Complementary 421
Multicultural Health
Chapter 3: Worldview and Health
Lois Ritter and Donald H. Graham
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Overview of Chapter Topics
- What is worldview and how does it relate to culture?
- How does worldview impact health decisions and communication?
- Introduction to religion, spirituality, and ritual.
- Religion in the U.S.
- Religion and health behaviors
- Effect of religion on health-related behaviors
- Religion and health outcomes
- Religion and medical decisions
- Rituals in relation to health practices.
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Worldview
- Overall perspective from which one sees and interprets the world.
- Sets of assumptions and beliefs that express how cultures see, interpret, and explain their experience particularly in terms of time, personal space, individual autonomy, free will, and fate.
- Closely linked to cultural and religious beliefs.
- Culture built upon worldviews.
- Has profound health care implications.
- e.g., People with chronic diseases who believe in fatalism (predetermined fate) may not adhere to treatment because they believe that medical intervention cannot affect their outcomes.
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Major Facets of Worldview
- Time orientation
- Personal space
- Social organization
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Time Orientation
- Time orientation
- In the West, time is logical, sequential, and present focused, moving with incremental certainty toward a future.
- In the East, time feels like it has unlimited continuity, and it does not have a defined boundary. Birth and death are not such absolute ends because the universe continues, and humans, though changing form, continue as part of it.
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Time Orientation
- Past, present, or future
- Past oriented: Tend to value elders and honor traditions, e.g., the Asian culture values and performs traditional healing practices, such as acupuncture and herbal remedies
- Present oriented: May see living in the moment as the priority and are less willing to forego immediate pleasures for future benefits—less focused on prevention, e.g., American Indians and African Americans
- Future oriented: Understand that healthy behaviors in the present impact our health in the future, and future-oriented people are willing to make sacrifices now for future benefits, e.g., Western culture
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Time Orientation
- Punctuality
- Some very timely, e.g., Polish culture
- Others less rigid and may be late for appointments, e.g., Latino culture
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Personal Space
- Personal space includes interpersonal space and boundaries.
- e.g., North Americans tend to prefer a large amount of space, and Europeans tend to stand more closely together when talking and are accustomed to smaller personal spaces.
- Violating boundaries can be offensive.
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Social Organization
- Social organization refers to dominant patterns of social interaction.
- e.g., How people interact and communicate, the kinship system, marriage residency patterns, division of labor, who has access to specific goods and knowledge, social hierarchy
- Four components of social organization that have an immense impact in health care are explored here:
Individualism vs. collectivism
Fate vs. free will
Communication
Family relationships
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Individualism vs. Collectivism
- Individualism and collectivism have contrasting perspectives and values.
- Individualists see a person as a social unit, and each person has primary responsibility for him- or herself.
- In the United States, the overarching culture values individualism, autonomy, and independence, and these qualities are rewarded and respected.
- Other individualistic cultures include Germany, Canada, and Sweden (Purnell, 2013).
- If someone is successful, it is primarily because of these personal qualities.
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Individualism vs. Collectivism
- Collectivists societies view themselves as part of a larger group, such as a family, community, or tribe, so the group is the social unit, and dependence and connections with the group is valued.
- An individual’s identity is determined by the groups with which he or she interacts and the relationships within those groups.
- Decisions are made based on what is good for the group rather than what is good for the individual.
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Individualism vs. Collectivism
- Saving face and respect for others is valued.
- The needs and goals of the individual are subordinate to those of the larger group and should be sacrificed when the collective good so requires.
- Achievement is a product of society.
- Collective cultures include Amish, Chinese, Mexicans, and Vietnamese (Purnell, 2013).
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Individualism vs. Collectivism
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Table 3-1: Individualism versus Collectivism
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Individualism vs. Collectivism
- Individualistic societies make health decisions independently.
- Direct questioning, sharing personal issues, and asking personal questions are typical in this culture.
- Advanced directives are seen as prolonging autonomy.
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Individualism vs. Collectivism
- Collectivist societies want to involve family in the decision-making process.
- Illness is seen as a family event.
- Disagreeing or saying no to a healthcare professional is considered rude, therefore, a healthcare professional may ask if the patient understands and he or she may receive the answer “yes” when understanding has really not occurred.
- Stigmatized health problems such as disabilities and mental health issues, may be kept hidden to “save face” and hence treatment may be delayed and care provided in the home (Purnell, 2013).
- Advanced directives may not be accepted as families should make the decisions and not the individual.
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Fate vs. Free Will
- Free will is the degree to which people believe they are the masters of their own lives.
- Fate is the degree to which they believe that they are subject to events outside our control.
- Both fate and free will refer to the beliefs that people hold about their ability to change and maneuver the course of their lives and relationships.
- This concept is also called locus of control.
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Fate vs. Free Will
- People who believe that they have control over their health have an internal locus of control (free will belief).
- People who believe that their health is outside of their control (fate belief) have an external locus of control.
- In some ethnic groups, factors outside of medical intervention, such as a divine plan and personal coping skills, may be more important for health and survival than medical intervention and health behaviors.
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Communication
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Effective Interpersonal Communication
- Defined: An interactive process that involves sending and receiving information, emotions, thoughts, and ideas through verbal and nonverbal means.
- Effective communication enables healthcare professionals to accurately exchange information, establish relationships, and understand the person’s needs and concerns.
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Effective Interpersonal Communication
- Effective communication is important in all facets of life, but in health care it can be the deciding factor between life and death.
- Intercultural communication is sensitive to exchanging information across cultural boundaries in a way that preserves mutual respect and minimizes miscommunication and conflict.
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Effective Interpersonal Communication
- Effective interpersonal communication can lead to:
- Better health outcomes
- Higher patient satisfaction
- Continued care
- Better adherence to treatment recommendations
- Reduced conflict and errors, lost opportunities for encouraging health behavior changes, misinterpretations of treatment plans, damaged relationships (including a loss of trust) between the provider and patient or community member, and legal actions
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Verbal Communication
- Potential barriers in verbal communication include:
- Varying connotative meanings of words.
- Specialized biomedical jargon and vocabulary.
- Culture-specific taboos against patients questioning healers.
- Culture-specific taboos against discussing specific topics.
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Nonverbal Communication
- Modes of nonverbal communication
- Gestures
- touch
- Posture
- Body language
- objects
- Silence
- Spacial relationships
- Facial expressions
- Amount and location of touch
- Eye contact
- Physical appearance
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Family Relationships
- Includes issues such as:
- Who makes decisions in the home
- Family goals and priorities
- Child-rearing practices
- Family and community social status
- Marriage decisions
- Divorce acceptance
- The roles of the elderly and extended family
- Acceptance of alternative lifestyles
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Family Relationships
- Impacts issues such as health behaviors and decisions, living situations, and age of marriage.
- Related to the quality of social support from family, which has been shown to have significant consequences for health.
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Worldview and
Medical Decisions
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Worldview and Medical Decisions
- Impacts medical decisions such as:
- Abortion
- Use of birth control
- Permission to allow blood transfusion
- Utilization of chemotherapy
- Advance directives
- Euthanasia
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Beginning of Life Decisions
- Birth control use:
- Prohibited by some religions, i.e., a violation of the design built into the human race by God.
- Permitted with restrictions by other religions, i.e., the use of hormonal birth control methods such as pills, patches, injections, and implants, but do not allow the use of birth control methods that block or destroy sperm, such as condoms and vasectomies.
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Beginning of Life Decisions
- Abortion: The core question is about when life begins.
- Many religions will approve of abortion under certain circumstances. These circumstances may include:
- The health of the mother will be at risk if the pregnancy is continued.
- The child may be born with a disability that will cause suffering.
- The pregnancy resulted from rape or incest.
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End of Life Decisions
- Death is inevitable.
- How people respond to death has cultural ties:
- Appropriateness of crying, sobbing, and wailing loudly while others conservatively control their grief and stoically in public.
- Variations in the burial and grieving processes.
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End of Life Decisions
- Modern technology has changed the process through life-extending technologies, such as organ transplantation, respirators, antibiotics, surgical procedures, and feeding tubes enabling life to be prolonged.
- Other technologies, such as lethal injections, may hasten death.
- The decision to use these technologies is a complex choice.
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End of Life Decisions
- Organ transplant is the removal of tissues of the human body from a person who has recently died or from a living donor for the purpose of transplanting or grafting them into other persons.
- Some religions that previously prohibited organ donation are now altering their views and seeing it as an act of compassion.
- Some continue to prohibit organ donation because of their beliefs of life after death and resurrection.
- Some religions will consent to an organ donation if they are certain that it is for the health and welfare of the transplant recipient, but if the outcome is questionable, then the donation is not encouraged.
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End of Life Decisions
- Euthanasia is the act or practice of ending the life of an individual who is suffering from a terminal illness or an incurable condition by lethal injection, or the suspension of extraordinary medical treatment.
- Euthanasia is a Greek term that means “good death.”
- This is also called mercy killing.
- Murder and suicide are against the belief systems of most religions, so in those systems it would be considered morally wrong (in some religions, such as Hinduism, suicide is acceptable if it is done by fasting because it is nonviolent).
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End of Life Decisions
- Other reasons for religious opposition to euthanasia:
- Concern for patients who may be in vulnerable positions because of their illness or their lack of social and economic resources.
- Fear that patients who cannot afford expensive treatment, for example, will be pressured to accept euthanasia.
- Concern about the moral nature of the doctor’s professional self.
- Karma and rebirth.
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End of Life Decisions
- Most religions also consider acts of compassion and concern about the dignity of the dying person to be part of humanity.
- Concern for the welfare of others as one is dying is a consideration, because it can be seen as a sign of spiritual enlightenment.
- A person can decide to forego treatment to avoid imposing a heavy burden of caregiving on family or friends.
- He or she may also stop treatment to relieve loved ones of the emotional or economic distress of prolonged dying.
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End of Life Decisions
- Advanced directives are legal documents that enable a person to convey his or her decisions about end-of-life care ahead of time.
- Includes the living will and durable power of attorney.
- Provides a way for patients to communicate their wishes to their family, friends, and healthcare professionals and to avoid confusion later in the event that the person becomes unable to do so.
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End of Life Decisions
- A study revealed significant differences among racial and ethnic groups in the rate of completion of advance directives.
- Whites are more likely to complete advanced directive than African Americans and Hispanics.
- This difference is likely attributable to several factors, including cultural differences in family centered decision-making, distrust of the health care system, or poor communication between healthcare professionals and patients.
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End of Life Decisions
- Collectivist groups, such as Hispanics, may be reluctant to formally appoint a specific family member to be in charge because of concerns about isolating these persons or offending other relatives. Instead, a consensually oriented decision-making approach appears to be more acceptable in this population.
- Among Asian Americans, aggressive treatment for elderly family members is likely to be frowned upon because family members should have love and respect for their parents and ancestors and because of their high respect for the elderly.
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Worldview and Response to Illness
- Worldview has an impact of how people perceive and respond to illness.
- Dominant values and standards regarding pain and illness impact behaviors of the individual.
- When people with a biomedical worldview of the mind and body being separate was shared by providers and most patients, this shared belief often contributed to substantial patient stress and alienation.
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Worldview and Response to Illness
- Stigma plays a role in how people respond to illness.
- People express pain and suffering differently.
- Some are stoic and some emotive.
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Religion, Spirituality, and Ritual
- In earlier times, physicians were often clergy and for hundreds of years religious organizations were responsible for licensing physicians.
- The belief in the ability of the supernatural to heal surfaced in shamanism thousands of years ago.
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Religion, Spirituality, and Ritual
- There is considerable overlap between religion and spirituality.
- Religion is a belief in and respect for a supernatural power or powers, which is regarded as creator and governor of the universe, and a personal or institutionalized system grounded in such a belief or worship.
- Spirituality is often described as a belief in a higher power, something beyond the human experience.
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Religion, Spirituality, and Ritual
- A person may be spiritual but not religious.
- Religion is more associated with behaviors that can be quantified easier than the term spirituality.
- Religion can be categorized by denomination, so there is more agreement about the meaning of the term, and it can be more easily quantified (i.e., place of worship).
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Religion, Spirituality, and Ritual
- Overlap exists between religion and ritual.
- Religion may include established rituals, but not all rituals are associated with a specific religion.
- Consequently, this chapter examines the relationship between ritual and health separately from the relationship between religion and health.
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Religion and Health Behaviors
- Lifestyle is the single most prominent influence over health today.
- People with religious ties have been shown to follow healthier behavioral patterns than the nonreligious related to
- Wider networks of social support, which are often key to coping with life stress
- Proscribed behaviors (i.e., no alcohol consumption or premarital sex)
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Religion and Health Behaviors
- Dietary practices with possible effects on health
- Prohibition or restriction of consumption of animal products and beverages
- Fasting
- Prohibition or restriction of use of stimulants and depressants because of addictive properties
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Religion and Health Behaviors
- Religion is thought to correlate to positive outcomes with respect to:
- Hypertension
- Mortality/longevity
- Depression
- Suicide
- Promiscuous sexual behavior
- Drug and alcohol use
- Delinquency
- General feelings of well-being
- Hope/purpose/meaning in life
- Self-esteem
- Educational attainment
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Religion and Health Behaviors
- Some religions incorporate the use of stimulants or depressants into their ceremonies.
- Religious practice may correlate with positive health behaviors generally, as well as with reduced rates of depression and higher rates of marital stability.
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Religion and Health Outcomes
- Religion can also harm health.
- Sometimes used to justify hatred, aggression, and prejudice.
- Can be judgmental, alienating, exclusive.
- Can cause feeling of religious guilt or feeling of failure to meet religious expectations.
- May restrict health care services because belief that health is in God’s hands.
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Clinical Implications
- Many patients are religious and/or spiritual and have spiritual needs related to medical or psychiatric illness.
- Religion and spirituality influences the patient’s ability to cope with illness.
- Religious and spiritual beliefs affect patients’ medical decisions, may conflict with medical treatments, and can influence compliance with those treatments.
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Clinical Implications
- Physicians’ own religious or spiritual beliefs often influence medical decisions they make and affect the type of care they offer to patients.
- Religion and spirituality is associated with both mental and physical health and likely affects medical outcomes.
- Religion and spirituality influence the kind of support and care that patients receive once they return home.
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Religion and Medical Decisions
- Beginning of life decisions
- Abortion: Opposed or strictly limited by many religions (exceptions include health of the mother is at risk if pregnancy continued; child would be born with a disability that will cause suffering; rape; incest).
- Birth control usage: Varying methods approved or strongly opposed by certain religions; some religions permit hormonal methods but not the methods that block or destroy sperm.
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Religion and Medical Decisions
- End of life decisions
- Religious beliefs may influence decisions to accept/reject optional treatments to prolong life at the end, i.e., respirators, organ transplants, feeding tubes.
- Euthanasia and do not resuscitate orders are viewed differently by various cultures and religions.
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Ritual in Relation to Health Practices
- Ritual: A set of actions that usually are very structured and have symbolic meaning or value.
- Rituals may be performed on certain occasions, at regular intervals, or at discretion of individuals or communities; they are held in private or public.
- Rituals are tied to numerous activities and events, i.e., births, deaths, holidays, club meetings, etc.
- There are many rituals in the health care setting, i.e., being on time for appointments, how people are addressed, where patients sit.
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Ritual in Relation to Health Practices
- Objects as rituals (i.e., amulets, bracelets, statues, crosses)
- Importance of shrines in ritual activities (many are for health and healing)
- Rituals involving animal sacrifice (done to build and maintain personal relationship with a spirit)
- Birth rituals (i.e., food restrictions, silent birth, how placenta is discarded)
- Death rituals (how and when the body is disposed of, prayer, dress, use of flowers)
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Summary
- Worldview is our perception of how the world works.
- This includes issues such as moral and ethical reasoning, social relationships, and communication, to name a few.
- Healthcare professionals need to take a person’s worldview into consideration as it effects behaviors, perceptions, communication, and decisions.
- These decisions are made daily, such as whether to take a medication or not, as well as major decisions, such as beginning and end of life decisions.
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Summary
- Religion and spirituality play a major role in people’s lives and in their health decisions and behaviors.
- Religion has been shown to improve health, but also can contribute to health problems.
- Religion and spirituality can impact medical decisions.
- Many rituals are related to health and some are tied to specific religions.
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