This study provides insights into how healthcare providers experienced culture as a factor that influences or explains adherence to self-care advice for patients with chronic heart failure and how their own cultural background shapes their experiences and their practices. The findings illustrate that the cultural background of both the healthcare provider and the patient can affect the practice of providing self-care advice.
An important reflection of the healthcare providers was that culture permeates in all facets of self-care and it is not enough to focus only on one behaviour or only one aspect of culture, e.g. food habits or religion. With regard to lifestyle changes, the cultural differences in this study seemed to be most distinct between the Jewish and Arab cultural groups. This is congruent with findings from previous research where a discrepancy was described between wanting to change and actual healthy behaviours in the Arab-Muslim population in Israel.18
These findings also support differences found in other studies reflecting self-care differences in culturally diverse populations or in different countries worldwide. 2,19
Some types of self-care advice can interfere with strong cultural traditions or beliefs and the barriers may therefore be difficult to overcome. For example, culinary traditions, religion’s daily cooking, attitudes to physical activity.20
In this study health care providers from different cultural backgrounds recognized the importance of self-care for their heart failure patients. However, from previous discussion in literature it is important to consider that people with different backgrounds might have different goals for their self-care and the concept of self-care can be seen as being too focused on Western culture and might not been seen as important in cultures that are less focussed on autonomy. In some cultures individuals are less focussed on their own needs and autonomy as in many Western cultures but instead are more than focussed on not disrupting the happiness of others, even at the expense of their own quality of life.21
Cultural traditions and beliefs or religion do not always support medical treatment or adherence to self-care. 22 10,21
In this study is was of particular interest that health care providers described their constant awareness of the cultural issues related to self-care and the impact it had on the care provided.
Cultural background of both the health care provider and the patient and the interplay between those were important considerations. A shared cultural background facilitated better understanding between health care provider and patient and the health care providers expected this to lead to stronger adherence to self-care advice in their patients. This is in line with findings from an US study in which black patients had highest adherence to medication when treated by a black healthcare provider.23 Healthcare providers in our study described that they adapted their way of giving advice based on the cultural or religious background of their patients, but they were aware of issues of mistrust or prejudice. Such a mistrust or frustration because of non-optimal communication was previously described.24 Cultural distance is described as possibly negatively associated with the patients’ trust in their healthcare professionals and their ratings of quality of care.25
Finally, as described in our findings ‘culture is only part of the puzzle’, other factors might be more prominent than culture; for example, the different socioeconomic levels that are connected to a certain cultural group in certain circumstances. 26
In this study we found that several different aspects of culture, economic situation and health knowledge were interrelated. The category describing ‘Mutual cultural background can help or hinder’ described the complex matter of culture of patients and health care professionals and the professionals also described several issues that does not only reflect the country people are born in or the religion people practice but that sometimes the combination of several aspects colored the perception of the health care professional. An intersectional theory approach is relevant for future studies in which micro- and macro-structures of power that operate in patients’ lives can be within the unique social spaces that they occupy. A recent study on stroke prevention in Arab immigrant women in Canada showed that there were unique pathways of privilege or vulnerability stemming from life stressors, lack of health literacy, and limited financial resources.27
Summarizing, this study on the perspectives of health care providers gives important insight in the need to be aware of cultural background of both health care providers and patients. With increasing global migration, a wide cultural competence is needed. Earlier research has shown the benefits of specialised programmes aiming to improve cultural competence among healthcare providers, although more research is needed to provide evidence of better patient outcomes. 28 An education module for healthcare providers treating HF patients from different cultural backgrounds might be helpful for improving communication between healthcare providers and patients and thus possibly increasing patient adherence to self-care.
Finally, it is important to retain a patient-centred approach and, although adjusting care based on patients’ cultural background is vital, it is also important to consider that not all patients might identify themselves through their culture or feel a strong cultural identity.
Strengths and limitations
This study has several strengths and limitations that need to be considered when interpreting the findings. The aim of the study was to gather information in a relatively unexplored area of research and provide a foundation for further research. To keep the discussion about culture broad we did not define culture before the interview but instead ask the participants to reflect on what culture was for them first before starting the questions. We did not give them a definition on what we meant by culture but left it to the participant. On one hand this can be seen as a strength, since we gave the participants the freedom to have a broad interpretation without steering them in a certain direction. On the other it might make the interpretation of the results less clear.
A strength of the study is that we included health care professionals from various cultural backgrounds who also treated patients with different cultural heritages. Talking about cultural differences is sensitive and carries the danger of talking about prejudice towards people from a certain culture.. We acknowledged this in the interviews and ensured that the interview discussions were strictly confidential. The language differences might have created a barrier to fully understanding every participant, but most of the participants were fluent in English. The interviewer was not of Israeli origin and thus impartial, which might have facilitated unbiased discussions with regard to the different populations examined. Since there is a current political conflict in the country, this could have influenced the participants’ willingness to answer questions and might have coloured their answers.
Since we used a convenience sample and the main goal was not to focus on professions, we did therefore not activity look for an equal balance in health care professions. Future studies might look for a more balanced sample and even compare different professional background for similarities and differences.