Deliver Culturally Competent Care

The United States Department of Health and Human Services Office of Minority Health defines culture as the “integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values and institutions of racial, ethnic, religious or social groups.”¹ Cultural and linguistic competency helps oral health professionals deliver care that respects patients’ cultural beliefs and language preferences.²

In the ongoing efforts to improve the oral health of all Americans, promoting awareness of the importance of oral health among racial/ethnic minorities and populations that experience high levels of oral diseases is important.³ By tailoring services to an individual’s cultural and language preferences, health professionals can improve health outcomes. Culture often influences oral health care practices. Beliefs, experiences, and values shape judgments about what is appropriate in the provision of health care, including oral health. To address these issues, American dental education now includes cultural competence as an educational requirement.⁴

Oral health professionals are charged with improving their cultural competency, and self-assessment is an important step in this process. Campinha-Bacote⁵ describes personal awareness as the first stage in her model of culturally competent health care delivery. Cultural awareness is a process of examining one’s cultural and professional background, Campinha-Bacote asserts, in order to note biases, prejudices, and assumptions about individuals of different cultures.⁵ Cultural competence begins with the desire to prevent biases that may hinder treating individuals with respect. It requires an honest assessment of positive and negative assumptions about others. Learning to evaluate one’s own level of cultural competency must be part of an ongoing effort to provide optimal health care. For example, ethnocentrism is the belief in the inherent superiority of one’s own ethnic group or culture. Ethnocentrism can lead to an attitude in which beliefs that differ greatly from one’s own are wrong.

LANGUAGE BARRIERS

Language barriers can influence oral health literacy. A patient lacking oral health literacy may have trouble with tasks such as understanding written information, scheduling appointments, determining the risks and benefits of certain procedures, or following up on treatment plans. To increase understanding during communication, limit the use of jargon and use plain language, pictures, or drawings. Limit the amount of information given at once. Repeating information is also helpful.^6,7

Due to the rising number of immigrants in the US, the demand for medical interpreters is increasing. Trained interpreters allow for timely information exchange that is both accurate and culturally sensitive. Translation services should be provided by interpreters, who can provide accurate and unbiased meaning of terms. Children and family members should not be used to translate for patients.

One of the first steps to providing culturally and linguistically appropriate oral health care is increasing awareness of varying cultural differences in oral health behaviors. The following examples provide insight into how various cultures view oral health.

ISLAM

The miswak is a traditional oral cleaning tool used in Asia, Africa, Latin America, and the Middle East, particularly by Muslim inhabitants of these areas. The use of the miswak is frequently advocated in the hadith (the traditions relating to the life of Muhammad). Twigs from Salvadora persica or the “toothbrush tree” are cut into small sections, and the bark is pared back and the end chewed to create a frayed end.^8,9 Almas and Al-Zaid¹⁰ have reported the antibacterial properties of the miswak, and demonstrated a significant reduction in Streptococcus mutans compared to toothbrushing.¹⁰ Despite these positive effects, improper use of the miswak can contribute to gingival recession.⁶

Additionally, modesty is important in the Muslim culture. Patients may not wish to have physical contact with the opposite sex, preferring to be treated by a practitioner of the same gender.¹¹ Modesty often requires women to don traditional clothing that covers the face and neck. This may impede oral health professionals from conducting a comprehensive extraoral examination.¹ Open discussion about what is involved and the importance of such examinations should help clinicians gain consent.¹¹ Many Muslims adhere to a Halal diet, which prohibits alcohol. This may limit use of certain mouthrinses as adjunctive oral hygiene aids;⁸ however, many alcohol-free alternatives are available.

Another factor to consider is that Muslims fast in the daylight hours during the period of Ramadan, which is in the ninth month of the Islamic calendar and lasts 30 days. When possible, avoiding dental appointments during this time is prudent. Fasting can contribute to increased breath malodor, which may be misinterpreted as poor oral health. Also, while injections and gargling are widely viewed as acceptable, swallowing water spray from a handpiece or ultrasonic scaler may break the fast. Also, fasting individuals tend to be more irritable due to their lack of food and disrupted sleep patterns.¹¹

HINDUISM

Hinduism is the third largest religion in the world, and is the most popular faith among residents of India and Nepal. Hindus are often vegetarians, which may increase their risk of anemia due to low iron and vitamin B12 levels. Anemia may cause glossitis and angular chelitis in the oral cavity.¹²

Like Muslims, Hindu communities often use chewing twigs for oral hygiene practices. Hindus typically use cherry wood for teeth cleaning, but twigs from mango, coconut, or cashew trees may also be chewed.¹²

CHINESE CULTURE

Chinese beliefs about health and illness are often theorized in context of hot-cold, yin-yang, as well as qi (chi) and holism. Some Chinese use the Meridian Theory, a belief that there are 12 main channels with energy flow (yin) that are paired with a corresponding organ known as yang. A disorder within a meridian, or energy pathway, generates conflict within that channel. For instance, a maxillary toothache may be related to an illness of the stomach meridian, or a mandibular toothache may be related to an illness of the large intestine meridian, as the large intestine and the mandible run along the same energy channel.¹³

Some Chinese immigrants have blended traditional health folklore with scientific evidence. The beliefs of urban Chinese adolescents residing in China tend to be shaped by modern scientific knowledge mixed with traditional Chinese theories of disease and health.¹³ While the scientific process of caries development is well understood, gingivitis may be caused by an “internal fire” due to poor lifestyle choices.⁹ Respecting patient beliefs and complementing existing traditions will ensure that patients don’t feel alienated by dental practitioners.⁹

INDIGENOUS AUSTRALIANS

There is a clear disparity between the health of indigenous Australians and the greater Australian population. Aboriginal Australians experience a higher incidence of chronic diseases, such as diabetes and cardiovascular diseases, which, in turn, influence oral health.¹⁴ Further, a recent report on the oral health of Aboriginal children reported that 82% of children seen had dental caries.¹⁵ Access to culturally appropriate services is a major barrier to improvements in health status, not only in Australia but worldwide.

In Australian Aboriginal culture, personal identity is strongly linked to kinship, rituals, and a spiritual connection to the land. There is a clear hierarchy in the family, as well as gender-specific roles. As such, it may cause great distress if these boundaries are breached—affecting exchanges about health problems and treatment.¹⁶ It may be more appropriate for a patient to be treated by a practitioner of the same sex, or for discussions to occur with an elder.

Traditional health beliefs and language may create barriers in providing care to Aboriginal Australians. Health practitioners should clearly explain the disease process and treatment options, but allow patients to contextualize this within their belief systems.¹⁷ With many Aboriginal dialects, interpreters or Aboriginal health workers can be engaged to ensure optimal communication. Lack of eye contact is often a sign of respect (not a sign of rudeness).

Bush medicine and traditional healers may be used to alleviate health problems. Herbal preparations, diet modifications, massage, and smoke or steam are some examples of bush medicine. Healers may use these methods, along with healing songs, chanting, counseling, or rubbing affected areas to improve health.¹⁷

UNITED STATES

Many American baby boomers were taught to brush their teeth after every meal with a fluoride toothpaste and to visit the dentist twice a year. This message has evolved to brushing for 2 minutes twice a day. Currently, the advice for good oral health is brush, floss, chew xylitol gum, and rinse. Despite many types of power-assisted brushes, a variety of interdental and tongue cleaners, mouthrinses, antimicrobials, gum, and other products, oral health disease remains widespread among all patient populations in the US.

In order to improve the oral health of Americans, culturally sensitive care is important. The US population is composed of individuals from many different races and ethnicities, and different habits and/or preferences from native cultures may affect oral health regimens and status.¹⁸ Tobacco, betel nut, and alcohol use, complementary medicine, oil pulling, and other cultural practices have significant affects on oral health.

While smoking has declined significantly over the past 30 years, it is still widespread in the US, with about 18% of American adults using tobacco.¹⁹ The highest rates of tobacco use are seen among those living below the poverty level and young people. In the US, approximately 19% of whites, 18% of African Americans, 12% of Hispanics, 21% of American Indians/Alaska Natives, and 10% of Asians smoke.¹⁹ Individuals from different cultures also have unique ways of using tobacco.

Quid chewing is common among ethnic minorities, particularly Asian cultures, in which millions of people chew betel nut from the areca tree. This tree is a type of palm that grows in India, Bangladesh, Japan, Sri Lanka, south China, the East Indies, the Philippines, and parts of Africa.²⁰ The nut may be used fresh, dried, or cured by boiling, baking, or roasting. Betel quids are parcels of areca nuts and tobacco wrapped in a lime-coated betel leaf.²¹ Spices may be added for taste, including cardamom, saffron, cloves, and sweeteners.²² Due to its stimulating effects on the central nervous system, betel nut is used in a manner similar to the Western use of tobacco or caffeine. Betel quids are the fourth most commonly used psychoactive substance after tobacco, alcohol, and caffeinated drinks. Oral manifestations include reddish brown discoloration of teeth and gums, ulcers, periodontal diseases, oral cancers, and oral submucous fibrosis.²³

Alcohol consumption has also been associated with increased cancer risk, particularly in combination with tobacco use.²³ Alcohol consumption is often a social habit within cultures, so health education and promotion strategies are essential.

Different cultures often rely on folklore and complementary medicine to treat health problems. Clinicians who are aware of their patients’ beliefs in these methods will build rapport with and enable culturally appropriate services to be provided.

Oil pulling is a method of teeth cleaning originating in India and southern Asia thousands of years ago that is now making a resurgence in the US.²⁴ This technique is viewed as an adjunct to mechanical brushing, and involves swishing approximately 2 teaspoons of oil—such as sesame, sunflower, olive, or coconut—for at least 10 minutes. Research has not demonstrated that this technique is effective in reducing caries, whitening teeth, or improving oral health, but little study has been conducted.²⁵

Many individuals from Central America, the Mediterranean, Asia, the Middle East, and Africa believe that illness and bad luck are caused by an evil eye or curse—usually issued by someone who is envious of the cursed individual.⁷ Mediterranean cultures use charms against the gaze of the evil eye. In Spain and Latin America, children are believed to be particularly vulnerable to the evil eye and may be protected by rituals or a bracelet. In Northeast Brazil, mothers make amulets out of deciduous teeth by perforating a small hole in the tooth and hanging it on a red string around children’s necks as protection against the evil eye.²⁶ Clinicians must be mindful that delivering culturally competent care means respecting the views and belief systems perceived to cause illness.

Women in some areas of the US and other parts of the world believe that bleeding gums and tooth loss occur during pregnancy because the baby is leaching calcium from the mother’s bones.⁷ If the mother’s intake of calcium is inadequate during pregnancy, her bones—not her teeth—will provide the calcium her growing baby needs. Clinicians can help educate women about the importance of maintaining oral health during pregnancy to ensure both maternal and fetal well-being.

STRATEGIES FOR CULTURALLY COMPETENT CARE

With increasingly diverse, multicultural populations, health practitioners are charged with providing culturally sensitive and appropriate services to their patients. Early experiences of dental services are essential in shaping positive associations and increasing the value patients place on oral health.²⁷

Communication is integral to building positive rapport with patients of all ages and cultures. It is important to understand that what may be considered positive communication strategies in Western cultures may not be perceived the same way in other cultures. For some, prolonged eye contact is perceived as a negative behavior.²⁷ Furthermore, comforting patients through touch may also be seen as inappropriate. The family unit may be of high importance in various cultures; therefore, involving parents, grandparents, and other relatives in health care discussions might be helpful in ensuring understanding and compliance. Older adults may not be proficient in English, making access to interpreter services integral to ensuring messages are accurately communicated.

As discussed, cultural differences in patients’ oral health practices may be observed. An awareness of these alternative habits will help overcome any potential barriers in delivering oral health messages. Clinicians should not recommend any changes to behaviors that are not detrimental to oral health.^18,28

With growing concerns about health inequities and the need for health care systems to reach increasingly diverse patient populations, cultural competence has become a matter of global concern. A free online educational cultural competency course has been developed by the US Office of Minority Health that targets dental hygienists, dental assistants, dentists, dental specialists, and other professionals who can help improve access to care, quality of care, and oral health outcomes. The course is available at: oralhealth.thinkculturalhealth.hhs.gov.

CONCLUSION

Oral diseases are a product of behavioral, economic, social, cultural, and environmental factors. Throughout the world, culture is embedded within religious, political, and social contexts and is historically based. Culture influences attitudes and perceptions of health. It is, therefore, important for clinicians to understand how cultural perceptions impact their responses to the health care needs of various cultural groups.²⁹

REFERENCES

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22. World Health Organization. Review of areca (betel) nut and tobacco use in the Pacific: a technical report. 2012. Available at wpro.who.int/tobacco/documents/201203_Betelnut/en/. Accessed December 20, 2014.
23. Zain RB. Cultural and dietary risk factors of oral cancer and precancer—a brief review. Oral Oncology. 2001;37:205–210.
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26. Nations MK, Calvasina PG, Martin MN, Dias HF. Cultural significance of primary teeth for caregivers in Northeast Brazil. Cad Saúde Pública. 2008;24:800–808.
27. Charbonneau CJ, Neufield MJ, Craig BJ, Donnelly LR. Increasing cultural competence in the dental hygiene profession. Can J Dent Hygiene. 2009;43:297–305.
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From Dimensions of Dental Hygiene. January 2015;13(1):62–65.