Study Abroad in Ghana: A Path to Cultural Competence

By Connie Currier, Renee Canady, and Denise Saint Arnault

As the world becomes increasingly “globalized,” U.S. health care providers need to understand health issues outside of our borders and develop skills to interact with patients in a culturally competent manner. A male physician who is culturally unaware might not understand why his repeated attempts to establish eye contact with a veiled female Muslim patient and efforts to communicate treatment options to her were met with a lowered gaze and responses from her husband. Yet understanding the cultural dynamics of this exchange is exactly what is required for the successful patient-provider relationship. Increased access to care and reduced health disparities are also directly related to cultural competence, and it is likely that health outcomes will be linked to cultural competence.

Faculty in the College of Nursing (CON)--Canady, Saint Arnault, and Vinson--have proposed a new integrative model for the development of cultural competence (CC). Though CC content can be included in theory courses and clinical experiences for students in the U.S., study abroad courses provide a unique opportunity for health professions students to develop CC. CC can be defined as the ability to use culture in the resolution of a human health need. 1 The CON CC model integrates the models proposed by Campinha-Bacote (1994) and Cross et al. (1989). In the CON model, self awareness (A), cultural knowledge (K), and cultural skills (S) are considered to be dynamically interactive. The cultural encounter is the context through which these components interact. What fuels the student toward increasing levels of competency within the context of cultural encounters is known as cultural desire. In other words, cultural desire represents the motivation of the clinician/student to proceed with the difficult work of self-reflection, study, and personal change because this work is inherently worthy and meaningful. Cultural desire is necessary prerequisite for CC, as it emerges from a spiritual or ethical imperative that provides the energy source and foundation for one’s journey towards CC.

The developmental nature of the integrative model is evident in Figure 1. The process of learning in this model is set along the X axis and movement along the developmental trajectory is set along the Y axis. The model suggests that there is movement both through time and up the continuum toward the CC outcome. As students progress along the continuum, there is the expectation of greater and more sophisticated comprehension and application across advancing levels of self awareness, cultural knowledge, and cultural skill.

In the modified CON Model (Canady, Saint Arnault, Vinson and Currier), six intersecting aspects of the cultural encounter are proposed to increase CC. The intersecting aspects are measurable and quantifiable, and characterize the nature of the encounter through the following: 1) length of the encounter; 2) regularity and nature of contact with home country nationals (as opposed to host country nationals) during the encounter; 3) level of cultural immersion during the encounter, and country characteristics (including numbers 4-6); 4) socioeconomic congruence between the encounter site and the site of student origin, in this case the U.S. 5) cultural congruence between the encounter site and the student’s country of origin, i.e. “cultural distance”; and 6) need to learn a new language. Study abroad experiences provide an ideal case for investigating the developmental process of CC attainment in nursing students. With this framework as a backdrop, the study abroad program, Ghana: A Multidisciplinary Perspective, lends itself particularly well to evaluating this integrative model. The potential for personal growth is greatest during those times when we are most vulnerable and uncomfortable with our circumstances, or as Mezirow (2000) would say, when we are presented with a “disorienting dilemma” that causes us to question our beliefs about the world. Therefore, exposing students to the health disparities that exist in a developing country such as Ghana, combined with the ability to critically reflect on and analyze the experience, provides a unique opportunity for personal growth that contributes to the development of CC.

Ghana : A Multidisciplinary Perspective

Ghana: A Multidisciplinary Perspective, a 6-week long, summer study abroad program, was offered for the third time in summer 2006 to 15 students: 10 were nursing students, one was a premedical student, and four were students from other disciplines. Every year, the program is offered in two sessions. For the first three and one-half weeks, students take four credits of one of the following three classes: Integrated Arts and Humanities – Area Studies and Multicultural Civilizations (IAH 211A), Integrated Social Sciences – Africa: Social Science Perspectives (ISS 330A), or Journalism (JRN 490). The goal of all of these classes is to learn about Ghana’s historical, social, political, economic, and cultural environment in a historical context. For the remaining two and one-half weeks, students enroll in Health Care in Ghana (NUR 429) for 2 credits. This course provides an overview of health status indicators and determinants; major health programs and strategies; organization of the health care system; access to and payment for care; role, image and status of health care providers; and the interface between Western and traditional medicine in Ghana. Students are encouraged to compare and contrast the Ghanaian health system with that of the U.S. and, importantly, to withhold judgment--to understand that there is nothing “bad” or “wrong” with what Ghanaians believe, their beliefs are just different.

Nature of the Encounter

The CON model proposes that 1) the longer the study abroad program, 2) the more opportunities the student has to be immersed in the culture, and 3) the more independent time a student spends traveling and interacting with host country nationals unaccompanied by home country instructor, the more readily the student will progress along the CC developmental continuum. Students spend six weeks in Ghana--not a full semester, but longer than most MSU summer study abroad programs. While in Ghana, students reside in a guest house in the capitol, Accra. Residents of the guest house are predominately Ghanaian, and the atmosphere is informal, allowing students to interact frequently with Ghanaian residents and staff. Throughout the program, students participate in field trips that expose them to historical, social, political, and cultural experiences including visiting museums, slave castles, traditional healers, local bead makers, craft villages, traditional dancing, and more. Students also spend three days participating in a journalism internship experience.

The program concludes with students having the opportunity to live for three days in the rural village of Danfa. During this time students interview Ghanaian nationals about their beliefs and practices related to health and illness. Health disparities between urban and rural Ghana and between Ghana and the U.S. are readily apparent. Students experience firsthand life in a small, rural village, allowing them to apply what they have learned about Ghanaian health beliefs and practices to a new level of understanding. One student noted:

Today we met the fetish priestess, saw her shrine, and received a blessing from her…Upon seeing the bowls my initial thought was, “how silly, she worships bowls with bugs around them, I wonder what is in them.” Soon after I felt really bad for judging this woman’s religion. How is worshiping a bowl any different from worshipping a cross or a statue of the Virgin Mary?…From this experience I learned…that I need to be open to all the experiences I have here and not close myself off or dismiss other’s beliefs as silly.

Students learn what “lack of access” to health care really means. While there is a health clinic in the village, there are numerous financial barriers to care. A young mother described the costs of her young daughter’s recent clinic visit: 10,000 cedis for the clinic visit, 60,000 for the medicine--a total of 70,000 cedis or $7.70--a prohibitive amount when the woman’s daily income was only 10,000 cedis or $1.10. This same mother had a cloth wrapped around her leg, providing coverage for a quarter-sized suppurating ulcer. She explained that she didn’t have the money for treatment. Realizing that the mother would sacrifice her own needs to provide for those of her daughter gave the students a greater appreciation for the dynamics of “access to health care” in this family. Although the mother’s treatment would cost only $8.00, it represented 25% of her monthly income. 2

Ample independent time for students to explore Ghana on their own, without the continuous supervision of their instructor, is important. This independence gives students the freedom to interact with the local people as much as possible and contributes to their understanding of the culture. On one occasion, a group of students made a weekend trip to the town of Winneba, about 75 kilometers outside of Accra. “It was a bus ride unlike any I have experienced before,” said one student. “At the beginning of the bus ride, a man stood up and asked us to pray…for the safe trip of the bus and all the people on it….Ghanaians seem to have many traditions and practices that while small, do help the people to feel united and close to one another. Not to mention the fact that praying for the safe trip of a bus is one of the many prominent displays of religion here in Ghana.” This experience made the student reflect upon American culture and what she described later as the lack of clear practices and traditions in the U.S. because of the blending of so many cultures. This is a common reaction among students and appears to occur repeatedly after approximately four weeks in the program. Students observe the many facets of Ghanaian language and culture and begin to question their own cultural identity: “Why don’t we have any ‘culture’ in the U.S.? Why don’t we learn special dances in school? What traditions do we have?” These queries provide a critical “teachable moment” and a wonderful opportunity for directed journaling and values clarification assignments.

Country Characteristics

The CON model proposes that students’ values and perspectives are more likely to be challenged the greater the socioeconomic differences between the student’s country of origin and the host country, the greater the “cultural distance” between the two countries, and the greater the need for bilingualism. If the student is required to learn a new language in the study abroad country, the more likely the student will be further propelled along the cultural competence continuum. Language is like a window to another culture, and learning a language opens doors in many unexpected ways. Although students are not required to learn another language while in Ghana since English is the official language, students learn basic greetings in Twi, a commonly spoken dialect in the southern part of the country. While traveling, students often mention how excited Ghanaians become whenever they try to speak Twi and that it is evident how proud Ghanaians are of their language. Students’ efforts are often rewarded with long conversations that lead to a better understanding of both the Ghanaian people and their culture.

It is readily noted that Ghana is economically distinct from the U.S. As of 2004, the gross national income per person in Ghana was $2,280, whereas in the U.S. it was $39,710. While in Ghana, students are forced to live in conditions to which they are unaccustomed and they lose access to many of the daily amenities we take for granted. One student commented in her journal: “These things have made me realize how much I really take water for granted. Simply being in Ghana and going places where there is no sink or the water gets shut off at a certain time helped me to realize the luxury I have of water a little bit.”

Differences in cultures have been analyzed by individualism or collectivism related to behavioral priorities and values, and along vertical or horizontal dimensions related to social structure/organization (Triandis, 1999). Based upon these criteria, the U.S. could be considered a Vertical-Individualistic society and Ghana could be considered a Horizontal-Collectivist society, making these two societies culturally “distant.” Traditional, agricultural-rural cultures where individuals define themselves as part of a group, relationships are of greatest importance, and social behavior is often predicted by norms and perceived duties and obligations tend to be collectivist. Cultures that are marked by equality and a strong sense of cooperation tend to be horizontal. While conducting interviews in the village, students commented on their observations of the role of women noting that they were doing all of the cooking and cleaning, taking care of the children, fetching the firewood, and so on, and that men did not participate in these activities. One student wrote, “it is a different culture here in Ghana, and the men and women’s roles are very different than in the U.S. It is hard to understand when you have been taught for so long about values and ways of life. I am keeping an open mind about Ghana and I hope to be able to understand the culture better.” Students observed and learned about collective village-based activities, for example community gardening efforts to support the local primary school. These experiences force students to examine their values in comparison to those of another culture. Moreover, they challenge students to form an opinion about the values and principles they live by, or want to live by, and what they truly believe to be important.

The Ghana: A Multidisciplinary Perspective study abroad program gives students tremendous insight into privilege, vulnerable groups, and how culture and socioeconomic status affect health :

Learning all that I have about when and how people seek care has changed how I look at health care. As the theme of this trip, Americans have a “just do it” mentality. Being here has shown me that things are not always so simple. In America you get an infection from germs, you go to the doctor, you get an antibiotic, and that is that. Here, with cultural beliefs, lack of access and resources …getting health care is a far more complicated thing than at home.

Going to Danfa made me realize how difficult it is to change how people view healthcare or how they view being healthy. It is easy to say, well just clean up the trash, just make sure there is no standing water because that will prevent malaria, or just wash your hands. Ghanaians…have been living this way for hundreds of years and this is what they know.

Students learn that the factors that contribute to health disparities and efforts to eliminate them are, in fact, very complex. Students state they have become more adaptable, better able to converse with others, more flexible, more open-minded, and more humble as a result of studying abroad. One student said, “I have changed in many ways since coming to Ghana. One important way is a heightened sense of others and their perspective. The idea that just because we do something one way doesn’t make it the right or only way. I think this awareness will help me in society to deal with several viewpoints.”

It is clear from anecdotal comments, conversations about the program, and journal notes that the Ghana study abroad program has a profound impact on students. It is a transformational learning experience that often leads to a change in students’ worldview. This cross-cultural encounter challenges students to question their values, their lifestyle, their own culture, what their home country represents, and their role in the world. The length of this program, combined with the independence it grants, and the characteristics of the host country, result in a profound and life-changing experience for students. The program forces students to consider disparities in health and health care in Ghana, in the U.S, and between the U.S. and Ghana. The facilitation of the development of CC for health professions students will ultimately benefit their future practice and their patients.

Notes

1. Adapted from James Green, 1995, 1989.

2. The woman’s treatment was paid for to thank her for participating in the group interview.

References

Campinha-Bacote, J. 1994. Cultural competence in psychiatric mental health nursing: A conceptual model. Nursing Clinics of America 29(1): 8-11.

Canady, R., D.M. Saint Arnault, and J. Vinson. (Under Review). An integrative model of cultural competence. Nursing Education.

Cross T.L., B. Bazron, K.W. Dennis, and M.R. Isaac. 1989. Toward a culturally competent system of care. Monograph produced by the CASSP Technical Assistance Center, Georgetown University Child Development Center.

Green, J. 1995, 1989. Cultural awareness in the human services: A multiethnic approach (2 nd Ed). Toronto: Allyn and Bacon.

Mezirow, J. (2000). Learning to think like an adult: Core concepts of transformation theory. In J. Mezirow & Associates (Eds.), Learning as transformation: Critical perspectives on a theory in progress. San Francisco: Jossey-Bass.

Triandis, H.C. 1999. Cross-cultural psychology. Asian Journal of Social Psychology Special Issue: Theoretical and Methodological Advances in Social Psychology April 2(1): 127-143.