Title Page
Copyright Page
Foreword
Preface
Advisors
Acknowledgement
Section 1 Diversity, Cultural Considerations and Definitions
Aim
Outcome
Introduction
Cultures and Cultural Considerations
Families
Diversity
Definitions
Diseases Prevalent in New Immigrants from Resource-Poor Areas
The Immigrant and Acculturation
The First Phase
The Second Phase
The Third Phase
Disparities in Health and Determinants of Health
Oral Health in Minority Groups
Oral Health Beliefs
Oral Health Practices
Oral and Dental Health
Lifestyle Habits Affecting Oral Health
Chewing products
Lifestyle Habits Implicated in Cancer
Tobacco
Alcohol
Ethnic differences in cancer and cancer care
Traditional Practices Affecting Oral Health
Hard-tissue mutilation
Soft-tissue mutilation
Traditional Healing
Disparities in Oral Healthcare of Minority Groups
Barriers to Oral Healthcare
Effects of Acculturation
Addressing Disparities in Healthcare
Addressing Disparities in Oral Health
Culturally Sensitive Healthcare
Cultures — Recognising without Stereotyping
Healthcare Values in Different Cultures
Cultural Assessment
Communicating
Greeting Patients
Notions of Modesty
Touching Patients
Interpreting
Taking a Culturally Sensitive History
Sensitive Issues in the History
Examination
Investigations, Therapy and Prognostication
Patient Information
Concerns about Healthcare Products
Commonly Used Agents of Animal Derivation
Haemostatic Agents
Establishing if a Drug is of Animal Origin
Oral Healthcare Products that may Contain Culturally Unacceptable Materials
Mouthwashes
Dentifrices (toothpastes)
Artificial salivas
Other products that might contain animal derivatives
Facilities
Relevant Websites
Section 2 Religions and Faiths
Aim
Outcome
Overview
Religions and Faiths
Non-Believers
Agnosticism
Atheism
Non-Believers and Healthcare
Religions (Faiths)
African Religions
Background
Beliefs
Main Religious Days
Dietary and other Habits and Restrictions
Main Languages
Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Bahá’í Faith
Background
Beliefs
Worship
Holy Days and Festivals
Dietary and other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing traditions
Oral Healthcare Issues
Relevant Website
Buddhism
Background
Beliefs
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Christianity
Background
Beliefs
Culture
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Adventism
Background
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Christian Scientists
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Jehovah’s Witnesses
Beliefs
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Mormonism (Church of Jesus Christ of Latter-day Saints)
Background
Beliefs
Worship
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Pentacostalism
Holy Days and Festivals
Dietary Restrictions and Habits
Catholicism (Roman Catholicism)
Background
Beliefs
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Confucianism
Background
Beliefs
Holy Days and Festivals
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Falun Dafa and Falun Gong
Background
Beliefs
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Hinduism
Background
Beliefs
Worship
Culture
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Islam
Background
Beliefs
Culture
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Jainism
Background
Beliefs
Culture
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Judaism
Background
Beliefs
Orthodox Judaism
Reform/Liberal/Progressive Movements
Culture
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Paganism
Background
Beliefs
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Rastafarianism
Background
Beliefs
Culture
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Shintoism
Background
Beliefs
Holy Days and Festivals
Culture
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Sikhism
Background
Beliefs
Culture
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Websites
Taoism
Background
Beliefs
Main languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Zoroastrianism
Background
Beliefs
Culture
Worship
Holy Days and Festivals
Dietary and Other Habits and Restrictions
Main Languages
Ideas of Modesty
Attitudes to Healthcare Professionals
Health and Healing Traditions
Oral Healthcare Issues
Relevant Website
Section 3 Cultural Groups
Aim
Outcome
Overview
Cultural Groups
Africans
History
Population
Religions
Languages
Culture
Greetings
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Arabs
Terminology
Arab countries
History
Religion
Languages
Culture
Greetings
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Australasians
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Caribbeans (West Indians)
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Central Asians
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues (see Islam)
Chinese
Countries
History
Population
Religions
Festivals
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Traditional Chinese Medicine (TCM)
Oral Healthcare Issues
East Asians
Europeans
Countries
History
Population
Religions
Languages
Culture
Southern Europe
Northern Europe
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Filipinos
History
Population
Religions
Languages
Culture
Greetings
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Japanese
History
Population
Religions
Languages
Culture
Greetings
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Kurds
Countries
History
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Latin Americans
Terminology
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
North Americans
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Roma/Gypsies
Countries
History
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
South Asians
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
South East Asians
Countries
History
Population
Religions
Languages
Culture
Dietary and Other Habits and Restrictions
Health and Healing Traditions
Oral Healthcare Issues
Cultures and Countries
Websites and Further Reading
Further Reading
Quintessentials of Dental Practice – 35
General Dentistry – 1
British Library Cataloguing-in Publication Data
Scully, Crispian
Culturally sensitive oral healthcare. - (Quintessentials of dental of dental practice; 35. Clinical practice; 1)
1. Dentistry - Social aspects - Great Britian 2. Dentistry - Religious aspect 3. Minorities - Dental care - Great Britian
I. Title II. Wilson, Nairn H.F.
617.6’0089’00941
ISBN 1850973369
The authors and publishers and all those otherwise involved in preparation and publication of this book consider all people to be equal irrespective of race, colour, ethnic origin, religion, beliefs, culture practices, citizenship, age, gender, socioeconomic and family circumstances, disability and any other related factors, and would wish through this book to encourage and promote, rather than in any way detract from equality. Should for any reason any omission, mistake or failure in any part of this book give the wrong impression or cause misunderstanding, the authors and publishers would wish to unreservedly apologise and assure readers that no offence is intended.
Copyright © 2006 Quintessence Publishing Co. Ltd., London
All rights reserved. This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without the written permission of the publisher.
ISBN 1-85097-336-9
A striking feature of health in contemporary Britain is the diversity among different ethnic groups. Cultural differences may be important in risk of disease. They are also important in contacts with the healthcare system: no less for oral disease than for other health problems. An understanding of the culture of patients, and of differences between healthcare provider and recipient, is vital for quality healthcare that meets people’s needs. This book is, therefore, timely and necessary and much to be welcomed.
Professor Sir Michael Marmot KBE
MBBS, MPH, PhD, FRCP, FFPHM
Director, International Centre for Health and Society
Professor of Epidemiology and Public Health, University College London
Chairman, Commission on Social Determinants of Health
Dentists and dental care professionals (DCPs) may work in countries foreign to them, or provide care to refugees or other patients who have immigrated into their country of work. History shows centuries of conflict and the movement of populations in many, if not most parts of the world. Colonisation and subsequent decolonisation, wars, natural disasters, competition for limited resources and the natural desire of human beings to explore new worlds, have resulted in enormous changes, especially in recent times. There is scarcely a country that has been exempt from such changes and, even in the 21st century, conflicts and disasters seem set to continue, with the likelihood of further population shifts and more immigration into countries that provide a safe haven. The world is also shrinking, with globalisation following tremendous technological advances, facilitating travel and communication. Most countries, in particular the so-called developed countries, are thus becoming increasingly culturally, ethnically and racially diverse. This trend is certain to continue and probably to escalate. The many diverse people of the world are thus now widely distributed, living in either fully integrated or multicultural societies. Similarly, people travel widely, with increasing exposure to other cultures.
Modern healthcare delivery demands that the religious, cultural and ethical beliefs of patients be considered as a part of their treatment. There is therefore an increasing need to understand other cultures. Culture is a term used to refer to shared patterns, meanings and behaviours of a social group. Understanding and respecting differing cultures, religions, ethnicities and values within society is increasingly recognised as critical to good quality healthcare provision. All healthcare providers (HCPs), including dentists and dental care professionals (DCPs), increasingly need to understand the culture of their patient. Some HCPs have been tardy in appreciating the importance and the improved quality of care that comes from patient-centred care. Each dental patient is an individual with personal views about their illness. These views may not concur with those of the HCP. Patients have personal wishes, needs and concerns that demand the understanding and respect of the HCP. Patients increasingly and rightly expect to be offered choice, not just about when and where they receive treatment, but also about what kind of treatment they receive, how it will be delivered and by whom. Extending choice is especially important in responding to the needs and preferences of an increasingly diverse population. Also, it is increasingly recognised that involving patients as full partners in decisions about treatment leads to better health outcomes. Many studies have shown that patients’ attitudes to the benefits and risks of treatment, and the extent to which they find adverse effects tolerable, can differ markedly from assumptions made by HCPs. Patients’ beliefs and views are key influences as to whether and how they accept treatment. Patients are generally much more likely to complete treatment if their views and preferences have been recognised and taken into account, and they have been active partners in decisions. Client-centred, contemporary dental practice will be realised only if clinicians are equipped to interact with and provide care for clients of varied cultures and cultural backgrounds.
We work in a multicultural society. For example, in 2006 in London, about 300 languages were spoken, and more than one in three of the population was from minority ethnic populations. There are now more new registered dentists in the UK who have qualified overseas than there are those who have qualified in the UK and, furthermore, many of the latter are not of Anglo-Saxon British culture. Few places in the world are as religiously, ethnically and culturally diverse as the UK. Experience in London and other centres, reinforced by teaching and working with colleagues from a multitude of backgrounds, has made us particularly aware of the need for formal guidance for dentists and dental care professionals (DCPs). This need extends to dentists and DCPs from many different cultures. Despite this, there still appears to be a need for more formal information for dentists and DCPs.
We have attempted to address this need by developing this book to provide members of the dental team with a reference source to culturally sensitive care in everyday clinical practice. This is not a text about technical dentistry. Neither is this book intended to cover the orofacial problems that can affect people of various cultures and lifestyles, although they are mentioned where relevant. This book is about patient care.
The knowledge base to be culturally sensitive is enormous. Lists of cultural traits and religious customs and beliefs can help, but inevitably give a very false impression of uniformity. Thus, in making reference to such lists, it is crucial to remember that there is considerable variation within every cultural and religious group and to avoid stereotyping. The information given applies only to certain patients. It is not a recipe for all solutions: we simply provide guidelines as a starting point for individualising dental healthcare. Individuals’ views, practices, needs and wishes vary widely and can be influenced by religion, ethnicity, educational, socioeconomic, acculturational and other factors.
This book is presented in three sections. The first section covers the many aspects of culturally sensitive healthcare, the second section outlines features of various religions and faiths and the third discusses cultural groups. In the second and third sections, topics have been arranged alphabetically for convenience. We do not attempt to be comprehensive. Cross-referencing has been essential.
We have been strongly influenced by the excellent works of Michael Marmot, Alix Henley and Judith Schott, and by Raman Bedi, and must pay tribute to their ideals and efforts. We have also sought advice from advisors who have been listed. We are grateful to all for their comments. We are particularly grateful to Arun Haricharan, who works in the community providing oral healthcare to a wide range of peoples, for his generous reading and criticism of the text. We are also grateful to John Huw Evans for his diligence in checking the various websites for the latest URLs (accessed October 2005). We, however remain responsible for any errors. Indeed, we are acutely aware that, despite our efforts to the contrary, what we have written could be regarded by some as incorrect, or unnecessarily or incorrectly generalising or stereotyping. We have tried throughout to emphasise the enormous diversity in cultures, health beliefs and practices. Individuals may subscribe to all, some or none of these. The only way to provide culturally sensitive healthcare is to listen and be sensitive to each and every patient and, when appropriate, ask about personal needs and wishes.
Individual interpretations of religions and the influence of cultural practices means there are no universal healthcare practices and beliefs in any religion or culture. Assumptions are no alternative to seeking and respecting the wishes of individual patients.
Although we are based in the United Kingdom, we hope that our efforts will help improve culturally sensitive oral healthcare worldwide.
Crispian Scully
Nairn Wilson
London, 2006
Advisor | Affiliation | Topics |
Oslei paes de Almeida | University of Campinas, Brazil | Latin Americans |
Tereza Belai | Eastman Dental Institute London, UK |
Eritreans Ethiopeans |
Toshio Deguchi | Matsumoto Dental University Japan |
Japanese |
Andrew Eder | Eastman Dental Institute London, UK |
Judaism |
Mohammed El-Maaytah | Eastman Dental Institute London, UK |
Arabs Islam |
Channa Jayasena | The Hammersmith Hospital London, UK |
Jainism Indians |
Navdeep Kumar | Eastman Dental Institute London, UK |
Indians Sikhism |
Rachel Leeson | Eastman Dental Institute London, UK |
Christianity |
Serdar Mutlu | Istanbul University, Turkey | Kurds Turks |
Yuan-ling (Paula) Ng | Eastman Dental Institute London, UK |
Buddhism Chinese Confucianism Taoism |
Mohammed Maryoud | Eastman Dental Institute London, UK |
Islam Somalis |
Naresh Pindolia | Eastman Dental Institute London, UK |
Hinduism Indians Jainism |
Cynthia Pine | University of Liverpool, UK | Caribbeans |
Rene Ponciano | Eastman Dental Institute London, UK |
Filipinos |
Keith Shear | University of Birmingham, UK | Africans African religions |
Mervyn Shear | University of the Western Cape South Africa |
Africans African religions |
Prasanna Sooriakumaran | Royal Surrey County Hospital Guildford, UK |
Hinduism Indians |
David Wiesenfeld | Royal Melbourne Hospital Australia |
Australasians |
We are grateful to Taylor & Francis Publishers (London) and to Drs Scully, Flint, Porter and Moos, for permission to reproduce some illustrations from their Atlas of Oral and Maxillofacial Diseases (2004).
The aim of this section is to offer an overview of aspects of culturally sensitive healthcare, with an emphasis on culturally sensitive oral healthcare provision.
Having read this section, readers should be more aware of the immediate steps needed to make their patient management more culturally sensitive, before exploring the religious, cultural and other aspects of healthcare dealt with in more depth in subsequent sections.
Many areas of the world are short of resources, and this applies especially to the tropics, and areas fraught by natural and man-made disasters. Difficult environments, inadequate nutrition and insufficient healthcare are common in resource-poor areas, leading to enumerable health and other problems. The fact that there are disparities in health between different ethnic, cultural or other groups is not new.
Culture (Latin colere; to inhabit, to cultivate, or to honour) is a term that refers to patterns of human activity and the symbolic structures that give such activity significance. Culture can be seen as consisting of three elements:
Values – comprise ideas about what seems important and guides the rest of the culture.
Norms – consist of expectations of how people should behave in different situations. Each culture has different methods, sanctions, of enforcing its norms, which vary with their importance. Norms that a society enforces formally have the status of laws.
Artifacts – things, or material culture, which derive from the culture’s values and norms.
Cultures can differ in a number of ways. Cultural differences are based on combinations of values, norms and artifacts. This has many implications for healthcare.
Cultures are often based on some sort of religion or faith, or similar basis developed for inculcating and preserving established or ‘correct’ cultural behaviour. Groups of immigrants, exiles or minorities often form cultural associations or clubs to preserve their own cultural roots in the face of a surrounding (generally more locally-dominant) culture. On a broader scale, many countries market their cultural heritage internationally, both in the promotion of tourism and in cultural development abroad.
Cultural changes can and do occur – in particular in response to the environment (including education and socioeconomic status), to inventions (and other internal influences), and to contact with other cultures. When this affects an individual or groups of people, it is often termed ‘acculturation’.
Multicultural societies are now common in many parts of the world, with increasing numbers of immigrants and their families seeking local access to culturally sensitive routine oral healthcare provision (Fig 1-1).
In addition, the healthcare professions have become much more multicultural, given increasing numbers graduates from different cultures and backgrounds, with many being more aware of religious and cultural issues than some older members of the professions. It is clear that healthcare professionals in a multicultural society must function across cultural divides.
The health manifestations of culture are significant and determine patient behaviours. Immigration is not a new phenomenon and is unlikely to cease. Migrants from diverse social, economic and educational backgrounds arrive in other countries for a variety of reasons. Many are refugees fleeing war, political upheaval, persecution, natural disasters or deprivation in their home countries. Some are joining families from which they have been separated for years. Yet others come seeking education or financial advantage, or to provide or seek work. Evidence suggests that the desire or need to emigrate from various places around the world is unlikely to diminish (Fig 1-2).
Many immigrants arrive with inadequate economical support and language skills and tend to suffer social exclusion and inequality of healthcare provision. In many countries there is inequality of healthcare provision to a minority of the population who are the most deprived and socially excluded: this minority is often related to ethnic or cultural differences.
Cultural considerations in oral healthcare are increasingly important. As in healthcare in general, dentists and dental care professionals (DCPs) are increasingly expected to be familiar with ethnic, cultural and religious issues that impact on healthcare provision, and to be willing and able to treat patients belonging to different religious and ethnic groups in ways that will not cause embarrassment, let alone distress through breaches of religious and ethnic groups’ taboos. Dentists and DCPs may work in countries foreign to them, or provide care to patients who have immigrated into their country of work. In either case, it is important for the dentist and DCP to understand and recognise the culture of patients. Most members of the dental team work in their home countries and will have experienced interactions with new immigrants, those who have acculturated, and individuals who are descendants of people who may have immigrated some time ago.
In many societies, it is suggested that the need for culturally sensitive oral healthcare provision has traditionally tended to be relatively limited or ignored, with relatively small numbers of patients in religious and ethnic minority groups having tended to seek dental and related oral healthcare from HCPs within their group. This may have involved a number of barriers such as cost, fear, mistrust, the need to travel long distances at inconvenient times, or the absence of dental HCPs able and willing to accommodate specific cultural and ethnic needs. The exception is hospital-based and salaried dental services, which individuals of all religious and ethnic groups tend to access for emergency and possibly specialist care. Culturally sensitive healthcare is a phrase used to describe a healthcare system that, in addition to being accessible, respects the beliefs, attitudes and cultural lifestyles both of the patient and, as a consequence, is sensitive to issues including culture, race, gender, sexual orientation, social class and economic situation. At the most simple level, it is easy to offend by asking for a ‘Christian’ name (from someone who may not be Christian) rather than a ‘personal’ (‘first’) name.
Cultural competency is the understanding that we all have different values that affect the way we view our health and healthcare, and how we view the world. It implies the ability to successfully navigate through other cultures while understanding, appreciating, making comparisons to, and moving beyond stereotypes, while remaining sensitive to one’s own cultural elements and those of other persons. The goal is to provide the best care possible to each individual patient. Culturally competent care requires more than simply a knowledge of other cultures; it involves attitudes and skills as well.
Once attuned to the cultural beliefs of the patient, the healthcare professional can become a more effective HCP, and a more positive health advocate. Thus healthcare is offered in a way that respects and recognises different religions and cultural needs.
In Anglo-American cultures there is a high proportion of nuclear families and, increasingly, lone-parent families and families in which parents live together but are not married, including some single-sex families. Independence is a characteristic of these cultures.
The family structure is a significant feature of cultures where the extended family is more common than the nuclear family. In extended families, the elders act as role models, are in control, and are respected. Often the family decides where to seek healthcare, whether this be from a HCP, a traditional healer, or even a neighbour. They also may decide whether to comply with appointments and accept medication and other treatments.
The perceived advantages and disadvantages of different family systems are highlighted in Table 1-1.
Perceptions | Extended families | Nuclear families |
Features | Strong family, higher social control, lower individualism. | Weak family, lower social control, higher individualism. |
Healthcare decision-making | Often by older male, more educated family member, or more wealthy family member | Often by individual. Parent spouse or partner may be consulted by the individual. |
Advantages | Limited involvement in aberrant behaviour. Strong family support. Infrequent loneliness. | Less conformation. More freedom. |
Disadvantages | Less freedom. More conformation. | Tendency to aberrant behaviour. Less family support. Frequent loneliness. |
It is important to be aware of the various possibilities in a specific culture. But it is equally important to recognise that individuals within a culture may not conform to the cultural norms, in particular if living in a different country or community and if they have undergone acculturation.
Populations are diverse, and are becoming increasingly more diverse in many, if not most, countries. Section 3 of this book gives a broad outline of the various cultural groups of the world, highlighting diversity in and between most countries, in particular the developed countries of the world. Diversity extends beyond the colour of a person’s skin and religion to age, socio-economic status, sexual orientation, gender identification and lifestyle differences. Thus, there is both visible and invisible diversity (Fig 1-3). Furthermore, diversity may decrease or even increase in immigrant populations as they acculturate in the dominant culture of their host country (Fig 1-4).
Cultural, religious and healthcare views can be diverse and can also be difficult to interpret and can change. Frequently, the level of devotion and adherence to a cultural or religious practice will vary between patients and over time, depending on factors such as age, events and circumstances. The view of a specific cultural or religious group may also differ, depending on the denomination or sect, the leader in a particular area and other powerful influences, including education and socio-economic status.
In view of the enormous diversity in cultures, religions and faiths, and health beliefs and practices, it is not possible to discuss these here from the traditional perspective as seen in the home country. Individuals may subscribe to all, some or none. The only way to provide culturally sensitive healthcare is to be aware, listen and be sensitive to each and every patient and, when appropriate, ask about personal needs and wishes. Assumptions are no alternative to seeking and respecting the wishes of individual patients.
The debate on terminology pertinent to diversity and equality is constantly evolving. Some of the more common terms are noted above, but others include the following: