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NUR416
WEEK 2
Lecture Title: Culture and Health
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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