Cultural Competency

Goal for the Course

The goal for the course is to provide you with a strong foundation in social,

cultural, and behavioral issues that relate to the public health field, which

you can then build on throughout your health sciences profession.

Lecture Overview

Increasing Your Cultural Competency

In this interactive media application, you will be exposed to five different cultural groups and their perceptions regarding health and illness. Each is very unique. As you go through each one, you will be able to connect some of the theories and worldview perceptions outlined in your readings to each population. Increasing your cultural competence is critical to understanding how different communities experience public health.

What is Cultural Competency?

The term cultural competence can loosely be defined as a public health practitioner’s knowledge, awareness, and practice with other individuals and populations with diverse cultural backgrounds. The assessment at the end of the media application is a good place to begin evaluating your cultural competency as a current or future health professional.

Steps to Becoming More Cultural Competent

The first step to becoming culturally competent is realizing that you bring your own beliefs and worldview to your profession. Acknowledging this will help you minimize the interference that these beliefs may have as you work with others (i.e. patients, clients, colleagues, community, and public). The most important steps you can take as public health professionals to be coming more cultural competent is to listen, have patience, and practice humility when you have limited knowledge regarding something or when you have done something wrong.

Bolivia, South America

2019 Estimated Population: 11,314,615 % of World Population: 0.15%

The Guaraní tribe is just one of the many indigenous groups that populate rural Bolivia. With an estimated population of 80,000, they are characterized by their Guaraní language, traditional attire, and communal living. Income - generating activities traditionally include fishing, farming, and hunting.

Chagas Disease; found primarily in Latin American and the Caribbean.

Chagas Disease in Bolivia

Chagas disease, found primarily in Latin American and the Caribbean, is a neglected infectious disease that is passed on by the bite of an insect known as the vinchuca bug in Bolivia. When an individual is bitten, serious complications can result over 10-20 years, including an enlarged liver, megacolon, arrhythmia, enlarged heart and even cardiac arr est. In addition to the serious medical concerns, the disease can severely impact the economy of

the families affected as well as the country overall by reducing quality of life and life expectancy for the significant portion of the population that suffers from it.

The vinchuca bug thrives in homes with thatched roofs and mud walls, which are primarily present in rural regions of Bolivia. Many poor families are disproportionately burdened with the disease due not only to poor quality housing, but also lack of education regarding transmission and treatment, and difficulty accessing health services. In total, approximately 20% of Bolivia’s population is infected with the disease.

Boliva’s rural regions have high rates of poverty ranging from 94% to 98.9%. There are high rates of illiteracy in women (37%) and low education rates, with only 58% of the population under the age of 15 still enrolled in the education system. Bolivia is a multicultural and multilingual country, where most of its 10 million inhabitants are either of mixed descent, or part of 37 ethnic groups that are officially recognized. Due to this cultural diversity, reaching optimal levels of health and development create a major challenge for government leaders and public health professionals sinc e worldview and perceptions of quality are different for each ethnic group.

Effective interventions for decreasing infection rates of the disease include improving housing conditions through the repair and construction of new homes, implementing insecticide spraying campaigns, promoting preventative education, providing testing for individuals at -risk, and treatment for individuals who are infected. Implementing these various interventions in communities can be difficult however, especially when cultural beliefs and practices do not align with best practice intervention methods.

The Guaraní tribe is just one of the many indigenous groups that populate rural Bolivia. They reside in various South American countries, including southwest regions of Bolivia. With an estimated population of 80,000, they are characterized by their Guaraní language, traditional attire, and communal living. Income-generating activities traditionally include fishing, farming, and hunting. Most Guaraní villages are formed with 12 to 15 families living in a circular pattern. Their homes are primarily built wit h local materials, such as logs, mud, straw or palm leaves. They prefer home with no walls, and a dirt floor in order to bury the dead under their home. Cooking together and meals are an important part of the culture. Kitchens usually consist of an open fi re that is placed outside of the home, and is shared by several families. It is not

uncommon for villagers to seek the help of a traditional healer when there is illness in the home, instead of seeking out a government clinic.

There are high rates of Chagas disease in many Guarani communities, primarily due to their rural, more tropical locations, communal living, and housing structures. Traditional methods of intervention have not been as effective due to their cultural practices. They are resistant to cem ent floors in their homes since that is where they bury the dead, and do not want enclosed homes or kitchens. Health messages also have been to be tailored to include messages that will be meaningful to their specific culture. For example, one local organization had to redo their Chagas prevention posters five times in order to finally be effective in communicating the messages to the Guarani people. Local organizations are working with the Guaraní to find creative solutions that will prevent the spread of Chagas disease, while also being sensitive to their cultural practices and beliefs.

Questions:

1. How is the Guarani culture contributing to the spread of Chagas disease?

2. As a public health professional, what key steps would need to be taken to address barriers for preventing Chagas disease while still preserving important practices of their culture?

3. What challenges could a public health professional confront when working on public health projects with indigenous populations like the Guarani?

Health Indicators:

• Infant mortality: 98 deaths/1,000 live births. • Maternal Mortality: 234 deaths/100,000 live births. • Child Mortality: 66/100,000 live births. • Life expectancy at birth: 65 years

Video Media: http://www.youtube.com/watch?v=7qiLm5SpMgs

http://www.youtube.com/watch?v=U7YBZAcHWfc&feature=channe l

China, Asia

2019

Estimated Population:

1,418,100,454

% of World Population:

18.41%

The five element theory holds that everything in the universe is guided by five elements: wood, fire, earth, metal, and water. The Chinese believe that each of these elements correspond to particular parts of the body and senses.

Medicine; Traditional Chinese Medicine (TCM), originated over 5,000 years ago in the ancient philosophy of Taoism.

Traditional Chinese Medicine

The population of China is over 1.3 billion. A primary form of medicine in China is known as Traditional Chinese Medicine (TCM), which originated over 5,000 years ago in the ancient philosophy of Taoism. It is widely used in China, and is a common alternative form of medicine in the United States. The focus of this holistic type of medicine is on the patient. The practice of TCM comes with the perspective that humans are connected to the larger universe, and subject to its forces. The human body is perceived as having parts with specific functions but each part is interdependent. Therefore, health and disease relate to a balance of the functions.

There are several key components to TCM. The central component is the yin - yang theory. Yin and yang are two opposing, yet complementary forces that shape the world and all of life. The internal organ systems and four bodily constituents (qi, blood, moisture, and essence) are important to maintaining balance in the body. If there is a deficiency or excess in the yin or yang, an unbalance occurs which can lead to illness and disease. The five element theory holds that everything in the universe is gui ded by five elements: wood, fire, earth, metal, and water. The Chinese believe that each of these elements correspond to particular parts of the body and senses. The eight primary principles in order to diagnose illness include: cold/heat, interior/exterio r, excess/deficiency, and yin/yang. The five element theory and eight guiding principles are used to help determine energy imbalances of an individual and what treatment should be prescribed.

Health professionals who practice TCM are identified as practiti oners. They primarily use four methods to evaluate a person’s condition: observing (especially the tongue), hearing/smelling, asking/interviewing, and touching/palpating (especially the pulse).

The most common therapies or treatments include Chinese herbal medicine and acupuncture. With herbal medicine, plants, minerals, and animal products are perceived to affect the body in a certain way, and are therefore prescribed to fight the ailment and improve health. With acupuncture, specific points on the body are stimulated by inserting needles through the skin in order to remove blockages in the flow of qi. Other common therapies include moxibustion, cupping, Chinese massage, tai chi, and dietary therapy.

TCM has become integrated into China’s national health ca re system. There is formal training and quality standards in its health care delivery. As a result, there is now more on research and science-based approaches, which has improved its credibility both nationally and globally. Chinese hospitals practicing TCM report that they have treated more than 200 million outpatients and almost 3 million inpatients annually.

Although there is widespread use of TCM in China and in many westernized countries, there is still limited scientific evidence to determine its effectiveness. A review of the evidence shows inconsistency in the study results yet, poor methodology is mostly to blame. There is definite preliminary evidence of Chinese medicine’s benefits for some illnesses. Regardless, many individuals afflicted with ill nesses such as cancer, diabetes,

HIV/AIDS, and bodily pain, are seeking it out for relief, and using it in conjunction with westernized medicine or as an alternative.

Questions:

1. What are some key components of TCM that are different than westernized medicine?

2. Why would it be difficult to collect scientific evidence to show the effectiveness of TCM?

3. How may traditional Chinese views of the body and illness clash with modern medicine?

Health Indicators:

• Infant mortality: 16.6 deaths/1,000 live births. • Maternal Mortality: 36.6 deaths/100,000 live births. • Child Mortality: 24/100,000 live births. • Life expectancy at birth: 74 years

Possible Videos:

http://www.youtube.com/watch?v=f3mm83DMoGA&feature=player_embedd

ed#!

India, Asia

2019

Estimated Population:

1,362,908,943

% of World Population:

17.74%

With a population of over 1.1 billion people, there is significant demand for the indigenous medicine system of Ayurveda. India has over half a million practitioners who are registered in traditional medicine.

Medicine; A Traditional medicine known as Ayurveda, focuses on the prevention, health promotion, and treatment of diseases.

Ayurveda in India

In India, the traditional system of medicine is known as Ayurveda, which originated more than 5,000 years ago. This natural health care system focuses on the prevention, health promotion, and treatment of diseases, especially chronic diseases. Ayurveda means the science of life and is considered essentially to be a way of living. Its purpose to increase a person’s lifespan and provide optimal health and well-being.

There are key theories that relate to Ayurveda’s perception of health. In Ayurveda there are three forces which govern all life processes in humans, and other organisms or creations which include plants, animals, seasons, plants, and galaxies. These three forces are known as Vata, Pitta, and Kapha, which together are known as the three doshas. Vata governs bodily functions relating to movement; Pitta governs functions related to transformation; Kapha governs the structure and cohesion of the body. At birth, each person is born with a certain ratio of these forces, which is called Prakriti. When this balance of Prakriti is maintained, the person is healthy. However, lifestyle behaviors and outside factors can cause an imbalance of the doshas which ca n lead to illness. This imbalance is known as Vikriti. The main goal of Ayurveda is to prevent disease from developing by maintaining balance in the physiology, mind, behavior, and environment.

Treatment of disease is highly individualized, and there is si gnificant focus given to developing a person’s state of consciousness through meditation. Treatments that are prescribed by Ayurveda practitioners are primarily common spices, herbs, herbal mixtures, special preparations known as Rasayanas, and purification procedures known as Panchakarma which remove toxins.

The backbone of rural health care in rural India is traditional medicine, much of which is Ayurveda. This is generally the only system of medicine available in villages and remote areas. With a populat ion of over 1.1 billion people, there is significant demand for the indigenous medicine system of Ayurveda. India has over half a million practitioners who are registered in traditional medicine. The Ayurvedic colleges have over 20,000 physicians graduate every year. Traditional practices in Ayurveda such as Pachakarma are so popular that there are waiting lists at many institutions.

India’s government is in support of Ayurveda and has developed a government department which specifically focuses on indigeno us health systems. There are formalized training institutes throughout the country, and there is more of a focus on research, education, and standardized drug testing.

Research has shown promising results for treating various illnesses including depression, sleep disorders, diabetes, Parkinson’s disease, Alzheimer’s disease, and hypertension. Bringing evidence base to the practice of Ayurveda is critical for the credibility of this health care system. There has been research on Ayurvedic methodologies however, additional research is needed that uses current scientific technologies.

Questions:

1. How are the three primary forces, also known as the doshas, connected to health and illness?

2. What are some similarities between Ayurveda and Traditional Chinese Medicine?

3. How would Ayurveda shape the way Indian’s think about their body in health and illness?

Health Indicators:

• Infant mortality: 52 deaths/1,000 live births. • Maternal Mortality: 250 deaths/100,000 live births. • Child Mortality: 69/100,000 live births . • Life expectancy at birth: 64 years

Media options:

http://dsc.discovery.com/videos/discovery -atlas-india-ayurveda.html

http://www.youtube.com/watch?v=zfIOnWr-4xc

Mozambique, Africa

2019

Estimated Population:

31,051,691

% of World Population:

0.41%

Cultural practices and rituals have also been identified that are contributing to the increased risk of infection, especially in traditional communities. For example, many ethnic groups or traditional communities practice polygamy in Mozambique.

HIV/AIDS; Traditional African beliefs and rituals need to be integrated into HIV/AIDS prevention efforts.

HIV/AIDS in Mozambique

The region hardest hit by HIV continues to be Sub -Saharan Africa, where over 67% of the globe’s HIV population lives and 72% of global AIDS deaths occurred in 2007.

There is an estimated 20 million people in Mozambique, located in the southeastern region of the African continent. An estimated 70% of the population live below the poverty line. Rates of HIV/AIDS are at an estimated 13%. Infection rates continue to rise. It is estimated that in 2010, 1.4 million Mozambicans will die of the disease, and over 1 million children will be left as

orphans. Populations at a social disadvantage because of poverty, lower educational levels, and a lack of access to social goods and healthcare services are more vulnerable to HIV/AIDS.

The primary message that is being spread within the HIV/AIDS prevention community is what is known as ABC - Abstinence, Being Faithful, and Condom use. Although there is significant global funding going towards the HIV/AIDS epidemic in Mozambique, not all interventions are taking socio -cultural factors into account. “Thinking globally, acting locally” is considered by many the best guiding principle for AIDS policies and initiatives. Traditional African beliefs and rituals need to be integrated into HIV/AIDS prevention efforts, as many cultural practices are contributing to the spread of the disease.

There are many myths and beliefs in Mozambique surrounding HIV/AIDS. A large part of populations in some regions do not believe in the existence of HIV or that AIDS is the results of a virus. Some believe that imported condoms are already contaminated with HIV. Some believe that traditional healers can cure HIV/AIDS in its early stages, or that HIV/AIDS is cau sed by witchcraft.

Cultural practices and rituals have also been identified that are contributing to the increased risk of infection, especially in traditional communities. For example, many ethnic groups or traditional communities practice polygamy in Mozambique. Some religions endorse it. A death rite known as ritual sex encourages a man or woman to have sex with another person to cleanse themselves after their spouse’s death. In some communities, when the husband dies, the widow will be inherited by a ma le relative in order to “safeguard” their property, thereby exposing the male relative should the widow be infected. Early traditional marriage is also common in some areas which is the practice of girls being ready to marry and bear children after their first menstruation. All these cultural practices increase the number of individuals exposed to the HIV/AIDS infection, therefore further exacerbating infection rates.

Recent assessments of current HIV/AIDS interventions in Mozambique are encouraging public health professionals and government leaders to integrate socio-cultural aspects into preventative programming in order to change behaviors and attitudes. One of the key recommendations is increasing the involvement of influential leaders at the community l evel, such as traditional healers, nurses, teachers, and religious leaders as they play a large role in transferring and disseminating knowledge. Communicating about sex and

reproduction are areas that have to do with culture, customs, and habits reconciling traditional and modern knowledge with regard to cause of illness.

Traditional healers have historically been reluctant to participate in government programming. However, since they are widely respected and feared by the community, as well as influencing the behaviors of those in their communities, securing their involvement is critical for the future success of combating the HIV/AIDS epidemic in Mozambique.

Questions:

1. How are traditional African perceptions regarding health and illness affecting the spread of HIV/AIDS in Mozambique?

2. When developing HIV/AIDS programming in Africa, why should the community always be involved? Should traditional healers also play a role?

3. When should public health professionals try to change traditional African cultures and beliefs and when should they not?

Health Indicators:

• Infant mortality: 100/1,000 live births • Maternal Mortality: 408/100,000 live births • Child Mortality: 145/1,000 live births • Life expectancy at birth: 47.4 years

Media Possibilities:

http://www.pbs.org/newshour/rundown/2010/11/preview -sustaining-

mozambiques-hivaids-fight.html

http://www.pbs.org/newshour/bb/health/july -dec10/mozambique_11-

23.html

Nicaragua, Central America

2019

Estimated Population:

6,324,570

% of World Population:

0.08%

The Miskito Indians are an especially impoverished group of Nicaraguans. They are one of six ethnic groups that reside on Rio Coco River of the Caribbean Atlantic coast in northeastern Nicaragua. Their population amounts to an estimated 50,000, with over 90% living in extreme poverty.

Griski Siknis; This indigenous group has become well-known internationally for an illness known as Griski siknis, or “crazy sickness.”

Griski Siknis in Nicaragua

The country of Nicaragua is geographically diverse. The population is estimated to be over 5.5 million. Nicaragua is one of the poorest countries in Latin America, with 47% of the population living on less than $2 a day.

The Miskito Indians are an especially impoverished group of Nic araguans. They are one of six ethnic groups that reside on Rio Coco River of the Caribbean Atlantic coast in northeastern Nicaragua. Their population amounts to an estimated 50,000, with over 90% living in extreme poverty. The area is very isolated and requires days by foot or canoe in order to access the region. There is only one health clinic and food and medications are scarce. This indigenous group has been fighting for increased autonomy and even complete separation from the Nicaragua government, partl y because they would like to define their own health model according to their traditions and beliefs.

The Miskito Indians are very much connected to their surrounding land. They believe that all life, including rivers, mountains, and animals, are controlle d by a spirit. Imbalances in health can be caused by contact with these spirits which can lead to disease. In order to cure the disease, one first has to understand what spirit has caused the illness then treat it in a way that satisfies the spirit. Traditional healers and witches are considered gifted in that they are able to communicate with these spirits. Treatment for disease can include a combination of medicinal plants, ritualistic ceremonies, or abstaining from certain activities or things. This perc eption of health and illness is very much a part of the Miskito Indian culture, and traditional healers and witches are the primary health care providers.

This indigenous group has become well-known internationally for an illness known as Griski siknis, or “crazy sickness.” It is an illness that only happens within this population, and medical experts from all over the world have come to study its origin. It is now deemed a cultural bound syndrome which is defined as a form of disturbed behavior that is spe cific to a cultural system and does not necessarily conform to western classification of diseases. An example of this in the U.S. would be anorexia, which is a disease only present in western cultures.

Symptoms of Griski siknis include a frenzied state of behavior, shortness of breath, aggression, trance, panic, and loss of consciousness. Seizures can last for as long as an hour and can affect a person up to several times in one day. When in a trance, they can cause damage to property, animals, other people , or themselves. Some describe it as almost being possessed. Individuals can be affected for up to several months. Once they are cured or it passes, they return to a normal state. Interestingly enough, it primarily affects young adults. Usually the disease will affect multiple individuals during a short time

period. In 2003 for example, there was an outbreak of over 60 people affected with a several month period.

Modern medicine can not explain the disease. Blood tests provide no insight. Medications seem to only make it worse. However, health professionals state that the disease definitely exists as many report seeing it first -hand. The indigenous people believe that spirits or black witches are causing it and will drive out those who they believe are at fault. Local traditional healers are the only ones who are able to cure it at this point by using traditional medicine.

Questions:

1. What characteristics surrounding the Grisi Siknis illness make it a culture bound syndrome?

2. As a public health professional, how would you address the prevention of this illness?

3. What perceptions regarding health and illness are leading the Miskito Indians to be affected by Grisi Siknis?

Health Indicators:

• Infant mortality: 21.8/1,000 live births • Maternal Mortality: 170/100,000 live births • Child Mortality: 27/1,000 live births • Life expectancy at birth: 74 years

Media options:

http://www.youtube.com/watch?v=7i-vbei4D4Q