Contents
Cultural
Dimensions of health. 1
Introduction: 1
Background: 1
Culture
in population health: 3
Sick
role model: 4
Cultural
Competence and Responsiveness in health care practices: 4
Cultural
Competence: 5
Anthropology
studies human health problems and healing systems in their broad social and
cultural contexts. A specialised branch of anthropology, i.e, medical
anthropology has engage in both basic research into health and healing systems
and applied research aimed at the improvement of therapeutic care in clinical
settings or community public health programs in prevention and disease control.
Drawing from biological and social sciences, as well as clinical sciences,
medical anthropologists have contributed significantly to the understanding and
improvement of human health and health services worldwide. As a result, the
growth of the subdiscipline in recent years as reflected in publications and
meetings, training programs, and influence outside of anthropology has been
remarkable. Medical anthropology is not characterized by a single theoretical
paradigm. For example, ethnographic description and analysis of religion and
healing systems are as old as anthropology itself, while new approaches like
critical medical anthropology are the product of more recent intellectual
trends. This has sometimes led to intense debates within the field such as
those between clinically applied medical anthropologists (interested in making
cultural knowledge useful to the aims of medical practitioners) and critical
medical anthropologists (interested in the phenomenology and political economy
of biomedicine). But, even though the scope of intellectual inquiry is very
diverse, it is possible to identify five basic approaches: biomedical,
ethnomedical, ecological, critical, and applied. These approaches share three
fundamental premises:
1.
illness and healing are
fundamental to the human experience and are best understood holistically in the
contexts of human biology and cultural diversity
2.
disease represents an aspect of
the environment that is both influenced by human behavior and requires
biocultural adaptations
3.
the cultural aspects of health
systems have important pragmatic consequences for the acceptability,
effectiveness, and improvement of health care, particularly in multicultural
societies
The developed
world has transformed from industrialized societies organized around the
production of goods by machines into technocracies: societies organized around
evolution through the development of sophisticated technologies and the global
flow of information through these technologies. Thus, Davis- Floyd has labeled
its dominant health care paradigm “the technocratic model of medicine” to
highlight biomedicine’s precise reflections of technocratic core values. The
technocratic model emphasizes the separation of mind and body and metaphorizes
the body as a machine and the patient as an object (“the gall bladder in 212”).
The resultant mechanicity and often impersonal nature of biomedical care have
been mitigated in recent years by increasing emphasis on humanism within
biomedicine. The “humanistic model” stresses the importance of “mind-body
connection,” defines the body as an organism, and sees the patient as a
relational subject; it views the relationship between patient and practitioner
as an essential ingredient of healing. While encompassing the relational values
of humanism, most alternative healing methods are ideologically grounded in a
third transnational paradigm, the “holistic model of medicine,” which
recognizes mind, body, and spirit as a whole, and defines the body as an energy
field in constant relation to other energy fields, demanding attention to
energy-based healing—a radical departure from the mechanistic approach of
biomedicine.
Illness and disease as cultural
constructs:
Disease is
distinguished from illness, which refers to a person's perceptions and lived
experience of being sick or "dis-eased" a socially disvalued state that includes
disease but is not limited to it. In recent years, the disease illness distinction
has been criticized because the process of separating biological
"facts" from cultural constructions falsely suggests the superiority
of the non-cultural biomedical model (Hahn 1995). From an anthropological perspective, diseases
have played a significant role in the evolution of both human biology and
cultural systems. Infectious diseases, for example, represent challenges to
survival and therefore act as agents of selection for biological or cultural
adaptation. Livingstone's (1976) analysis of the history of the sickle-cell
genetic trait in West Africa remains a classic example of this phenomenon. Here
the introduction of SWIDDEN horticulture resulted in increased P. falciparum
malaria, which, in turn, increased the frequency of the sickle-cell gene that
gave resistance to that disease, in spite of the huge costs sickle-cell anemia
otherwise exacts on the human body. A cultural-ecological approach to
understanding disease emphasizes the fact that the environment and its health
risks are largely created by culture (Inhorn & Brown 1997). Culture
determines the social-epidemiological distribution of disease in two general
ways. From a microsociological perspective, culture shapes individual behaviors
(diet, exposure to contaminated water, sexual practices, etc.) that predispose
people to certain diseases. From a macrosociological perspective,
political-economic forces and cultural practices make people interact with
their environment in ways that may affect health either by exacerbating disease problems or
protecting people from disease. The building of dams for the intensification of
agricultural production, for example, can increase rates of schistosomiasis or
malaria.
In epidemiology
there is a distinction between epidemic diseases, which occur at greater than
expected amounts, often in outbreaks linked by time or place, and endemic
diseases, which occur at a more constant rate in a population. Epidemics are
usually characterized by high mortality rates and socioeconomic disruptions,
and have been very influential in history (McNeil 1976). Endemic diseases,
often characterized by high morbidity, can be so commonplace in a population
that they are considered normal rather than an illness. Infectious diseases
caused by bacteria, viruses, fungi, unicellular parasites, and so on often
trigger immunological responses in hosts so that individuals build up a
repertoire of immunities to endemic (childhood) diseases. Infectious diseases
can also be contrasted with chronic diseases (cardiovascular disease,
hypertension, etc.); these are sometimes called the "diseases of
civilization" because of their increased prevalence in wealthy
populations. Chronic diseases have multifactorial causes, partly linked to diet
and exercise patterns. Many anthropologists see the rise of chronic disease as
a reflection of the discordance between ancient genes and modern lifestyles
(Eaton et al. 1988).
Disease patterns
change over historical time. Through a process of mutual adaptation of host and
pathogen, an epidemic disease can become an endemic one within a single
population. Armelagos and Dewey (1970) have identified three
"epidemiological transitions" in human history. The first was a
general decrease in health and increase in infectious-disease burden associated
with the domestication of plants and animals (Neolithic Transition). The second
was a decrease in infectious disease and an increase in chronic disease as a
result of improved housing, sanitation, diet, and (to a lesser extent) medical
care in Europe and the United States at the beginning of the twentieth century.
The third epidemiological transition is the rise of antibiotic-resistant
pathogens and the emergence of new diseases such as HIV/AIDS or Ebola viruses
at the end of the century. These are not isolated phenomena. In 1992, the list
of new diseases included 17 forms of bacterium, rickettsia, and chlamydia, 27
forms of virus, and 11 forms of protozoon, helminth, and fungus (Lederberg et
al. 1992). In an ecological sense, these new diseases reflect evolutionary
processes in which pathogens exploit new ecological niches created by
environmental changes.
Scholars like Hruschka (2009) argues that culture
is a powerful determinant of health outcomes and disparities. In such accounts,
culture can be either a barrier to health or a protective factor, it can stymie
health interventions, reinforce and perpetuate behaviors that impinge on
well-being and explain otherwise inexplicable population differences in health
(Health Canada 1998; Young 1998; Kindig and Stoddart 2003; Eckersley 2006).
Yet, among the frequent references to culture as a factor in health
disparities, the precise mechanisms by which cultural factors influence health
outcomes are rarely clarified, and
relatively few empirical studies in the epidemiological literature actually
operationalize and measure putative cultural mechanisms in an attempt to assess
their plausibility. This mismatch between culture’s assumed role in health
disparities and the relative lack of empirical investigation has lead to recent
calls for more careful definition and investigation of the pathways by which
culture might impinge on health and well-being (Dressler 2006; Janes 2006;
Kelly et al. 2006). As a precursor to this goal, this paper systematically
reviews how population health scholars use culture as an account for health
disparities. To give a background to the culture concept, I briefly trace its
history and provide a working definition of the term. Then, using published
articles as a lens, I document the historical increase in how epidemiologists
(and more recently population health scholars) have used culture as an
explanation, and in more detail how they use the term today. Finally, I
identify key weaknesses in how culture is currently used by epidemiologists and
population health scholars, and describe promising ways to define and evaluate
culture’s influence on variations in health. Key points of the review are that:
1.
Culture is not self-evident and
needs careful definition if it is to be used as a scientific explanation.
2.
Culture comprises a number of
different mechanisms and pathways that can be hidden if we simply invoke
‘culture’ as an explanation.
3.
Cultural explanations are only
hypotheses, and they require careful specification and testing against other
proposed explanations.
4.
Because culture is learned, and
can differ arbitrarily between groups, cultural explanations require in-depth
study of a particular setting in conjunction with population-based quantitative
studies.
The 20th century invasion of academic
discourse by ‘culture’ equally affected population health and epidemiology
(Trostle 2005). There are several important questions that need to be answered
in order to understand the concept of culture in population health. How is
culture used as an explanation for health outcomes, health disparities, and the
differential success of interventions? How are such claims about culture’s
influence evaluated? And to this end, how has culture been measured, how have
cultural variables been analyzed, and how has an understanding of cultural
pathways been used to improve interventions?
Talcott Parsons (1951:436) described the "four
aspects of the institutionalized expectations system relative to the sick
role." He argued (in The Social System, 1951) that whilst disease involves
bodily dysfunction, being sick—that is, being identified and accepted as ill—is
a role governed by social expectations, of which he listed four. First,
exemption from normal social role responsibilities: this exemption must be
legitimated by some authority, often a medical practitioner. Second, exemption
from responsibility for being ill, which means that the sick must be looked
after. Third, since sickness is deemed undesirable, the sick are obliged to
want to get better; and also, fourthly, to seek technically competent help and
co-operate in trying to get better.
The concept draws attention to the social
regulation of illness: to the mechanisms that guarantee the compliance of sick
persons, help to restore them to health, and ensure that only the genuinely
sick are exempt from normal responsibilities. It also provides a means of
analysing the motivational factors involved in illness. Indeed, Parsons
suggested that because of these motivational components (he was influenced here
by Freudian theorizing), illness could be considered a special form of
deviance, functional to the social system in directing deviant tendencies away
from group formation, solidarity, and successful claims to legitimacy.
Critics have questioned the universality of
Parsons's specification of the expectations governing the sick role, the extent
to which illness is motivated, the model's relevance to long-term sickness, and
his focus on what is functional for society. None the less, the concept of the
sick role has been central to sociological thinking about health and illness,
and its importance would be hard to overestimate.
The increasing
diversity of the nation brings opportunities and challenges for health care
providers, health care systems, and policy makers to create and deliver
culturally competent services. Cultural competence is defined as the ability of
providers and organizations to effectively deliver health care services that
meet the social, cultural, and linguistic needs of patients.(1) A culturally
competent health care system can help improve health outcomes and quality of
care, and can contribute to the elimination of racial and ethnic health
disparities. Examples of strategies to move the health care system towards
these goals include providing relevant training on cultural competence and
cross-cultural issues to health professionals and creating policies that reduce
administrative and linguistic barriers to patient care.
Cultural
competence in health care means delivering effective, quality care to patients
who have diverse beliefs, attitudes, values, and behaviors. This practice
requires systems that can personalize health care according to cultural and
linguistic differences. It also requires understanding the potential impact
that cultural differences can have on healthcare delivery. For example, race,
socioeconomics, health literacy, and other factors can influence: How patients
perceive symptoms and health conditions When and how patients seek care Patients’
expectations of care Patients’ preferences regarding procedures or treatments Patients’
willingness to follow doctor recommendations or treatment plans Who patients
believe should participate in making healthcare decisions While cultural
competence in health care initially referred to meeting the needs of people
from distinctive ethnic and racial groups, it now also refers to meeting the
needs of people with disabilities, those from diverse socioeconomic
backgrounds, and members of the LGBTQ community.
The Need for Cultural Competence in Health Care
Differences
between healthcare providers and patients can affect communication. This can,
in turn, impact both clinicians’ and patients’ decisions with regard to
treatment. For example, a clinician may misinterpret a patient’s silence as a
lack of interestin receiving care. As a result, the clinician may not order a
diagnostic test, when in fact the patient’s response reflected their notion of
respectful behavior.
When healthcare
providers fail to recognize the differences between them and their patients,
they may inadvertently deliver lower-quality care. Cultivating skills that
improve cross-cultural communication can play an important role in delivering
equitable care.
Additionally,
building teams with healthcare professionals who reflect the diversityof the
patient populations served can also improve cross-cultural communication.
Diverse teams have a wider cultural knowledge base that they can share with one
another. This makes them likely to respond with empathy to the unique cultural
needs of patients.
Language
accessibility is also key. Language barriers keep patients from accurately
describing their symptoms and providers from explaining diagnoses. Language
barriers can also create unsafe and inappropriate situations in other ways.
For instance,
clinicians may rely on children to serve as interpreters, putting young people
in the position of telling a parent they have cancer. As another example,
clinicians may rely on abusive spouses to interpret for their battered
partners. Both situations pose significant problems.
The need for Cultural Responsiveness in health care:
Cultural
responsiveness is a new way of thinking about culture. It means being open to
new ideas that may conflict with the ideas, beliefs and values of your own
culture, and being able to see these differences as equal. For example, in many
cultures spiritual beliefs are an important part of overall wellbeing.
It means being
respectful of everyone’s backgrounds, beliefs, values, customs, knowledge,
lifestyle and social behaviours. It helps you provide culturally appropriate
care and support, so people are empowered to manage their own health.
Cultural
responsiveness is important for all social and cultural groups, including:
·
Aboriginal and Torres Strait
Islander peoples
·
people from culturally and
linguistically diverse backgrounds
·
refugees or displaced migrants
·
people at all life stages,
including end of life
·
people with different
abilities, including intellectual and cognitive disabilities
·
LGBTIQ people
·
people from priority
populations and sub-cultures, such as the deaf and vision-impaired community.
Cultural
responsiveness involves continuous learning, self-exploration and reflection.
It draws on a number of concepts, including cultural awareness, cultural
sensitivity, cultural safety and cultural competence
Evidence shows
that when there is a lack of cultural responsiveness, health outcomes are much
poorer.2 Improving cultural responsiveness can not only remove barriers to
accessing healthcare, but may also reduce inequitable health outcomes for
marginalised and vulnerable groups.
In Australia,
there is a movement towards cultural support planning in health, social and
community services.
This includes:
·
language, such as translating
and interpreting services
·
food preferences
·
access to health professionals
of the same gender
·
religion and spirituality for
palliative care and end of life.
Materials used:
https://publichealth.tulane.edu/blog/cultural-competence-in-health-care/
https://aci.health.nsw.gov.au/resources/primary-health/consumer-enablement/guide/how-to-support-enablement/culturally-responsive-practice
https://hpi.georgetown.edu/cultural/
http://sumananthromaterials.blogspot.com/2017/08/medical-anthropology.html
Culture as an explanation in population
health by DANIEL J. HRUSCHKA, 2009, Annals
of Human Biology, MayJune 2009; 36(3): 235247
The Sick Role Concept: Understanding
Illness Behavior By Alexander Segall: Journal
of Health and Social Behavior, Vol. 17, No. 2 (Jun., 1976), pp. 162-169
See
also: http://sumananthromaterials.blogspot.com/2017/08/medical-anthropology.html