narrators to validate themselves and their reality. Validation of
negative points could lead to a critical self-examination of the life of the narrator. Stories
affirming joy and goodness are also uplifting and energising, for both the narrator and the
listeners.
5.3.3.8 Venting and catharsis

Understandably, storytelling could enable people to vent emotions and provide a means of
catharsis about some or other issue. It is also conceivable that storytelling could serve as a
vehicle that would allow the storyteller to repent in an indirect way. Together with venting and
catharsis, this could, with the necessary caution regarding the amount and nature of personal
information divulged, serve to ease tension, stress and frustration, which is very necessary in
the health care profession. Deering (1995:39±394) also corroborates and validates the
therapeutic physiological effect of self-disclosure (of which storytelling is one form).
5.3.3.9 Applications
The applications for storytelling in an educational programme are as varied as the stories
themselves. Storytelling gives students permission to tap into the tacit knowledge embedded in
their professional nursing experiences and to learn from one another. It also serves as a
springboard for dialogue about the deeper issues of professional practice that may not be
easily explored through other methods. Experienced health professionals tend to undervalue
the amount of information they bring to their practice. Validation of this knowledge by peers
during storytelling provides awareness and a new affirmation for practice.
Over the course of years, people have learnt many things through education or experience.
Storytelling is a way to share their knowledge and wisdom with the group. The educational use
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of storytelling is especially obvious in the discussions about health. Frequently, storytelling is
used to evaluate how adaptive behaviours and thought processes learnt from previous
generations. It could be termed habits of survival ± could affect current health. Group
storytelling also provides opportunities for people belonging to the same cultural group to
share their pain, frustration, joy and wonder. This can serve to decrease the sense of isolation
that many may experience in their larger professional and social environments. It could also
help people to develop strategies for resisting negative mythology and images. For most
people who share so many of their life experiences, it may be a rare and welcome opportunity.
(Mayers 1995:280±282)
5.3.3.10 Planning phase

Storytelling should be planned so that it is an enlightening and meaningful experience for
participants. The facilitator needs to create an environment conducive to the sharing of stories.
Because the telling of stories should be unhurried, group size will be determined by the
amount of time allowed for the activity. Allowing three to five persons in a group usually
provides time to share and reflect on stories within one hour. The chairs should be close
together so storytellers can attend to one another, but far enough from other groups to allow
privacy. Darken the room slightly and eliminate overhead pagers, public address
announcements and other interruptions as much as possible.
5.3.3.11 Guidelines
A few guidelines will help participants engage fully in a storytelling session. Directions can be
given orally or on a written handout. Invite participants to share their stories around the theme
of the programme. Participation in storytelling should be voluntary. If someone chooses not to
tell a story, a simple hand motion or an `Ì pass'' is adequate and the next speaker gets a turn.
Ask them to respect and maintain confidentiality about the stories that will be shared.
Some general time parameters for this experience can be suggested to the storytellers, but
flexibility is the key, for each story varies in length. Ask listeners to use their best listening
skills, with good eye contact and attentive facial expressions and body language. The intensity
demonstrated by listeners is a major factor in creating a sense of communication within the
group. This sense is enhanced by inviting participants to move from one story to another
without any intervening interpretation, exploration or judgment. The first few times the
participants engage in storytelling they find it difficult to honour the request; but, ultimately,
this attentiveness enriches the experience.
When all stories have been shared, the facilitator initiates a group discussion about the process
of storytelling, not about the stories that were shared.
Some questions that may assist in debriefing about the experience include the following:
& How did the storytelling experience go for you?
& How did it feel to be listened to in this way?
& Did you discover anything you would like to share?
& What other applications would there be for storytelling in your practice?
After a discussion of the process of storytelling, focus the discussion on the power of the
stories that were shared. In this way, the discoveries made from the storytelling are related to
expected learning outcomes. As groups become more comfortable with storytelling, it is not
necessary to discuss the process itself. At that point, discussions can focus on individual and
group discoveries from shared storytelling.
88
Storytelling can be taught as a way of caring: caring for the individual who is telling the story
by giving this individual a vehicle for reviewing his or her life, and caring for the listener who
grows from the wisdom of the storyteller's experience.
For health professionals, particularly as women, being allowed to voice their own strengths is
an empowering act, and it is also empowering to realise that their own stories can give other
people ``plots'' on which to build their life stories.
In a diverse setting, sensitivity to and awareness of their experiences may create a better
understanding of humankind.
An understanding of the connections and contrasts of life experiences can begin to create a
better appreciation of others' experiences and to see beyond stereotypes.
The power of these stories and human insights suggests that the creativeness that lurks close
to the boundaries of society has important implications for everyone's lives.
5.18
& Collect stories from books, journals and by speaking to grandmothers. Put these
in your portfolio and use them when necessary.
& In your place of work ask your colleagues to each tell a story at a human
resources development session, while you act as the facilitator. Write down your
conclusions.
5.3.4 The use of gaming strategies in a transcultural setting

The introduction of gaming strategies can enhance the effectiveness of learning in a
transcultural setting by reducing the communication and cultural barriers often associated with
diverse groups of students.
Providing educational programmes conducive to diverse learning styles can help to keep
health professionals in health care settings for longer.
Knowledge of a culture and its ways of knowing and learning is essential to providing culturally
appropriate and responsible educational experiences.
Educators must develop teaching strategies to fulfil the educational needs of health
professionals working/studying in diverse practice settings.
Educators must be aware that the cultural context of the educational content presented may
provoke an uncomfortable or embarrassed reaction among different cultural groups. Language
and communication pose another potential problem in a transcultural learning environment.
Educators must be aware of the language competencies of the participants involved in the
educational program and gear the speed of delivery and content level accordingly. Using a
variety of sensory teaching/learning methods incorporating both visual and auditory features
has proved the most successful with multicultural participants in a diverse setting.
Gaming is one teaching/learning strategy which has proved to be successful in meeting the
complex, diverse educational needs of health professionals who differ in learning styles,
communication patterns, life experiences and practice abilities.
This section will discuss how the use of gaming exercises evolved and how games are being
used effectively as an educational tool for health professionals in a transcultural environment.
To understand how gaming can be developed and evolved in a specific setting, we need to
HSE3701/1 89
explore cultural and educational diversity issues (which we have been doing throughout this
module).
Gaming strategies in general will be discussed (as well as some specific games):
& Games are teaching/learning strategies well suited to group learning situations.
Incorporating gaming strategies into the teaching/learning plan creates a nonthreatening
learning environment that encourages active participation, enables students to
demonstrate and apply previously or newly acquired knowledge and skills, enhances
communication and teamwork, and is fun.
& Games can also be used to reinforce lecture content and stimulate motivation. They are
particularly useful with heterogeneous groups of students.
& Gaming techniques are not used as a primary method to introduce new information but
as a reinforcement of previously learnt or studied material.
& Gaming techniques can be utilised to prepare one to take a variety of proficiency
examinations.
& Greater cultural diversity among participants requires the game facilitator to ensure that
the rules of the game are properly explained and understood by all the participants.
& Educators need to note subtle considerations, such as avoiding colloquial language and
particular mannerisms, when conducting the games. For example, using finger pointing
as a mechanism to acknowledge a response to a question or as a method of selecting
the next response could be considered offensive by some ethnic groups. Changing
game rules in some instances, to have the individual or group raise their hands when
responding to questions in the gaming exercises for example, would reduce possible
perceptions of offensive or aggressive behaviour.
We will now proceed to discuss some puzzles and board games which you could use, but
when educators become more familiar with gaming, they can produce their own games, for
their own circumstances.
5.3.4.1 Puzzles
Puzzles are a gaming strategy used to reinforce content already learnt or to review content
presented during class. As a gaming strategy, puzzles are designed to be participatory,
adaptable, brief, fun, and to present a low risk to students.
Puzzles which can be used in a transcultural environment include the Circulatory System
Puzzle and the Shock Syndrome Puzzle.
a Circulatory System Puzzle

The Circulatory System Puzzle requires the completion of four separate puzzles designed to
review key concepts presented in the text.
Prior to class, tables are arranged in four groups so the class can form teams. This table
arrangement provides a flat surface on which the puzzle pieces can be arranged.
Each team, consisting of 2 to 4 players depending on the number of puzzle pieces to be

arranged, works independently from the others and has 15 minutes to complete their puzzle.
Team members are requested to work as a group and, after completing the puzzle, select a
spokesperson to present the puzzle to the rest of the class. The educator then circulates among
the groups to ensure that the directions are understood and to assist where necessary.
90
The educator gives directions before the class begins and also posts directions at the head of
each table arrangement.
The Circulatory System Puzzle works best with groups of 10 to 15 students.
Each group arranges the pieces of their puzzle to construct the following:
& puzzle 1: chambers of the heart, layers of the heart, valves and support structures, major
blood vessels leading to and from the heart, and blood flow through the
cardiopulmonary system (28 puzzle pieces)
& puzzle 2: electrical conduction system of the heart, electrical presentation of arterial and
ventricular depolarisation and repolarisation, and labelling of the normal electrocardio-
gram waveform (16 puzzle pieces)
& puzzle 3: major arteries and veins, vessel wall layers, cardiodynamics of blood pressure,
factors affecting blood pressure and blood flow, and location of pulse points (35 puzzle
pieces)
& puzzle 4: cardiodynamics of heart sounds and murmurs, determinants of cardiac output,
foetal circulation and the physiology of the lymphatic system (16 puzzle pieces)
b Shock puzzle
The shock puzzle is a novel way to conclude the theory component of a formal class or a fun
approach which enables students to apply newly acquired knowledge in programmes such as
critical care courses, and various unit-based workshops. The class works as a group and has
15 minutes to arrange the 44 pieces of the puzzle. Participants are expected to arrange the
puzzle pieces, on tables or taped to the wall, whichever is more convenient. Categories include
definition of shock syndrome, classifications of shock, pathophysiology, causes, risk factors,
stages of shock, compensatory mechanisms, clinical signs and symptoms, nursing/medical
management and, depending on the learning outcomes, special populations such as paediatric
or oncology patients. After completing the puzzle, the educator reviews key concepts and
answers questions. The puzzle works best with groups of five to seven participants. With larger
groups, each of the above-named categories of the puzzle is divided among two to three
students with a review of the entire puzzle at the end.
5.3.4.2 Board games

The playing of board games is also a popular method of studying the content of review
courses. For example, in a lifespan development course, a board game called Mid-life Crisis
was developed to review physical changes, socio-emotional changes and developmental
theories associated with middle adulthood.
The board game concept can also be used in training programmes. After lectures on infections,
antimicrobial therapy and infection control practices, a board game called Bug Busters can be
used to reinforce key concepts and promote critical thinking related to the clinical care of
patients.
A playing board designed as a wheel with three spokes is divided into 33 spaces. Three colours
are used in the spaces, making sure the end of each spoke is a different colour. The end of each
spoke is designated as a ``category headquarters''. A dice (or die) is drawn into three spaces on
the wheel to indicate continuation of a turn by rolling again.
Three categories of question-and-answer cards are prepared, with all questions from one
category on a coloured card which corresponds to coloured spaces on the playing board.
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Approximately 25 to 30 question-and-answer cards are needed for each category.Three sets of
category headquarters cards are prepared, and one dice and three player tokens are needed.
The winner is the team that first returns to the hub and correctly answers a question in a
category chosen by the other players. Before attempting a game-winning question, a team must
land in each of the three category headquarters and obtain a category headquarters card by
correctly answering a question in that category.
Students are divided into two to three teams with two to four students on each team.
To start the game, the player tokens are placed in the hub. The team rolling the highest number
begins play by rolling the dice and, starting from the hub, moves the token the indicated
number of spaces in any direction. The team is asked a question corresponding to the category
space in which the token has landed.
If the team correctly answers the question, the turn continues with another roll of the dice.
If the team answers the question incorrectly, the turn passes to the team on the left.
If the token lands in a category headquarters space and the question is answered correctly, the
team gets a category headquarters card.
If the team answers a question incorrectly while in the category headquarters space, the team
must leave the headquarters space on the next turn and later re-enter it and again attempt to
obtain a category headquarters card.
A team landing in one of the spaces featuring a dice continues the turn by rolling again.
Any number of tokens may occupy the same space.
When a token lands in the hub before the team has met the three headquarters requirements,
the hub is treated as a wild-card space and the team chooses the category for the subsequent
question.
After a team has correctly answered a question in all category headquarters, the team's token
must make its way to the hub.
When the token lands in the hub, opposing teams select the category for the final question.
If the question is answered correctly, the game is won.
If it is answered incorrectly, the team must leave the hub on the next turn and re-enter it for
another question.
5.3.5 Humour as a teaching strategy

''He who laughs ... lasts'' (anonymous).
Humour can be used in the classroom to improve creativity and retention of content.
Health care staff deal with people at their best and worst Ð new life is born, defences are
down, coping strategies are depleted, and hope can be renewed or gone, in some cases.
Couple these factors with responsibility for clients' lives, constantly changing technology and
research, inadequate staffing and irregular hours. Students must deal with many emotional
situations that they may be ill-equipped to handle because of their experiences. So health care
can be extremely challenging and stressful. Humour is seen as a necessary tool to enable one
to maintain some semblance of sanity in an often sobering or bizarre setting.
92
Humour Ð What is it?
& Humour is defined as a pleasure in which humankind indulges at the slightest excuse. A
sense of humour seems to be an inborn affective trait, one that is unique and changing
as one matures. Laughter is the natural result of a sense of humour, and is accompanied
by an involuntary contraction of 15 facial muscles and irrepressible noises. It has no
value related to survival, but has many positive benefits for humanity. Laughter can also
be seen as a natural part of the human organism that helps us to deal with the mundane
aspects of our lives.
& The sense of humour follows a developmental pattern that parallels the intellectual and
emotional development of the student as described by Piaget, Kohlberg and others.
& Other influences include culture, education, intelligence, gender and opportunities for
fantasy and play.
& The child's demonstration of humour begins with the first smile and progresses to the
late adolescent's ability to distinguish what is appropriate humour.
& Six characteristics that seem to be essential to a humorous outlook are
Ð flexibility, spontaneity, unconventionality, shrewdness, playfulness, and humility
5.3.5.1 Process
Humour involves a three-stage process which includes arousal, problem solving and
resolution. During arousal, the individual focuses on cues that the situation is a humorous one.
Cues may include such things as symbols, twinkling eyes or a smile. During the
problemsolving stage, one makes sense of incongruous information and begins to anticipate
the punch line.
Resolution occurs when the individual hears the punch line, understands the joke and reacts to
it. Humour may be classified into a variety of groupings, such as superiority, incongruity,
sympathy, surprise, ambivalence and relief.
5.3.5.2 The value of humour

Humour has many benefits Ð physical, emotional, social, economic and cognitive:
& The physical effects of humour and laughter include muscle relaxation, stimulation of
the circulatory system, exercise for the lungs and chest muscles, pain control through
distraction and increased production of endorphins (the body's natural painkillers) and
lowered pulse and blood pressure.
& Emotionally, humour decreases anxiety, creates a sense of freedom and trust, and a
positive self-image and attitude, and improves motivation and perceived quality of life.
& A sense of humour may also benefit one socially because it helps open communication
lines, crosses social and cultural barriers (although perceived humour varies somewhat
between cultures), helps deal with difficult or awkward moments, and may help solve
problems through different perspectives.
& Humour has also been identified as a coping mechanism, beginning early in a child's
development.
& Many employers (including hospitals) see the benefits of an attitude of humour as a
management tool, resulting in happier employees, better rapport, reduced tension,
increased motivation and productivity, and more satisfied consumers. They may in turn
reward the ``positive'' employees and let go the ``negative'' ones.
There are many identified benefits of humour for the classroom setting, although few have been
documented through empirical research:
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& Humour can be a planned teaching strategy, a spontaneous event that may help explain
a point or part of extracurricular activities.
& Further benefits include increased attention and interest, student/educator rapport, better
comprehension and retention of material, motivation toward learning, satisfaction with
learning, playfulness, positive attitudes and classroom environment, improved
productivity, lively class discussions, creativity, generation of ideas, improved quality
and quantity of student reading, and promotion of divergent thinking.
& Other benefits include decreased academic stress and anxiety, dogmatism, boredom and
class monotony. Stress is reduced when humour is used in student evaluation in a
clinical task situation.
& Humour can be used to manage disruptive behaviour in the classroom.
& Humour has also been identified in a continuing education setting as a trigger for the
discussion of personal attitudes and as a method of coping with problematic situations.
5.3.5.3 Classroom use of humour

Two basic questions are usually asked:
1 Does this method/strategy aid in decreasing student anxiety Ð in testing, laboratory
checks, patient care and future practice?
2 Does this method/strategy help students retain and transfer content and concepts from
the classroom to the practice setting?
The educator must be careful when using humour, however, to avoid some of the pitfalls Ð
such as ridicule, sarcasm, and racist or ethnic jokes. It is important to be able to laugh with
someone, not at them, so as not to offend them.
The wrong kind of humour can be demeaning and destroy self-esteem and confidence, interfere
with communication and sever relationships. The educator can use humorous anecdotes
(anonymously, but most from real clinical settings), comic transparencies (from newspaper
cartoons) to break up the monotony of some otherwise very dry materials, a comical mnemonic
(such as one used as a student to memorise the 12 cranial nerves), roleplay and role
modelling, and bulletin boards. By actively using humour as a teaching strategy and
discussing when humour is appropriate, the educator can model for the students and show
them that life and health care can be enjoyable, even when circumstances seem to be
overwhelming.
The educator can also show the students that it is possible and necessary to be able to laugh at
ourselves, and the educator could begin by introducing herself or himself with the following
words:
''My name is Parrott, just like the bird, but with two tails.''
Another method to use with students is to portray the ideal as opposed to the real world of
health care in a slightly exaggerated and humorous, but truthful manner. This will hopefully
soften some of the reality shock that new students experience, and reinforce the content areas
being discussed. Educators refer to the ideal as the `ìvory tower'' in major metropolitan
teaching hospitals (tongue-in-cheek, of course, with the ideal being an unlimited budget,
supplies, high technology equipment, and staff). This could then be compared with what a
health care professional might encounter in a small town hospital, with a red telephone for the
volunteer fire department and the weather band radio at the nurses' station, nurse-staffed
ambulance call, only one registered nurse on the night shift, and the physician 20 kilometres
away. These scenarios may be repeated many times, with different content areas and concepts
presented, such as legalities of practice, triage and priority setting, and conflict resolution.
Students have commented repeatedly during evaluations that some of the ``small town'' stories
94
helped them to remember concepts. Students may tell the educator that the real world often
does not differ from the ``small town'' world, and that the stories helped them to remember
some important concept or standard in practice.
Other useful tools for using humour as a teaching strategy:

& Bulletin boards. Bulletin boards are another method used in teaching, and could display
supplemental materials, poignant stories, verse and comic strips. Some favourite stories
and comics are those that depict life but poke fun at it, such as the ``Love Is-'' series,
Garfield, Madam and Eve, and many others. These serve as retention cues, to emphasise
points, or to reduce anxiety over certain topics (such as aging, dieting, adapting to
change, or death). The bulletin board is changed with every new content unit.
& Roleplay. Another successful teaching strategy using humour is a roleplay of ``Granny
Grits, from the Home Down the Way'' (the educator in grey hair and costume). She (or
he) makes frequent visits to medical/surgical classes to help present content on aging.
The educator is most frequently a surprise visitor for a class, with the collaboration of
some student or tutor presenters. She offers her ``86 years' of wisdom, experience,
philosophy and wit'' in a realistic, humorous manner, without being demeaning to the
elderly. After the initial shock of her (or his) entry (and the accompanying laughter)
wears off, the presentation continues, with Granny included in the presentation of
content such as history-taking, assessment and questions.
& Cartoons. Cartoons can also be used where humour is incorporated as well as ``the
message''. The same steps are followed. The educator can collect various cartoons (see
figures 5.3, 5.4 and 5.5 on professional practice) and use them in his or her teaching.
A sense of humour is no longer seen as an uncontrolled and undignified trait. Humour can be
used in constructive ways for healing and teaching. It can nurture and revitalise both nurses
and clients. The challenge for nurse educators is to study empirically the value of humour in
nursing and health care as a coping tool, a therapeutic technique and a teaching strategy.
Figure 5.2
HSE3701/1 95
Figure 5.3
Figure 5.4
5.3.6 Other teaching strategies

Let's look at some other useful teaching strategies:
& Ethnomusic. Ethnomusic therapy can be used in conjunction with humour to teach the
components of cultural competence.
& Audiovisuals. Audiovisual resources such as videos, DVDs and films can be used to
teach the use of humour as a culturally specific intervention. Audiocassettes of African
music could also be used to demonstrate the use of music with different cultures
(ethnotherapy).
96
& ''Cultural bingo''. To teach a session on cultural knowledge, the educator could make
use of an exercise called ``cultural bingo''. This exercise encourages participants to
casually interact and ask specific questions about the worldviews, customs and practices
of several culturally/ethnically diverse populations. The first participant to get the
answers to four questions across, diagonally or vertically, wins the game of bingo. For
example, participants learnt how ``coining'' and ``cupping'', which are two Southeast
Asian folk remedies, could be misinterpreted as child abuse if they are not understood
within the context of the Asian culture.
& Outside Expert Awareness Exercise. To teach a session on cultural awareness, the
educator could use Pedersen's (1988) Outside Expert Awareness Exercise. This
experiential exercise emphasises the process of engaging with another culture as an
outside expert. The goal of this experiential exercise is to make students aware of their
own cultural background, and of the ``labelling'' of another person's behaviour. This could
also lead to an awareness that students will realise that they could misdiagnose a client.
& Self-assessment or family assessment. This assessment encourages students to learn
about various beliefs, customs and values in the light of their own cultural background
and family ancestry. Detailed interviews with family members can serve as a primary
method of data collection. A printed guide will help students focus their investigation on
such activities as family traditions, historical events, health care practices, celebrations
and home remedies. Some examples which could be included in the guide:
Ð How did relatives in your family meet and marry?
Ð What are the customs or traditions that exist in your family?
Ð Find out all you can about your family's last name.
Ð Trace family stories that you heard from your parents or grandparents.
Ð What are your family's health practices, especially those related to prevention of
illness and promotion of health?
Ð In addition to relatives, what other persons are considered part of the family?
& Investigation of a cultural or ethnic group of their choice. Some students could explore a
culture similar to their own in an attempt to learn more about it, others could choose
groups which they are completely unfamiliar with and which they express ``discomfort''
with. Giger and Davidhizar's transcultural assessment model can be used as an effective
cultural assessment tool to investigate key dimensions of culture. This tool was
discussed with you at the beginning of this study unit.
& Field experiences. Field experiences are another exercise that will expose students to
``culture'' in its broadest sense. Students can volunteer to spend time in local community
clinics of their choice; these clinics provide health-related services to groups of persons
that students perceive as being different from themselves. Students can conduct their
field experiences in places such as homeless shelters, long-term care centres, schools
for disabled children, homes for unwed mothers and substance abuse clinics. A printed
guide will help students to focus on key elements of the field experience and to make the
broad conceptual connection between the specific groups served by the clinics and
elements related to cultural diversity. For example, students may be asked to examine
the group in a similar manner to their previous cultural assessment and to include
perceptions of the group's attitudes toward health care. After these experiences students
must share any positive or negative changes in their personal perceptions of the groups
they studied as a result of their field experiences. They can then analyse their responses,
make recommendations and identify specific skills they may need to provide health care
services to these groups.
& Cultural awareness simulation, known as BaFa BaFa. The primary objectives of BaFa
BaFa are to create an environment that permits participants to explore the concept of
culture, simulate feelings in participants similar to those experienced when visiting an
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unfamiliar culture, and provide experience of observing and interacting with members of
a different culture. In essence, BaFa BaFa is a mechanism for students to experience
culture shock in a realistic yet safe classroom environment. This activity can be
scheduled for the last class session, and can then also serve as a cultural celebration.
Each student will be required to bring food to share that has a special ethnic or cultural
meaning.
& Reflective journals. These are discussed in your second-year study guide.
5.19
Revise the use of reflective journals in your second-year study guide. As an educator,
how would you utilise this teaching method for a class with diverse students? Write
down your responses.
5.4 Recommended practices: culturally responsive teaching

When students fail to learn, we often blame incompetent teaching. However, in a multicultural
setting, the problem might simply be that educators have not been sensitive enough to their
students' learning needs. In this section we suggest teaching methods for the multicultural
class.
Note: The following points are very important. The main guiding principle for all teaching in
multicultural classes is that a wide variety of approaches, methods and techniques should be
used. Since teaching styles and methods are to some degree culturally influenced, some
teaching styles and methods will work better with some students than with others. Educators
who assume that the same methods will work equally well with all students are ignoring the
influence of culture and other factors in the teaching and learning process. When selecting and
applying particular methods, teachers should consider whether the methods are suitable for all
students or only for certain groups. For example, Lemmer, Meier and Van Wyk (2006:101)
indicate that the enquiry method which is widely used and which is based on questioning and
problemsolving is not appropriate for all students, especially those who are accustomed to
learning facts off by heart. Always consider a student's field sensitivity or preferred learning
style when you are selecting teaching methods and approaches.
It is suggested that educators gradually introduce and apply a variety of teaching methods,
such as roleplay, games, independent study, project work and group work, and that they
should be more flexible in their approach. So get to know your students' learning styles and
match your teaching methods to the students' learning styles.
5.20
1 What are your teaching style preferences?
2 Which teaching methods are suitable for teaching multicultural classes?
3 What are the benefits of cooperative teaching and peer teaching in a multicultural
classroom?
98
4 How flexible and spontaneous are you as an educator in terms of being able to
implement a variety of teaching styles, approaches, strategies and methods?
5.4.1 Teaching styles

We would like to introduce you to five different teaching style categories (Fischer & Fischer in
Bennett 1995:59±60):
Five Teaching Style Categories ± Barbara Bree Fischer and Louis Fischer
1 The Task Oriented. These educators prescribe the materials to be learned in Bennett
(1995) and demand specific performance on the part of the students. Learnings to be
accomplished may be specified on an individual basis, and an explicit system of
accounting keeps track of how well each student meets the stated expectations.
2 The Cooperative Planner. These educators plan the means and ends of instruction with
student cooperation. They are still `ìn charge'' of the learning process, but with their adult
experience and professional background they guide the students' learning. Opinions of
the students are not only listened to, but are respected. These teachers encourage and
support student participation at all levels.
3 The Subject Centred. These educators focus on organized content to the near exclusion
of the student. By ``covering the subject'', they satisfy their consciences even if little
learning takes place.
4 The Learning Centred. These educators have equal concern for the students and for the
curricular objectives, the materials to be learned. They reject the overemphasis of both
the ``child-centred'' and ``subject-centred'' styles, and instead help students, whatever their
abilities or disabilities, develop toward substantive goals as well as in their autonomy in
learning.
5 The Emotionally Exciting and Its Counterpart. These educators show their own intensive
emotional involvement in teaching. They enter the teaching-learning process with zeal
and usually produce a classroom atmosphere of excitement and high emotion. Their
counterparts conduct classrooms subdued in emotional tone, where rational processes
predominate, and the learning is dispassionate though just as significant and meaningful
as in the classrooms of the emotionally more involved educators.
5.21
Can you recognise your teaching preference? Do you think that you would be able to
use any of the other teaching styles mentioned in this extract? How flexible are you in
terms of teaching style?
5.4.2 Learning styles of students

Research has shown that students perform better in classes where they are taught by educators
whose learning styles are similar to those of the students. This makes sense if one assumes
that most educators teach in ways that match their own learning styles. Only recently are
educators being expected to become more flexible and use a variety of teaching styles in order
to respond to the diversity of learning styles among the students in their classes. We all know
gifted teachers, who through their awareness and sensitivity, are able to bridge cultural and
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individual gaps. They manage to provide each learner with what he or she needs to be
successful. However, it may never be known to what extent this flexibility and openness depend
on basic personality traits. Bennett (1995) suggests that we should adopt the following
guidelines, to ensure that we are taking steps that will open the channels of success to all
students, regardless of cultural or individual characteristics:
& Know our own teaching and learning styles of students.

& Decide how far we can stray from these strengths and preferences and still be
comfortable.
& Build classroom flexibility slowly, adding one strategy at a time.
& Use all sensory modes (visual, auditory, tactile and kinaesthetic) when teaching
concepts and skills.
5.22
Revise the learning styles of students in your second-year study guide and on page
186 in Tjale and De Villiers (2004). Answer the following questions:
1 Describe the connection between socialisation and learning style and learning
environment and learning style.
2 How would you manage your teaching to incorporate your students' learning
styles into your teaching programme?
5.4.3 Teaching methods

Two teaching methods that have proved successful in multicultural classes are cooperative
teaching (student team learning) and peer tutoring.
In order to introduce you to the possibilities that group work holds for multicultural
classes, it might be logical to start by looking at the advantages of using small groups
in class, as discussed in Tjale and De Villiers (2004:197±199).
5.23
What are the advantages of small group work? You may have found the answer in your
prescribed work, but we add other advantages which may not be mentioned below:
1 Small groups allow for individual instruction and help to provide for the many
differences among students.
2 Small group work promotes effective learning:
& Small groups seem to be more successful in problemsolving than
individuals are.
& Their techniques help to develop critical thinking skills.
& They provide a wide variety of information.
& They provide opportunities for in-depth study and wide coverage.
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& They provide opportunities to develop research and study skills.
3 Small groups provide students with opportunities to develop social skills and to
develop good social attitudes as a result of the give-and-take.
4 Small groups can help to foster leadership ability.
5 Small groups can help to develop self-reliance and independence (responsibility).
6 Small groups add variety and interest to classes:
& They provide release from the tedium of ordinary class and give pupils the
opportunity to work off their energy through active participation.
However, cooperative team learning is not without its problems. Some of the most
serious problems in a multicultural cooperative class arise from
& the differences in the students' academic status (existing or entry-level skill
and knowledge, and language proficiency)
& the difference in students' social status (as ascribed by society at large)
& the differences in peer status (friendship networks)
Students need to be taught to work together effectively in cooperative classrooms.

Successful teaching strategies include the following:
& training students to use cooperative behaviours such as listening, giving
everyone a chance to talk and asking for help
& rotating the functional roles in the groups, such as the roles of group leader,
facilitator or secretary
& using stimulating learning materials that are intrinsically motivating and not solely
dependent on reading
& including assignments or tasks that are graded and open-ended so that some students
can work at higher levels of complexity than others, while concurrently providing tasks
for those who need to work on a simpler level
& introducing each set of activities in such a way that multiple abilities are required
& publicly praising the outcomes of all students, especially those who complete simpler
tasks
The following discussion deals with group work. It focuses on six useful techniques:
1 launching group work

2 how to form and work with buzz groups
3 how to use the fishbowl technique
4 how to work with teams
5 how to use a working committee
6 evaluating a group project
After having studied the criteria, you should
& know how group work can be launched

& know how to form and work with buzz groups
& know how to work with teams
& be able to evaluate a group project
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5.4.3.1 Launching small group work
When students are not familiar with small group work and lack the social skills necessary to
make group work successful, begin working with them slowly. Perhaps the best method is to
start off by forming small transitory committees to perform definite tasks (eg the bulletin board
committee, the lab cleanup committee and the committee in charge of handing out materials
for students to work with). The use of buzz groups is another approach often used by educators
to introduce small group techniques to their students.
5.4.3.2 Buzz groups

Buzz groups are small groups of about six students who discuss a topic freely and informally
for about six minutes. Because of these characteristics ± six people meeting for six minutes ±
buzz groups are sometimes called 6 x 6 groups. Buzz groups are transitory groups called
together for a specific immediate purpose. As soon as its mission is accomplished, the group
is dissolved.
Buzz groups are extremely useful because they can prevent classes from centring on the
teacher or on a small group of dominant (or even domineering) students. Buzz groups are often
used to do the following:
& launch large group discussions

& reformulate the objective and background ideas of a discussion that has broken down
& decide what to do next
& brainstorm
& set up rules
& exchange ideas and experiences
& formulate questions and problems for investigation
& formulate questions and problems as a basis for group discussion, to put to guest
speakers or panellists, and so on
& bring out and speak frankly about controversies and differences
& draw out students
& share insights gleaned from such experiences as homework, plays, films, and so on
& provide a forum for students to express quick reactions to issues
5.4.3.3 Conducting buzz groups

Buzz groups are relatively easy to organise and run. Buzz groups do have to be planned,
however, or they may ``blow up''. Impromptu buzz groups organised on the spur of the moment
to solve some classroom exigency (eg a disastrous discussion) may work well in experienced
classes, but wise educators keep impromptu buzz groups to a minimum.
The members of a buzz group are usually selected by some simple informal and somewhat
arbitrary means. Among the methods used successfully are the following:
& by the seating plan (eg the first four persons in a row, or the six students sitting in the
first three seats of rows 1 and 2)
& by the alphabet
& by counting off (1, 2, 3, 4, 5, 6; 1, 2, 3, 4, 5, 6)
& by lottery (eg all who draw number 1 from a group of numbered cards are in group one)
102
& by virtue of the educator's knowledge of the students' talents, interests, background, and
so on (you may wish to make special provisions based on these characteristics, but
since buzz groups work for such short periods of time it seems hardly worth the effort)
Each buzz group should have at least three, but no more than six, members.
To prepare students for the buzz group, take care that the mission for the group is clear and
simple. Then make sure that everyone understands the mission and knows what to do. Time
limits should be set explicitly. It is better that the time limits are too short than too long ± six
minutes is usually about right. If the students need more time, you can extend the limit. Each
group needs a leader and a recorder or secretary. The choice of leader and secretary is not
crucial because of the shortness of the buzz group's life.
At the end of the buzz session, the group may report its conclusions. When group reports are
expected, make sure that the students know just what the reporting procedure will be before
they start working. A common method of reporting is for each group to appoint a representative
to a panel who discusses the suggestions of the buzz groups. When this is done, a recorder
may keep an account of the major suggestions on the chalkboard or overhead projector. It is
sometimes better to omit the group reports and let the class move from buzz group sessions to
a whole class discussion, without any intermediate steps.
5.4.3.4 The fishbowl technique

The fishbowl technique is useful for developing skills in participation and for making group
decisions. To conduct the fishbowl technique, use the following procedure:
1 Confront the class with a problem, issue or conflict that requires a solution or decision.
2 Divide the class into subgroups and arrange the groups around a circle.
3 For each group, select or have them select a representative who will argue the group's
position.
4 Give the group members five or six minutes to discuss and to take a position on the
problem, issue or conflict under consideration.
5 Have the representatives of the various groups meet in the centre of the circle and argue
the case in accordance with their instructions. No one else can talk, but group members
may pass instructions to their representatives by written notes.
6 Allow any representative or group to call a recess for group representative consultation, if
it seems necessary.
7 End the fishbowl session after a set period of time or when the discussants have reached
a decision or resolved the conflict.
8 Follow up the discussion with a critique.
5.4.3.5 Student teams

a Small student teams
Small student teams are particularly effective since they are a medium for cooperative learning.
Cooperative learning is an excellent motivation stimulator, because when students work
together toward a common objective, they tend to encourage one another and to reinforce one
another's effort. Cooperative learning also tends to produce more and better ideas, to increase
retention and to aid in problemsolving. These results are an outcome of three concepts always
present in student team cooperative learning: team rewards, individual accountability and equal
opportunities for success.
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b Achievement division
The student team approach called achievement division is best used for teaching well-defined
objectives of a low cognitive level. Basically, it follows the direct teaching model. Here the
educator presents the lesson to the students, who then divide into pairs to compare their
answers to questions, discuss differences, point out discrepancies and errors, and generally
help each other. In this way they not only strengthen their learning but also motivate each other
to do well in order to share in the team reward.
5.4.3.6 The jigsaw approach

The jigsaw approach is really a sort of game in which the students are formed into groups of
six or so, and the content to be studied is also formed into an equal number of segments. Then
each group member is assigned one of the content segments on which to become an expert.
The experts in each content segment from each of the groups meet together to discuss their
content segments and thus further build up their expertise. Finally, the experts report back to
their groups to inform them of what they have learnt.
In a slightly different version of the jigsaw technique, all the students read or study the same
content material. Then each student is assigned a content area in which he or she is to become
an expert. The experts from each group meet together to bone up on their content assignments.
After their consultations, they return to their original groups to pass on what they have learnt.
5.4.3.7 Group investigation

In the group investigation technique, the topic under study is divided into subtopics. Each of
these subtopics becomes the province of a subgroup, which divides the subtopic into
individual tasks. After the individuals have completed their investigations or other tasks, the
group combines the individual finds into a group report which is presented to the entire class.
This is the technique underlying the procedures of many working committees.
5.24
1 How do you teach? What are your preferred teaching styles?
2 Which teaching strategy will you use to enhance students' field independent
3 Which teaching methods should you improve on in order to make your teaching
in a multicultural setting more functional?
4 Could you improve your teaching by introducing any of the strategies and
methods mentioned in this section? Please discuss and supply examples.
5.5 Preparing and selecting instructional material for use in a

multicultural context
Like any other system in South Africa (and no doubt elsewhere), such as the economic, social
or political systems, the education system is in transition. Existing instructional material of any
educational system is continually questioned and alternative structures are sought to deal with
important and sensitive issues. For this reason, in this section we look at some of the issues
104
that need consideration when one prepares and selects instructional material for a multicultural
education system.
5.25
Focus in this section will be on the following questions:
1 What should educators guard against when preparing and selecting instructional
material for a multicultural education system?
2 Why is it important that we select instructional material carefully when preparing
for a multicultural education system?
3 What should educators look out for when preparing and selecting instructional
material for a multicultural education system?
5.5.1 Key concepts

While you are studying this section you will come across a number of familiar and unfamiliar
concepts. Some of these familiar concepts might be used in a new way. Some concepts are
listed below. You could also add more concepts to this list while you work through this
section.
5.5.2 Instructional material

Let's do the following activity.
5.26
Read Tjale and De Villiers (2004:199-200) and discuss the different forms of bias
which one can identify when choosing instructional material for a teaching session.
Instructional material is made up of sources such as articles, books, films, notes,

pictures, videos and worksheets which make possible the processes of teaching and
learning in a formal institution of learning such as a formal school or university.Study
the following definitions of concepts:
Bias: Bias means instilling a thought or feeling with prejudice.

Criteria: A criterion (plural: criteria) is a standard by which a thing is judged.
Guidelines: Guidelines are directing principles.
Selecting: To select means the act of sorting out and choosing what is the most
suitable.
Preparing: To prepare means the act of getting something ready, such as
instructional material, or lessons, by studying what was done previously.
HSE3701/1 105
5.5.3 What to avoid when preparing and selecting instructional material
A number of things need to be guarded against when you are selecting and preparing
instructional material in a multicultural context. Carefully study the following compilation
which concerns the themes of inequality and equal human dignity. Keep it in mind as you
study the rest of this section.
It has been said that any claim that a multicultural approach strives for a fairer
dispensation for every cultural group must be rejected on the grounds that
pedagogically it is the greatest conceivable injustice to a child if he or she is not
educated completely within his own culture. A situation which cannot be allowed to
arise is one which causes conflict between the culture taught at home and that taught
at school. As a result, students from minority groups often find themselves in an
agonising and bewildering dilemma accompanied by an identity crisis.
Literature on this topic frequently relates how these students fade into insignificance
as a result of this dissonance between the two cultural worlds in which they live ...
Americanised Mexicans, for example, are scolded and belittled by fellow-Americans
who address them with names such as vendido, sell-out, Tio Taco and coconut. As
such the Mexican American has a riven conscious life. Being neither American nor
Mexican, he suffers a severe loss of identify or, at least, a profound identity crisis.
Bearing this in mind, the educator should not be deceived by the claim of
multicultural education proponents that all people are equal and that teaching should
therefore be the same for all.
Reality contradicts the claim that a multiethnic and multicultural school can foster
mutual understanding, peaceful coexistence and ultimately the survival of humanity
(mankind). This is sufficiently illustrated by many cases of racial riots, frictions,
tension and clashes among students from different ethnic and cultural groups in
multicultural schools in cities such as Boston, Miami and Los Angeles. For example
it is even considered a cruel and unusual punishment to expect children (from a
variety of ethnic groups) to attend (the same) state schools in Los Angeles.
Having read the extract thoroughly, you should now have some background on this topic. We
now continue to study some of those things which need to be guarded against when preparing
and selecting instructional material for use in a multicultural context. These include
ethnocentrism, stereotyping, omissions, distortion, gender preferences and conflict of values.
5.5.3.1 Ethnocentrism
Some instructional material could be ethnocentric, that is reflect the attitudes, values or other
points of view of a particular ethnic group in the society as being the best and therefore
superior to those of others. This is a one-sided point of view.
5.27
Referring to the extract above, try to answer the following questions which focus on
ethnocentrism:
1 Which ethnic group is portrayed as inferior in this extract?

2 Why do you say so?
106
3 If you had to improve this extract so that it did not reflect any signs of, how would
you do it?
5.5.3.2 Stereotyping
Stereotyping occurs when individuals of a particular group are portrayed as having the same
attributes by virtue of creating false impressions through inaccurate information and
perpetuating a particular view.
5.28
Use the extract to answer the following questions on stereotyping:
1 Would you agree that the extract you read is stereotyped?
2 Justify your opinion, using examples from the extract.
5.5.3.3 Omissions
Omissions (which are often deliberate) refer to leaving out information. As a result incomplete,
false and/or one-sided versions of information might surface. That is another way in which
instructional learning material could remain biased.
5.29
The following questions are based on omissions. Use the extract to answer them:
1 What do you think has been omitted in the extract which could either falsify or
verify information?
2 Why do you think it has been omitted?
5.5.3.4 Distortion
Instructional learning material could also be biased by distortions, that is through omitting,
stereotyping and distorting the information and thus creating confusion and misunderstand-
ings.
5.30
Answer the following questions on distortion by referring to the extract:
1 Do you think the information in the extract is distorted?
2 Make use of as many examples as possible from the extract to verify your answer.
HSE3701/1 107
5.5.3.5 Gender preferences
The preparation and selection of instructional material could be biased by portraying either
men or women in an unbalanced manner. For example, the social history and achievements of
women or men could be negatively portrayed if they are not included in the textbooks used in
schools, for example if women are not shown in leadership positions or men in nurturing roles.
5.31
Refer to the extract to answer these questions on gender:
1 Are there any identifiable biases that are based on gender in the extract? If so, try
to list them.
2 What suggestions could you make to help avoid gender bias in instructional
material?
5.5.3.6 Conflict of values

Many education systems are confronted by conflicting values. Conflict is caused by cultures or
societies (from which the students come) in various stages of transition. Parents are
sometimes to blame for clinging to cultures which they wish to transmit to their children.
5.32
Read the extract carefully once more and then answer these questions on conflict of
values:
1 Would you agree that the author supports the conflict of values among the
students from different cultural backgrounds?
2 Support your answer to question (1) by quoting from the extract.
3 Say you are an educator in a multicultural nursing college. What could you do to
ensure that there are no conflicting values in the class you teach? (Use the extract,
if possible, to guide you in your answer.)
5.5.4 The importance of selecting instructional material carefully when

preparing for a multicultural education system
It is most important to select instructional material carefully, to avoid material that is biased in
terms of ethnocentrism, gender, omissions, stereotyping, and so on.
In selecting instructional material, educators must develop educational instructional material

(resources) which is devoid of racism, sexism, ageism and cultural bias in general. They must
become engineers of multiculturalism. As an engineer of multiculturalism, you must not only
design educational materials that are fair and characterised by cultural diversity, but must also
take monocultural and/or culturally biased materials and point out their deficiencies.
108
In selecting and preparing instructional material for a multicultural education system,
educators should look out for instructional material that is not biased in any way. Having noted
that, some criteria for exploring bias in instructional material should be formulated and used
for that purpose. These criteria will enable the educator to evaluate existing instructional
material to determine whether it is suitable for use in a multicultural context and decide what
changes need to be made.
5.33
You could use the following questions as facilitating criteria to evaluate and thus
improve instructional material:
1 Are there positive role models presented in the material with whom students from
various cultural groups can identify?
2 Are the customs, lifestyles and traditions of people presented in a way that helps
to explain the value, meaning and role of customs in their lives?
3 Is the material free from terms and images that might be felt to be insulting and/or
degrading by people of certain cultural groups?
4 Is the role of females and their impact on society adequately presented in the
instructional learning material?
5 Is the material presented from a standpoint of multicultural or intercultural
diversity?
6 Does it provide a balanced representation of various cultural groups in the
country?
7 Does the instructional material present cultural and racial groups in such a way
that it will boost mutual understanding and respect?
8 Does the instructional material provide a variety of experiences that will help
develop positive attitudes towards one's own group and acceptance of other
cultural groups?
9 Are the illustrations in the material realistic and accurate?
5.6 Assessment and examination guidelines
Revise your second-year study guide on assessment. Remember that assessment

strategies must be appropriate to the assessment standards to be assessed, and that
all students must clearly understand the purpose of the assessment. A major difficulty
associated with student assessment in multicultural health care institutions is that
most traditional tests are culturally biased against the non-English-speaking student.
These students are often perceived to be poor achievers and the reason for declining
standards.
Multicultural education thus implies using assessment strategies that are non-discriminatory.
This does present a problem, however, since there is little consensus on what constitutes non-
discriminatory assessment. In terms of informal educator-constructed class tests, cultural bias
can be reduced if educators have sufficient information about the languages and cultures of the
HSE3701/1 109
students. The educator can acquire this valuable information by doing a culturalogical
assessment with each student prior to the commencement of a semester.
Multicultural education also requires a more flexible, creative and innovative approach to
assessment. Educators should use a variety of strategies that include written and oral tests as
well as observation strategies. Furthermore, written tests should have an appropriate reading
level in terms of the complexity of the sentences, vocabulary and concepts (especially with
first-year health care students). Test items should also reflect the diversity of cultures and take
into consideration the students' life world. Finally, tests and examinations should be
continually monitored for racial, gender and social bias.
5.34
After revising your second-year study guide on assessment, and the above paragraph,
do the following:
1 Describe the types of assessments that are mentioned.

2 Describe the obstacles that you will identify in tests, now that you have studied
this module.
3 Describe observation as an assessment method. For example, some of the
following points about this type of assessment:
& The use of checklists. These can be developed to focus on specific skills and
behaviours. They provide educators with direction and guidance that can
help to reduce subjectivity and inaccuracy.
& Videotapes. Educators can record students' behaviour, performance and

interaction with other students. Videos can be useful for helping students to
review and criticise their own performance.
& Anecdotal records. Recording specific situations, conversations, interaction
behaviours or events can provide a rich source of information. Care should
be taken to record information regularly, accurately and sensitively. One way
of using so is by using index cards. In a class of about 50 students,
information should be recorded at least once a month.
4 Furthermore, write down the assessment guidelines you would use in your
classroom. You may have thought of the following (Lemmer, Meier & Van Wyk
2006:105±106):
& Use a variety of assessment techniques.
& Use observation, an important assessment technique.
& Use oral and open-book quizzes.
& Have students assess one another.

& Ask students to assist you to set assessment questions.
& Make use of frequent tests than a big test at the end of a semester.
110
& Make time for students to feel free to clarify and understand the assessment
questions.
& Provide meaningful and constructive feedback after each assessment.
5.7 Developing multicultural lesson plans

Revise the development of lesson plans in your second-year study guides. Multicultural
lessons contain the same guidelines as any other lesson. However, multicultural lessons are
based on the underlying assumptions and goals of multicultural education, as we have
discussed.
Although there are various approaches to planning a lesion, Bennett (Lemmer, Meier & Van
Wyk 2006:107±108,109) identifies the following three steps:
& Step 1. The multicultural curriculum's goals must be known: The goals must be decided
upon and how best they must be achieved.
& Step 2. Identify outcomes for student learning: Both educator and student must know
what is expected, what must be achieved. The outcomes must be specific and attainable.
& Step 3: Write the lesson plan: When writing the lesson plan the following will be set as
guidelines to be considered:
± The nature of the student: The level of the student, the knowledge and skills of the
student, interests, values, beliefs, learning styles, self-image, motivation level,
previous education experiences and social background
± The educator's knowledge: What are the key concepts, skills and knowledge to be
taught? What are the important connections between goals of multicultural
education and the subject matter? What resources are available?
± Statement of multicultural goals: What goals does the educator wish to achieve in
the lesson or series of lessons?
± Student learning outcomes: What does the educator hope the student will gain
from the lesson?
± Lesson opener: How will the educator introduce the lesson? What pre-knowledge
does the educator expect the student to have?
± Teaching strategies and activities: Which teaching strategy will be chosen for the
lesson( eg small group discussion, reading, films, field trip, story telling,
cooperative learning)? What examples will the educator present? Do the examples
reflect the real world, the world of the student and will they be appropriate? How
will you check students' understanding? Which activities will the educator use for
the lesson?
± Materials: What equipment and resources will be used?
± Assessment: Which assessment strategies will the educator use to attain the
outcomes of the lesson? How will the educator check for student understanding?
How will the educator know whether the outcomes have been attained?
Note: When considering the content of the lesson for a culturally diverse classroom, it is
HSE3701/1 111
important to provide the content in such a manner that any student from any cultural
group will be able to identify with the content.
5.35
Study and familiarise yourself with the following topics in your prescribed book
(Andrews & Boyle 2003):
& pain
& HIV/AIDS
& TB
& any STIs
& contraception
& labour
& cancer
You will also be able to study these topics in Helman (2007). You may be asked to
write about these topics in an assignment or in the examination.
5.8 Conclusion
In this module we attempted to provide you with some guidelines to use when teaching a
culturally diverse group of students.
There is so much information on this subject; however, because of the time constraints of a 12-
credit module, we have tried to cover the main topics. These studies will guide you in your
preparation as an educator who knows your students and knows how to teach in a multicultural
environment.
We hope that you found this module challenging and that you will find the time to do some
extra reading on each topic.
112
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Multicultural education is an approach to education which aims at taking account of the

Purpose of the module

This module deals with the following issues.

As stated earlier, this module is structured according to Campinha-Bacote's (1996) adapted

Culturally competent nursing care

This symbol indicates feedback on the activity. It may be reinforcement of information

After having worked through this module you should be able to

& describe the foundations of transcultural nursing

Composition of the study package

The recommended learning process

Assessment of the module

Prescribed reading for this module

Recommended reading for this module

Campinha-Bacote, J, Yahle T & Langenkamp, M. 1996.The challenge of Cultural Diversity for

1.2 Leininger's theory: culture care diversity and universality

Leininger's theory highlights the importance of teaching students how to render

Principles to teach students are

Principles to apply in the teaching-learning environment:

1.4 Giger and Davidhizar's cultural assessment model

You could have included points such as exposing students to self-knowledge

1.5 Campinha-Bacote's model

Role of the educator/student:

(1) Educator available, caring, respectful

(1) Democratic, caring

(1) Problem-based learning

(1) Problem-based approach

1.7 Cultural competence

& eating habits

& famous members

1.9 Self-testing questions

Prescribed reading material

Recommended reading material

& demonstrate ability to apply cultural awareness in your teaching practices

2.2 Intercultural communication

According to Giger and Davidhizar (2004:22), health professionals require a thorough

2.3 The process of communication

2.4 Verbal and nonverbal communication

2.4.1 Verbal communication

2.4.2 Nonverbal communication

2.7 Social class

2.10 Self-testing questions

Prescribed reading material

Recommended reading material

& cultural awareness

We view values clarification as a major strategy in helping us to become multiculturally aware.

3.2 Cultural sensitivity and awareness

Analyse your own cultural sensitivity by doing the following activity.

The presence of students/patients from multicultural backgrounds is a source of potential

3.5 Race and racism

Asian people tend to ..

I am reluctant to talk to foreigners because ..

I feel ................................................................................................. toward black men.

Alcoholics deserve ................................................................................. in my opinion.

BMW drivers make me .............................................................................................................

Gays should be .........................................................................................................................

The ANC is ................................................................................................................................

I believe the Sotho people are ..................................................................................................

I feel the AWB caused ..............................................................................................................

Hairdressers are ........................................................................................................................

3.7 Cultural imposition