Question

Discuss Cultural Considerations Across the Lifespan and in Health and Illness

Answer 1

Culture Influences Health

• Culture is a pattern of ideas, customs and behaviours shared by a particular people or society. It is constantly evolving.
• The speed of cultural evolution varies. It increases when a group migrates to and incorporates components of a new culture into their culture of origin.
• Children often struggle with being ‘between cultures’– balancing the ‘old’ and the ‘new’. They essentially belong to both, whereas their parents often belong predominantly to the ‘old’ culture.
• One way of thinking about cultures is whether they are primarily ‘collectivist’ or ‘individualist’. Knowing the difference can help health professionals with diagnosis and with tailoring a treatment plan that includes a larger or smaller group.
• The influence of culture on health is vast. It affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer.
• Both health professionals and patients are influenced by their respective cultures. Canada’s health system has been shaped by the mainstream beliefs of historically dominant cultures.
• Cultural bias may result in very different health-related preferences and perceptions. Being aware of and negotiating such differences are skills known as ‘cultural competence’. This perspective allows care providers to ask about various beliefs or sources of care specifically, and to incorporate new awareness into diagnosis and treatment planning.
• Demonstrating awareness of a patient’s culture can promote trust, better health care, lead to higher rates of acceptance of diagnoses and improve treatment adherence.

Culture is the patterns of ideas, customs and behaviours shared by a particular people or society. These patterns identify members as part of a group and distinguish members from other groups. Culture may include all or a subset of the following characteristics:

Given the number of possible factors influencing any culture, there is naturally great diversity within any cultural group. Generalizing specific characteristics of one culture can be helpful, but be careful not to over-generalize.

• ethnicity
• language
• religion and spiritual beliefs
• gender
• socio-economic class
• age
• sexual orientation
• geographic origin
• group history
• education
• upbringing
• life experience

Culture is:

• dynamic and evolving,
• learned and passed on through generations,
• shared among those who agree on the way they name and understand reality,
• often identified ‘symbolically’, through language, dress, music and behaviours, and
• integrated into all aspects of an individual’s life.

The cultural continuum

Culture is commonly divided into two broad categories at opposite ends of a continuum: collectivistic or individualistic. Most cultures fall somewhere between the two poles, with characteristics of both. Also, within any given culture, individual variations range across the spectrum. Still, being familiar with characteristics of collectivistic and individualistic cultures is useful because it helps practitioners to ‘locate’ where a family falls within their cultural continuum and to personalize patient care.

Collectivistic and individualistic cultures can give rise to different views on human health, as well as on treatment, diagnoses and causes of illness. Depending on where a patient ‘fits’ along their cultural continuum, including extended family in discussions about disease origin, diagnosis and treatment may be helpful. Consent for certain diagnostic and therapeutic interventions may be needed from extended family members.

Characteristics of collectivistic and individualistic cultures

Collectivistic	Individualistic
Focus on “we”	Focus on “I”
Promote relatedness and interdependence	Value autonomy
Connection to the family	View ability to make personal individual choices as a right
Value respect and obedience	Emphasize individual initiative and achievement
Emphasize group goals, cooperation and harmony	Lesser influence of group views and values, and in fewer aspects of life
Greater, broader influence of group views and values

Impact of culture on health

Health is a cultural concept because culture frames and shapes how we perceive the world and our experiences. Along with other determinants of health and disease, culture helps to define:

• How patients and health care providers view health and illness.
• What patients and health care providers believe about the causes of disease. For example, some patients are unaware of germ theory and may instead believe in fatalism, a djinn (in rural Afghanistan, an evil spirit that seizes infants and is responsible for tetanus-like illness), the 'evil eye', or a demon. They may not accept a diagnosis and may even believe they cannot change the course of events. Instead, they can only accept circumstances as they unfold.
• Which diseases or conditions are stigmatized and why. In many cultures, depression is a common stigma and seeing a psychiatrist means a person is “crazy”.
• What types of health promotion activities are practiced, recommended or insured. In some cultures being “strong” (or what Canadians would consider “overweight”) means having a store of energy against famine, and “strong” women are desirable and healthy.
• How illness and pain are experienced and expressed. In some cultures, stoicism is the norm, even in the face of severe pain. In other cultures, people openly express moderately painful feelings. The degree to which pain should be investigated or treated may differ.
• Where patients seek help, how they ask for help and, perhaps, when they make their first approach. Some cultures tend to consult allied health care providers first, saving a visit to the doctor for when a problem becomes severe.
• Patient interaction with health care providers. For example, not making direct eye contact is a sign of respect in many cultures, but a care provider may wonder if the same behaviour means her patient is depressed.
• The degree of understanding and compliance with treatment options recommended by health care providers who do not share their cultural beliefs. Some patients believe that a physician who doesn’t give an injection may not be taking their symptoms seriously.
• How patients and providers perceive chronic disease and various treatment options.

Culture also affects health in other ways, such as:

• Acceptance of a diagnosis, including who should be told, when and how.
• Acceptance of preventive or health promotion measures (e.g., vaccines, prenatal care, birth control, screening tests, etc.).
• Perception of the amount of control individuals have in preventing and controlling disease.
• Perceptions of death, dying and who should be involved.
• Use of direct versus indirect communication. Making or avoiding eye contact can be viewed as rude or polite, depending on culture.
• Willingness to discuss symptoms with a health care provider, or with an interpreter being present.
• Influence of family dynamics, including traditional gender roles, filial responsibilities, and patterns of support among family members.
• Perceptions of youth and aging.
• How accessible the health system is, as well as how well it functions.

Providing health care to different cultural groups

Developing a guide to help health professionals understand cultural preferences and characteristics around the world would be a mammoth undertaking. Also, any such document would be biased by the authors’ own cultural perspectives. Culturally, health professionals in Canada are increasingly diverse, viewing the world and the people they see through many different lenses.

However, health care providers should learn skills around cultural competence and patient-centred care. Such skills can be a compass for exploring, respecting and using cultural similarities and differences to improve quality of care and patient outcomes.

Above all, remember that:

• Cultures are dynamic.
• There is huge diversity within any culture.
• Even when you think you understand one culture, it will have evolved or you will have identified exceptions