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Intercultural Differences
504
Key Words Culture, upbringing, symbols, heroes, rituals, values.
by Niels G Noorderhaven
Intercultural Differences Consequences for the Physical Therapy Profession
Summary Cultural differences have a bearing on health and can influence the effectiveness of treatment. It is possible to compare different cultures using the criteria of power distance, Individualism collectivism, masculinity-femininity and uncertainty avoidance.
Background According to Moliere, the French 17th century playwright, there is a sort of decency among the dead, a remarkable discretion: you never find them making any complaint against the doctor who killed them! Physical therapists may be assumed to have harder times, as more of their patients survive. So the physical therapist must work hard to give the best possible care to his or her clients. In doing so, the physical therapist has to take into account not only the specifics of the physical problem, but also the expectations and preferences of the client with regard to the way he or she per forms his or her professional role. These preferences and expectations are influenced, among other things, by culture. Cultural differences are becoming more and more relevant, in general as well as to health care professionals, for two reasons. First, the world is becoming smaller and smaller, and we become more and more ardent travellers. Physical therapists increasingly work in countries other than their own, either permanently or temporarily. Secondly, even if people do not go out into the world, the world is coming to them. Increasing international migration brings the world of cultural differences into our own countries. For example, in the USA nowadays more than one out of four Americans identify themselves as AfricanAmerican, Hispanic, Native American, Asian Noorderhaven, N G (1999). or Pacific Islander (US Census, 1990). ‘Intercultural differences: The process of globalisation makes Consequences for the interactions between people from different physical therapy countries and cultures more intense, but it profession’, Physiotherapy, would be naive to think that as a result these 85, 9, 504-510. Physiotherapy September 1999/vol 85/no 9
differences will automatically become smaller. Superficially, people from different cultures may appear to become more and more alike. The proverbial youth in Karachi or Shanghai sipping from a can of coke while listening to pop music may look deceptively like his contemporaries in Detroit or Amsterdam. But similarities on the outside may hide differences at deeper levels. As a matter of fact, contacts between cultures sometimes make cultural differences more pronounced, as people tend to become aware of their own cultural identity more intensely when they meet with other cultures. When talking about cultures, it is useful to distinguish different levels (Hofstede, 1991, pages 7-9). At the most superficial level, we find symbols (see figure). These are words, gestures, pictures or objects that carry a particular meaning. Examples are flags, hairstyles, or a jargon specific to a certain
Symbols Heroes Rituals Values
Layers of culture (adapted from Hofstede, 1991, page 9)
Professional articles
group, for instance an age group. Coca Cola to many in the world is much more than just a soft drink, it is a symbol of modernity. As we peel the onion of culture, we come to deeper, more fundamental levels. Heroes are persons, alive or dead, real or imaginary, who possess characteristics which are highly prized in a culture. An example of a partly imaginary classical American hero is the pioneer, going West, stretching the frontier to new limits in his struggle against the forces of nature. Japanese cultural heroes are often samurai. An example is provided by the true history of the 47 'ronin', samurai who had become masterless when their lord had been forced to commit suicide. The 47 ronin demonstrate two important values in the Japanese culture. By revenging the death of their master they showed their unquestioning loyalty. But after the revenge, they subjected themselves to the Shogun, demonstrating their respect for the law. At a still deeper level than that of the heroes we find rituals. Rituals are collective activities which are technically superfluous, but which, within a culture, are seen as socially desirable, if not essential. Ways of greeting and paying respect to others, social and religious ceremonies are examples. Professional conferences, at which people gather for face-to-face information exchange are also increasingly assuming a ritual nature in this age of electronic communication. Finally, we come to the deepest level, the core of a culture: values which are shared within a society. Values are broad tendencies to prefer certain states of affairs over others. They tell us what is evil and what is good, what is dirty and what clean, ugly and beautiful, unnatural and natural, abnormal and normal, paradoxical and logical, irrational and rational. Values are among the first things people learn. Around the age of ten, most children have their value system firmly in place. However, because they were acquired so early in life, values mostly remain implicit, and even unconscious to those who hold them. They cannot directly be obser ved by outsiders, but only be inferred from the way people act under various circumstances. Values are much more difficult to change than the more superficial levels. Therefore they form the hard core of a culture. Importance of Differences Cultural differences are important for healthcare professionals, including physical therapists, for a number of reasons. First,
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cultural differences have a bearing on health (see for example Bond, 1991). An interesting example is the rate of heart attacks in Japan and the USA. For Japanese living in Japan, the rate is among the lowest in the world, approximately 1.8 per 1,000, The rate is a bit higher for Japanese living in Hawaii, 3.8 per 1,000. But this is still much lower than the rate for US Caucasians, with 9.8 per 1,000. The most interesting observations, which strongly suggest that we are indeed dealing with a cultural phenomenon here, pertain to Japanese living in the USA. The more acculturated (Americanised) Japanese Americans are, the more likely they are to have a heart attack rate similar to that of US Caucasians (Triandis, 1995, page 134). Secondly, cultural differences are important because they can influence the effectiveness of your functioning as a physical therapist in another country, or your cooperation with nationals from other countries. Culture influences the expectations we have of people in particular roles. Many expatriates have found that out the hard way. We may expect other people to be open to our point of view, to understand that we don’t have a ready answer to all questions, to be motivated by a challenging task, but we may be mistaken. Conversely, if we don't live up to the expectations of others, relationships can quickly become very tense, and it may be difficult to change that subsequently. Some examples of the ways in which expectations can clash are given later in this paper. Thirdly, cultural differences have a bearing on the provision of health care, even within one's own country. Those dealing with a culturally diverse clientele are going to encounter understandings of illness, pain, diagnosis, therapy and healing which are quite different from their own (MacLachlan, 1997, page 59). This may cause anxiety in therapists and clients alike, and may seriously hinder effective treatment.
Author and Address for Correspondence Niels G Noorderhaven PhD is director of the Institute for Research on Intercultural Cooperation and professor of international management, Faculty of Economics and Business Administration, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands. This article was presented as a keynote lecture at the World Confederation for Physical Therapy Congress in Japan in May, 1999. It was received by Physiotherapy on June 18, 1999, and accepted on July 30, 1999.
How to Cope Whereas it is undoubtedly important to take cultural differences into consideration, it is not easy. In dealing with cultural differences, one has to navigate between the Scylla of stereotyping and the Charybdis of assuming that group differences are irrelevant. Stereotyping takes place when we over-generalise and think that all Scots are stingy, or that Africans, being always happy, don't get depressed (MacLachlan, 1997, Physiotherapy September 1999/vol 85/no 9
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page 35). However, if in our urge to avoid stereotyping we go to the other extreme, we may end up denying the importance of group characteristics, which means that it becomes very difficult to prepare for intercultural encounters. The opposition between the tendency to over-generalise and the urge to avoid stereotyping is important. Some degree of generalisation is unavoidable if we want to learn about other cultures. We must assume that the ‘average’ Frenchman behaves differently from the ‘average’ Englishman, otherwise it would be pointless to study cultures. Of course, we realise that we will never actually meet this mythical average Frenchman or Briton, but if we do not believe that there are differences in ideas and behaviour between countries, we should abolish the concept of 'national cultures'. However, differences between national cultures have been shown to be significantly related with a plethora of phenomena, including political violence, press freedom, development assistance, nationalism, economic growth, and, as we have seen, health (Hofstede, 1991; MacLachlan, 1997). But to avoid stereotyping, should not everyone just be treated as an individual? Johnette Meadows, of the American Physical Therapy Association, some years ago voiced a strong opinion on this issue. According to her there is no set approach to providing culturally sensitive care, because everybody is an individual. She said: 'I would never attempt to give anybody a book on how to treat an entire race or ethnic group, because that is racist. How do you treat an AfricanAmerican? Well you treat him like a human being, and from there you go where you need to go' (quoted in Federwisch, 1996). Two comments are apposite. First, if we are to discuss culturally sensitive care, we must not confound race and culture. The concepts are entirely different, and I completely agree with Meadows that a book on how to treat people from a specific race would be questionable, if not ridiculous. Culture is about learned, not inherited values and beliefs. But a study of definitions of culture given by health care students in Australia revealed that many were mixing up culture, race and ethnicity. In particular, physical therapy students had a tendency to use relatively exterior concepts, like 'lifestyle' or ‘attitudes’ when describing 'culture', and less often more interior concepts like ‘values’ and ‘beliefs’ (Fitzgerald and Mullavey-O'Byrne, 1996). We should take Physiotherapy September 1999/vol 85/no 9
care not to link culture to rather superficial characteristics of people. The second observation is that regarding everybody as an individual is not necessarily going to help. If the client is an entirely unique individual, we have no idea as to what to do in order to provide the best possible care. As a matter of fact, we may fall in a trap here. By focusing on the unique individual that everyone of us presumably is, we may be enacting our own culture. The emphasis on the uniqueness of the individual is typical for Western cultures, and in particular for the United States. People in the US dislike the suggestion that they are like ‘the average’ American (Triandis, 1995, page 46). This is not necessarily true of people from other countries. My guess would be that many Japanese would not mind that much being likened to the ‘average Japanese’. I think the position recommended by Meadows can be taken as an illustration of the fact that we cannot just step out of our own culture. Our intentions in trying to do so may be excellent, but that does not guarantee a good outcome. ‘Going where you need to go’ is difficult if you have no clue as to the ways in which cultures can differ. For this reason I advocate a position between the extremes of stereotyping on the one hand and of condemning every form of generalisation on the other. Like individual personalities, cultures are unique, if you look closely enough, but also like personalities, cultures can be compared in a number of dimensions, In personality theory we have the ‘Big Five’. In comparing cultures, four dimensions have proven to be exceedingly important. Comparative Measures This section is based on the work of Geert Hofstede, a Dutch social scientist who in the late 60s and early 70s conducted a largescale sur vey in more than 50 national subsidiaries of IBM. All in all, he collected data from over 100,000 respondents. In 1980, after years of analysing these data, he published his book Culture’s Consequences (Hofstede, 1980), which is generally considered a landmark study of national cultures. The analysis showed that a large part of the differences in values between countries can be described in terms of four dimensions. These dimensions are labelled power distance, individualism-collectivism,
Professional articles
masculinity-femininity, and uncer tainty avoidance. They are described with some speculation about the consequences of each dimension for the therapy profession Power Distance Power distance is defined as 'the extent to which the less power ful members of institutions and organisations within a country expect and accept that power is distributed unequally’ (Hofstede, 1991, page 28). Large power distances are found in many Latin countries, for instance Latin American countries. Small power distances for instance exist in the Scandinavian countries. Key differences between small and large power distance societies relate to preferences with regard to inequality and privileges, In small power distance cultures, the general idea is that inequality should be minimised. Some degree of inequality is unavoidable because of the different roles of people in society, but this should be kept to a minimum. In large power distance societies, inequalities between people are seen as not just unavoidable, but even desirable. Hierarchical relations are seen as the very fabric of an orderly society, as in the teachings of Confucius. People in small power distance societies tend to dislike the idea of privileges and status symbols. All should have equal rights, and status differences should not be ostentatious. In large power distance societies power-holders are entitled to privileges, and status symbols are accepted. Let us now speculate briefly about the consequences of differences in power distance for health care professionals, and in particular physical therapists, operating at cultural interfaces. Let us assume that a physical therapist is from a small power distance culture, as in northern Europe or the Anglo-Saxon countries. One thing that he will have to bear in mind when interacting with clients from large power distance countries is that as a health care professional he is likely to be regarded as an authority and treated with respect. This means that it may be difficult for someone coming from a large power distance culture to adjust to the informality of manners preferred in most small power distance countries,. This may create a feeling of confusion and uneasiness in both parties. Another thing to be borne in mind is that in large power distance countries, powerholders tend to be inaccessible to
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those with less power. You can only reach an important person, if at all, through a consecutive series of secretaries and assistants. By the time you reach the big boss, you are assured that your case or request is relevant and legitimate. A health professional originating from a small power distance country may consider all of this nonsense, and make him or herself as directly accessible for everybody as possible. Paradoxically, this may raise an almost insurmountable barrier to those who are used to deal with secretaries and assistants first. Direct access to a person in power can be very frightening. Individualism-Collectivism The second dimension is bipolar: individualism-collectivism. Individualism stands for a society in which the ties between individuals are loose; everyone is expected to look after himself and his immediate family only. Collectivism stands for a society in which people from birth onwards are integrated in strong, cohesive in-groups, which throughout people's lifetime continue to protect them in exchange for unquestioning loyalty. All the Anglo-Saxon countries are strongly individualistic. Most of the continental European countries are also individualistic. The Latin American countries are strongly collectivistic, and this is true for almost all developing countries. In general, the richer the country, the more individualistic the culture of its inhabitants. The causation is from affluence to culture: the richer a country is, the more people have access to resources which allow them ‘to do their own thing’ (Hofstede, 1991, page 76). In poorer countries strong ingroups like the extended family provide an indispensable safety net. Over the last few decades, we have witnessed a world-wide shift towards more individ-ualism. The available evidence, however, indicates that the differences between countries are relatively stable, as even the countries which were already strongly individualistic in the 70s have become even more so since then. In highly individualistic societies, people are motivated by self-actualisation: they feel an obligation towards themselves to live up to their full potential. In collectivist societies the most important obligations which have to be fulfilled are those to the family, the ingroup, and in some cases society at large. Because of the strong distinction between ingroup and out-group in collectivist societies, Physiotherapy September 1999/vol 85/no 9
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it is no surprise that in these countries value standards differ for in-groups and outgroups. People from your own family, clan or corporation are treated differently from others. In individualistic societies universalism is the ideal, with the same value standards applying to all. Health care professionals coming from individualistic cultures may experience communication problems when dealing with colleagues or clients from more collectivist societies. Because the preservation of face and of harmony is seen as very important in collectivist societies, the word ‘no’ is virtually taboo. Refusals will often be phrased so subtly that they escape notice by someone from an individualistic country, where the language use is more direct. There is a long history of difficulties in trade relations negotiations between the USA and Japan, which can at least in part be attributed to this problem. A related issue is the tendency of people from individualistic cultures in business conversations to get right to the point. This is seen as highly impolite in more collectivist societies, where it is the custom initially to exchange social pleasantries for some time. While these communication problems may cause annoyances, more fundamental moral dilemmas may stem from the difference between universalistic and particularistic values. For instance, if a more personal relationship has evolved, a client from a collectivistic culture may expect preferential treatment, eg in scheduling appointments. If the therapist insists on applying the same rules to friends and strangers, this may be seen as betrayal, and a sign of bad character. Masculinity-Femininity The third dimension identified by Hofstede is masculinity-femininity*. Masculinity stands for a society in which social gender roles are clearly distinct: men are supposed to be assertive, tough, and focused on material success; women are supposed to be more modest, tender, and concerned with the quality of life. Femininity stands for a society in which social gender roles overlap: both men and women are supposed to be modest, * The culture dimension labelled ‘femininity’ should not be confused with ‘feminism’, which is something completely different. Also, the intention is not to ascribe certain behaviour to the genders. I simply borrow a label which has become widely used in comparative cultural studies. Physiotherapy September 1999/vol 85/no 9
tender, and concerned with the quality of life. An example of a strongly masculine country is Japan. In Japan it is highly valued if people (and particularly men) have ‘gaman’, meaning that they can endure hardships without complaint. The life of the average Japanese ‘salaryman’ gives ample opportunity to demonstrate ‘gaman’. The 47 ronin also demonstrated this quality. Other examples of masculine cultures are those of Latin countries like Italy and Mexico, where ‘machismo’, ostensibly tough male behaviour, is valued. In contrast, the Scandinavian countries, but also my country, the Netherlands, are strongly feminine, meaning that more tender, nurturing values are entertained by both men and women. For instance, in what are designated as ‘masculine’ cultures material success and progress are important goals. In feminine cultures caring for others and preservation of nature are important. Of course, this is a matter of degree. Material success and progress are not unimportant in feminine cultures, only caring for others and preservation of nature are relatively more important than in masculine cultures. In masculine cultures, people tend to have sympathy for the strong, like the ‘man who has made it’ in the USA. In feminine cultures there is a lot of sympathy for the weak. In the Netherlands, the more successful one is, the more important it is to remain modest, otherwise one becomes the subject of ridicule. Healthcare professionals from feminine cultures should be aware that decisiveness is very much appreciated in masculine cultures. Showing doubt may be seen as sign of weakness, and thus may undermine the professional authority of a therapist. Furthermore there are many issues which are strictly speaking not subsumed under the masculinity-femininity dimension as defined here, but have to do with differences in what are seen as proper roles and behaviour for men and women. This very often is linked to religion, for instance Islamic rules concerning the kinds of contact permitted between a man and a woman who are not married or close relatives. This kind of difference can easily lead to tensions, as neither of the parties may be inclined to give in and act according to the norms cherished by the other, even if he or she is fully aware of them. A rather painful incident happened in the Netherlands some time ago, when a Muslim member of a work group on minority issues
Professional articles
announced that he would not shake hands with a female town mayor at a meeting planned for the near future. The mayor then cancelled the meeting, and both parties lost as a result. Intercultural cooperation is not always just a matter of communication. Uncertainty Avoidance The last dimension of cultural differences I want to discuss is uncertainty avoidance, defined as the extent to which the members of a culture feel threatened by uncertain or unknown situations. Countries with a very strong uncertainty avoidance can for instance be found in southern Europe: Greece and Portugal, Weak uncertainty avoidance can be found in the UK, and in countries with a high proportion of ethnic Chinese in their populations, like Singapore and Malaysia. In strong uncertainty avoidance cultures the uncertainty inherent in life is felt as a continuous threat which must be fought. One way of fighting uncertainty is through rules. In strong uncertainty avoidance countries, people have an emotional need for rules that give a situation a clear structure. In weak uncertainty avoidance countries, uncertainty is seen as a normal feature of life and each day is accepted as it comes. In strong uncertainty avoidance countries, classifications of what is abnormal, dirty and dangerous are tight and absolute. Behaviour which does not correspond to the norm is condemned. What is different, is dangerous. In weak uncertainty avoidance countries deviant behaviour is not necessarily felt to be threatening. People and ideas which are different arouse curiosity. Uncertainty avoidance has been shown to be strongly related to the incidence of stress, anxiety and neuroticism in a society (Hofstede, 1991, pages 114-116). In the healthcare sector, uncertainty avoidance has an interesting effect on the ratio of nurses to doctors. In weak uncertainty avoidance countries there are significantly more nurses to every doctor than in strong uncertainty avoidance countries. The explanation is that expertise is seen as very important in strong uncertainty avoidance countries. In weak uncertainty avoidance countries nurses are allowed to do jobs that are done only by the experts, the doctors, in strong uncertainty avoidance countries. Physical therapists, as experts, may also expect to be highly esteemed in strong uncertainty avoidance
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countries. However, they should be aware that an expert can easily fall from his pedestal if he shows ignorance. The expert is assumed always to have an answer at hand, and consulting a book in the presence of a client may lead to a sudden loss of respect (MacLachlan,1997, page 235). Another thing to keep in mind is that in strong uncertainty avoidance countries there is a preference for 'hard' and unambiguous data and a scientific, ‘biological’ approach. Physical problems are physical problems, and there is little inclination to look for a psychological dimension (cf Draguns, 1990). Aids to Understanding These are the four dimensions found by Hofstede: power distance, individualismcollectivism, masculinity-femininity, and uncertainty avoidance. Of course the enormous variety of cultures on the globe cannot be described completely with just four dimensions. Other dimensions have been identified, and the closer one looks, the more one sees. But there is a trade-off between paying attention to the details and looking at the broad picture. Describing cultural diversity in four dimensions is a bold generalisation, but it has the advantage of providing us with some tools for understanding the complex reality surrounding us. Positions of countries on the four Hofstede dimensions represent solutions to fundamental questions which all societies have to answer, like the function of authority and the relationship between individual and society (Hofstede, 1980). No position on any of these dimensions is intrinsically better than another. But because we were raised in a particular culture, we have preferences we can never completely obliterate. Perhaps that is the reason that someone coming from a highly individualistic society stresses that everybody should be treated as a unique individual. But in intercultural relations, treating others in the way you would want to be treated is often unhelpful. Instead, we must ask ourselves the difficult question of how they would like to be treated (Gropper, 1996, page 164). I think the only chance of finding an answer to that question is by doing three things at the same time. First we should learn about cultural differences in general. What I told about the Hofstede dimensions can be the beginning of that journey. Secondly, we must try to learn as much as possible about the specific culture of the Physiotherapy September 1999/vol 85/no 9
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person we are dealing with. Of course, this is not always feasible. But whenever the possibility exists, I strongly recommend reading in advance about a country or culture. And finally, we should always remain alert to subtle communication cues of the individual in question, to find out whether our approach is the right one with a particular individual in a specific situation
(Gropper, 1996, page 164). If we try to put ourselves in the position of others, we will become more aware also of our own set of values, and which of them are more, and which are less important to us. Dealing with other cultures is not always easy, but it definitively is something from which we can learn a lot, not least about ourselves.
References
Gropper, R C (1996). Culture and the Clinical Encounter: An intercultural sensitiser for the health professions, Intercultural Press, Yarmouth.
Bond, M H (1991). ‘Chinese values and health: A cultural-level examination’, Psychology and Health, 5, 137-152. Draguns, J (1990). ‘Applications of cross-cultural psychology in the field of mental health’ in: Brislin, R W (ed) Applied Cross-cultural Psychology, Sage, Newbury Park. Federwisch, A (1996). ‘Professional organisations increase care providers’awareness of cultural diversity’, Nurse Week/Health Week, posted 10/11/96 (http://www.nurseweek.com/features/diverse.html)
Hofstede, G (1980). Culture’s Consequences: International differences in work-related values, Sage, Beverly Hills. Hofstede, G (1991). Cultures and Organisations: Software of the mind, McGraw-Hill, London. MacLachlan, M (1997). Culture and Health, Wiley, Chichester. Trandis, H C (1995). Individualism and Collectivism, Westview, Boulder.
Fitzgerald, M H and Mullavey-O’Byrne (1996). ‘Analysis of student definitions and culture’, Physical and Occupational Therapy in Geriatrics, 14, 67-89.
Key Messages ■ Understanding cultural differences is increasingly important for healthcare professionals. ■ A concept of cultural differences should avoid stereotyping and individualism.
Physiotherapy September 1999/vol 85/no 9
■ Hofstede's four-dimensional model provides useful insights for physiotherapists ■ Shared value systems form the core of a culture; they are not superficial group characteristics.
Key Words Culture, upbringing, symbols, heroes, rituals, values.
by Niels G Noorderhaven
Intercultural Differences Consequences for the Physical Therapy Profession
Summary Cultural differences have a bearing on health and can influence the effectiveness of treatment. It is possible to compare different cultures using the criteria of power distance, Individualism collectivism, masculinity-femininity and uncertainty avoidance.
Background According to Moliere, the French 17th century playwright, there is a sort of decency among the dead, a remarkable discretion: you never find them making any complaint against the doctor who killed them! Physical therapists may be assumed to have harder times, as more of their patients survive. So the physical therapist must work hard to give the best possible care to his or her clients. In doing so, the physical therapist has to take into account not only the specifics of the physical problem, but also the expectations and preferences of the client with regard to the way he or she per forms his or her professional role. These preferences and expectations are influenced, among other things, by culture. Cultural differences are becoming more and more relevant, in general as well as to health care professionals, for two reasons. First, the world is becoming smaller and smaller, and we become more and more ardent travellers. Physical therapists increasingly work in countries other than their own, either permanently or temporarily. Secondly, even if people do not go out into the world, the world is coming to them. Increasing international migration brings the world of cultural differences into our own countries. For example, in the USA nowadays more than one out of four Americans identify themselves as AfricanAmerican, Hispanic, Native American, Asian Noorderhaven, N G (1999). or Pacific Islander (US Census, 1990). ‘Intercultural differences: The process of globalisation makes Consequences for the interactions between people from different physical therapy countries and cultures more intense, but it profession’, Physiotherapy, would be naive to think that as a result these 85, 9, 504-510. Physiotherapy September 1999/vol 85/no 9
differences will automatically become smaller. Superficially, people from different cultures may appear to become more and more alike. The proverbial youth in Karachi or Shanghai sipping from a can of coke while listening to pop music may look deceptively like his contemporaries in Detroit or Amsterdam. But similarities on the outside may hide differences at deeper levels. As a matter of fact, contacts between cultures sometimes make cultural differences more pronounced, as people tend to become aware of their own cultural identity more intensely when they meet with other cultures. When talking about cultures, it is useful to distinguish different levels (Hofstede, 1991, pages 7-9). At the most superficial level, we find symbols (see figure). These are words, gestures, pictures or objects that carry a particular meaning. Examples are flags, hairstyles, or a jargon specific to a certain
Symbols Heroes Rituals Values
Layers of culture (adapted from Hofstede, 1991, page 9)
Professional articles
group, for instance an age group. Coca Cola to many in the world is much more than just a soft drink, it is a symbol of modernity. As we peel the onion of culture, we come to deeper, more fundamental levels. Heroes are persons, alive or dead, real or imaginary, who possess characteristics which are highly prized in a culture. An example of a partly imaginary classical American hero is the pioneer, going West, stretching the frontier to new limits in his struggle against the forces of nature. Japanese cultural heroes are often samurai. An example is provided by the true history of the 47 'ronin', samurai who had become masterless when their lord had been forced to commit suicide. The 47 ronin demonstrate two important values in the Japanese culture. By revenging the death of their master they showed their unquestioning loyalty. But after the revenge, they subjected themselves to the Shogun, demonstrating their respect for the law. At a still deeper level than that of the heroes we find rituals. Rituals are collective activities which are technically superfluous, but which, within a culture, are seen as socially desirable, if not essential. Ways of greeting and paying respect to others, social and religious ceremonies are examples. Professional conferences, at which people gather for face-to-face information exchange are also increasingly assuming a ritual nature in this age of electronic communication. Finally, we come to the deepest level, the core of a culture: values which are shared within a society. Values are broad tendencies to prefer certain states of affairs over others. They tell us what is evil and what is good, what is dirty and what clean, ugly and beautiful, unnatural and natural, abnormal and normal, paradoxical and logical, irrational and rational. Values are among the first things people learn. Around the age of ten, most children have their value system firmly in place. However, because they were acquired so early in life, values mostly remain implicit, and even unconscious to those who hold them. They cannot directly be obser ved by outsiders, but only be inferred from the way people act under various circumstances. Values are much more difficult to change than the more superficial levels. Therefore they form the hard core of a culture. Importance of Differences Cultural differences are important for healthcare professionals, including physical therapists, for a number of reasons. First,
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cultural differences have a bearing on health (see for example Bond, 1991). An interesting example is the rate of heart attacks in Japan and the USA. For Japanese living in Japan, the rate is among the lowest in the world, approximately 1.8 per 1,000, The rate is a bit higher for Japanese living in Hawaii, 3.8 per 1,000. But this is still much lower than the rate for US Caucasians, with 9.8 per 1,000. The most interesting observations, which strongly suggest that we are indeed dealing with a cultural phenomenon here, pertain to Japanese living in the USA. The more acculturated (Americanised) Japanese Americans are, the more likely they are to have a heart attack rate similar to that of US Caucasians (Triandis, 1995, page 134). Secondly, cultural differences are important because they can influence the effectiveness of your functioning as a physical therapist in another country, or your cooperation with nationals from other countries. Culture influences the expectations we have of people in particular roles. Many expatriates have found that out the hard way. We may expect other people to be open to our point of view, to understand that we don’t have a ready answer to all questions, to be motivated by a challenging task, but we may be mistaken. Conversely, if we don't live up to the expectations of others, relationships can quickly become very tense, and it may be difficult to change that subsequently. Some examples of the ways in which expectations can clash are given later in this paper. Thirdly, cultural differences have a bearing on the provision of health care, even within one's own country. Those dealing with a culturally diverse clientele are going to encounter understandings of illness, pain, diagnosis, therapy and healing which are quite different from their own (MacLachlan, 1997, page 59). This may cause anxiety in therapists and clients alike, and may seriously hinder effective treatment.
Author and Address for Correspondence Niels G Noorderhaven PhD is director of the Institute for Research on Intercultural Cooperation and professor of international management, Faculty of Economics and Business Administration, Tilburg University, PO Box 90153, 5000 LE Tilburg, The Netherlands. This article was presented as a keynote lecture at the World Confederation for Physical Therapy Congress in Japan in May, 1999. It was received by Physiotherapy on June 18, 1999, and accepted on July 30, 1999.
How to Cope Whereas it is undoubtedly important to take cultural differences into consideration, it is not easy. In dealing with cultural differences, one has to navigate between the Scylla of stereotyping and the Charybdis of assuming that group differences are irrelevant. Stereotyping takes place when we over-generalise and think that all Scots are stingy, or that Africans, being always happy, don't get depressed (MacLachlan, 1997, Physiotherapy September 1999/vol 85/no 9
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page 35). However, if in our urge to avoid stereotyping we go to the other extreme, we may end up denying the importance of group characteristics, which means that it becomes very difficult to prepare for intercultural encounters. The opposition between the tendency to over-generalise and the urge to avoid stereotyping is important. Some degree of generalisation is unavoidable if we want to learn about other cultures. We must assume that the ‘average’ Frenchman behaves differently from the ‘average’ Englishman, otherwise it would be pointless to study cultures. Of course, we realise that we will never actually meet this mythical average Frenchman or Briton, but if we do not believe that there are differences in ideas and behaviour between countries, we should abolish the concept of 'national cultures'. However, differences between national cultures have been shown to be significantly related with a plethora of phenomena, including political violence, press freedom, development assistance, nationalism, economic growth, and, as we have seen, health (Hofstede, 1991; MacLachlan, 1997). But to avoid stereotyping, should not everyone just be treated as an individual? Johnette Meadows, of the American Physical Therapy Association, some years ago voiced a strong opinion on this issue. According to her there is no set approach to providing culturally sensitive care, because everybody is an individual. She said: 'I would never attempt to give anybody a book on how to treat an entire race or ethnic group, because that is racist. How do you treat an AfricanAmerican? Well you treat him like a human being, and from there you go where you need to go' (quoted in Federwisch, 1996). Two comments are apposite. First, if we are to discuss culturally sensitive care, we must not confound race and culture. The concepts are entirely different, and I completely agree with Meadows that a book on how to treat people from a specific race would be questionable, if not ridiculous. Culture is about learned, not inherited values and beliefs. But a study of definitions of culture given by health care students in Australia revealed that many were mixing up culture, race and ethnicity. In particular, physical therapy students had a tendency to use relatively exterior concepts, like 'lifestyle' or ‘attitudes’ when describing 'culture', and less often more interior concepts like ‘values’ and ‘beliefs’ (Fitzgerald and Mullavey-O'Byrne, 1996). We should take Physiotherapy September 1999/vol 85/no 9
care not to link culture to rather superficial characteristics of people. The second observation is that regarding everybody as an individual is not necessarily going to help. If the client is an entirely unique individual, we have no idea as to what to do in order to provide the best possible care. As a matter of fact, we may fall in a trap here. By focusing on the unique individual that everyone of us presumably is, we may be enacting our own culture. The emphasis on the uniqueness of the individual is typical for Western cultures, and in particular for the United States. People in the US dislike the suggestion that they are like ‘the average’ American (Triandis, 1995, page 46). This is not necessarily true of people from other countries. My guess would be that many Japanese would not mind that much being likened to the ‘average Japanese’. I think the position recommended by Meadows can be taken as an illustration of the fact that we cannot just step out of our own culture. Our intentions in trying to do so may be excellent, but that does not guarantee a good outcome. ‘Going where you need to go’ is difficult if you have no clue as to the ways in which cultures can differ. For this reason I advocate a position between the extremes of stereotyping on the one hand and of condemning every form of generalisation on the other. Like individual personalities, cultures are unique, if you look closely enough, but also like personalities, cultures can be compared in a number of dimensions, In personality theory we have the ‘Big Five’. In comparing cultures, four dimensions have proven to be exceedingly important. Comparative Measures This section is based on the work of Geert Hofstede, a Dutch social scientist who in the late 60s and early 70s conducted a largescale sur vey in more than 50 national subsidiaries of IBM. All in all, he collected data from over 100,000 respondents. In 1980, after years of analysing these data, he published his book Culture’s Consequences (Hofstede, 1980), which is generally considered a landmark study of national cultures. The analysis showed that a large part of the differences in values between countries can be described in terms of four dimensions. These dimensions are labelled power distance, individualism-collectivism,
Professional articles
masculinity-femininity, and uncer tainty avoidance. They are described with some speculation about the consequences of each dimension for the therapy profession Power Distance Power distance is defined as 'the extent to which the less power ful members of institutions and organisations within a country expect and accept that power is distributed unequally’ (Hofstede, 1991, page 28). Large power distances are found in many Latin countries, for instance Latin American countries. Small power distances for instance exist in the Scandinavian countries. Key differences between small and large power distance societies relate to preferences with regard to inequality and privileges, In small power distance cultures, the general idea is that inequality should be minimised. Some degree of inequality is unavoidable because of the different roles of people in society, but this should be kept to a minimum. In large power distance societies, inequalities between people are seen as not just unavoidable, but even desirable. Hierarchical relations are seen as the very fabric of an orderly society, as in the teachings of Confucius. People in small power distance societies tend to dislike the idea of privileges and status symbols. All should have equal rights, and status differences should not be ostentatious. In large power distance societies power-holders are entitled to privileges, and status symbols are accepted. Let us now speculate briefly about the consequences of differences in power distance for health care professionals, and in particular physical therapists, operating at cultural interfaces. Let us assume that a physical therapist is from a small power distance culture, as in northern Europe or the Anglo-Saxon countries. One thing that he will have to bear in mind when interacting with clients from large power distance countries is that as a health care professional he is likely to be regarded as an authority and treated with respect. This means that it may be difficult for someone coming from a large power distance culture to adjust to the informality of manners preferred in most small power distance countries,. This may create a feeling of confusion and uneasiness in both parties. Another thing to be borne in mind is that in large power distance countries, powerholders tend to be inaccessible to
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those with less power. You can only reach an important person, if at all, through a consecutive series of secretaries and assistants. By the time you reach the big boss, you are assured that your case or request is relevant and legitimate. A health professional originating from a small power distance country may consider all of this nonsense, and make him or herself as directly accessible for everybody as possible. Paradoxically, this may raise an almost insurmountable barrier to those who are used to deal with secretaries and assistants first. Direct access to a person in power can be very frightening. Individualism-Collectivism The second dimension is bipolar: individualism-collectivism. Individualism stands for a society in which the ties between individuals are loose; everyone is expected to look after himself and his immediate family only. Collectivism stands for a society in which people from birth onwards are integrated in strong, cohesive in-groups, which throughout people's lifetime continue to protect them in exchange for unquestioning loyalty. All the Anglo-Saxon countries are strongly individualistic. Most of the continental European countries are also individualistic. The Latin American countries are strongly collectivistic, and this is true for almost all developing countries. In general, the richer the country, the more individualistic the culture of its inhabitants. The causation is from affluence to culture: the richer a country is, the more people have access to resources which allow them ‘to do their own thing’ (Hofstede, 1991, page 76). In poorer countries strong ingroups like the extended family provide an indispensable safety net. Over the last few decades, we have witnessed a world-wide shift towards more individ-ualism. The available evidence, however, indicates that the differences between countries are relatively stable, as even the countries which were already strongly individualistic in the 70s have become even more so since then. In highly individualistic societies, people are motivated by self-actualisation: they feel an obligation towards themselves to live up to their full potential. In collectivist societies the most important obligations which have to be fulfilled are those to the family, the ingroup, and in some cases society at large. Because of the strong distinction between ingroup and out-group in collectivist societies, Physiotherapy September 1999/vol 85/no 9
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it is no surprise that in these countries value standards differ for in-groups and outgroups. People from your own family, clan or corporation are treated differently from others. In individualistic societies universalism is the ideal, with the same value standards applying to all. Health care professionals coming from individualistic cultures may experience communication problems when dealing with colleagues or clients from more collectivist societies. Because the preservation of face and of harmony is seen as very important in collectivist societies, the word ‘no’ is virtually taboo. Refusals will often be phrased so subtly that they escape notice by someone from an individualistic country, where the language use is more direct. There is a long history of difficulties in trade relations negotiations between the USA and Japan, which can at least in part be attributed to this problem. A related issue is the tendency of people from individualistic cultures in business conversations to get right to the point. This is seen as highly impolite in more collectivist societies, where it is the custom initially to exchange social pleasantries for some time. While these communication problems may cause annoyances, more fundamental moral dilemmas may stem from the difference between universalistic and particularistic values. For instance, if a more personal relationship has evolved, a client from a collectivistic culture may expect preferential treatment, eg in scheduling appointments. If the therapist insists on applying the same rules to friends and strangers, this may be seen as betrayal, and a sign of bad character. Masculinity-Femininity The third dimension identified by Hofstede is masculinity-femininity*. Masculinity stands for a society in which social gender roles are clearly distinct: men are supposed to be assertive, tough, and focused on material success; women are supposed to be more modest, tender, and concerned with the quality of life. Femininity stands for a society in which social gender roles overlap: both men and women are supposed to be modest, * The culture dimension labelled ‘femininity’ should not be confused with ‘feminism’, which is something completely different. Also, the intention is not to ascribe certain behaviour to the genders. I simply borrow a label which has become widely used in comparative cultural studies. Physiotherapy September 1999/vol 85/no 9
tender, and concerned with the quality of life. An example of a strongly masculine country is Japan. In Japan it is highly valued if people (and particularly men) have ‘gaman’, meaning that they can endure hardships without complaint. The life of the average Japanese ‘salaryman’ gives ample opportunity to demonstrate ‘gaman’. The 47 ronin also demonstrated this quality. Other examples of masculine cultures are those of Latin countries like Italy and Mexico, where ‘machismo’, ostensibly tough male behaviour, is valued. In contrast, the Scandinavian countries, but also my country, the Netherlands, are strongly feminine, meaning that more tender, nurturing values are entertained by both men and women. For instance, in what are designated as ‘masculine’ cultures material success and progress are important goals. In feminine cultures caring for others and preservation of nature are important. Of course, this is a matter of degree. Material success and progress are not unimportant in feminine cultures, only caring for others and preservation of nature are relatively more important than in masculine cultures. In masculine cultures, people tend to have sympathy for the strong, like the ‘man who has made it’ in the USA. In feminine cultures there is a lot of sympathy for the weak. In the Netherlands, the more successful one is, the more important it is to remain modest, otherwise one becomes the subject of ridicule. Healthcare professionals from feminine cultures should be aware that decisiveness is very much appreciated in masculine cultures. Showing doubt may be seen as sign of weakness, and thus may undermine the professional authority of a therapist. Furthermore there are many issues which are strictly speaking not subsumed under the masculinity-femininity dimension as defined here, but have to do with differences in what are seen as proper roles and behaviour for men and women. This very often is linked to religion, for instance Islamic rules concerning the kinds of contact permitted between a man and a woman who are not married or close relatives. This kind of difference can easily lead to tensions, as neither of the parties may be inclined to give in and act according to the norms cherished by the other, even if he or she is fully aware of them. A rather painful incident happened in the Netherlands some time ago, when a Muslim member of a work group on minority issues
Professional articles
announced that he would not shake hands with a female town mayor at a meeting planned for the near future. The mayor then cancelled the meeting, and both parties lost as a result. Intercultural cooperation is not always just a matter of communication. Uncertainty Avoidance The last dimension of cultural differences I want to discuss is uncertainty avoidance, defined as the extent to which the members of a culture feel threatened by uncertain or unknown situations. Countries with a very strong uncertainty avoidance can for instance be found in southern Europe: Greece and Portugal, Weak uncertainty avoidance can be found in the UK, and in countries with a high proportion of ethnic Chinese in their populations, like Singapore and Malaysia. In strong uncertainty avoidance cultures the uncertainty inherent in life is felt as a continuous threat which must be fought. One way of fighting uncertainty is through rules. In strong uncertainty avoidance countries, people have an emotional need for rules that give a situation a clear structure. In weak uncertainty avoidance countries, uncertainty is seen as a normal feature of life and each day is accepted as it comes. In strong uncertainty avoidance countries, classifications of what is abnormal, dirty and dangerous are tight and absolute. Behaviour which does not correspond to the norm is condemned. What is different, is dangerous. In weak uncertainty avoidance countries deviant behaviour is not necessarily felt to be threatening. People and ideas which are different arouse curiosity. Uncertainty avoidance has been shown to be strongly related to the incidence of stress, anxiety and neuroticism in a society (Hofstede, 1991, pages 114-116). In the healthcare sector, uncertainty avoidance has an interesting effect on the ratio of nurses to doctors. In weak uncertainty avoidance countries there are significantly more nurses to every doctor than in strong uncertainty avoidance countries. The explanation is that expertise is seen as very important in strong uncertainty avoidance countries. In weak uncertainty avoidance countries nurses are allowed to do jobs that are done only by the experts, the doctors, in strong uncertainty avoidance countries. Physical therapists, as experts, may also expect to be highly esteemed in strong uncertainty avoidance
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countries. However, they should be aware that an expert can easily fall from his pedestal if he shows ignorance. The expert is assumed always to have an answer at hand, and consulting a book in the presence of a client may lead to a sudden loss of respect (MacLachlan,1997, page 235). Another thing to keep in mind is that in strong uncertainty avoidance countries there is a preference for 'hard' and unambiguous data and a scientific, ‘biological’ approach. Physical problems are physical problems, and there is little inclination to look for a psychological dimension (cf Draguns, 1990). Aids to Understanding These are the four dimensions found by Hofstede: power distance, individualismcollectivism, masculinity-femininity, and uncertainty avoidance. Of course the enormous variety of cultures on the globe cannot be described completely with just four dimensions. Other dimensions have been identified, and the closer one looks, the more one sees. But there is a trade-off between paying attention to the details and looking at the broad picture. Describing cultural diversity in four dimensions is a bold generalisation, but it has the advantage of providing us with some tools for understanding the complex reality surrounding us. Positions of countries on the four Hofstede dimensions represent solutions to fundamental questions which all societies have to answer, like the function of authority and the relationship between individual and society (Hofstede, 1980). No position on any of these dimensions is intrinsically better than another. But because we were raised in a particular culture, we have preferences we can never completely obliterate. Perhaps that is the reason that someone coming from a highly individualistic society stresses that everybody should be treated as a unique individual. But in intercultural relations, treating others in the way you would want to be treated is often unhelpful. Instead, we must ask ourselves the difficult question of how they would like to be treated (Gropper, 1996, page 164). I think the only chance of finding an answer to that question is by doing three things at the same time. First we should learn about cultural differences in general. What I told about the Hofstede dimensions can be the beginning of that journey. Secondly, we must try to learn as much as possible about the specific culture of the Physiotherapy September 1999/vol 85/no 9
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person we are dealing with. Of course, this is not always feasible. But whenever the possibility exists, I strongly recommend reading in advance about a country or culture. And finally, we should always remain alert to subtle communication cues of the individual in question, to find out whether our approach is the right one with a particular individual in a specific situation
(Gropper, 1996, page 164). If we try to put ourselves in the position of others, we will become more aware also of our own set of values, and which of them are more, and which are less important to us. Dealing with other cultures is not always easy, but it definitively is something from which we can learn a lot, not least about ourselves.
References
Gropper, R C (1996). Culture and the Clinical Encounter: An intercultural sensitiser for the health professions, Intercultural Press, Yarmouth.
Bond, M H (1991). ‘Chinese values and health: A cultural-level examination’, Psychology and Health, 5, 137-152. Draguns, J (1990). ‘Applications of cross-cultural psychology in the field of mental health’ in: Brislin, R W (ed) Applied Cross-cultural Psychology, Sage, Newbury Park. Federwisch, A (1996). ‘Professional organisations increase care providers’awareness of cultural diversity’, Nurse Week/Health Week, posted 10/11/96 (http://www.nurseweek.com/features/diverse.html)
Hofstede, G (1980). Culture’s Consequences: International differences in work-related values, Sage, Beverly Hills. Hofstede, G (1991). Cultures and Organisations: Software of the mind, McGraw-Hill, London. MacLachlan, M (1997). Culture and Health, Wiley, Chichester. Trandis, H C (1995). Individualism and Collectivism, Westview, Boulder.
Fitzgerald, M H and Mullavey-O’Byrne (1996). ‘Analysis of student definitions and culture’, Physical and Occupational Therapy in Geriatrics, 14, 67-89.
Key Messages ■ Understanding cultural differences is increasingly important for healthcare professionals. ■ A concept of cultural differences should avoid stereotyping and individualism.
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■ Hofstede's four-dimensional model provides useful insights for physiotherapists ■ Shared value systems form the core of a culture; they are not superficial group characteristics.