Case Study Suggestions (Prepared by Willa Y Aaron and Julie Walsh Kroeker)

Definitions of Disease

• Attitudes and beliefs toward illness and disease are culturally influenced. Some diseases are believed to be supernaturally imposed, or the result of “black magic.” Treatment options depend on the definition or perceived cause of an illness.
• Ex. Head lice are not considered something in need of a cure, but rather a cause for socializing.
• Westerners characterize Marshallese as delaying seeking treatment and then not following treatment plans completely. Marshallese, however, are often seeking relief from discomfort, rather than a cure for an illness.
• Preventative care (ex. Screening) is not viewed as necessary, and correspondingly follow-up care is limited once a patient begins to feel relief.

Traditional vs. Western Medicine

• Traditional medicine has a social (and sometimes spiritual) association. Compliance with traditional medicines is much greater because patients understand the social implications of not following the practitioner’s recommendations. The patient believes that he or she will be scorned by others if s/he does’ comply. Also, the family is involved in making sure the patient follows all the recommendations.
• This highlights a significant difference in health care practices. In western medicine, the emphasis is on individual physical health; in traditional medicines, the emphasis is on communal relations and social cohesion. Lack of approval or acceptance, marginalization by one’s society can cause personal health problems, just as smooth relationships can cure them.
• Thus, it is very important for Western practitioners to convey care and concern for their Marshallese patients, and to acknowledge the participation of the family in any individual’s treatment.

Taboo Topics 

• Discussion of sex, sexual organs, etc. is highly restricted. It is highly inappropriate in the presence of the opposite sex, and particularly in the presence of relatives.
• In practical terms this means that the gender of the doctor and also the translator are important factors in obtaining accurate information from patients. If at all possible, the patient, translator and doctor should be the same sex.
• This restriction also impact the ability of patients to discuss sexual history, sexually transmitted diseases, family planning, and other issues openly with a provider, or through a translator who may or may not be a relative. The patient could provide a trusted friend for translation in this case.

Translation - Guidelines for working with interpreters (Setness 1998)

• Use qualified interpreters and don’t depend on children or other relatives or friends to interpret (they may filter information inappropriately or the patient may be reluctant to discuss potentially embarrassing issues with the provider).

• Have a brief pre-interview meeting with the interpreter.
• Establish a good working relationship with the interpreter.
• Allow plenty of time for the interpreted session.
• Speak directly to the patient and not to the interpreter.
• Use words, not gestures, to convey your meaning.
• Speak in normal voice, clearly and not too fast.
• Avoid jargon and technical terms.
• Keep your statements short, pausing to allow interpretation.
• Ask only one question at a time.
• Expect the interpreter to interrupt when necessary for clarification.
• Expect the interpreter to take notes if things get complicated.
• Be prepared to repeat yourself in different words if your message is not understood.
• Have a brief post-interview meeting with the interpreter.

Cultural Concerns about Translation  

• Interpreter knowledge and ability
• The relationship between the translator and patient – issues of authority.
• Gender of translator – same sex is more appropriate
• A child should not translate for an adult
• Confidentiality is difficult to ensure because of the size of the community. Interpreters must assure the patient that what they say will not be shared with others.
• Suggestions: Ask about the relationship between the interpreter and patient. Speak directly to the patient. See Guidelines for interpretation.

Time

• Time is a cultural concept, much like disease. The Marshallese language has three verb tenses; English has twelve.
• Marshallese society is present-oriented. This represents a priority on the people one is with at the present moment. It may be considered rude to ignore the people around you in favor of keeping a prior commitment. Marshallese people understand this and allow for flexibility for social and family obligations. In a Western context this behavior has negative interpretations and consequences when appointments are late or missed, and strict schedules are interrupted.
• The different value placed on time also impacts interpretations of Western practices, since Marshallese patients may be offended by hurried or seemingly impersonal treatment.

Time and Appointments

• Present oriented, e.g. No date books, calendars
• Family interdependence vs. individual responsibility
• Suggestions: call to remind about appointment
• Request phone number for English speaking friend or relative
• Schedule longer appointment times so patients don’t feel rushed, especially since they may be late upon arrival.
• Don’t make patient feel embarrassed over missed appointments; but express care and concern and personal interest in treating patient.
• Be cautious about labeling patients “non compliant” – explore the reasons behind the behavior. (Was the patient receiving any traditional treatments? Was there a transportation issue?)

“Yes” 

• Be aware that YES has more than one meaning due to the necessity of cooperating with authority and the discomfort of refusing others’ requests.
• Yes may mean yes, no, or maybe.
• Ask follow up questions. WAIT PATIENTLY.
• “Can you come at 4?” can be followed with: How will you get here? Would 4:30 be better for you? Can you take the bus if your ride is late? Would you give me a call if you won’t be able to come so I can schedule other patients?
• Make it clear that No is an acceptable response. “It’s okay if that time doesn’t work for you. Tell when is better.”
• Assure them they are welcome to bring a friend.

Oral/Aural vs. Written Societies

• The value placed on life in the present is strengthened by the oral emphasis of the Marshallese language. Oral communication is not “fixed” in time. Unlike written documents, the spoken word is fluid -- it can be altered, revised, repeated, or ignored.
• Written documents while recognized as powerful, are also not commonly saved, stored, or valued, unless extremely necessary.
• Many documents are incomplete, or have inconsistent spellings of names.
• Unaware of the necessity for many documents, many immigrants arrive without the appropriate paperwork to enroll children in school, serve as guardians, etc.

Parenting Patterns and Roles

• Traditionally, parents are viewed as authority figures to be obeyed and respected. Children are expected to learn through observation and participation, not through questioning.
• Children are expected to work for the family, to have responsibilities and chores, such as preparing rice, doing laundry, or babysitting younger relatives and siblings.
• Discipline is often reactive, involving verbal and physical interaction. Mothers frequently defer discipline to the father, or another male.
• Grandparents are the cultural educators and teachers of the children. They may also be emotional supports for the grandchildren. Some restrictions of the parent-child relationship are relaxed between grandparents and grandchildren.
• “Parenting” is not the sole responsibility of mother and father, but rather a shared extended family responsibility for all the children.
• The intensity of parenting in nuclear family settings is unfamiliar and challenging to Marshallese immigrants.

Communication Strategies

• Recognize that your own authority impacts your interactions. Patients will be deferential and want to please you.
• Ask questions clearly and listen patiently --very, very, very patiently.
• Offer alternatives and encourage choices – avoid yes/no questions.
• Inquire about household composition, transportation, accessibility to resources, translation possibilities, familiar health practices, diet, etc.
• Express your care and concern; acknowledge the assistance and necessary cooperation of other family members for successful treatment.