Tutor Notes
Module ONE – Introduction to Cultural Diversity – TUTOR NOTES
Aim:
To explore the interaction between culture and health, and the influence culture has on the identity and health beliefs of both patients and health care providers.
Primary Learning Objectives/Outcomes:
On completion of Module One, students will be able to
- reflect upon their own culture and describe how culture influences health and health beliefs;
- describe the health impacts of cultural assumptions and stereotyping;
- explain the rationale for cultural sensitivity;
- explain the meaning of culture and diversity within cultures including workplace or organisational cultures; and
- practise effective communication using Kleinman's explanatory model of Illness.
Activity One – Introductory activities
Tutor note - Activity One (5 minutes)Open the tutorial with brief introductions including your own professional and cultural background.
Set any ground rules you would like for the group e.g. listening respectfully, acknowledging that different values and assumptions will exist in the group, and that we all bring our own cultural perspective.
Explain about how this session will run (using simulated patient or video presentations).
Identify the aims and learning outcomes for the session. Explain that after some discussion and preparation students will have a chance to interview a culturally diverse simulated patient if this option is chosen.
Activity Two – Cultural influences on health
Definitions of culture and the influence of culture and life experiences on an individual's health belief system will briefly be discussed.
Tutor note –Activity Two (5 minutes)Briefly discuss the definition of culture, and describe how various cultural identities such as age, gender, SES status, ethnicity and sexual orientation are associated with significant health inequalities. Consider the following:
- Oxford Dictionary Online - ‘the ideas, customs, and social behaviour of a particular people or society’
- wiki.answers.com - ‘Culture has many meanings. Culture can be a way of life for someone, or it can be a person's background, or it can simply be many different nationalities coming together as one community.’
- ‘Culture provides people with ways to make sense out of life, aiding in imposing meaning on thoughts, behaviours and events, and allowing us to make assumptions about life and how it ought to be led.’ (Chrisman, 1991)
Activity Three - Influences of culture on health beliefs
"Illness is culturally shaped in the sense that how we perceive, experience, and cope with disease is based on our explanations of sickness, explanations specific to the social positions we occupy and systems of meaning we employ." (Kleinman, 1978) Discuss.
Tutor Notes - Activity Three (10 mins)Ask students to suggest different ways culture can influence our health beliefs. Examples may include
- attitudes about medical care;
- ability to understand, manage, and cope with illness;
- ability to understand a diagnosis, and the consequences of medical treatment;
- roles and expectations of the patient, carer and family;
- how much information about illness and treatment is desired;
- how death and dying will be managed;
- bereavement patterns;
- processes for decision making.
Activity Four –Kleinman's Explanatory Model of Illness
Explanatory models are a useful concept to assist health providers and patients to reach a common understanding of the ways that culture can influence health.
“Eliciting the patient’s (explanatory) model gives the physician knowledge of the beliefs the patient holds about his illness, the personal and social meaning he attaches to his disorder, his expectations about what will happen to him and what the doctor will do, and his own therapeutic goals.”
Kleinman, A. Conflicting Explanatory Models in the Care of the Chronically Ill (Chapter 7). In: The Illness Narratives: Suffering, Healing and the Human Condition. 1988. Basic Books, New York.
Kleinman’s Explanatory Model of Illness- What do you think has caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to you? How does it work?
- How severe is your sickness? Will it have a short or long course?
- What kind of treatment do you think you should receive?
- What are the most important results you hope to receive from this treatment?
- What are the chief problems your sickness has caused for you?
- What do you fear most about your sickness?
Tutor Notes - Activity Four (10 mins)
Introduce and ask students to read the Kleinman quotation. Pose questions such as:
Do patients spontaneously tell us about their belief systems, the meanings they attach to their illness? Any examples?
If not, why not? How can we facilitate this discussion?
Has anyone ever asked a patient about this? If so, how did it go?
Activity Five - What are my own health beliefs?
Use the Kleinman's questions to explore with one another our own health belief systems.
Tutor note - Activity Five(20 minutes)Discuss the different explanatory models of patients, carers and practitioners. Ask students how these differences might hamper effective communication between practitioners and patients.
Ask students what they notice about the Kleinman's questions? They are all open questions. What are the pros and cons of open questions and closed questions?
Role play
Students will now use peer role-play to rehearse using the Kleinman's questions with one another to explore their own health beliefs.
Ask students to get into pairs to do the peer role-play. One student will interview the other about a health issue that is influenced by culture for about 5 minutes, then they will swap over. They may use their own experiences or those of their families and friends. Remind students to observe privacy and confidentiality.
If there is enough time, ask each pair to share one key point they learnt with the larger group.
Activity Six– Interview with a simulated patient
Students will be introduced to the simulated patient and asked to conduct an interview regarding why they are attending the health service today. Students will try using the Kleinman's questions or variations of them.
Tutor note – Activity Six (15 minutes)Provide ground rules for the simulation and describe the role of the interviewer and purpose of the interview, which is to sensitively explore the issues.
Explain that the interview will be conducted as a ‘fish bowl’, where a series of students will move in and out of the interviewer’s chair and continue the interview where the previous student left off.
Explain that you will call a “timeout” during the interview where you can pause and discuss the process and information and where the student group can determine and suggest alternate methods to progress the interview.Explain that the simulated patient will remain in role throughout the interview, and that there will be plenty of time for further discussion and feedback about the interview after it finishes.
Introduce the simulated patient and the setting:
One of five possible cases:
- Case 1A patient with asthma and magico-spiritual health belief
- Case 2A religious person with end-stage cancer requiring palliative care
- Case 3An Asian patient with diabetes
- Case 4An international student with acute abdominal pain
- Case 5A non-English speaking mother requiring support with parenting
Activity Seven – Debriefing
Students will have a chance to discuss what went well and the challenges for them after the interview. Students will also hear from the simulated patient about their perspective of the interview, ask questions and reflect on the use of the Kleinman's questions.
Tutor note – Activity Seven (15-25 minutes)Your role is to facilitate a safe environment in which students can talk about the interview openly, receive positive feedback and feedback on areas for improvement. It is also to direct questions to the simulated patient, who will come out of role for this debriefing.
Ask students to consider whether the Kleinman questions were useful.
Close the session by summarising the key points raised and encouraging students to feel confident to explore culturally sensitive issues with patients. Direct students to the list of resources at the end of their session notes outline.
Hand out the post session evaluation form and collect before the students leave the room.
Resources and Extra Reading
•Centre for Culture, Ethnicity and Health. Tip Sheet 'Cultural considerations in health assessment'. Available from
•Kleinman, A. Conflicting Explanatory Models in the Care of the Chronically Ill (Cahpter 7). In: The Illness Narratives: Suffering, Healing and the Human Condition. 1988. Basic Books, New York.
•Holland, K. Culture, race and ethnicity: exploring the concepts (Chapter 1). In: Holland K, Hogg C. Cultural Awareness in Nursing and Health Care: An Introductory Text. Second Edition 2010. Arnold, London.
•Queensland Health. Five Cross Cultural Capabilities for clinical staff. Available from
•Royal Australian College of General Practitioner. Multicultural Health. 2011. Available from
•Kljakovic M. How cultural differences impact on my consultations. NZ Family Physician. 2004 (Oct); 31(5):294-6. Available from
1