global health promotion
sjsaaorabi
Chapt6Slides.pptx1/15/2016
Culture and Health
Chapter Six
Chapter 6 Culture and Health
In this chapter we will be examining the link between culture and health as they relate to global health in low and middle income countries.
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Culture
A system of thoughts and behaviors
shared by a group of people.
Our cultural backgrounds
have tremendous impact on our lives.
Culture contributes to the
richness of human experience.
Source: GHEC
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When we think about culture, we think about the elements that we can see like music and dance. These elements could be described as the exposed part of the iceberg of culture. The majority of the factors that shape out behaviors lie well below the tip level of the iceberg. Each person is an individual who lives within cultural context. Having said that, we all share some universal elements within different cultures. One way to define culture is that a group of people share a system of thought and behaviors that have tremendous impact on their lives.
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The Importance of Culture to Health
Culture is related to health behaviors.
Culture is an important determinant of people’s perceptions of illness.
Culture affects usage of health services.
Different cultures have different health practices.
The influence of culture on health is an integrated one. What people eat is related with the health outcome-obesity or malnutrition, birthing practices within a culture could determine whether the outcome will be beneficial or detrimental to mother’s health. Culture also determines how people perceive about illness. Different cultural groups have different definition for good health and illness. Culture also determine how the people live within that culture are going to use health services-some people see health care provider as soon as they are ill, some may go when they are really sick. Different cultures also have different health practices. For example Chinese and Indian cultures have distinct health practices and well defined system of medicine.
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The Concept of Culture
Culture - “behavior and beliefs that are learned and shared.”
Influences family, social groups, individual growth, communication, religion, art, politics, the economy.
Society - “a group of people that occupy a specific locality and share the same cultural traditions.”
Health policies and programs must always keep culture in mind.
Very similar to culture concept, there is another notion which is society. Society is defined as specific locality people share the same culture. Culture influences every aspect of life, for instance social, art, politics, religion, communication etc. As health policies are designed, it is crucial that culture of the specific population should be kept in mind.
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Culture –Good or Bad?
Ethnocentrism versus Cultural relativism
Questions
Is female genital mutilation health enhancing or harmful?
Should a newborn be given sugar water?
Should women eat less for an easy delivery?
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In examining the relationship between culture and health, it is important from which perspective we are examining a certain culture. When a culture is viewed by someone who does not belong to that specific culture and trying to see through their own prism and thereby judge a society as a lacking one, that view is known as Ethnocentrism in anthropology. On the other hand there is another idea which states because cultures are unique; they can be evaluated only according to their own standards and value. This view is known as “Cultural relativism”.
In this course we are going to follow an approach which is a question. And that is “How well does a given culture satisfy the physical and psychological needs of those whose behavior it guides?” Can you answer the questions mentioned here with this approach?
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Culture ……
Spirit Child (25:00)
An investigation into the ritual killing of disabled Ghanaian children deemed to be possessed by evil spirits.
http:// www.aljazeera.com/programmes/peopleandpower/2013/01/201319121124284358.html
Rites of Passage (5:58)
Maasai male moves towards becoming a man.
https:// www.youtube.com/watch?v=u_zmQlNmge4
Albinos in Africa (3:11)
Killing albinos for body organs.
https:// www.youtube.com/watch?v=9F6UpuJIFaY
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Watch these videos to see how culture and health go hand-in-hand.
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Health Beliefs and Practices
Cultures vary in views of what is illness, what causes illness, and what should be done about it.
Different ideas about how to prevent problems, what health care they should seek, and the types of remedies that health providers should offer.
Different cultures have different views of what is illness, what causes illness, and what should be done about it. Similarly, people from different cultures hold different ideas about how to prevent problems, what health care they should seek, and the types of remedies that health providers should offer.
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Health Beliefs and Practices
Perceptions of Illness
Vary across groups
One culture may view certain signs or symptoms as an affliction while others consider them normal
Perceptions of illness vary cross group. Malaria is very common in Sub Saharan Africa that many families see it as normal phenomena. In India women do not consider back pain as a morbidity they are suffering from. In Nepal people interpret cold and flu as regular part of their daily life and continue to do their work.
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Health Beliefs and Practices
Perceptions of Disease
Disease - “malfunctioning or mal-adaptation of biologic and psycho-physiologic processes in the individual”
Illness - “personal, interpersonal, and cultural reactions to disease or discomfort”
Some cultures believe illness can be caused by emotional stress, supernatural causes, or bodily imbalance
High income countries follow “Western medical paradigm”
Traditional societies in low/middle income countries concentrate on factors other than biological agent
Out of balance
Supernatural cause
The evil eye
In medical dictionary we have distinct definition for disease, and illness. However, when the variable “culture” added to the equation of disease perception, the definition could vary according to geographic location. In western countries or high income countries, people follow western medical paradigm. People here try to reason why the disease is occurring and what could be done about it. As for low income countries, people try to concentrate on factors other than biological origin of disease. Say for instance, in Nepal (or countries of similar culture) when people get fever they try to categorize the fever with their own perception. It is very much granted that after a heavy work someone is very much likely to get a fever. Similarly, it is very much expected that in hot, rainy season people will be suffering from malaria (Nepal is a malaria endemic country).
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Health Beliefs and Practices
Folk Illness
Cultural interpretations of physical states that people perceive to be illness, but that do not have a physiologic cause
Efforts to improve health need to consider these beliefs
Example:
A woman receives traditional Chinese medical treatment with a walnut on her eye and ignited dry moxa leaves in her ear.
To understand health problems in low and middle income countries, it is also important to acknowledge the existence of folk illness for which there may or may not be any physiological cause but certain cultures have specific etiology and symptoms defined in describing the disease. For instance, in Latin American culture there is an illness named “Empacho” which according to that culture caused by consumption of inappropriate food and to cure this illness families rely on limiting food, performing warm oil massage or taking the patient to local healers.
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Selected Examples of Cultural Explanations of Disease
This table lists some of the culturally defined causes of illness.
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Health Beliefs and Practices
The Prevention of Illness
Many cultures have taboos that concern avoiding illness.
Many concern foods to avoid during pregnancy.
Wide variety of ritual practices to avoid illness.
In many culture, there are certain practices that they do to avoid illness. A large number of taboo concern what to eat or not during pregnancy. In a study in western Malaysia, researchers have found pregnant women avoid some foods as a cultural practice that is good source of vitamin. There is also use of ritual practices that people practice to avoid illness. In Nigeria people wear charms, amulet, in some tribal groups in India put charms on crossings to inflict harm on others, to avoid themselves from harm, or to appease an evil spirit.
In the picture on the left, a voodoo priest uses divining cards during a traditional medicine consultation in Haiti. In most of rural Haiti, the voodoo priest is the first stop when illness occurs. They employ a whole range of herbal medicines as well as mystical healing process (Source GHEC)
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Health Beliefs and Practices
The Diagnosis and Treatment of Illness and the Use of Health Services
Common to try a home remedy, then visit a local healer, then consult a “western doctor.”
“Patterns of resort” affected by cost of services (direct & indirect), means of payment, manner in which the provider treats them socially.
“Home Treatment” vary in high income and in middle or low income countries.
For many cultures, when people are ill, they rely on home remedies, then go to local healer and finally they look for western medicine. The manner people care for illness follows a pattern known as “Patterns of resort”. Various factors comes in consideration when people look for health care. The cost of seeing the provider, transportation cost, means of payment each needs to be evaluated by a low/middle income family before they seek for health care. If a local healer charges less than a western doctor, probability are high people will go for a local healer. Use of the service is also dependent on the manner of the health care provider-if the provider is someone from the community, speaks their language, or show respect then the usage of health system also increases.
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Health Beliefs and Practices
Health Providers
Depends on location.
Local practitioners of indigenous medicine - traditional birth attendants, herbalists, priests.
Practitioners of western medicine - community health workers, nurses, physicians.
Pharmacist/stores dispense drugs/medical advice in many low and middle income countries.
Traditional Medicine in Nepal (12:57)
https:// www.youtube.com/watch?v=cyCjN8nV33o
There are a number of different kinds of health care providers. Some practice indigenous medicine, traditional birth attendants, priest, herbalist etc. In low income countries pharmacist or stores that sell drug often dispense drugs and medicines. The western medical systems are more structured with licensed physician, nurse, health care workers.
Watch the video to see how traditional medicine is validated and used in Nepali culture.
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Select Examples of Health Services Providers
This table lists some examples of health care service provider.
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Video example of healthcare providers
Witch doctors in Uganda (28:37)
Uganda's children live in fear of becoming the next to be sacrificed due to superstitions fuelled by witchdoctors.
https:// www.youtube.com/watch?v=IlQA5CLf7cQ
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Leading causes of death in low and middle income countries
Diseases
IHD
CVD
HIV
Pneumonia
Malaria
TB
Diarrhea
Risk factors
Malnutrition
Tobacco use
Unsafe sex
Hygiene
Indoor air pollution
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Behaviors are conducive to good health. Cultures where food taboo prevents women from eating appropriate and enough food, it could be anticipated those culture have low birth weight babies. Also, the timing for breastfeeding and introduction of complimentary feeding could determine the nutritional status of a child. Hygiene , lack of sanitation or safe water are well established risk factors for water borne disease, however, behavior like not washing hand after using toilet, or properly boil water for drinking or other household purposes also add to the existing burden of disease occurrence in low income countries.
In the images you see here,
A mother bathes her daughter with water from the most polluted river in Jakarta, Indonesia.
A Guatemalan woman sits in smoke caused by cooking over a inside stove.
A nurse in rural India weighs a baby girl who had been malnourished.
A Nepali man is smoking where smoking has been portrayed as a masculine habit
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Health Behaviors and Behavior Change
Improving Health Behaviors
The Ecological Perspective
The Health Belief model
Stages of Change model
The diffusion of Innovations Model
We will be examining couple of health behavior change models very briefly.
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Improving Health Behavior
The Ecological Model
“Health related behaviors are affected by, and affect, multiple levels of influence”
“Behavior both influences and is influenced by the social environments in which it occurs”
The Health Belief Model
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Self Efficacy
The ecological model states that health behaviors are affected by and affect multiple levels of influence .They are intrapersonal or individual factors, interpersonal factors, institutional factors, community factors and public policy factors.
In health belief model which was formulated to understand why or why not people do not do a certain behavior when an opportunity to do the behavior is offered. This model sates that people’s health behavior depends on their perception of getting the disease and the perception of the severity of disease if they get it. This model also says the likelihood that people will be engaging in health protecting behavior depend on their perception about the benefit of engaging in that behavior and the barriers to engage in the behavior. This model emerged an important concept, self-efficacy defined as the belief of people about actually carrying out the desired behavior.
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Illness
Perceived likelihood of getting the illness
Perceived severity of the illness if they get it
Illness Preventing Behavior
Benefits of engaging in the specific behavior
The barriers to engage in the behavior
Stages of Change Model
Improving Health Behaviors
Decision
Pre-contemplation
Contemplation
Change is a process and different people are at different stages of the process.
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Action
Maintenance
Stages of change model says that change in behavior is a process and different people are at different levels of readiness for change. The five stages that are designated for this model are pre-contemplation, contemplation, decision, action and maintenance. It was originally developed for use in the work on alcohol and drug abuse. Can you connect the dots between this model and alcohol addiction?
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Improving Health Behaviors The Diffusion of Innovations Model
Communication promotes social change.
Diffusion is the process by which innovations are communicated over time among members of different groups.
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The idea of this model is that communication is needed to promote social changes and the diffusion is the process by which innovations are communicated over time among different members of groups. This model classify groups in 6 different categories and indicate that the rate of the adoption will be influenced by the perceived gain, the compatibility with existing culture and values, easiness of the innovation, existing role models and the cost, time, money, and energy needed to adopt the innovation.
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Innovators
Early Adopters
Early majority
Late majority
Late adopters
Laggards
The gain
Culture and value compatibility
Easiness
Existing role models
Cost, time, money and energy efficiency
Understanding and Engendering Behavior Change
Understanding Behaviors Requires assessment of:
Behaviors that are taking place
Extent to which they are helpful or harmful
Underlying motivation for these behaviors
Likely responses to different approaches to changing the unhealthy behaviors
Photo source: K4health
To promote a behavior change, it is necessary that we carefully examine all the factors that are in play for that particular behavior. For instance, breastfeeding, if we want to promote this behavior among a population we first need to find out to what extent this behavior is taking place (or not) among the population. Questions like when do women start breastfeeding, is it on demand or schedule basis, who breastfeed and who does not, if they do not why they don’t, if they do what are the motivating factors and such are necessary to ask to formulate a plan for behavior change.
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Changing Health Behaviors
Changing a behavior is the interaction among different levels like individual, community, and society levels.
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Society level
Community level
Individual level
Changing Health Behaviors
Community Mobilization
Engage entire community in efforts to identify problems and promote healthy behaviors
Leaders in community need to be mobilized, willing to champion change
Ending chronic malnutrition in Nepal
Mass Media
Often uses radio or educational performances to get a message across
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https:// www.youtube.com/watch?v=X8QrZf-DXIM&index=798&list=UUZceliiH71OLw4t4HcvKKjw
One very important and effective way to change a health behavior is community Mobilization. For an effective intervention, the community leaders should also be mobilized and willing to be the champion for the needed changes. Several projects in India, Egypt and Latin American have achieved significant successes by introducing interventions for diseases like malnutrition, diarrhea, and polio.
In this age of media, mass media could help achieve the goals in health behavior change in significant ways. Radio, television, internet, could be used as tool to promote better health. Governments in low income countries have launched educational films, or soap opera to address urgent health needs and to access mass population about the importance of the problems and probable solutions.
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Social marketing has achieved significant success in health sector. Social marketing is the application of the tools of commercial marketing with the aim of promoting health actions or products. This has been used in family planning work, diarrhea control, selling bed nets for malaria control. The success of social marketing depends on very careful market research and good understanding of the local culture. The basic of social marketing depends on 4 Ps which are
Attractive product
Affordable price
Convenient places
Persuasive promotion
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Changing Health Behaviors-Social Marketing
Application of tools of commercial marketing to promote a behavior change.
Depends on careful market research and understanding of local culture and values.
Social Marketing video
Antenatal Care TV spot (Pakistan)
https:// www.youtube.com/watch?v=9UzUcQ6P5xs (:45)
Aids Awareness(India) (:36)
https:// www.youtube.com/watch?v=SvkXGkC4ktw&list=PL23F20264D1A479A6
WHO oral Rehydration(India) (1:58)
https :// www.youtube.com/watch?v=qoN3CQU0FEQ
Health education could be done in many forms for instance, in classroom setting, in news media, on radio, television, and on the internet. Successful health education should focus on risky behaviors and provide on clear information. It should identify the target group and geared the content according to the need of the group.
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Health Education
Comes in many forms such as:
Classroom
Mass media(radio, television & internet)
Successful programs are clear, provide accurate information, gear content to target group.
Call to Action for Wash in School
Source: UNICEF
Countries are focusing on providing cash incentives for the desired outcome in behavior change. This economic incentive helps reduce the poverty and encourage in behavior change. Government, in this type of program, offer payments to the families on an agreed upon time frame under the condition that the families will take part in certain behavior change programs. Couple of examples of behavior change programs are -giving birth at a hospital, engaging in regular well-baby care, sending female children to school on a regular basis.
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Conditional Cash Transfers
A government agency provides an economic incentive for families who engage in a certain healthy behavior.
Project: Conditional Cash Transfers
for Education in Morocco
Goal: To reduce the drop out rate
from primary schools
Intervention: Every two months
a specific amount of cash was
offered to the parents of children
Attending school regularly (at least 80%)
Conditional Cash Transfers is given by a government agency. It is an economic incentive for families who engage in a certain healthy behavior. An example of this is the conditional cash transfers for Education in Morocco. The goal was reduce to the dropout rate from primary schools. Every two months, a specific amount of cash was offered to the parents of children attending school regularly. At least 80% attended regularly.
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Social Assessment
Social assessment - “a process for assessing the social impacts of planned interventions or events or and for developing strategies for the ongoing monitoring and management of those impacts.”
Important to include the affected communities.
A social assessment is the process for assessing the social impacts of planned interventions or events or and for developing strategies for the ongoing monitoring and management of those impacts. It is important to include the affected communities.
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