Perspective
Understanding health
workers' anxieties in a diversifying world
From a qualitative study, Joe Kai and colleagues have identified
opportunities to empower health professionals to respond more
effectively to challenges in their work with patients from diverse
ethnic communities. Karen Daniels and Leslie Swartz discuss the study in
this ‘perspective’ article.
We live in an age of
evidence-based medicine[1],
and with good reason. It is
important to be able to evaluate
the likely impact of
various interventions, and it
is no longer acceptable to
practice health care on the
basis of received wisdom
and anecdotal evidence,
which has convincingly
been shown to be subject to
serious bias[2].
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One of the dangers of the
evidence revolution in
health care, however, is that
the emphasis on an actuarial
approach (see Glossary)
to evaluating health interventions
may obscure the
influence of more complex
interactions between
patients and health professionals[
3]. The impact of
these interactions upon
health care outcomes may
be idiosyncratic and rather
difficult to measure.
Two
important ways in which
evidence-based medicine
has attempted to account
for these interactions are (1)
the increasing emphasis on
what is variously called
effectiveness (as opposed to efficacy) research, and (2)
the project to turn evidence
into clinical practice guidelines
so that patients receive
consistent care.
What is clear, however, is
that neither of these developments
can ever account
fully for the nuances in style
and attitude that may differentiate
one clinician from
another, or one group of
clinicians from another.
We
know, for example, that
users of services may prefer
to be treated by clinicians of
a particular gender or background[
4,5], and that they
may at different times and
in different contexts wish to
be treated by someone very
similar to or very different
from oneself[6].
A new qualitative study
Qualitative research is the
best way to access the
nuances of difference that
may occur across different
contexts and individuals.
A
new qualitative study of
how health professionals
respond to ethnic diversity
among their patients, by Joe
Kai and colleagues, provides
an excellent example of the
contribution that qualitative
research can make to
our understanding of the
messier, more complex side
of health care[7].
The study involved 18
focus groups that included
106 health professionals
from a variety of disciplines
working with an ethnically
diverse patient population
in the Midlands region of
the United Kingdom.
Using
the constant comparison
method to analyse the interview
transcripts, a number
of themes emerged.
Professionals experienced
discomfort and uncertainty
in responding to the needs
of patients whose ethnicity
was different to that of the
professional, and they
worried about the possibility
of showing culturally
inappropriate behaviour.
Implications of the study
Kai and colleagues' study
provides a useful way to
think about the range of
anxieties felt by health
workers in the face of the
global phenomenon of
increasing diversity in populations,
and hence in health
care users and providers.
The authors call on us to
consider the implications of
the fact that despite the
existence of many (probably
numbering in the hundreds)
manuals and guidelines on
health care practice in the
context of cultural diversity,
the “real-world” experiences
of health workers may be
marked by uncertainty,
confusion, disempowerment,
and even fear.
Many manuals on intercultural
health care implicitly
position health care
workers as ethnocentric
(i.e., looking at the world
through the lens of their
own culture) and uninformed
about diversity,
therefore in need of
training.
But Kai and
colleagues' study suggests
that even when health care
workers are well aware of
intercultural issues, they
may feel trapped by their
sense of inability to do the
right cultural thing.
Perhaps
it is time for those of us
interested in cultural issues
in health to consider far
more carefully the
complexity of personal and
political positions in which
heath care workers, such as
the participants in this
study, find themselves to be
trapped.
The problem for at
least some health care
workers is no longer that
they know nothing about cultural diversity, but rather
that they feel disempowered,
as these authors show,
by what they do know.
This
finding suggests, in fact, the
opening of a new research
agenda. We need to know
far more about how health
workers in a range of
contexts experience and do
their work, not from a position
of naïveté about
cultural issues but as
consumers of a wealth of
literature exhorting them to
be more culturally sensitive.
A diversifying world
Kai and his colleagues' study
appears at a particular
moment in world history.
Not only is there increasing
mobility of populations
across the globe at an
unprecedented rate
(including large migrations
of health workers[8]), there is
also a sense in popular
media in a post-9/11 world
that diversity may be
dangerous[9].
The “other,”
once cosily romanticised in
many texts about culture
and health, is now sometimes
portrayed by both
governments and media as
potentially dangerous, not
only to individuals but also
to the fabric of entire societies.
Within health care,
furthermore, empowerment
of patients, and the erosion
of the automatic authority
once associated with
medical doctors in particular,
have led to a situation
in which health workers
can no longer rely on an
easy sense of their own
authority.
Global shifts, therefore,
combine with issues more
local to health care in
creating an environment
that is much more uncertain
for both health care professionals
and their clients
than it once was, and this
uncertainty mirrors and
reproduces much of what is
felt in society as a whole.
Readers of this journal who
are concerned with
providing the best possible
health care in a changing
world would do well to
consider carefully the implications
of the article by Kai
and his colleagues, and to
provide more examples of
fine-grained research that
should help us move to a
more sophisticated understanding
of what culturally
sensitive health care can
and should be.
The Authors: Karen
Daniels is at the Health
Systems Research Unit,
Medical Research Council,
Cape Town, South Africa.
Leslie Swartz is in the
Department of Psychology, Stellenbosch University,
Stellenbosch, South Africa.
Email: kdaniels@mrc.ac.za
Copyright: © 2007
Daniels and Swartz. This is
an open-access article
distributed under the terms of the Creative Commons
Attribution License, which
permits unrestricted use,
distribution, and reproduction
in any medium,
provided the original author
and source are credited.
Citation: Daniels K,
Swartz L (2007)
Understanding Health Care
Workers' Anxieties in a
Diversifying World. PLoS Med 4(11): e319 doi:10.1371/ journal.pmed.0040319
Competing Interests: The
authors have declared that
no competing interests exist.
References
Online links to references
are available with the original
article published
online: doi:10.1371/
journal.pmed.0040319
1. Sackett DL, Rosenberg
WMC, Gray JAM, et al.
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2. Davies HTO, Nutley SM
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(1998) Qualitative
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9. Swartz L (2002)
Diversity and danger
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Z J Fam Ther 23: 4.
Date
of upload: 22nd Jan 2008
