THE IMPLICATIONS OF CULTURE SHOCK FOR HEALTH EDUCATORS : REFLECTIONS WITH BARER

Culture shock is an intensely personal universal human experience that may emerge in any cross cultural social encounter. Therefore, it may be deduced that culture shock is an experience that may occur in all spheres o f life in which irutividuals are confronted by world views and life styles that differ from their own whether in terms of health, education or occupation amongst others. !t is a situation that ccdls for adaptation or adjustment on the part of the individual. TTtis article explores the relationship between culture shock and culture adaptation as an aspect o f learning which has been developed by Thelma Barer-Stein. Stress is laid on the role o f the individual, as health educator, and the choices must make if he/she is to gain an understanding o f the community in which he/she serves and to attribute new meanings to the situation by which he/she is confronted


INTRODUCTION
It may be stated that educators, by and large, internalise and reflect prevailing social values towards cultural sub-groups within society and that these values strongly influence the educational outcomes of learners (Frazier, 1977:13).In turn, every learner brings a unique cultural identity to the educational mibeu.Every educational and, indeed, social situation is a coming together not only of expectations concerning social roles, but also of cultural and personal identity in which notions of self-concept and self-identity play an integral role (Arthur, 1995: 306).
According to Lambert (1989: 273-274), to a large extent psychological comfort is related directly to the perception of a threat to one's 's e lf the core o f who one feels one is.Self-concept acts as the centre of one's phenomenological world in terms of which all external things are measured and judged.When an individual perceives a situation as hostile or a th reat to an aspect of the self-image, defences are raised which become barriers between the self and the perceived threat.In a learning situation in which participants represent a variety of cultures, the potential for psychological discomfort is high.Defence mechanisms therefore may come to the fore in the behaviour o f both health educators and their clients.
Parties to cross cultural health education encounters may experience each other at different levels of th d r respective percepmal fields in terms of 's e lf.Educators and learners are prepared, albeit in different ways and to varying degrees, to defend that perception.In multicultural societies, clearly identifiable racial and ethnic groups as well as the lo w er classe s, fem ales and ru ral populations will generally maintain a high degree of social distance when they meet.They will probably also perceive each other as representatives of 'we-them' configurations, at least, initially (adapted from Qiristensen, 1985:69-71).
Every social situation is a coming together, not only of self-concept, self-identity and social roles, but also of shared realities: that which constitutes the intersubjective structure of consciousness.
What is taken for granted by the native is problematic for the stranger.In a familiar w orld, people live through the day by responding to daily routine without question or reflection.To strangers, however, every situation is new and is therefore experienced as a crisis" (Parillo, ifl: Gudykunst and Kim, 1984:221).
When people meet who have been socialised within groups with different objectives, but m ore p a rtic u la rly , su b je c tiv e cu ltu ral characteristics, a cross cultural interaction occurs.The unintentional conflict that emerges as a result of a misunderstanding or the misreading of the cultural cues within the c ro ss c u ltu ra l e n c o u n te r is u su a lly experienced as some form of 'culture shock' by both educators and learners alike (Arthur, 1995:310-311).

CULTURE SHOCK
The concept of 'culture shock', as introduced by Oberg 0958), traditionally has been used in regards to people belonging to a particular cultural or sub-cultural grouping who settle, either temporarily or permanently, amongst those whose cultural affiliations are different from their own.H ow ever, in a world characterised by increasing globalism, the notion has been transferred into the arena of b u sin ess m anag em en t in in te rn a tio n a l corporate conglomerations.Barer-Stein (1987 (a);1987 (b);1988), has translated the theme into a theory of culture adaptation as an aspect of learning.This is the sense in which the reality of culture shock plays an important role in the success attained by health educators when wotlcing with groups whose cultural fi^me of reference is different fh)m their own.'Culture shock' is the term used to describe anxiety stemming from a person losing his sense of 'how' and 'when' to do the right thing and the ensuing process o f adjustm ent.Initially, the situation involves a non-specific state of uncertainty in which an individual does not know what others expect of him or what he can expect of others in respect of behavioural, psychological, emotional, or cognitive responses.The most frequently quoted indicators of culture shock include an absence of familiar cues about how to behave; a sense of helplessness in the new setting; a reinterpretation of familiar values about what is good; an emotional disorientation ranging from anxiety to uncontrollable rage; a feeling that the discomfort will never disappear and a nostalgic idealisation of how things were.In any radically new situation, including health education in the cross cultural encounter, the cultural context is changed in unexpected ways that involve adjustments in respect of social roles and self-identity which result in culture shock (Pedersen, 1994:192).
According to Adler (Pedersen, 1994:192), the culture shock experience is classified into five stages.The first stage of initial contact has been called the 'honeymoon' stage because people initially are enraptured and intrigued by the intercultural experience.The second stage com m ences w hen people becom e frustrated by their inability to interpret the situation appropriately due to a 'disintegration of that which is familiar'.Difference intrudes in a manner which cannot be ignored.The person experiences loneliness, depression, w ith d ra w a l and s e lf-b la m e .H ig h ly ethnocentric reactions may emerge and a high probability of conflict occurs as the third phase begins.Self-blame may turn to hostility, rejection and attacks against the new setting.T rifo no vitch (B arer-Stein, 1988: 77-78;Cushner, 1989: 320) combines the second and third stages as described and aptly labels them the 'hostility phase' during which fear, dislike and d istru st are com m only experienced emotions (Rothenburger, 1990(Rothenburger, : 1352)).This stage is very volatile as 'reintegration of new cues' takes place.Things are getting better, but n ot fast enough.P eople begin to understand the subjective culture of those with whom they work and the way in which things are perceived and accomplished in the new environment.The fourth stage of 'developing a new identity' begins when both differences and sim ilarities are acknowledged.The individual becomes more self-assured as he learns to fimction in accordance with the new c o n d itio n s, a c ce p ts th e s tre n g th s and weakness of his old and the new system, adopts some of the local values and becomes integrated within the new social network.This is the phase in which acculturation may be perceived to have set in.The fifth stage ideally leads towards a multi-or bicultural identity.In essence, a stable state of mind is reached ranging from a preference for what has gone before, true bicultural adaptation in which the present is on a par with the past or total conversion to the new environment (Cushner. 1989:320;Hofstede, 1991:209-210;Pedersen, 1994: 192-193).Pedersen (1994: 193) suggests that recent research on culture shock demonstrates that while the process may be painful, it is not necessarily a negative experience for it results in new insights and positive human growth.Conversely, when intergroup contact fails, the end result frequently includes exclusionary behav io u r such as biased ev a lu atio n s, denigration and disparagement of others, blaming the victim or displacement of the blam e for o n e's actions, self-righteous c o m p a ris o n s ju s tify in g r e ta lia tio n s , dehumanisation of the individual, double standards and psychological distancing among others.Any one of these responses on the part of the health educator, singly or in com bination, negatively influences the outcome of health education programmes in cross cultural encounters.Barer-Stein (1988:89), having developed a theory that incorporates notions of culture adaptation and culture shock as aspects of a process of learning, hypothesized that it may be less important for educators to be familiar with the countless details of custom, values, language, behaviour et cetera, than it is for them to understand their own learning as a process.
If enculturation is the outcom e o f the acquisition of new knowledge and skills, then it may be posited that enculturation is the first step towards acculturation or the ongoing phenomenon of change that occurs when people with different world views come into continuous first hand contact with one another.The act of learning itself implies change (A rthur 1995: 321-322) and the education encounter provides an environment w here e d u c a to rs and le a rn e rs sh o u ld assimilate some of the views, perceptions and ethos of one another during the course of interaction (Banks & Lynch, 1986: 22-23).

Existing circumstances and cultural content determine what is accepted and thus learned
or what is rejected and, therefore, not leamed.If one accepts the truism that people do not leam what is already known, but learn in varying degrees what is not known, it may be concluded that learning is an ongoing "... sequential process of experiencing that which is different or unfam iliar" (Barer-Stein, 1987(a):89).The question may now be posed as to whether a relationship exists between learning, adaptation to culture difference and culnire shock.If culture represents the many w ays in w hich people group together, constitute, understand and live their daily lives while at the same time transmitting their way of life to others, then cultural adaptation in cross cultural encounters m ust involve learning in the form of some sequence of modification or adjustment to a different mode o f daily living.A connection between le a rn in g and a tta in m e n t o f c u ltu ra l understanding is hereby established.Culture shock, in these terms, may be viewed "... as a synonym for coming face to face with the u n fam iliar" (B arer-S tein , 1988:88): an experience which may occur in any sphere of life whether in terms of health, occupation or education amongst others.
In developing a model of the process of experiencing the unfam iliar, Barer-Stein (1987(a): 9 1 -9 2 , 9 4 ) d ra w s on her c o n c e p tu a lis a tio n o f 'S u rf a c e ' and 'S ubm erged K no w led g e'.T he form er represents knowledge of which a person is fully aware and the latter, the more obscure levels of knowledge that require effort to recapture.Intrinsic to the approach is an acknowledgment that human consciousness, however fleeting, is an awareness of being faced with that w hich is unfam iliar or different.The experience is accompanied by a deliberate effort by the indi vidual to exhume, analyse and interpret or reflect on the event.It is an attempt to force aside a natural reluctance to think about that which is unfamiliar and potentially disturbing in order to realise new possibilities and new meanings.As a result of the new understandings derived from in-depth thought or reflection, people are able to reconstruct their current know ledge and activities so that their new insights can be acted upon.In other words, learning takes place in the form of accommodating to the unfamiliar.
The p h en o m en o lo g ically b ased m odel comprises five phases, each of which is a s so c ia te d w ith e s s e n tia l th e m e s or characteristic behaviours that permeate the entire process with varying degrees of intensity.At each level, reflective pause occurs during which a decision is made whether to move forward towards further understanding or not.At least three sets of interpretive cognitive activities are involved, namely: • a collecting of information; • a questioning of that which is collected and • a comparison with previous knowledge; The themes are experienced throughout, either cyclically or on a sequentially regressive or progressive basis.Each phase is entered into voluntarily as a matter of individual choice.The possibility of remaining in a phase or essential theme exists (Barer-Stein, 1987(a): 94); 1987(b):29-30; 1988:81-81).Each phase is lin k ed to the in d iv id u a l's personal experience of culniral difference and his/her response to such differences.
The initial phase of the model, labelled Being Aware, denotes access to the unfamiliar.The individual must "... be aware of something in order to distinguish it from anything else" (Barer-Stein, (1987(a):95; 1987(b):30).The three themes or behaviours within this phase represent • an awareness o f the interest itself; • curiosity in the sense of a desire or need to know and • seduction in the form of an inducement or incentive to do som ething about the situation.
The second phase of O bserving suggests an attentiveness to that which is observed.Brevity and superficiality are characteristics of the reflective pause at this stage.There is no real focus, commitment or responsibility to act.The individual is merely a spectator to that of which he has become aware and now observes.Should attentiveness intensify and focus on a specific interest, the theme of spectator progresses to that of sightseer (B a r e r-S te in , 1 9 9 7 (a ):9 5 -9 6 , 102; 1987(b): 30-31; 1988:81).
The third phase of Acting, more appropriately called A ctin g in th e S cene, depicts a movement closer to the object of interest by the individual, from audience to participant.The associated theme or behaviour labelled wittiess-appraiser indicates an intensification of reflective pause as the individual repeatedly delves deeper into his accum ulated and increasing knowledge of the event and of self Activity melts into that of cultural-missionary or behaviour characterised by a perception that the world is divided into those who have certain collections of knowledge and those who do not.The perception embodies a conviction that one's own culture is correct and is accompanied by a concomitant zeal to do something for those perceived as less fortunate in the form of sharing (perhaps imposing) the benefits of one's own culture on them cluster-judgem ent and depicts the 'we-they' dichotomy.Since neither group in this d ich o tom y is able to co m p reh en d the complexity or reality of each other's culture, cluster-judgement becomes apparent on both sides.Living the life o f is the last essential behavioural theme of this phase and represents an ultimate expression of professed familiarity with an unfamiliar situation.It involves an over simplification of the ease with which a person is able to fit into the life-style of another g ro u p ( B a r e r-S te in , 1 9 8 7 (a ):9 6 -9 8 ; 1987(b); 31-33; 1988:81).
Confronting, o r th e fo u rth p h a s e , is commonly taken to imply impending conflict, but carries the implication of coming face to fa c e w ith so m e th in g not p re v io u s ly recognised.The complexity of the life-style of the other group now becomes increasingly apparent.A shift in behaviour occurs as the unfamiliar within the familiar is disclosed, either as an aspect of daily life or from within the self.Security is undermined when the familiar ceases to yield to meaning when reflective pause is applied.The perception that fam iliar practices no longer work increases and solidifies.As always, the individual has a choice.He may choose to be passive and ignore the confrontation and allow it to pass in a way that denies the capacity for tran sc en d in g w hat is le arn ed , thereby inhibiting forward movement.Alternatively, he may choose to engage in conflict utilising the various mechanisms for conflict resolution to disprove the differing reality or he may withdraw into himself or his past familiar world to escape the source of his anxiety.The possibility o f a continued Awareness of Interest always exists, in which case the individual transcends or rises above his immediate situation and expands his present reality through the discovery of new meanings and greater understanding (Barer-Stein, 1987(a);98-99;1987(b):35-38;1988:82-83).
The final phase is that of Involvement.It represents the reality of experiencing the unfamihar in such a way that the object or subject that was different now finds an integral place of importance as part of the personality of the individual together with all the other personally relevant meanings that make up his/her daily life.Inherent in the final phase of Involvement is a movement towards a phenomenon that occurs when a particular interest becomes so deeply entrenched within the personality that it becomes internalised and an inextricable part of the self.It becomes one with the daily life of the individual.
Barer-Stein's approach to culture adaptation p la c e s e m p h a sis on th e in d iv id u a l's experience and his response to that experience as opposed to culture p e r se or group relationships.It is an approach that is of direct relevance to the work of health educators when working with groups of people whose world view is different from their own whether in respect of health related matters, social roles and ro le e x p e c ta tio n s , or p attern s o f communication.

IM PL IC A T IO N S F O R H E A L T H ED UCA TO RS
Education or cultural adaptation cannot be said to have taken place as long as learning (as an aspect of understanding that can be acted upon meaningfully) dwells in any place outside of the self.Learning only becomes uniquely personal and part of the self when it is used in some way through an act of involvement.In other words, the onus is on health educators to think deeply or reflect on that which is different or unfamihar about the culture of the community in which they work.
Health educators need to become consciously aware of the fact that they may be experiencing culture shock in varying degrees in their encounters with others whether in terms of ethnicity, social class, gender or rural-urban distribution.Culture shock may manifest in a variety of responses ranging from surprise that people cannot see the benefits of what is being offered to outrage that communities reject what is perceived as being the only logical effective course of action.
Barer-Stein's approach offers a means for h ealth e d u c a to rs to gain a co n scio u s understanding of the unfamihar through acts of reflection in order to guide communities to learn more effectively about health related matters.In this sense, the cultural adaptations required are related to the occupational role of the health educator and not necessarily with a view to becom ing integrated within the community itself.
The first two phases in Barer-Stein's model are familiar to all health educators -at least in respect o f the objective culture.All are Aware of unfamiliar beliefs and practices and are compelled to be interested in these features as they impact directly on their field of work.Curiosity is generally present in so far as prior training has stressed the need to identify differences with a view to doing something about them.The incentive, goal or seduction element has been built into formal planning sessions.Observing is another built-in factor of health education training.For many, the commitment remains at tiie level of spectator or sightseer in which differences in objective behaviour are noted with a view to changing those perceived to be detrimental to health.At th is litage, h ealth e d u c a to rs o ften are stimulated by the challenges posed by health education in the cross cultural encounter but all too frequentiy, tiie subjective rationale underlying the beliefs and practices of the community are ignored.Frequently, there is no awareness of the subjective aspects of culture nor of the fact that many variables w hich d ire c tly a ffe c t th e o u tco m e o f educational programmes, are not subject to external observation.Failure to reflect deeply on difference as observed and to concentrate purely on objective observations results in previously mentioned behaviours such as biased evaluations, stereotyping, projection of failure onto cHents and the community and mistrust as well as non-realisation of the goals of health education and health promotion.
It is impossible for health educators not to Act in the Scene for they are active participants in all educational events.Q uestions arise concerning the nature of the participation.
• Is the approach based on direct advice stemming from professional health related k n o w led g e and o b je c tiv e o b se rv e d d ifferen ce?If the answ er is in the affirmative then health educators cannot be said to have progressed from the second phase of O bserving and the end result of their efforts is likely to be almost inevitable failure.
• If a decision is made to move forward in an attempt to understand the community through acts of analysis and interpretation, what are the potential outcomes of such reflection?So often, the behaviour of the e d u c a to r, re p re s e n te d by the label witness-appraiser, g iv e s ris e to the activities of the cultural missionary.Such an approach culminates in a tendency towards imposing personal, professional and cultural practices on others.This action results in cluster-judgem ent and a reinforcement of the 'we-they' dichotomy in which dislike and distrust become manifest.Further progress is unlikely to take place w ithout client-com m unity participation in order to establish the subjective experience of health related matters by both individuals and groups within the community.In this connection, ind iv iduals should n o t be treated in isolation from their reference groups (Dovey & Mjingwana, 1985:82) for it is a truism to state that psychological, social and physical problems are usually 'group' and seldom 'individual' problems.Shared subjective experience is essential in p ro v iding health ed u cato rs with the necessary basehne information on which to ponder and reflect • The question 'where to now?" becomes relevant.At this stage, health educators m ay re a c h th e s ta g e o f an oversimplification of their understanding of the life-style and world view of their clientele as outlined in Barer-Stein's essentia] theme of living the life.
In order to promote movement towards further understanding, the notion o f community participation needs to be extended to that of participative learning where learners are called upon to contribute their wide range of quantitative and qualitative experience to the educative event.It is a process in which the reservoir of knowledge and experience of clients and educators are in te g rate .It is also a process during which it is recognised that the health needs as perceived by professionals may not coincide with those o f the community its e lf .
N ee d s a re n o t p re se n t unproblem atically in p eo p le's lives, but proceed from their interests and goals based on value judgements (Alexander, 1987:137) which evolve from differing socio-economic, cultural and political contexts.It also may be assumed that any group coming together for health education has an unwritten agenda about what they wish to know (Strechlow, 1983:41).In these terms, the decisions and choices made by the community may not be those favoured by health educators.The stage is set for the re-emergence of ethnocentric reactio n s and m echanism s fo r conflict resolution on the part of heath educators and, dependent on their response, a resumption of the 'we-they' dichotomy.
On C onfronting the realisation o f unexpected educational outcomes, health educators are again faced by the unfamiliar.Insecurity is generated in terms of what has or, more realistically, what has not been accomphshed.Preconceived goals have not been met and predetermined familiar practices no longer work in terms of desired outcomes.Once again the cultural context has changed in unexpected ways that involve an adjustment in respect of both social and educational roles and self-identity.Should health educators ignore the confrontational issues inherent in the situation by • withdrawing into themselves.
• retreating into their past familiar world or • actively engaging an attempt to disprove the opposing realities, forward movement in understanding the community will be inhibited and successful health ed u catio n outcom es threatened.Conversely, it is possible for an Awareness of Interest to continue once the undeniable existence of multiple life-world realities is recognised.
Health educators who continue to reflect on and question their own life-world perspectives reduce the likelihood that they will impose p re c o n c e iv e d , in a p p ro p ria te p e rso n a l cognitions onto the meaning structures of the different orders of reality experienced by learners (Collins, 1984:184).
Involvement entails an acknowledgement that both similarities and differences co-exist within and across cultures.The unfamiliar is experienced in such a w ay that health e d u c a to rs n eed to m o v e b ey o n d a pre-occupation with self to understand and confront the issue of how their personal prejudices and prior understandings influence the outcome of any cross cultural encounter.
Focus is brought to bear on building mutual understanding rather than concentrating on specific areas of overt cultural difference (Broome, 1991:245-246).In the context of health education, the educator acquires a readiness to suspend taken-for-granted norms in favour of a critical stance towards the everyday experiences of others (Collins, 1984:18Ci-181) as integral part of the self.
As the health educator begins to place em phasis on the experience of cultural difference as opposed to cultural difference perse, the potential for learning that which is unfamiliar is increased.Deeper insights into the reality of the cross cu ltural health education encounter may be characterised by the emergence of unique norms and values which may not have existed previously."A shift into a different behaviour than was previously experienced."(B a re r-S te in , 1988:81) or enculturation takes place.
Acculturation in health education practice may be perceived to have set in once the health educator moves away from conventional educational methods which entrench the educator as expert, to those methods founded on placing education within the context in which the cross cultural encounter takes place.By so doing, educators and learners are able to explore the conditions that constitute the structure of their respective life-worlds and come to some understanding of the variables affecting these worids in order to plan for and take purposeful action to bring a ^u t desired change in health related matters with the community.In exploring options for change, the cognitive map of health educators can be extended and limitations in the vision of learners can be reversed (Mitchell, 1991:19) in order to realise the aims of health education and health promotion.
CONCLUSION "Health education is an essentially practical activity rooted within educational practice" (French, 1990:9) in which interpersonal and intergroup relationships are an integral part: From the preceding discourse, it may be accepted that in order to develop cross cultural understanding, educators must be motivated to put the necessary effort into working through d if f e r e n c e s , d e m o n s tra te s u f fic ie n t commitment to the encounter to overcome potential areas of breakdown, be willing and able to explore and negotiate alternative meanings for ideas and situations and be wilhng to participate in mutual creative exploration in a search for the development of a 'third culture' (Broome, 1991:246-247).The concept of third culture entails a focus centred on the co-operative creation of a shared reality pertaining to health related matters between health educators and clients as opposed to attem pts to understand individuals and communities as separate objective cultural entities (Broome, 1991:247). The . The dichotom y between cultures b ec o m e s so c o m p le te th a t in d iv id u a l differentiations blur as other people are v ie w e d as h o m o g e n o u s g ro u p in g s.Stereotyping occurs.The "... judgemental sweeping up of other individuals... into one in d istin guishable m ass..." (B arer-S tein, 1987(a):97; 1987(b):32) has been labelled initiative for the building of shared m ean in g b etw e en th e m se lv es and the community they serve lies in the hands of health educators.B arer-S tein's (1988)   ap p ro a ch to w a rd s "E x p e rien cin g the Unfamiliar: Culture Adaptation and Culture Shock as Aspects of a Process of Learning" provides the means whereby health educators, by an act of intent, can move beyond a focus on specific areas of overt cultural differences and p re o c c u p a tio n w ith s e lf to an understanding and confrontation as to how th e ir p e rs o n a l p re ju d ic e s and p rio r understandings influence the outcome of health education in cross cultural encounters.R E F E R E N C E SA lexander, D J .,(1987):Rural Development.Educational Needs and Resources.Studies in the Education o f Adults.19,(2), 137-144.A rthur, M.L. (1995): Health Education in Cross Cultural Encounters: An Agogical Perspective.Unpublished D.Ed.Thesis.Pretoria: Unisa.B a n k s, J .A .& L y n ch , J (E d s.) (1986): Multicultural Education in Western Societies.London: Holt, Rinehart & Winston.Barer-Stein, T. (1987a): Learning as a Process of Experiencing the Unfamiliar.Studies in the Education o f Adults 19, 87-108.Barcr-Stein, T. (1987b): On the meaning of Learning: Reflections with Dewey.The Canadian Journal o f Adult Education 1,(1), 25-50.B a re r-S te in , T .(1988): Experiencing the Unfamiliar: Culture Adaptation and Culnjre Shock As Aspects of a Process of Learning Canadian Ethics Studies 20(2), 71-91.