Guest Editor’s Introduction: Culture and Causal Chains of Care—A Perspective on the Chronology of Health and Medical Communication in Cross-Cultural Contexts

Abstract

Today, diseases can spread internationally faster and farther than ever before, and a range of public health issues can “go global” quickly and easily. The challenge becomes communicating ideas of care—that is, issues of health and wellness—across different cultures, languages, and geopolitical contexts. Doing so involves understanding the dynamics of such factors and how to apply this knowledge effectively. The entries in this special issue examine such factors and provide readers with frameworks for understanding and strategies for addressing these issues.

Keywords

culture care context context of care causal chains of care intervention points

Introduction

Care encompasses the processes we use to address health and wellness. Sometimes, these activities are restorative and focus on returning a person to a prior state of wellness. In other cases, they are preemptive and involve maintaining one’s current state of health. The objective of such activities is generally universal: To achieve a state of wellness that society considers “healthy” (World Health Organization, 2019). The approaches used to provide care, however, can vary from culture to culture (Agency for Healthcare Research and Quality, 2015). The better we understand such differences, the more effectively we can share care-related information across cultures (St.Amant, 2019).

Culture and Contexts of Care

Cultural approaches to care often differ according to how groups perceive the context of care, or settings where one administers or receives treatment (St.Amant, 2017a). Cultures can have varying expectations of how to assess and address health and wellness in different situations (St.Amant, 2019). In some instances, cultures differ in the bodily processes examined when evaluating health. Many of us, for example, consider blood pressure a biological factor assessed to determine our health. Evaluating the condition of our chi (i.e., life force), in contrast, is a care-related activity some groups use to assess wellness, but not others.

Determining how to interpret and respond to medical data can also differ from culture to culture (Moga, 2015; Srinivasan, 2014). The American Heart Association, for example, recently changed the criteria for the systolic and diastolic readings that constitute “high blood pressure” (Warner, 2017). As a result, a number of individuals found themselves with a condition—and needing a related plan of care—they did not have prior to this decision. Moreover, as the American Heart Association is a U.S.-based entity, that reclassification only changed the health status of individuals in the United States. This factor meant blood pressure readings interpreted as “normal” in one nation could be seen as indicating “high blood pressure” in another (Crimmins, Garcia, & Kim, 2019). It also meant the same numeric readings could result in different kinds of care across cultures.

Cultural Perspectives and the Dynamics of Care

The information collected when assessing wellness affects the practices used to maintain or restore health. Medical science, for example, generally addresses conditions based upon a particular approach to researching biological/biochemical processes (Evidence-Based Medicine Working Group, 1992; World Health Organization, Regional Office for the Western Pacific, 2001). This is because modern medical science often involves certain, relatively standardized approaches for collecting and evaluating biomedical data when assessing wellness (Richesson & Nadkarni, 2011). Such practices have led to the development of materials (e.g., pharmacological products) considered effective mechanisms for addressing a condition (see, e.g., US Food and Drug Administration, 2018). In essence, a particular approach to data collection and interpretation has led to a perspective of what constitutes legitimate care in a given society. Such practices also affect what a society considers legitimate materials for providing care.

More traditional (i.e., homeopathic) approaches to medicine often assesses factors modern science does not or cannot measure according to its current practices (Bassett, Tsosie, & Nannauck, 2012; Gorski, 2018). The assessment of one’s chi, for example, is common in much of traditional Chinese medicine. Determining health according to one’s chi, however, often encompasses data collection practices different from how current medical science approaches the assessment of wellness (see, e.g., Turner, Linden, Talbot Ellis, & Millman, 2010). Likewise, evaluating health based on one’s chi generally exists outside of modern allopathic approaches and relies on more traditional/homeopathic practices (Johnson, 2018). The same is the often case for treating poor health associated with the state of one’s chi. In these situations, care often involves a time-honored approaches versus those tested by scientific means like clinical trials. Thus, what constitutes legitimate caregiving practices can vary across and within cultures.

The approaches used to provide care can likewise vary from culture to culture. Certain groups, for example, consider the use of medication to manage blood pressure the standard approach to treating a condition. Other cultures are less quick to use pharmacological approaches as the primary method of care in these situations (Horne et al., 2004; Galanti, 2004; Putsch & Joyce, 1990). Rather, individuals might initially turn to diet and lifestyle changes to manage the same condition (Jarbøl et al., 2017). In such situations, persons could view pharmacological approaches as a much later or even final solution if other methods of treatment do not work.

Accessing Care in Cultural Contexts

Processes for accessing care can also differ across cultures. These variations can include who can engage in legitimate care-related practices, when, and where (Nielsen-Bohlman, Panzer, & Kindig, 2004). For many in the United States, one generally goes to a clinic or hospital to meet with a physician who assesses the individual’s health in that location. Based on this assessment, the physician might prescribe a course of treatment. If the physician considers a pharmacological product part of the needed care, the physician must provide the patient with the authorization needed to access the materials of care, or mechanisms essential to that treatment. (In this case, the physician must provide the patient with a prescription to obtain certain medication.) The patient must then go to a different location—a pharmacy—to have that material of care dispensed by someone other than the physician who reviewed her/his health, diagnosed the condition, and prescribed a course of care.

In France, by contrast, the approach to accessing care—and associated materials of care—can be quite different. For less acute conditions, many French individuals first go to the pharmacy, not the hospital. There, they meet with a pharmacist who will collect certain medical information (e.g., a verbal description of the condition) from them. Next, the pharmacist assesses this information and prescribes a course of treatment that sometimes involves a pharmacological product (materials of care). The pharmacist then dispenses that item to the individual in that location at that time (“French ‘Pharmacies,’” n.d.). In such cases, the patient does not visit a hospital or clinic or meet with a physician, nor does the individual need to go to different locations to engage in overall care-related practices.

Mapping the Journey of Care

The process by which individuals move to and through spaces when accessing and receiving care can be considered the journey of care (see, e.g., Guilcher et al., 2013). The idea is individuals need to move through certain locations in a particular order to access different aspects of care (Institute for Healthcare Improvement, 2003). Many U.S. patients, for example, enter a hospital at a check-in area where clerical staff collect certain information. They next move to a preliminary examination area where a nurse or physician’s assistant collects initial medical data (e.g., height, weight, blood pressure, and pulse rate). The patient then moves to an examining area to meet with a physician who performs a more in-depth assessment of the patient’s health.

In this journey of care, each space is often associated with receiving a certain kind of care from a particular individual (Reiling, Hughes, & Murphy, 2008). Such care generally involves different materials of care/instruments used to provide that care or collect care-related information in that space (St.Amant, 2018). These processes include everything from the collection of medical data to the assessment of health based on that information (diagnostics). They can also encompass the planning of a course of care and accessing the materials needed to receive or administer that care. The idea is each process is associated with a particular location where it is performed. These expectations, however, are based on the individual’s experiences of moving through the journey of care.

The different steps and locations in this journey and the order in which individuals visit them (or if they visit them at all) can vary from culture to culture. So too can the care-related processes that individuals expect to be performed in each location, the persons expected to perform those activities, and the materials associated with such practices. (Consider the prior example of visiting the hospital vs. the pharmacy first to receive care.) These variations can cause confusion when members of one culture create care-related materials for a different cultural group. Such differences can also lead to skepticism concerning if a given course of care is considered credible and worth pursing (Anderson, Scrimshaw, Fullilove, Fielding, & Normand, 2003).

The Timing of Accessing Care

The decision of when to seek care can also vary from culture to culture (American Academy of Pediatrics, 2019; Machado, 2014). This timing aspect is crucial in determining where individuals go to receive care (e.g., an emergency medical facility vs. a walk-in clinic). It also affects

The care needed to treat a condition at a given point in time

The materials required to providing such treatment

The medical practitioner—in terms of specialization—essential to providing that care

Treating a cut when it happens, for example, is different from treating an infection resulting from a cut that was left unattended over time. Understanding such timing dynamics is central to developing materials that meet the needs of patients based upon when they access care.

For the purposes of this entry, the term causal chains of care refers to how a medical condition can change over time. These chains examine

How a medical condition can progress and affect a patient’s health if not treated

What happens if proper treatment is not received in a timely and effective manner

Understanding causal chains of care can help health and medical communicators address the process individual go through to access care at a time of need. The question becomes, “When do individuals expect to access care, and what does this factor mean for their condition when they seek care?” The answer affects the care needed based on the state of patients when they receive treatment.

Causal Chains of Care

Health and medical changes affecting care often move in a certain direction if a condition is left untreated. The same is generally the case if ineffective treatment is administered either once or over time. This process generally develops according to the progression in Table 1.

Table 1.

How a Medical Condition Changes Over Time (Causal Chain of Care).

Healthy →	Event →	Malady →	Progression →	Damage
The state of normal health as defined by a given society	Something happens that affects the nature of one’s health moving it away from healthy	Failure to treat an event completely or effectively at the time it occurred leads to a new condition of degraded health	The newer, degraded health condition is left unattended or is ineffectively treated and the person’s health continues to decline	Lack of care—or ineffective care—over time causes a permanent change in the individual’s health—one where the individual cannot return to the state of health prior to the initial event that changed the person’s health

In this sequence, if an individual does not receive effective care at a particular point in time, one state of health leads to another, more degraded state requiring a different kind of care to treat the condition. This process continues until the final state—damage. At this point, the patient’s health has changed so greatly that a new course of care-related action is needed. It is a situation where the patient has undergone a permanent change that cannot be rectified (e.g., loss of a body part or loss of life). Each of these states of health and wellness represents a link in an overall chain of events where the individual’s health changes over time. As such changes occur, the patient’s health moves from one link in the chain to the next.

Consider the following example: An individual is at a state society considers “healthy”—having no maladies per societal definitions of them and all biomedical readings are “normal” per social conventions. Then the individual is involved in an accident and cuts herself or himself. This situation that causes injury—or a change in the person’s health condition—is the event (Event, n.d.). Often, the event requires some form of immediate treatment (e.g., cleaning the wound, bandaging it, and getting a tetanus shot) as the person’s health situation has been compromised.

If left untreated, the injury could lead to an infection (malady) that worsens the persons’ health. An untreated infection could become increasingly worse to the point where it threatens the person’s life if not treated (progression) —in the case of an untreated infection, sepsis could occur. If this progression situation goes untreated for too long, the person’s health could become so diminished that either an extreme form of treatment is needed (e.g., amputation of a gangrenous limb) or death occurs. Both final situations result in a state of degraded health that has led to irreparable damage to the patient and resulted in some permanent change to his or her body (e.g., loss of limb or death).

A similar situation can occur with infectious diseases. One is healthy and is then exposed to a pathogen (event). If this condition is left untreated after immediate exposure, it can lead to illness (malady). If the illness/malady is not treated, it can lead to the onset of an acute or advanced-stage condition (progression). And if care is not provided at that advanced stage, the result could be death or irreparable damage to the person’s body (damage).

In these scenarios, the nature of the event and the resulting adverse health condition might differ. In all of these instances, however, if care is not administered at certain points in this process, one state of health where certain care is needed can lead to a different, more degraded state of health. At this more degraded stage, a different kind of care is required to treat the condition. The care required to treat early stages of an illness, for example, often differs from the care needed to treat the advanced stages of the same illness. In these causal chains of care, each link represents a state of health that leads to the next link if one does not receive effective care at that link/stage.

Intervention Points in Causal Chains of Care

Within causal chains of care, one must make a decision about when to seek out treatment. The point in the causal chain where care occurs in an intervention point: It is the time at which someone intervenes to try to prevent a condition from moving to the next stage/link in the causal chain (Shiel, 2018). When this intervention point occurs affects the kind of care one needs and will receive based upon the individual’s health at that stage in the overall chain.

For some persons, the focus of care is on prevention, or continuous processes that maintain one’s level of wellness as “healthy.” Accordingly, the focus of actions is on preventive care involving a healthy lifestyle to avoid the onset of adverse health conditions. In such cases, intervention is a daily event in which one’s lifestyle involves maintaining health via all aspects of life (e.g., daily diet, exercise, avoiding hazards, etc.). In other cases, intervention occurs the moment an event happens: One has an injury and immediately goes to the hospital to have it examined and treated. Similarly, one might notice a change in daily wellness (e.g., a cough, headache, or a persistent pain) and quickly seek out care. In these situations, the focus is on treating a health change the moment an event happens or is noticed.

When an intervention occurs affects where care can be administered. For individuals focused on preventative care and staying healthy, the intervention generally occurs the contexts of one’s home on a daily basis. In the case of responding to an event, the intervention often occurs at a clinic or hospital where one needs access to certain expertise to treat a condition. Such dynamics affect who can administer care (e.g., the individual or a physician) based on where the intervention occurs.

Sometimes, individuals only seek intervention at a much later point in the causal chain of care. In these cases, the individual often ignores the initial event—be it dismissing a physical injury or disregarding a change in some aspect of health (e.g., a cut is not treated or a hacking cough is ignored). The person instead waits until the initial injury or condition has progressed to the state where some degree of nontolerable pain or discomfort results; only then does the individual seek treatment (the malady stage). At that intervention point, one must often address a more advanced stage of a condition (e.g., an infection or the complete manifestation of an illness). At these times, intervention often requires more focused and aggressive care than if treatment had been administered at the time of the event that led to the malady stage.

If, however, intervention does not take place at the malady stage, the condition could continue to worsen to a more acute state (e.g., one’s pneumonia goes untreated to the point the lungs have filled with fluid and it is almost impossible to breathe). At this point, the progression stage, individuals could find themselves so debilitated that without intervention, permanent damage—or even death—might occur. In such instances, intervention generally involves providing more extreme care to fend off worst-case scenarios that have become a possible reality. If intervention does not take place at this progression stage, the nature of the person’s health changes in a way that will result in a permanent alteration in his or her overall health, wellness, and state of being. At this point, a degree of damage has occurred and so it is no longer possible to return an individual to the state of health or lifestyle that existed prior to the event. Rather, some permanent alteration of the body has occurred (e.g., an organ will no longer work effectively) or the person has died.

When interventions occur—or when care is sought—within this causal chain affects both the kind of care expected and received as well as what that care entails (Committee on Assuring the Health of the Public in the 21st Century, 2002). The key is when individuals seek out intervention in this chain, for that timing affects what constitutes effective, expected, and acceptable care at that point in time.

Decisions of when to intervene in a causal chain of care are often individual; however, these individual preferences frequently reflect greater cultural perceptions and preferences associated with health, wellness, and care (American Academy of Pediatrics, 2019; Machado, 2014; Rosenstock, 2005). How cultures perceive interventions within causal chains of care affects the expectations individuals have for what care is and the communications and materials associated with accessing and receiving such care (Ferwerda, 2016; Sung & Park, 2019). Health and medical communicators need to understand such dynamics to create materials that address the needs of a group or that prompt members of a group to seek care at a particular point in time.

Culture, Access, and Interventions Within Causal Chains of Care

Perspectives of time can affect how cultural groups behave within causal chain of care. This is because the dynamics of when individuals seek to access and receive care can vary from culture to culture. So too can related expectations of when and how care is provided in different cultural contexts (St.Amant, 2017a; Country Health Rankings & Roadmap, 2019). Such differences can reflect when an intervention in the causal chain of care is possible or considered acceptable by certain cultures.

In some cases, these timing aspects involve hard infrastructures—or the physical realities of where a group is located (St.Amant, 2017a, 2017b). Access to health-care providers or facilities can be limited in certain regions. In such cases, individuals generally

Travel to other areas to receive care only when situations are dire

Must wait for traveling health-care services to visit their region

In either case, access to care is limited to times when it is available or when undertaking considerable travel is seen as the only option.

Per causal chains of care, such factors mean intervention points can be limited. As such, when an intervention occurs can be beyond the individual’s control, such as the schedule for when a mobile health service arrives next (St.Amant, 2017a). Alternatively, individuals could associate intervention with a level of difficulty, discomfort, or loss in terms of time, wages, or other factors of value. This situation could result from a lack of access to facilities in the area, thus requiring considerable travel. It could also reflect a relatively high cost of accessing care requiring one to save up a certain amount of funds over time. In these situations, the individuals in an area might only seek care when no other option seems available. Such factors affect when in the causal chain of care individuals can access treatment. These timing factors affect what treatment is needed, who can administer that treatment if specialized care is essential, and what materials, such as pharmacological products, are required to provide such care.

Access is a key to all aspects of these dynamics (St.Amant, 2017a, 2017b). If a care provider cannot access the materials needed to administer care at a given time, her or his ability to intervene in a causal chain of care is limited. This factor affects when in an overall healthcare situation individuals receive treatment for a condition. It also affects the quality of the treatment individuals can receive at a particular time. Similarly, certain kinds of care can require the use of particular items, like pharmacological products, over time. This factor affects how care is scheduled and treatment is provided in regions where regular access to such materials is limited or sporadic.

These constraints affect the nature of the intervention that takes place when individuals seek treatment within a causal chain of care. In cases of limited access, the scheduling of treatment often needs to change to address local realities (St.Amant, 2017a). The reality could be that the point at which a care provider sees a patient is the only time the patient has access to treatment. As such, the dynamics of time associated with that context of care require different approaches to the timing of treatment. Such approaches could involve providing one massive dose of antibiotics to treat an infection versus creating a schedule of regular, smaller doses of antibiotics over time. These factors can also influence if the resulting care can stop the progression of a condition from moving to the next, more dire stage in the causal chain. Such concentrated, short-term treatments, for example, might not be the best way to address a condition and could perhaps harm the patient. Unfortunately, such options might be the only ones available due to restricted access to care providers and care-related materials.

Perceptions, Preferences, and Interventions in Causal Chains of Care

In areas where hard infrastructure is stable, it is often relatively easy to access care facilities and care providers. In addition, an effective infrastructure generally means the predictable transport of individuals and of care items that permits more predictable planning of treatment. As a result, it is relatively easy to schedule regular visits to monitor and treat a condition. In such situations, the timing dynamics affecting when individuals access treatment often reflect factors of soft infrastructure—or cultural attitudes and behaviors associated with caregiving (St.Amant, 2017a, 2017b). Such soft infrastructure factors, moreover, can also affect perceptions of and behaviors associated with seeking care in most cultures, regardless of if hard infrastructure is stable or not.

Cultural perceptions and traditions of when to seek care can play a major role in when and how individuals access treatment (Saint Arnault, 2009). Certain cultures might consider it essential to access care at the first signs of a potential illness. As such, the negative social stigmas associated with taking time off for care and wellness checks might be less intense in these societies. This perception could prompt individuals from these cultures to engage in care-related practices very early on in causal chains of care.

Other cultures might consider it imperative to maintain a continual level of health and adjust their lifestyles and care-related visits with a regularity designed to maintain health versus treat illness (Jarbøl et al., 2017). Yet other cultures might associate care with a final approach to be used only when things are to the point that nothing else can be done or pain and suffering is too intense to tolerate. In these instances, individual do not seek out care until much later—if at all—due to social perceptions or taboos associated with how they might “look” or “appear” to others (see, e.g., Kramer, Kwong, Lee, & Chung, 2002). These cultural perspectives versus actual physical restrictions affect how cultures approach care in terms of when, where, and by whom it is administered.

Such soft infrastructure factors can also affect how cultures view lifestyles in relation to care and wellness. For certain groups, the desire to maintain one’s health and engage in healthy behaviors on a regular basis could be a core cultural belief. As such, the culture often encourages or facilitates such behaviors (Mesi, 2019; Whelan, 2019). The manifestations of such attitudes can range from the creation of public athletic facilities or parks that provide easy access to exercise facilities to taxes and legal restrictions limiting access to unhealthy foods or unhealthy substances. Such cultural practices can also include restricting unhealthy activities to certain locations (e.g., one can only smoke outdoors) that makes them inconvenient or that exposes individuals to a degree of public scrutiny and potential shaming. These cultural approaches can also encompass social pressures that prompt individuals to confirm to a group norm of wellness and healthy behaviors.

Other cultures might take a different view of health and wellness. The perspective could be individual’s rights to engage in an unhealthy lifestyle are paramount to the social good of advocating for healthy behavior across a society (Mohammadnezhad et al., 2015). In such cases, the use of public funds to create public spaces for health and wellness might be decided based on local decisions of what the community wants (e.g., to build a public park to foster exercise vs. a sports arena to foster passive viewing) versus centralized governmental determinations of what can contribute to the health and wellness of a community. These cultural perceptions can also affect the access individuals have to unhealthy foods and other substances such as the ease with which one can purchase cigarettes and the cost associated with purchasing them. Likewise, cultural perceptions can affect the uses of exclusionary or exposure behaviors designed to make adverse health practices unattractive and undesirable. Social and governmental policies, for example, could allow individuals to smoke indoors and in relatively private spaces versus require them to smoke outside or in restricted locations where they can be observed.

Infrastructure Conflicts and Access to Care

These factors of hard and soft infrastructure influence where individuals receive care, from whom, and the nature of the care received (Committee on Assuring the Health of the Public in the 21st Century, 2002). As such, they can create expectations cultures have for what constitutes legitimate or responsible care (St.Amant & Angeli, 2019). These expectations affect if one is seen as legitimately seeking care versus seeking excessive care to gain attention. They also encompass perceptions of recklessness with care-related behavior such as if individuals are seen as taking “too long” or “longer than is reasonable” to seek out care. These perceptions reflect cultural expectations of legitimate interventions. In causal chains of care, they also reflect cultural expectations of what constitutes legitimate care based on when an intervention occurs and what needs to be and can be done at that point.

Further complicating this situation is who may initiate an intervention according to cultural norms (American Academy of Pediatrics, 2019; Attum, Waheed, & Shamoon, 2019). Is there, for example, a socially acceptable minimum—or maximum—age at which individuals are expected to seek out and engage in caregiving activities themselves versus through parents or guardians? Are there situations when one must be a particular sex or status to interact with a caregiver and make greater society aware a family member needs care? The answers often depend on the culture of the individual seeking care.

These cultural dynamics can also affect the care one can legally receive in a society based on perceptions of conditions and the acceptable means of treating them. Access to screening for sexually transmitted diseases, for example, could be restricted in different areas based on cultural perceptions of a condition and associated behaviors. Similarly, certain care might be forbidden or limited due to legal or social factors that restrict who can provide such care, where, and when (Snyder & Crooks, 2015). These cultural–social–legal restrictions also apply to the materials one can access and use when administering or receiving care. Such restrictions can encompass pharmacological products legal for sale and use in one nation but not another (Wood, 2018). They can also encompass technologies considered tested, safe, and legitimate in one geopolitical-cultural area, but considered inadequately tested or unsafe according to the laws of another (Sullivan, 2018).

In certain cases, these soft infrastructure perceptions create hard infrastructure limitations by restricting access to care facilities, care providers, or materials of care. In such situations, individuals in one nation might have to travel to another region or country—and find the time and resources needed to do so—to receive care that is accessible in that other place, but banned where the individual lives (Snyder & Crooks, 2015). These factors of limited access can affect the kinds of sustained versus short-term care one can receive based on how easily one can access caregivers for follow-up visits or access materials essential to regular treatments.

All of these factors affect how individuals share information about care, health, and wellness across cultures. The better individuals understand the dynamics of causal change of care and intervention points across cultures, the more effectively they can create materials for communicating health and medical information to other cultural audiences. This special issue represents an initial examination of such factors. The contributors review different aspects of causal chains of care and intervention points. In so doing, these authors highlight how factors of hard and soft infrastructures affect what constitutes effective care communication in different regions and cultures. Through these approaches, the contributors reveal the nuances associated with communicating about care in different cultural contexts.

Overview of This Special Issue

The authors in this issue review different infrastructure aspect affecting when and how the members of a culture access care. Together, these articles reveal the ways physical barriers created by hard infrastructures and cultural parameters established by soft infrastructures influence access to and uses of health and medical information. The entries also detail how such aspects can influence when individuals from different regions and cultures seek intervention in causal chains of care.

The issue’s first entry, “Crowdsourcing, Social Media, and Intercultural Communication about Zika: Use Contextualized Research to Bridge the Digital Divide in Global Health Intervention” by Huiling Ding, presents a case study of care communication in cross-cultural contexts. Specifically, Ding’s article examines the Smarter Crowdsourcing project for addressing emerging Zika outbreaks in Latin America. Her review of the events associated with this process reveals how factors such as government policies, legal systems, and IT networks can converge to affect the sharing of care-related information. In so doing, Ding’s case study reveals the ways soft infrastructure factors like perceptions and attitudes can combine with hard infrastructure factors such as computer networks to affect access in causal chains of care. Ding also provides insights others can use to identify and address such factors in the future. Her entry reveals how an understanding of such dynamics is central to effective international intervention at key points in causal chains or care.

Lisa DeTora and Michael J. Klein continue this examination of infrastructures and access in global settings. In their entry “Invention Questions for Intercultural Understanding: Situating Regulatory Medical Narratives as Narrative Forms,” the two examine how the use of narratives in regulatory contexts can affect the international sharing of health and medical information. DeTora and Klein review how physical distances and cultural perspectives affect the ways nations engage in clinical trials. They also examine how such infrastructure aspects influence when individuals in different nations can access information and even treatment in causal chains of care. In so doing, DeTora and Klein present a framework for understanding narrative competence in medical contexts. They also note how technical communicators could use this framework to enhance the role they play in sharing health and medical information in international environments.

The final entry, “Glocalization of Health Information: Considering Design Factors for Mobile Technologies in Malaysia” by Evelyn H. Saru and Patti Wojahn, discusses how technical communicators can address infrastructures factors within a nation: Malaysia. Saru and Wojahn note technical communicators can use glocalization—or creating materials that meet the expectations and needs of specific groups—to devise technological approaches for sharing health and medical content with different cultural, linguistic, and religious groups in Malaysia. The authors then explain how individuals can achieve this objective by using the international patient experience design (I-PXD) method to guide such activities. In discussing these ideas, Saru and Wojahn present a method that technical communicators can use to address infrastructure factors affecting access to care in different international contexts. Their combined glocalization/I-PXD approach represents a mechanism for creating materials that meet the needs of different groups and can facilitate access to care. By using this method, Saru and Wojahn explain, technical communicators can help persons around the world access causal chains of care more effectively and more successfully.

Each entry in this issue presents a method for examining a particular communication issue in a given international or cross-cultural context. Through these examinations, the authors identify how infrastructure factors can affect access to treatment in causal chains of care. They also reveal how technical communicators can approach this area of inquiry and expand upon the ideas they discuss. By building upon such work, researchers, teachers, and practitioners in technical communication can make meaningful contributions affecting local care practices and enhancing global health outcomes.

Final Thoughts

The dynamics affecting when cultures seek interventions in causal chains of care is complex. Addressing such factors requires an understanding of the infrastructure aspects affecting access to care. Targeted research on specific, local contexts is essential to achieving this objective. By working with the members of a culture, technical communicators can identify the workings of causal chains of care and create materials that help individuals access care within such contexts. The entries in this issue represent important, initial research in this area. They all reveal how hard and soft infrastructures affect perceptions of and access to care. In so doing, the authors reenforce the idea that studying the cultures involved is essential to successful information sharing across nations and cultures.

In sum, the entries in this issue present examples of how to examine culture and causal chains of care. Readers should consider how to build upon these ideas to encompass an ever-growing range of cultures and areas. Key to this process is sharing information to provide the targeted findings needed to understand such cultural concepts and address local dynamics. It is a collaborative effort requiring input from an overall field and across disciplines. While engaging in such processes will not be easy, doing so is essential to providing effective care in today’s global age.

Footnotes

Acknowledgment

The author wishes to acknowledge the Eunice C. Williamson Endowment for its support in completing this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Kirk St.Amant

Author Biography

Kirk St.Amant is a professor and Eunice C. Williamson Endowed Chair in Technical Communication at Louisiana Tech University and is an Adjunct professor of International Health and Medical Communication with the University of Limerick in Ireland. He is also a Research Faculty member with Louisiana Tech’s Center for Biomedical Engineering and Rehabilitation Science (CBERS) and is the director of Tech’s Center for Health Communication.

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