Written by Morganne Skinner, RN, BSN
I distinctly remember standing in front of my friend in the village and telling her that my stomach was still hurting. I had a bout of schistosomiasis and giardia, and these conditions were hard to treat! She gestured for me to come closer, and whispered “You need a baby. Mudi mukati mulonga mudi muvumu nehi,” which translates to “You are sick because you are not pregnant.” This was the third time someone had told me that in my village.
I said, “Mu chisemwa chami, twatongajoki nakati mulonga nikweti kububu mwivumu,” in Lunda, which translates to, “in my culture, we think that I am sick because I have bugs in my stomach.” While this may not have been the most eloquent or detailed response, it was the best my novice Lunda could do!
Over the course of my two years in Zambia, I had many experiences similar to this one. They made me wonder just how many patients had I cared for that declined a medical treatment because their culture viewed a medical problem differently.
Gaining Cultural Understanding
As nurses trained in Western medicine, it's easy to slip into assuming that a patient needs more education in Western pathophysiology and treatment when they make decisions against our advice. These decisions, however, are often made due to fundamental and radical differences in beliefs. When patients have different beliefs around the cause of their illness, it only follows that they will want different treatments and have different expectations.
Luckily, I am not the first person to have pondered this. Dr. Arthur Kleinman, anthropologist and psychiatrist, created a list of questions for cultural understanding as it relates to illness. These questions help create understanding between our patients and healthcare providers, setting the stage for improved patient care. They are a great tool for nursing students, new nurses, and seasoned nurses.
The 8 Essential Questions
In the book, The Spirit Catches You and You Fall Down, about a Hmong family’s encounter with Western medicine, we see a dialogue involving these eight questions. The family’s daughter Lia has epilepsy according to Western medicine. The Hmong, however, have another name and explanation for epileptic seizures. The excerpt below, from the book, describes how epilepsy is viewed in Lia's culture and how her parents answered the eight questions.
1. What do you call the problem?
“Quag dab peg. That means the spirit catches you and you fall down.”
2. What do you think has caused the problem?
The Hmong believe that soul loss, in which the life-soul is separated from the body, is the most common cause of illness. Soul loss can happen because of anger, fear, grief, curiosity, or wanderlust.
This is quite different from the Western medicine concept that epilepsy may be caused by infections, brain abnormalities, genetics, head trauma, prenatal injury, or developmental disorders.
3. Why do you think it started when it did?
“Lia’s sister Yer slammed the door and Lia’s soul was frightened out of her body.”
4. What do you think the sickness does? How does it work?
“It makes Lia shake and fall down. It works because a spirit called dab is catching her.”
5. How severe is the sickness? Will it have a long or short course?
“Why are you asking us those questions? If you are a good doctor, you should know the answers yourself.”
6. What kind of treatment do you think the patient should receive?
“You should give Lia medicine to take for a week but no longer. After she is well, she should stop taking the medicine. You should not treat her by taking her blood or the fluid from her backbone.”
In the Hmong culture, the shaman (healer) is able to make a diagnosis immediately, and does not require blood draws or other invasive tests.
Her parents believed Lia should be treated at home with their Hmong medicines and animal sacrifices. They added, “We hope Lia will be healthy, but we are not sure we want her to stop shaking forever because it makes her noble in our culture.”
7. What are the chief problems the sickness has caused?
“It has made us sad to see Lia hurt, and it has made us angry at Yer.”
Yer is the Hmong word for the “youngest daughter."
8. What do you fear most about the sickness?
“That Lia’s soul will never return.”
Why should nurses ask these questions?
Using these questions as a guide helps us look at our patient’s problems through their lens, thus improving cultural competence. By approaching patients from their perspective, we meet them where they are and can deliver our ideas in the right context. This creates understanding and the opportunity to meet our patient’s needs. From there, we can form more appropriate care plans and truly advocate for our patients.
Fadiman, A. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. Farrar, Straus, and Giroux.
Morganne Skinner, RN, BSN (@fertilitydefined / Fertility Defined) is a registered nurse, writer, and fertility awareness educator. She is the owner of the fertility awareness business Fertility Defined. She has 7 years of nursing experience in the surgical-trauma ICU, rehabilitation, communicable disease and maternal child health. She served as a Peace Corps volunteer for two years in rural Zambia, where her passion for public health and women’s health grew. Her speciality writing topics include health literacy, cultural communication, fertility and women’s health.