Boundary mechanisms: a novel approach to foster intercultural partnerships in medically pluralistic countries
The World Health Organization (WHO) estimates that one-third of the world’s population, and as much as half the population in some parts of Africa, Asia and Latin America, have no regular access to biomedicine [
1]. Indeed, in many developing countries little has changed since Lee [
2] noted that biomedicine, although dominant in terms of power, prestige and wealth, was functionally weak in terms of equitable access and widespread utilization. Consequently, medical pluralism – meaning the coexistence and parallel use of traditional, alternative or complementary systems of health care – is the rule rather than the exception in many countries [
3,
4]. In 1978, the World Health Organization called for intercultural health teams to provide locally adapted primary health care [
5]. Ever since, medical partnerships have been promoted for reasons that include traditional medicine’s accessibility, the credibility and cultural significance it enjoys in the eyes of local people, and in many cases also its clinical effectiveness [
6‐
10]. Some countries have successfully implemented various models to advance intercultural care [
3,
10], but many traditional health systems remain neglected, poorly institutionalized or even suppressed.
Many researchers emphasise barriers for intercultural medical collaboration due to (1) inadequate access, (2) absence of trust and (3) lack of mutual understanding linked to disparate knowledge systems.
1)
Barriers to access are understood as geographical, economical, organizational or cultural factors hampering patients’ to get the medical services they need [
10].
2)
Trust is a precondition for collaboration and for the transformations of social relations [
11]. Trust is granted due to expectations of interests, moral commitments or psychological dispositions [
12] and draws upon collective narratives that are saturated with power, institutions, and history [
13]. Collaborative methods can create trust by (i) building on existing relationships, (ii) using trusted intermediaries, and (iii) providing an environment for repeated interactions in project work [
14].
3)
Knowledge systems are networks of actors, organizations, and objects that bridge knowledge and know-how with action [
15]. All health systems are also knowledge systems, which use different explanatory models to construct different interpretations of the same medical condition. This can lead to conflicting expectations, miscommunication, and ultimately to poor clinical care [
16].
Boundary management refers to the boundary between different knowledge systems. It is an aproach to bridge the barriers that often hamper communication and collaboration across these boundaries. Boundary management involves specialized actors for managing the interface between knowledge systems with clear lines of responsibility and accountability to opposite sides of the boundary; and use of ‘boundary objects’, i.e. palpable objects that all involved knowledge systems can directly understand in their own terms. Boundary objects focus communication, illustrate what actors refer to and thus enhance the mutual understanding of different viewpoints [
17]. Three requirements are important for successful boundary management: (i) repeated and inclusive communication (to create access), (ii) mediation (to ascertain procedural and substantial fairness, adequate levels of relevance and scientific adequacy), and (iii) translation (to facilitate mutual understanding) [
17‐
20].
Intercultural health is situated at the boundary of different medical knowledge systems, but literature on this topic is fragmentary [
21]. Indeed, most of it concerns herbal medicine and local health beliefs and healing practices. Some efforts address barriers of access, patient choice [
22‐
24], practitioner perspectives or attitudes to intercultural medical partnerships [
25‐
27]. Several collaborative methods have been suggested to bridge the gap between biomedicine and traditional medicine in medically pluralistic settings, including workshop formats [
28], comparative diagnoses as starting point to negotiate and understand meanings [
29], and patient referrals to improve health services [
8]. More complex approaches combine several of these elements into comprehensive research designs [
30,
31]. Some of those methods were, for example, applied in Mexico [
32‐
35], even though few projects have been conducted in true partnership with local communities from start to finish [
21]. Literature does, however, mostly focus on medical content and few methodological studies assess such collaborative efforts empirically [
36,
37]. Therefore, little is known about approaches to overcome barriers to successful implementation of intercultural health.
Specifically, we know of no study that (1) applies an integrated methodological design to foster partnership between biomedical and traditional practitioners in a collaboration that creates real value to all partners, and (2) comprehensively assesses intercultural processes and impacts that are triggered by that collaboration. These were important objectives in our case study in Guatemala, which was designed to investigate the role of a patient-centered boundary mechanism in creating access, building trust and fostering mutual learning between biomedical and traditional knowledge systems.
Barriers to intercultural medical partnerships in Guatemala
Guatemala is a medium-sized country on the Central American isthmus. Of its population of 15 million people, 40% belong to 23 indigenous, mostly Mayan groups, each with their own language [
38]. 52% of the population live in rural areas, and 51% are below the poverty line [
39]. Access to local biomedical health services is usually good in the sense that the facilities are nearby and consultations are free. However, the cost of treatments may be prohibitive and the quality is often poor [
40]. Referrals to higher-quality institutions entail more travel and higher costs. Communication between biomedical practitioners and the Mayan population is hampered by the linguistic diversity and differences in education, cultural expectations and explanatory models. These circumstances lead to mistrust towards biomedicine, as revealed in comments such as “not being attended” or “having to die” [
41], and many patients are discouraged from accessing these services [
22]. Furthermore, healers were explicitly targeted during the civil war (1960 – 1996), being regarded as local community leaders [
42]. Finally, many doctors mistrust Mayan healers, whom they accuse of delaying the visits of patients to biomedical institutions, with the consequence that their conditions can no longer be treated effectively [
43].
The history of inequality, racism and oppression of the Mayan population has been described as ‘structural violence’ [
44‐
47]. As an outcome of the 1996 peace treaties, Mayan medicine is now officially recognised in the Guatemalan constitution, but this has almost no impact on medical practice [
48]. For example, there are neither funding schemes nor formalized training opportunities [
1]. Unsurprisingly, therefore, intercultural medical partnerships in Guatemala are perceived as unsuccessful [
49], despite a few initiatives to improve the situation [
50]. Overall, the Guatemalan context offers a case study to assess current limitations of intercultural health care and how these can be overcome through boundary management. It thus offers a model for the situation in many other developing countries.