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NUR416 WEEK 2 Lecture Title: Culture and Health Slide Heading Script Slide 1 Culture & Health In this presentation we’ll look at several areas related to culture and health. Some of this material is in Chapter 4 of your text, with some illustrations of the applied theory given in Chapters 6 & 7. According to the determinants of health model, which you will recall from our first week, there are five areas that have crucial influences on health behaviors, health care, and health outcomes. One of those determinants was the social environment and we said that this area includes such things as family life and relationships, community coherence, safety, cultural norms, and political policy. This week we want to look more closely at the concept of culture. My hope is that you will learn a few new ideas that might help you become more culturally competent, effective nurses. Slide 2 Culture Perhaps you have heard of Madeline Leininger. She was a pioneer in this field, a nurse anthropologist who studied closely the effects of culture on health. Here is her definition of the concept: “Culture is the learned, shared, and transmitted knowledge of values, beliefs, norms, and life ways of a particular group that guides an individual or group in their thinking, decisions, and actions in patterned ways.” Slide Number Leininger’s definition of culture has some very good aspects; it points out that culture shapes how people think and act, that it is composed of patterns that are passed down from generation to generation. Essentially culture is about “how we do things” and it has a lot to say about who is in our group and who isn’t. But maybe the definition is too tidy and has some hidden hazards. For one thing, it makes it sound like culture is this mass of material that’s just handed down, when in fact culture is very dynamic; it is changing all the time. Just think of yourself and your parents, or even yourself and your siblings: do you have the exact same beliefs as they do? Is your home life organized in the same way? Even think about yourself from one decade to the next: do you have the same routines that you did in 1994? What influenced you to change? Over-doing this can definition can also lead to essentialism. Essentialism defines groups as “essentially” different, with characteristics that are supposedly “natural” to that group. Essentialism does not take into account variation within a culture. Essentialism can lead people to stereotype others. A nurse who has a Muslim patient, for instance, might come into the room with a whole host of understandings about what Muslims are like based on broad generalizations. On the contrary, cultural differences within groups can often be even greater than differences between groups (think of how much better you get along with your friends than your siblings!). So nurses should be on guard against any tendency to generalize or essentialize aspects of culture. Finally, we should realize that when looking at communities of people, we will have many different groups and cultures represented, making that community’s culture even more complicated. So in population health matters, beware of coming to hasty conclusions about what a group’s culture is contributing to the concerns you might have about their health. Slide 3 Culture includes and is influenced by… Culture is made up of a multitude of factors and in turn influences how people think and act about various aspects of personhood and relationships. Certainly the earliest influence is that of the family; our parents and grandparents values and beliefs and behaviors become ours until we decide to change them. Perhaps our own life experiences or education, or our move into a different social class, changes our understandings and we find that our culture has diverged from what we had received. Our perceived gender also is a huge influence in how we are treated, our self-image, expectations around appropriate toys or hobbies, our interests and occupation, etc. Ethnicity and race are important factors in culture also. What’s the difference, would you say, between ethnicity and race? Some will define ethnicity as having more to do with place of origin, tribe, ancestry, and history. Your ancestors might have been from Ireland, for instance, and so you identify with being Irish, especially if your family name still has that origin. Of course most Americans are of mixed ancestry: we might choose to identify with one particular place or group, like the Irish or Germans, but as we move further and further away from our immigrant days, most of us just think about ourselves as American. But this is especially true if you also see yourself as White. So what does race have to do with ethnicity, and culture? What do we mean by race? Is it also tied to people who are from a certain place originally? Is it basically tied to skin color or facial features? Does it have to do with genetic differences or biologic uniqueness in some way? Certain groups of people may share some shared distinguishable characteristics such as eye and skin color, bone structure, blood type. But again, as we move further and further from immigrant days, these racial characteristics get more and more vague. It turns out that genetic differences between races are very slim; there are often more differences genetically between people who look alike than there are between people who look very different. The Institute of Medicine (IOM) now suggests that racial categorization no longer adequately addresses the diversity of the U.S. population and ethnicity would be a better way of categorizing health data (1999). The Census Bureau has recognized this reality and has begun to allow people to check multiple categories of ethnicity to describe themselves. Finally, I will mention two concerns with just dropping the designation of race or not paying attention to ethnicity. For one, as health care providers, we do recognize that some diseases are more predominant in persons from certain ethnic or racial groups. We also experience some real ethnopharmacologic factors in treating patients, where certain medications seem to have more or less effect depending on ethnicity and race. So while we must beware of overgeneralizing, these differences are worth attending to. The second concern we should have with glossing over the real impact of race is the still present reality of discrimination, even in regards to health care treatment, based on racial characteristics and of the effects of racism on people in their daily lives. The evidence is very clear that many health disparities run along racial lines. Slide 4 social construct Social construct is a very important concept; it really gets to the core of what shapes culture. Who decides what is important in a society, the values and beliefs and lifeways that are promoted? This concept says that the dominant group is the one that gets to assign value to different aspects of culture. Groups within a society that are non-dominant in some aspects are less valued, seen as less-than-normal, and so experience limitations and discrimination. These groups become vulnerable populations, as we discussed in the lecture last week. Each of us, as members of a particular society, has learned certain ways of seeing the world, and each other. This is a natural and necessary occurrence, and serves us well in many ways. Children, certainly, need a solid foundation of values and habits, to help forge a stable personality. But social constructs can also set us up for poor choices as well as for bias and discrimination, in ways that are very subtle yet very real. Culture itself can be defined as a collection of social constructs; over time, we build up ideas about what is “real” and true by assigning meaning (the interpretive aspect of culture) to events, overlaying our constructs with more and more of our values and beliefs so that our constructs takes on the role of objective reality. We see everything through our socially, culturally-derived “lenses”. Can you think of a time when some image you had of others, some cultural construct, was challenged? I remember being in high school and meeting my first Black classmate, a fellow who would become a good friend. My experience with him broke through my fears about Black people and helped me realize he was pretty much like me, just a nerdy guy. Slide 5 Human nature There are three areas, representing important aspects of identity and culture that we’ll explore briefly here. Every person has an orientation toward these areas that is influenced by culture (Kluckhohn and Strodtbeck, 1961). As nurses, we need to be aware of our own values and beliefs, the social constructs that we carry in these areas and how these might affect our care, especially when we perceive our patients as different from us in important ways. The first orientation is our view of fundamental human nature. Let’s face it, people aren’t angels and we can often act in selfserving, unethical, and even illegal ways. So, ask yourself: How do I generally view people (including myself)? What do I believe about basic human nature? Are we basically good? Are there some people who are “bad”? Are there people who, due to how they appear to you, just automatically put you on alert? What kind of person are you most likely to judge, before they do or say anything? Certainly there are a lot of people out there who have very different lifestyles and beliefs from your own or from what you think is “right” or “normal”. Sociologists note at least seven ways that people might be very different from you: race or ethnicity; gender; religion; sexual orientation; age; socioeconomic status; and physical or mental ability (Tatum, 2013). So, how much “otherness” can you handle? More than you used to, or less? Do you find yourself becoming more cynical about people the longer you stay in nursing? Do you find it harder, or easier, to approach a new patient with what the social psychologist Carl Rogers called “unconditional positive regard”? Slide 6 Person-nature orientation A second area that is important to consider in relation to culture and health is person-nature orientation. This area looks at what people believe about how the universe is basically structured; these beliefs usually flow out of one’s spirituality, worldview, or philosophy. People who hold more of a “destiny” orientation, for instance, believe that there are larger forces at work over which they have little control. One example of this is the thinking in some cultures about the power of an evil eye, the “Mal de ojo”. People understand that their misfortune might be a punishment for something, for acting too high and mighty for instance. A patient who thinks that God sent an illness as punishment for past sins, or as a test of their worthiness, might be less likely to seek care or to believe that the prescribed treatment will be effective. If someone believes that they are destined to become overweight or diabetic because of family history, they may not make as much effort to maintain a healthy diet or exercise. “It’s in the cards for me,” they might say, “so why fight it. You have to die of something.” People who have a “mastery” orientation, on the other hand, are more likely to see themselves as the ones in charge of their fate. This can lead to them becoming very pro-active in their care; on the flip side it can also lead to a lot of self-criticism and blame and guilt if something terrible does happen: “I could have prevented this cancer, if only…” American society in general certainly has a “can do” cultural ethic and tends to put a lot of responsibility for what happens on the individual. Those who seem to have failed in their own health can be subjected to judgment by others, even by healthcare professionals. Finally, there are cultures which have a more middle-of-theroad kind of understanding, some sort of harmony in regard to fate versus control. “Bad things do happen,” a patient says, “but I have to do what I can. Then I’ll try to accept whatever comes.” People with this cultural orientation toward nature tend to believe in their own efficacy, their ability to achieve real results with effort, and to also appreciate what others can contribute to their health. Slide 7 Social relations and roles This third area of culture has to do with how people see themselves in relation to others. As we consider this area, ask yourself where you fit in this continuum, and what circumstances might change your social relations orientation. Some people generally see themselves as autonomous agents, making decisions with themselves as the primary consideration. Other people might have a more lineal, or family oriented way of seeing things. In many cultures it would be unthinkable to make important decisions without first considering the family and even calling people together for a discussion. You have probably seen this in operation many times in your nursing experiences, both in small situations and in moments of crisis. Finally, there are some individuals and cultures that make a point of thinking on a larger scale. Perhaps this means considering the impact of possible decisions or behaviors on their neighbors, or on the members of their religious communities. Some people operate with a global consciousness and feel a kinship with the earth and all created things that guides their actions. Asian and Native American communities often have this communal or collateral orientation in regard to social relations. Where do you fit in, regarding yourself in relation to others? Slide 8 Social roles and communication Another aspect of social relations is social roles, how people act out their understandings of self in relation to others. For instance, appropriate roles in decision making vary widely between cultures and is based upon considerations such as gender, age, position, education, etc. In some situations those roles can shift, but overall each culture has patterns. Health care decisions generally follow these cultural patterns, although things may be handled differently than other life situations, perhaps related to the severity of the situation. People with a traditional Appalachian culture, for instance, usually value independence and self-reliance very highly. When it comes to illness they usually prefer informal support rather than professional involvement; however, the culture allows for some relinquishing of control in a crisis, for instance in an intensive care situation. Cultural norms for interacting with authority figures and professionals also vary, and this influences communication. A person may defer to a doctor in face-to-face situations, for instance, rather than voice concerns over the feasibility of a prescribed treatment regime. One person may welcome a kind touch from a nurse while another would feel uncomfortable with it. You have probably encountered many examples of this in your practice, and there are probably plenty of situations that have gone unnoticed by you because your patient chose to avoid bringing it to your attention. Slide 9 Culture and Health So, when it comes to health, culture affects many aspects of behavior, as well as how we professionals deliver care. Michael Katz, a historian and social theorist, summarizes it nicely in this way: “Culture defines how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be given. In sum, because health care is a cultural construct, arising from beliefs about the nature of disease and the human body, cultural issues are actually central in the delivery of health services treatment and preventive interventions. By understanding, valuing, and incorporating the cultural differences of America’s diverse population and examining one’s own health-related values and beliefs, health care organizations, practitioners, and others can support a health care system that responds appropriately to, and directly serves the unique needs of populations whose cultures may be different from the prevailing culture”. Slide 10 Types of Health Care Who do people turn to when they need health care? That varies, partly with the seriousness of the condition but also due to other factors involving culture. Let’s look at three types of health care used in different ways by different cultures. Together these can form what is called a “therapeutic network”. Think back to when you were a kid and you woke up in the morning on a school day with a sore throat? How did your parents deal with that? If they had a “mastery” type of orientation toward illness, and the economic means for access to healthcare, they might have kept you home and even called the doctor to take you in to be seen. But maybe they just sent you on to school, because a sore throat wasn’t serious enough to keep you home and they could not afford to miss work anyway. Socioeconomics is certainly part of the cultural mix that determines actions. How many of us have friends or family members who call us first with questions about their symptoms due to a reluctance to go to the doctor or the ER? Sometimes this makes sense of course; people naturally go to their personal network first. We call this the popular type of health care because we are using our “people”. A second type of health care is the folk or generic. An example would be using a lay midwife to coach someone through a pregnancy or even deliver the child; this might be related to cultural customs or to system necessity in areas where professional health care is limited. Another example is someone who calls upon their faith community’s prayer chain for help, or who asks for anointing by their minister. A third type of health care is the professional type with which we are familiar through our work. Some people more easily jump to this type of care, perhaps because of their upbringing , education, or their economic situation. All three types of health care can be utilized in a given situation, depending on the seriousness of the concern. Slide 11 Madeline Leininger: Theory of Culture Care Diversity and Universality The nurse-anthropologist whose definition of culture we are using, Madeline Leininger, developed a full theory that describes what she called “transcultural nursing”. While some people might seem to be members of particular cultures, remember that each person has their own distinct take on culture. So doing “transcultural nursing” is something we do with each and every patient. It can also be tricky sometimes when you have a patient who you think is “just like me”. You can assume that s/he will see things just as you do, will want the same care you would. Be aware of this, since it can lead to some really poor outcomes. What we are always striving for is effective care for each patient, meeting them where they are and giving them care that they can really use to their best advantage. Leininger calls this delivering culturally congruent care. Slide 12 Leininger’s Sunrise Enabler Here is a picture of Leininger’s model. She called it the “sunrise enabler”, for obvious reasons. It begins at the top with different dimensions of culture, from the technological to the educational, across the yellow semi-circle. Below the horizon line you see nursing in the center oval, helping to bring together the generic/folk practices with the professional. Leininger saw nurses as the bridge in health care, the critical link helping people understand and utilize professional care, but also advocating for their patients in a healthcare system that can run over and dominate people. Slide 13 Meeting the challenge of diversity In her model Leininger envisioned 3 basic responses of health professionals as they interact with cultural patterns of health beliefs and behaviors. The first possible action is maintenance. When we encounter some health behaviors, we might see them as beneficial to health and so can encourage these practices and strengthen them. For instance, there is a cultural shift occurring in many places now toward the benefits of breast-feeding. It’s a traditional practice that is making a comeback and which health science supports. Some simple folk practices, such as eating chicken soup and resting when we get sick with a cold, are also seen as basically helpful (or at least as doing no harm), and so we can agree that these are good first line measures. A second type of culturally competent health care action is accommodation. A student of mine once shared with our class an example of a folk practice that needed to be challenged and negotiated a bit for a better health outcome. She said that an Asian woman came into the ER very ill with an apparent pneumonia. Upon examination the resident discovered some wounds on the patient’s back, long thin slash marks, some still open and oozing blood. The staff was alarmed at this and thought about calling protective services, but then someone recalled that there is a traditional practice called “coining”. The patient’s family confirmed that this is what they had been trying; it involves scraping the skin with an object (like a quarter), to open up channels for the infection to leave the body. When this and other folk measures had not resulted in healing, they had brought the patient to the hospital for care. The ER staff was able to discuss this with the patient and family and negotiate about future incidents, when to rely on folk remedies and when it might be time to seek professional care. Professionals should be wary of condemning practices that we do not understand or which rely on a different understanding of the body, mind, and spirit. When possible, we seek to respect and combine types of health actions, getting the best out of each system. We can encourage, for instance, home remedies along with I&D with antibiotics or prayer together with chemotherapy for people suffering with cancer. A third type of health care action is called repatterning. This is the most difficult situation, where there are cultural patterns that health care professionals regard as actually harmful to health. For instance, some people were raised with the belief that it is best to withhold all food and drink from a child who is ill with diarrhea. Teaching communities patiently yet persistently, presenting evidence for best results while respecting the intents of the folk practices, takes time but is yielding better health outcomes in many places around the world. Of course having oral rehydration solutions and access to care are other important reasons for changes in behavior. Slide 14 Becoming culturally competent How can we, as nurses, take steps to increase our cultural competence? This is really a life-long task, a "process in which the health care professional continually strives to achieve the ability and availability to effectively work within the cultural context of a client" (Campinha-Bacote, 2002b). Like Madeline Leininger, Josepha Campinha-Bacote is another prominent nursing leader in this field. She developed a model for how we can advance in cultural competence. Her model has five steps, symbolized by the five letters, ASKED. Slide 15 Awareness The first letter is A for Awareness. But this awareness isn’t just being aware of the beliefs and practices of other cultures; it also means each of us being self-aware, of our own culturally based biases. This might mean taking the time to ask a question and really listen to our patient’s needs and preferences. It could mean taking steps to become a more reflective practitioner, one who is conscious as we act and then spends a few moments reviewing our day for places where we acted without full consideration or respect for others. Slide 16 Desire D is for Desire: do you really want to do this, to extend yourself? After all, it takes time and energy to understand and appreciate people (especially people who are hard to like!). This characteristic is very hard to teach students: maybe you either have it or you don’t. Practicing nurses are at risk for losing some of their early desire over the years, getting cynical or rushed or discouraged. This gets back to that basic human nature orientation: do I intend to respect every person I meet today, to do my absolute best for them in the way that they need it, not in the way that is easiest for me? Hopefully each of us has moments and times of new insight, new energy and conviction that refresh our desire to be the best nurse we can be. Slide 17 Encounters E is for Encounters: do we take advantage of opportunities to grow, to challenge ourselves? Student nurses always dread taking care of people with conditions unfamiliar to them; it means a lot of prep work and scary first encounters. As we continue in our work, do we embrace the chances to work with others who are different from us? Whether it is caring for someone with AIDS, a church outing to a soup kitchen, or a medical mission trip to Guatemala, we have opportunities to grow in our cultural understanding if we choose to do so. Working with health professionals from different cultures, even in our own institutions, can be a great opportunity close to home. Slide 18 Knowledge K is for Knowledge. The intentional study of other cultures, through reading in cultural care manuals, visits to cultural events, new friendships with colleagues from various backgrounds and other means can help you grow in understanding and competence. (Big Bird is holding up the wrong letter here, but I could not resist the picture :) Slide 19 Skills And S is for Skills. It can be challenging to practice nursing with patients from other cultures. Language and social roles may be very different; understanding the stress level of the patient and what measures would best alleviate that can take adaptation of regularly used methods. Would more or less family presence be beneficial? Will your touch during a physical assessment be welcomed, or can it be adapted in some way? If the patient is very aware of the spiritual presence of her deceased parents, would it help to create a small area in the room for objects to symbolize that presence? Do they need more privacy today, or would they appreciate small talk? Our skills need to continuously evolve so that we can provide the best care in a way that respects the needs and preferences of the patient. Slide 20 Kleinman’s Assessment Questions In terms of skills to help you advance in culturally competent care, the medical anthropologist Arthur Kleinman (1980) has suggested this list of questions for any assessment. Read through them slowly… Aren’t these wonderful questions to help you enter into the patient’s experiences? I hope that you will try using one or more of these in your practice. Thank you for your attention to this material. Slide 21 References