Health & Culture : Health & Culture Nicholas Comninellis, MD, MPH
President, INMED
Institute for International Medicine
Presentation Objectives : Presentation Objectives To understand:
That health and culture are intimately related
The meaning of “culture”
The assumptions of the two basic types of cultures
That many health interventions will likely be ineffective without attention to the local culture
That errors can be avoided through a process of observing, understanding, and adjusting
Culture & Health: Intimately Related : Culture & Health: Intimately Related Family members carrying a person in convulsions bypass the hospital on their way to a traditional healer.
Culture & Health: Intimately Related : Culture & Health: Intimately Related The mother of a malnourished child feeds the family’s meat and eggs to the father instead of the child.
Culture & Health: Intimately Related : Culture & Health: Intimately Related City dwellers regularly spit on the pavement in public, in spite the high prevalence of tuberculosis and laws against the practice
Culture & Health: Intimately Related : Culture & Health: Intimately Related Rural people continue using human waste as fertilizer even while intestinal parasites commonly infect them.
Culture & Health: Intimately Related : Culture & Health: Intimately Related In China, traditional people are encouraged to donate blood, but few are willing, believing that blood contains one’s “life force,” and that to have their blood removed is therefore a death-defying event.
Culture & Health: Intimately Related : Culture & Health: Intimately Related In Pakistan, many believe a mother’s breast milk can be poisoned by an evil eye, black magic, a new pregnancy, or excessive cold or heat. So, they stop nursing their infants believing that it is better the child go hungry than be poisoned.
Paul F. Basch, Stanford University : Paul F. Basch, Stanford University “Many culturally influenced behaviors have important health consequence. It may be our intention to try to modify the behaviors of other people in ways that we consider beneficial – that is, to immunize their children, to maintain sanitary conditions during childbirth, or to plan their families. Such efforts are unlikely to result in the desired changes if we do not understand why local conditions are as they are” (Basch, 1999, 146).
Strange World of Health Behaviors : Strange World of Health Behaviors Consider the various cultural perspectives on:
Diet
Exercise
God
Blood
Strange World of Health Behaviors : Strange World of Health Behaviors In some Asian cultures people think that to be healthy they must eat snake, do Tai Chi, worship the ancestors, and never, ever give blood.
Strange World of Health Behaviors : Strange World of Health Behaviors In some African cultures people believe to be healthy they must eat a particular plant root, avoid exercise, offer sacrifices to the local gods, and be bled periodically.
Strange World of Health Behaviors : Strange World of Health Behaviors In North American cultures, many people believe that to be healthy they must drink wine daily, do yoga, have nothing to do with the gods, and regularly give blood to be tested in a laboratory.
Culture -> Health : Culture -> Health Cultural norms have a profound influence on health behavior, and ultimately on health outcomes.
What Is “Culture”? : What Is “Culture”? An integrated system of learned behavior patterns, including:
Manners
Customs
Values
Ceremonies
Religious beliefs
What Is “Culture”? : What Is “Culture”?
Myths & legends
Laws (written & unwritten)
Language
Arts and artifacts
Concepts of self
Morals
Accepted ways of behaving
Types of Cultures : Types of Cultures Scientific
Traditional
Types of Cultures : Types of Cultures Can be viewed in terms of:
Human nature
Relationship of humans to nature
Sense of time
Activity
Social relationships
“Scientific Culture” : “Scientific Culture” Our culture relies upon statistical analysis and research methodology
Therefore, our health professionals have concepts of health and disease that are highly based upon the scientific method, germ theory, and evidence-based medicine.
“Scientific Culture” : “Scientific Culture”
“Traditional Culture” : “Traditional Culture” Emphasizes the rule of:
Disruptions in the balances of vital forces
Supernatural influences
Fatalism
All impact health
“Traditional Culture” : “Traditional Culture”
Mixtures of Scientific & Traditional Culture : Mixtures of Scientific & Traditional Culture Most cultures today contain a broad mixture of both scientific and traditional viewpoints.
In Cameroon, leprosy, mental illnesses, epilepsy, convulsions, and tuberculosis are in the realm of the traditional healers.
Alternatively, diarrhea, measles, malaria, worm-caused ailments, STDs are considered the realm of modern medicine. (Azevedor, Prater, Lantum, 1995).
Conflicting Assumptions : Conflicting Assumptions “It is easy to recognize how any two people from different nationalities might have difficulties in communicating in health care situations... they are likely to have conflicting assumptions and expectations about health and health care due to their culturally based health beliefs” (Kreps & Kunimoto 1994, 5).
Examples of Misunderstanding & Ineffectiveness : Examples of Misunderstanding & Ineffectiveness In eastern Africa people with HIV are taught by health professionals to not “pass on” their disease. Many persons misinterpret this to mean they should “pass on” their disease, because this term infers they themselves will no long have the possess it.
Examples of Misunderstanding & Ineffectiveness : Examples of Misunderstanding & Ineffectiveness In southern Africa health officials encourage communities to build outdoor latrines. However, most are never used, for many people believe that the spirit of a person resident within their feces will enter another who approaches.
Examples of Misunderstanding & Ineffectiveness : Examples of Misunderstanding & Ineffectiveness In a Peruvian village diarrheal diseases were common, but only 8% of families were boiling drinking water. The health dept without success tried to convince people to do so. Only later did they learn that people resisted this because boiled water was considered suitable only for ill people
Avoiding Misunderstanding & Ineffectiveness : Avoiding Misunderstanding & Ineffectiveness How can we understand the health perspectives of our hosts, and avoid advocating actions that will likely be ignored or even be counterproductive?
Avoiding Misunderstanding & Ineffectiveness : Avoiding Misunderstanding & Ineffectiveness We must follow the most basic principles of cultural adaptation:
Observe
Understand
Adjust
1. Observe : 1. Observe Carefully perceive the events
Do not make a judgment
Do not give advice
2. Understand : 2. Understand Ask “But Why?”
And, “But Why?”
And again, “But Why?”
2. Understand : 2. Understand “I want to be pregnant again”
“But why?”
“Because I must name a child after each relative”
“But why?”
“Because I want to honor my family”
“But why?”
3. Adjust : 3. Adjust Test more effective methods of communication
Explore alternative solutions
Enlist help of other leaders or experts
3. Adjust : 3. Adjust “What are other ways you could honor your family?”
“Are you certain your relatives expect a child named after them?”
“What questions do you have about contraceptives?”
“What does your husband think about more children?”
“Would you like to try using a contraceptive?”
A Process Built On Trust & Relationship : A Process Built On Trust & Relationship In more traditional cultures, relationship is established through personal interaction rather than through contact negotiation.
Time spent simply chatting or eating together may appear non-productive, but actually be vital to building trust.
1. Observe : 1. Observe Febrile children in Angola are commonly fed a particular boiled root.
Acute hepatitis results, frequently progressing to liver failure and death.
2. Understand : 2. Understand “Why is your child sick?”
“I think he has malaria.”
Why do you feed him this root?”
“Because my family said to.”
“Why isn’t your child better?”
“Because this root is not helping.”
“Why don’t you try a different treatment?”
“Because I don’t know what else to do.”
3. Adjust : 3. Adjust “How can you prevent your child from being infected with malaria?”
“Next time your child has a fever, what will you do?”
“How will you respond when your family says to give him the boiled root?”
“What can the hospital do to help people understand the dangers of the boiled root?”
3. Adjust : 3. Adjust Questions are usually far more effective than giving direct advice.
People usually maintain self-respect and develop ownership when they discover the answers for themselves.
Summary : Summary Health and culture are intimately related
The two basic types of cultures are “scientific” and traditional”
Many health interventions will likely be ineffective without attention to the local culture
Errors can be avoided through a process of observing, understanding, and adjusting
Summary : Summary Keeping Asking
“But Why?”