'Compliance' in Health: Learning Lessons from Indigenous Science Education
Frederic B McConnel MBBS, DObstRCOG, MPH, FAFPHM, FACRRM, Public Health Physician, and
Michael Michie MSc, MEd, Education Consultant
Paper for presentation at AMA conference: 'Learning Lessons: Approaching Indigenous Health Through Education';22-24 November 2000, Darwin NT
Introduction
There are three assumptions underlying this paper:
· the word 'compliance' raises different images for different people, images which include unequal power relationships, "bending to the will…". In this paper it is used without prejudice to describe, simply, the uptake of medical (and other) advice and services.
· Western health professionals would generally concede that health activity in our hospitals, clinics, and in the community, is science based and that it is underpinned by the scientific knowledge and evidence of Western medicine.
· Western medicine has a culture, a recognisable set of beliefs, actions, and attitudes. It includes a scientific view of health, illness and disease. It contains a belief in the overwhelming centrality of health, and the awareness of health to all people. This belief system sets its practitioners apart from other professionals, from other groups in Western society, as well as from other societies.
Two events this year have been catalysts for the discussion which has generated this paper:
· the "Rethinking Compliance Project", and the presentation for discussion of a draft paper, "Forgetting Compliance: patient, practice and institution in indigenous health" by Kim Humphrey and Joe Fitz,
· the publication of Richard Trudgeon's book, "Why Warriors Lie Down and Die".
Rethinking Compliance
Recent Territory research under the auspices of the Cooperative Research Centre for Tropical and Aboriginal Health was called the "Rethinking Compliance Project". A draft paper, "Forgetting Compliance: patient, practice and institution in indigenous health" (Humphrey & Fitz, 1999) described research in the Territory which explored attitudes of nearly 80 health professionals to the issues of compliance in Aboriginal health. It was not research on Aboriginal people. The paper was circulated for discussion earlier this year. Very briefly, the outcomes of research were that compliance is generally regarded as an important issue, and non-compliance as a problem and a serious cause of failure to reach desired outcomes in Aboriginal health.
Solutions to non-compliance were seen in better health education, better patient education and better general education (i.e. education which supports a scientific approach to health); in negotiating treatment with patients, in better communication with patients, and in more and better cultural awareness training for health professionals
Two "Rethinking Compliance" workshops, for those who took part in the research, and for any other interested persons, were held in April. They were conducted by the project authors plus Geoffrey Angeles and Tarun Weeramanthri, and were designed to discuss the findings in light of the literature review, the philosophy and the research outcomes as part of an iterative process.
The word "education" featured prominently in these discussions, but this appeared to be entirely a Western medical idea of education. The education of patients, health education and negotiation of treatment was discussed only within the Western medical paradigm, the Western scientific system. The choices for patients were to conform or not conform to Western medical advice.
All of this education is applied science education, dealing with health science. There appears to be no perception in health that science teaching is any different from any other. There is also no apparent acknowledgment that Western medical and health education is assimilationist, that it embodies cultural violence, that patients are continually told, in effect, that their own worldview is inadequate or even wrong.
Cultural awareness was discussed in terms of deeper awareness of Aboriginal culture, not an examination of, or developing an awareness of our Western culture, in particular Western medical culture, with its arrogant dismissal of the validity of any other worldview. The workshop discussion produced very little comment on differences in worldview.
Cultural studies in science education
Research in cultural studies in science education has revealed several ideas about how students of different cultures, including the subculture of school, are able to cope with differences between their views of the world and that of scientists. None of this is necessarily unique to science education, however it is an area where it appears to have been given more consideration.
Fatima's rules
Fatima's rules (Larson 1995) were articulated originally as rules students use to minimise the effort required to pass chemistry classes without understanding much of the chemistry, by using strategies such as memorising only bold-faced words and phrases from textbooks. Atwater (1996) suggests that Fatima's rules can also include other strategies such as silence, accommodation, ingratiation, evasiveness and manipulation. The outcome of such strategies may be communicative competence (e.g. being able to pass exams) rather than meaningful learning in science or any other subject.
Fatima's rules apply not only to students but to teachers as well, and Aikenhead (1999) cites several examples from the literature that exemplify superficial teaching that can pass as legitimate teaching, such that students are working to get through chemistry (say) rather than working on learning chemistry. Classroom rituals and practices staged by teachers demonstrate unwitting complicity with Fatima's rules.
It is logical that Fatima's rules, or variants of them, would hold beyond the sub-culture of school science and apply in cross-cultural/intercultural situations as well. Strategies such as those suggested by Atwater may result in degree of communication ranging from no communication to competence rather than significant interchange. There is much anecdotal evidence of people (not only in cross-cultural situations) responding to communication by providing a response the inquirer anticipates and is happy with. The case of Margaret Mead and Coming of age in Samoa would seem to be a pre-eminent example. At the other extreme, Trudgeon (2000) cites an example where Yolngu elders had decided that they "would not say no to Balanda any more" (p.190).
As language is often a significant factor in cross-cultural communication, it may be the case that sufficient competence in both languages by each partner is a requirement for significant interchange. In Fatima's rules little effort is put into learning the language of science but rather into being able to repeat the key ideas.
Collateral learning
"Within an African community that has little or no contact with Western modes of thought, the children have the most privileged exposure to authentic, relevant and functional science, technology and mathematics. … In some cases, their relationships with their parents or grandparents who are village doctors, pharmacists or midwives give them an unparalleled minds- and hands-on experience in medicine and pharmacy. … Such a rural community knows no demarcation between indigenous science and traditional knowledge. They are interwoven, interdependent and interdisciplinary." (Jegede 1995, pp. 115-6)
However, few such situations probably exist today, either in Africa or Aboriginal Australia. Science education research is beginning to document cases of cultural dilemma and even cultural dysfunction where indigenous students learning about Western science and culture in schools (and increasingly through the media) have difficulty in equating it with their traditional belief systems. However, this is not always the case and there appears to be an accommodative mechanism for the conceptual resolution of potentially conflicting tenets within a person's cognitive structure; Jegede (1995) calls this collateral learning.
Collateral learning isn't isolated to cross-cultural learning. Although most Western people would agree with a heliocentric view of the solar system, we are more likely to describe a sunrise or sunset in language that is distinctly geocentric. Many people hold strong religious views that are at odds with our scientific understandings. However, there are four types of collateral learning that reflect the degree to which two opposing views can be maintained. These form a spectrum of collateral learning possibilities (Aikenhead & Jegede 1999).
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Parallel collateral learning |
· conflicting schemata do not interact at all · schema used depends on context |
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Simultaneous collateral learning |
· learning a concept in one schema facilitates the learning of a similar or related concept from another schema |
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Dependent collateral learning |
· a schema from one world view challenges another schema from a different world view, to the extent that it permits the learner to modify an existing schema without radically restructuring the existing world view |
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Secured collateral learning |
· conflicting schemata consciously interact and the conflict is resolved in some way |
It needs also to be said that collateral learning may not take place, because the learners have played Fatima's rules or they remove themselves either physically or intellectually (Aikenhead & Jegede, 1999).
Cultural borders and border crossing
Phelan, Davidson and Cao (1991) identified that adolescents in the US live in a number of social contexts or sub-cultures - mainly family, peer groups, classrooms and schools - and that they make transitions between these that "frequently require students' efforts and skills, especially where the contexts are governed by different values and norms" (p.224). They identified four types of transitions: smooth, managed, hazardous and impossible. Costa (1995) identified patterns among the relationships between students' worlds of family and friends and their success in school and science classrooms. She identified five categories, which have been matched to the transitions or border crossings (Aikenhead, 1995).
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Potential scientists |
Worlds of family and friends are congruent with worlds of both school and science |
Smooth transition between congruent worlds |
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"Other smart kids" |
Worlds of family and friends are congruent with world of school but inconsistent with the world of science |
Managed transition between different worlds |
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"I don't know" students |
Worlds of family and friends are inconsistent with worlds of both school and science |
Hazardous transitions between diverse worlds |
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Outsiders |
Worlds of family and friends are discordant with worlds of both school and science |
Impossible transition between highly discordant worlds |
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Inside Outsiders |
Worlds of family and friends are irreconcilable with world of school but are potentially compatible with the world of science |
Impossible transition between highly discordant worlds, although students have an intense curiosity about the natural world |
Worldviews
When dealing with peoples from other cultures, these "worlds" can be replaced by much broader cultural differences or worldview. Worldview provides a nonrational foundation for thought, emotion and behaviour, providing a person with the presuppositions of what the world is really like and what constitutes valid and important knowledge about the world (Cobern, 1996). It is how people see the world. Where two worldviews differ substantially, the abilities of people to make transitions between them need to be managed at best, but for many people such transitions will be hazardous or virtually impossible.
Obviously, for some people these transitions are not always problematic; there are examples in the literature of people from traditional cultures moving between their own and western culture, not specifically science, and some of these have western science credentials. The background of a number of researchers in cultural studies in science educators is a non-western culture - Olu Jegede (Nigeria), Masakata Ogawa (Japan), Oscar Kawagley (Alaskan Inuit), Liz McKinley (New Zealand) and Jane George (West Indies), to name a few. The term thinking differently was used by a student interviewed by Medvitz (cited in Aikenhead, 1997) to explain how they were able to move between the cultures, a situation potentially of parallel collateral learning.
Culture brokers
To facilitate cross-cultural transitions, one can take on the role of culture broker. The role of culture or cultural broker has received little attention in the research, although it has been used (in one form or the other) in health, education, business and tourism (both terms are used in the literature without any apparent distinction). Many people have taken on this role with varying degrees of success and without necessarily being identified as brokers. To be considered an effective culture broker, one would need to have at least a practical understanding of the workings of each culture, supplemented by a good working knowledge of the languages of both cultures. There is also a matter of trust of the broker by both cultural groups. A culture broker can come from either culture and in some situations may act as a two-way broker.
Science as the culture of the scientific community: Scientism
Ogawa (1995) defined Western modern science as "a collective rational perceiving of reality, which is shared and authorized by the scientific community" (p. 589). For many scientists, valid knowledge is identified only with science (Carsaniga, 2000). Ogawa (1999) defines this ideology as scientism: scientism has two major attributes:
· unconditional belief in science, a view mainly held and authorised by scientists which they unconsciously force general public in any cultural setting to accept and share
· uncritical conviction of valuing application of science into life-world settings, originating in the western traditional value system.
Ultimately, scientism is a worldview or 'religion' of its own. It probably conflicts with collateral learning as there is no room for any other way of seeing the world.
How can this science education research be put into action in a cross-cultural setting?
There have been attempts to overcome problems that occur with collateral learning. The first two examples seek to avoid any conflict.
· Some students attempt to avoid situations which would create conflict between the two ways of thinking. Fatima's rules are valuable here because learning is superficial.
· On the other hand some teachers would seek to denigrate Indigenous students' traditional learning, as being of little value at best, or made up of superstitions. This type of learning smacks of scientism but reflects more on hegemonic, colonialist or neocolonialist power relationships. A response by Indigenous people is to believe that their traditional knowledge has no value and reject it.
Other ways of teaching Western knowledge have taken into account the possibility of collateral learning.
· One way has been to treat the two areas of learning as being unrelated, a form of cognitive apartheid (Cobern, 1996). Knowledge is partitioned into Western knowledge and Indigenous knowledge. Such an approach results in parallel collateral learning, where the student replicates knowledge from the appropriate context.
· A more useful way is to scaffold Western knowledge onto what the students already know from either traditional teaching or experience. This would be seen at its best as secured collateral learning.
The term cross-cultural has been used in many settings but it has implications of the partitioning or compartmentalisation of knowledge. This can lead to cognitive apartheid with its implications of indigenous knowledge being quaint or primitive. We would rather use the term intercultural which conforms to a view of the universality of knowledge, and we consider it to be more valuable as it leads to secured collateral learning.
Trudgeon (2000) points out that the scaffolding of Western health knowledge (not his terminology) is an effective way of approaching health education with Aboriginal people. He believes that much of the understanding of Aboriginal health workers may be superficial because the links between the two fields of knowledge have not been made explicitly. In an example he shows how the germ theory can be linked to Aboriginal people's experience of living things, in this case minute living things that can only be seen using a microscope. Using a microscope can show their existence. The role of antibiotics to kill the bacteria can then be established, including the need to take the medication in a particular way. This goes part way to demystifying Western medicine and creates a rationale and environment for compliance.
How can the knowledge and experience of science education researchers be applied to the issues of compliance?
Trudgeon (2000) has given a number of examples from Arnhem Land, of processes involving careful communication, exploration of assumptions, innovative approaches using Western science and traditional knowledge, which have brought about major changes in attitude, and genuine partnerships in health. There has been a synthesis of knowledge, not a one-way process. Before such a synthesis can occur there needs to be cultural awareness, not just of Aboriginal culture, but of the hegemony of Western culture, of the religion of scientism. It appears that frequently, in the Western medical view, education somehow equates with literacy and articulateness. Literacy is confused with vocabulary, and there is little or no understanding that what is really expected is scientific literacy in English. There appears to be little or no concept in health sciences of a broad definition of literacy to include a repertoire of attitudes, behaviours, as well as jargon, what Gee (1992, cited in Beattie, 1998) terms 'discourse', and the pivotal role of that broad literacy in communication. Awareness of Western medical culture must also include awareness of the importance of discourses, of literacies. We also need awareness of the ease with which we have acquired our knowledge, and the relative difficulty for 'outsiders'
Situations of potential conflict arise when there are differences in worldview. The science education research cited above illustrates that many problems arise even between the subcultures of students and school science, and they are indicators that a greater dissonance can exist between cultures, particularly where the worldviews are substantially different. Even in our own culture there are some examples of the differences between subcultures. As participants in the health professions in a multicultural nation, many of you will have encountered difficulties when dealing with non-English speaking patients whether they understand the diagnosis and treatment.
Language is a major sticking point in communicating between cultures and even subcultures; scientific or medical literacy requires a different level of literacy to basic literacy even in the same language (or can be used for deliberate obfuscation). Every language uses words to describe objects and concepts. Objects are usually easily described, so translation between languages is reasonably simple. There is often a 1:1 match, or perhaps a 1:many match; if there is a 1:zero match then often the word is simply absorbed into the other language.
However, concepts are not so easily translated: Trudgeon (2000) uses the term intellectual language to describe a higher level of thinking (conceptual thinking), and we believe this relates to ideas of 'hidden English' and 'hard English' that have been expressed by some Aboriginal people for some time. Trudgeon considers that understanding of concepts takes place only when a person has sufficient experience in both cultures and both languages to be able to make links between the two intellectual languages (obviously through conversation between native speakers). His second point is that not everyone has access to their own intellectual language, so they will experience difficulty in accessing a differing worldview. He cites several examples of these situations.
Conclusion - a way forward?
Within Western society there are many cultures or literacies and it seems that where there are gaps between them there are compliance issues, e.g. conservative Western medicine and drug addicts or smokers. It is suggested that non-compliance is not the problem but the measure of the problem - an indicator of cultural dissonance, and not only in health. Non-compliance can be seen, by other names, in education (attendance and retention rates), criminal justice, housing, employment, etc.
Therefore approaching the problem cannot usefully be confined to health alone. There are a number of suggested steps on the way forward to better (health) outcomes: acknowledge individually and collectively the hegemony of Western (medical) culture, the existence of 'scientism' and the ease with which we, as potential scientists, have acquired our knowledge and entered the culture of Western medicine; acknowledge literacies in our discourse with patients/clients and other professions; actively seek a synthesis of knowledge systems embedded in dissonant world views; ensure that a spectrum of knowledge including new (synthesised) knowledge is acquired by the participants on both sides of this cross-cultural divide.
References
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