HCR230 Week 2, Lectures 2.1&2.

2 Culture, Society and Health

Dr. Michael Winkelman, M.P.H., Ph.D.

Overview
Managing differences National CLAS Standards Conceptualizing Differences Importance of culture Roles of culture in health Developing Culturally Responsive Care
Culture Care

Bases for Transcultural Care Race, Ethnicity, Class and Poverty Effects

Culture and Health Relations

Health Work and Diversity Issues
Multiple dimensions of cultural difference Ethnic, racial, class, generation, sexual orientation

How to relate to the Other?

Managing culture differences and conflict Managing self and others

Managing Differences
Problem with treating everyone the same
What is the same? Problems with self-reference

Do you treat everyone the same? Or Not?

The same as unconscious ethnocentrism The same as requiring different treatment
e.g., how to show respect

Why right to cultural respect?

Relationship to nursing careculture care Cultural Responsiveness Roles of ethnomedical concepts in health behaviors and communication Role of culture in effective diagnosis and healing

Cultural and Linguistic Competence

Understanding and responding effectively to cultural and linguistic needs affecting health care experiences National Standards DHHS CLAS Culturally and Linguistically Appropriate Services
See Blackboard

CLAS Standards
On-going Training for all staff
Providers, support personnel, administrators

Provision of qualified interpreter services and language-specific materials Community Inclusion

Advisory boards

Collect data on community and needs

Conceptualizing Differences: Societies, Cultures, Subcultures and Ethnicity

Cultural Pluralism and Multiculturalism Societies as Geopolitical Cultures as Learned Patterns
Subcultures and Ethnic Groups

Ethnicity as Identity
Ethnicity as inclusive and contrastive

Concept of Race as distracter (more later)

Using Concepts of Culture to Adapt

Generalizations versus stereotypes
Typical patterns versus oversimplifications Stereotypes as rigid, judgmental, prejudical

Cultural characterizations as norms

Ideals, normative expectations, typical patterns Cultural characterizations as flexible
points of departure

Importance of recognizing Intra-cultural variation

Internal Variation
Processes of Cultural Change
Acculturation and Assimilation

Dimensions and forms of assimilation

Biological, marital, economic/structural, cultural, psychological**

Heritage Consistency
Congruence of lifestyle with traditional cultural background Forms of Biculturalismsee Chapters 2 & 6*

Importance of Culture
Culture Definitions- learned behavior
Behaviors, Organization and Thoughts Material, Social and Mental

Meta-communication:
Attitudes, Beliefs, Ideology

Socialization and Psychocultural Development

Socialization of Human Biology

Features of Culture
Unconscious Determines behavior Seems normal Symbolic Softwarebrain program

Cultural Effects
Factors affected by culture
Food and self-care Personhood and Identity Social relations Communication Health and health behavior

Everything? What not?

Cultural Phenomena Affecting Health Systems Perspectives

Environment
Distribution of causes of disease Risk behaviors and exposures/protections

Social Organization
Economic, social and political effects Utilization of lay/popular and folk resources Health resources and provider responses

Mental
Communication Systems
Concepts of maladies, recognition of symptoms

Symbolic effects on health and maladies

Emotional and psychological influences on physiological responses

L 2.2 Developing Culturally Responsive Care

Awareness and SELF-awareness Sensitivity- behavioral modification Competence- participate in culture Responsiveness- competence in health care arena-- culture care All Involve Personal Developments/Change
Attitudes, Behaviors, Knowledge, Skills Maybe even identity

Culture Care
Culture Care Diversity and Universality Theory . . . Madeline Leininger, Grandmother of Transcultural Nursing Used for discovering care and health needs of different cultures Guide to thinking, practice and research on human care Why is human care mode important? Care is essence of nursing Necessary for recovery from illness and maintaining wellbeing Provides therapeutic care to diverse cultures

Care as Biological and Cultural

Care as part of the totality of human behavioral responses to health and illness
Broadest, most comprehensive, holistic and universal feature of human beings (p. 3)

Care as health, curing, well-being, + Action modes related to care are culturally based
Care is embedded in culture Specific cultural values, beliefs and lifeways are essential to expression of care Essential part of how humans deal with illness, disability, death and recovery

Culture Care Theory

Discover, document and explain interdependence of care and culture
Differences and Similarities among cultures Determine General and Specific care that is culturally congruent

Central domain of theory Culture and Care Relationships

Multiple factors influencing relations between culture and care

Acquired knowledge from informants stories about health and cultural lifeways Provides in-depth information about care and culture constructs

Nursing as Care
Leiningers definition of nursing emphasizes its focus on human care phenomena and activities . . . to maintain health in culturally meaningful ways (p. 7)
Care as the essence and central construct of nursing

Care as an essential perspectives for development of transcultural nursing

*necessary to meet societal and global needs produced by cultural diversity

Health characterized as a state of well-being that is culturally defined (p. 10)

Care and caring actions as leading to health

Nature of Care
Care as assistive, supportive and enabling experiences to improve human condition Care as symbolic, protective, respectful Culturally congruent care
Sensitive, knowledgable, meaningfully fit with cultural values, expectations, beliefs of client

Three major action modalities or decision modes

Necessary for providing culturally congruent nursing care
Culture care preservation and/or maintenance to retain, preserve beneficial care beliefs Culture care accommodation for culturally congruent safe and effective health care Care care repatterning to modify and restructure lifeways for better health care patterns

Summary: Bases for Cultural Care

Emic and etic data both have profound influence on care and health outcomes Emic as local, indigenous insider Etic as institutional knowledge and professional views
May be imposed (imperialistic) or cross-culturally valid

Culture Care Universalitycommonly shared care features of human beings Sunrise Enabler as cognitive map for discovering the specific cultural factors affecting health and care

HCR230 Week 2.2, Lectures 2.3 & 2.4

Concepts of Race, Ethnicity, Class and Poverty and Effects on Health

Overview
2.3 The Race Concept
History of the Racial Color Concepts Race and Human Biological Variation

Ethnicity
Concepts of Personhood and Identity

2.4 Class and Poverty

Mechanisms of Povertys Effects on Health

Understanding Human Differences: Race, National Origins, Ethnicity and Class

Race, Ethnicity and National Origin
Historical Sources Diversity in the U.S. Contemporary Persistence
Nature of differences? Biology or culture?

The Concept of Race

Historical Beliefs
biologically unique groups biologically homogeneous groups basis for differences in groups behavior Political motivations

Pseudoscientific Approaches- not true science but designed to confirm prior belief

Modern Concepts of Race

Anthropological Approaches
Continuity in human variation Most genes shared in common Cline as variation in single traits

Contemporary Uses
Social, Legal and Geographic Race as Racism and Ideology

Race & Skin Color

Skin Color
all except red formed by melanin found in other animals besides humans difference in distribution within skin

Sunlight Interaction
needs for differential absorption environmental adaptation

Human Biological Differences

Individual and Group Differences Greater within group variation than between group variation Population similarities and genetic profiles

Human Biological Differences and Nursing Care

Nature of differences
Statistical not categorical Often rare in target populations Significance in assessment

Ethnicity
Socially recognized groups
Collective Sense of identity

In-group vs. out-group differentiation Personal identity with group

Situationaly and personally variable

Perspectives on Ethnicity
Classic Perspectives on Ethnicity
Ethnic Categories are like races

Modern Views
A Construction of Ethnicity Ethnicity as socially relational/contrastive Ethnicity as variable within groups

Ethnicity as Relational
Included and Excluded other

Anthropological Approaches to Ethnicity

Indigenous Psychologies
Cultural concepts of person, internal dynamics & capabilities as manifested in expressive culture Personality and Self in Religion, Myths, Stories and Legends

Personality: concepts of person and psychological processes

Basic Personality Structures and Models

Self as identity embodied in roles Involve relations with others Social models for the person

Social Roles as Ethnicity

Social Status and Roles as Cultural Personalities Bases of Ethnic content Social Positions (status) parts to be played, positions in society Roles normative expectations about characteristic behaviors of people in certain status/positions Social positions and associated roles serve as the models ethnicity in ideals for behavior Also play roles in intergroup and class relations

Stages of Ethnic Identity Development

Multiple Models Types of Intercultural Adaptation
Ghettoization Passing Nativistic Marginality Mediators Multicultural

Minority and Majority Differences

Minority Ethnic Identity Development
Conformity Dissonance Resistance Introspection Internalization

Changes with ethnic revival and reassertion

 Dominant Groups Ethnic Awareness

Pre-exposure Contact Defensive/zealot Psuedo-independence Autonomy

L2.4 Sociocultural Effects on Health

Concept of Class
Access to resources, power, connections, knowledge

Poverty as manifestation of deprived class status

Numerous health problems associated with poverty Issues of Access

Social Class and Health

Social Conditions as Fundamental Causes of Disease
Increase in diseases and morality following economic recessions (infant mortality, cardiac arrest, mental illness)

Alameda Co. CA Study

Effects of economic hardship on health functioning 3Xs for poorest group
Independent of controls for age, sex, smoking, drinking, activity, BMI

General Class Associations with Multiple Health Measures

Evidence of general impact of economic status on health Effects of macrolevel on microlevel Persistence of class differences in spite of proximate/microlevel changes in lifestyle
E.g., hygiene/sanitation, housing, working conditions, general diet

Mechanisms of Povertys Effects on Health

Access to care Neighborhood characteristics and risks Quality of housing Environmental Hazards Health Promotion Knowledge and Promotion Culture and Care Preferences affecting Utilization Access to jobs with health benefits

Characteristics of Culture
Culture as totality of socially transmitted behavior patterns-- learned
Most (everything?) that humans do (or how they do it)

Explicit and implicitmostly unconscious Impact in clients and providers expectations Determinant of behavior
Including beliefs and practices affecting health behaviors and care expectations

Societal influences- may appear as cultural

Summary: Race, Ethnicity, Class & Culture

Culture- learned beliefs and behaviors
may be embraced or accepted

Race- falsely presumed biology

actually social category

Ethnicity- group identity

may or may not reflect culture

Class/Poverty/Social Stratification
Effects of resources on well-being