Culture, Health, & Social Change

We have talked a lot about culture and health. In this sense, I was rethinking some critical questions. How is culture related with health? Why is culture so important in health care and health communication? How do researchers and health care practitioners locate culture in their research and work? What do they need to do to improve health outcomes, as well as achieve individual behavior change and social change? We have discussed most of them, however, as to the social change issue, it probably is hard to develop a certain answer. The role of culture in social change is always being re-evaluated, and dynamics over time and across regions. Culture is such a shared belief system, I think, that acts as a mirror upon which we might gaze in order to better understand our history, our present, and predict the potential future. It is because the way in which we think, believe, and behave, is strongly supported by different cultural values. This is not only about understanding why individuals perform the actions in terms of the contexts in which they act, as well as exploring the links of cause and influence on social, economic and political practices, but also concerns the expectations and hopes that individuals embrace.

When it comes to the health of a population, social problems largely depend on individual solutions through application of series of knowledge to inform people. I was impressed by the diffusion-of-innovation theory mentioned in Collins & Zoch’ paper (2001). One of the properties of innovation is compatibility. It assumes that if an innovation is perceived to be more consistent with individual’s values, and needs, the individual would be more likely to adopt the innovation. To approach target audiences in different cultures, thus, the diffusion of innovation is required to consider different decision making processes. For example, in Chinese culture, and other Eastern cultures, young adults or adolescents largely reply on information and suggestions from family members or older parents, whereas in western cultures, young people are more independent. In this case, it is not only the decision makers should be viewed as a target in the health campaign, but also how strong their opinions works should be identified in different issues.

The articles of Bollen et al., (2001), and Millen et al., (2000), who are talking about SES, class and political impact of transnational corporations, lead me to think about the strong link between inequalities caused by social, economic, and political forces and health. We strive to make change on the society and policy because the inequalities exist. So who are suffering? The poor who are vulnerable in economy, the women who have less power in the society, the young children who are ignored in the communities, the minority groups who are in silence in the dominant culture. The interaction between the indicators of health and how they are processed are influenced by the health care system and context where the interactions happen. Individuals (are forced to) make “rational” choices based on the social relations of which they are a small part.

Thus, what to do with the inequalities? How to make a social change in health care? Understanding, I think, is always the first step. Understand the problems, how the issues have taken place; understand the social, economic, and political context where the problems emerge; understand who are struggling in the pain, how people perceive their experience, what do they believe. And then, enlightened by the cultural sensitivity approach and culture-centered approach (Dutta, 2007), both approaches put culture on a vital position in health applications, I think is to effectively respond to the norms of the culture, infusing the culturally sensitive voices into dominant health system, and designing appropriate interventions towards target group. Otherwise, the strategies which are blind to cultural values are just like air, no sense to people. There is never an end. The society is changing, health status is changing, as well as culture. The road we are walking on is infinite, although numerous directions are ahead. That’s why the colorful future is so fantastic.

Culture and Prevention II

Entertainment-education programs are widely utilized to deliver educational knowledge about peer group norms, protective health behaviors, and ways of disease prevention in entertaining form. I was thinking what is the advantage of entertainment-education compared with pure education? Entertainment is an approach to engage the attention, interest, and curiosity of target audience. More importantly, the ultimate goal is to seek change of knowledge, attitudes, and behaviors to an issue. The social and cultural norms also might be influenced (Nariman, 1993). In the case of health, entertainment-education strategy is aimed to promote lifestyle change or prevent disease. For example, to address sensitive youth issues, combination of education and entertainment has been found to effectively influence young people about HIV/AIDS.

In this sense, I was wondering whether the format of entertainment would overweigh the purpose of education. Is knowledge of causes, consequences, and intervention of prevention of HIV infection sufficient to motivate behavior change such as promoting condom use? The concept of culture plays a vital role in understanding human behavior, which should be incorporated in disease prevention intervention. It makes meanings to the population in communities to their health status. Thus, it seems that knowledge transmitting may not enough to stimulate behavior change. It also needs to be cultivated through audience involvement, peer rapport, supportive social norms, and cultural beliefs. Individuals therefore are likely to talk about media knowledge within the social network. That might be the ways in which entertainment-education intervention build positive relationship between self-efficacy about control of self sexual behavior, mass and interpersonal communication about condom use, utilizing various media (Sood, 2002).

Besides entertainment-education strategy, cultural values, especially cultural gender norms regarding sexual behavior contribute to effectiveness of HIV prevention intervention. Condom use or request, the effective way to prevent HIV infection, is associated with many cultural and behavioral factors. Women are more likely to face difficulty in negotiating safer sex behavior with men due to the perceived power imbalance in sexual decision making. I was impressed by the assumption of McQuiston (2000), which argued that “the timing for condom use was never right”. For the men, communication is based on trust, while trust is built on communication for the women. Not only power imbalance exists between genders, but also male and female always behave differently because of distinct perceptions towards sexual behaviors. Requesting a partner to use a condom require the woman to obtain a dominant role in sexual practice – very hard in many cultures. For men in most cultures, condom use might mean distrust and bring sense of distaste. It can be extremely difficult to negotiate safer sex within complex situations. For steady partners, how can a woman gain power and improve condom use? Can the timing for condom use be right and match between men and women? One more question, what if the man has a spiritual belief that “God tells me do not use condom/control birth”? How do we, as researchers, persuade them to change the way to do it?

Culture and Prevention I

     Cultural perceptions and health beliefs would greatly affect health promotion and disease prevention. Every ethnic group faces particular health challenges due to genetics, cultural practices, and epidemiologic difference. Thus it is important to understand the role and influences of culture and tradition on health. For example, Chinese culture emphasizes harmony, self-control, interdependency, and yin-yang balance. The cultural norms are achieved by social relationship, balancing the state of mind and body, and health-seeking behaviors. Therefore, coherence between the cultural values and the disease prevention strategies can accomplish acceptance of health information.

     As Donohew (1998) argued that adolescents who are high sensation seekers – the ones who seek for novel, exited, and complex experiences and sensations – would be difficult to reach through conventional and rational approaches, I was thinking about some questions: why some people pursue novelty? How to reach high sensation seeker? People are attracted by novelty sensation may be due to the needs for detecting risk and design strategies for survival. But the sensation seeking behavior also potentially puts people in the risk. Reaching high sensation seeker and avoid risky behavior, such as drug use among adolescents, is very difficult. At least, I was thinking, is to reduce the number of individuals who use drug for the first time, and to intervene with those who are using. The two target groups should be quite different in designing prevention. For example, training peer group resistance may be effective in nonusers groups, but it may not in users. Various factors should be identified, such as family environment, physical abuse, and poor performance in school. We need to find ways to attract attention of target audiences and persuade them to engage in positive behaviors. For example, high sensation seekers may be more likely attracted to messages that are creative, complex, fast-paced, and emotionally powerful.

     The term of self construal reminded me of the difference of Western and Eastern conceptualization of the self. In Western culture, specifically, people seem to construe the self independently as separate from social context, emphasizing autonomy, whereas Eastern culture construes the self as an interdependent part of social context. I recall the example of Confucianism. Confucianism might be the most influential philosophy in traditional Chinese culture due to its systemic and detailed norms in social, interpersonal, and familiar relationships. Confucianists focus on collectivism, in contrast to individualism in the West. Collectivist values affect Chinese people’s health beliefs and behaviors. So how does self-construal affect the strength of attitudinal and normative component of the TRA (Park, & Levine, 1999)? Self-construal seems to vary across individuals and contexts. It also influences cognitive performance, social interaction, and other facets of behavior. When people observe social icons, and family norms, they might change preferences, which alternatives are adequate on the attributes. For example, Chinese people believe in the group identity, interdependency, thus their health behavior is largely affected by social context and family members. It is correspondent with what Parrott (1998) assumed in the behavior adaptation model, that an individual tends to behave in a certain way when significant others expect one to adapt his/her behavior to reduce risk resulted from a particular action. In decision-making process, elderly parents usually leave important family decision to adults children, especially son.  

     In addition, behavior adaptation emphasizes building habitual practices with the adoption of particular prevention to reduce the harm in relation to the risky behavior. I was reminded of the situation of Chinese American. Acculturation levels of Chinese American into the Western lifestyle were linked to access to and utilization of health services. However, the processes Chinese Americans underlying adaptation to residency in the US are complicate. For example, Chinese immigrants may follow some recommended health treatments, but may not comprehend why many Western diagnostic tests are necessary. Many Chinese immigrants integrate traditional Chinese medicine and conventional Western medicine as “alternative medicine” to heal illness. But as to disease prevention, they usually believe diseases are preventable or controllable through maintaining balanced state and proper eating habits.

Culture and Sexuality

     Why do we concern with sexuality nowadays? Why talking about sexual issues is a taboo in some cultures (Shefer, & Strebel, 2002)? It is as natural as food. I think perhaps it is because sexuality is more than physical aspect of sex. Sexuality includes more social and cultural meanings. So what does sexuality mean? Besides the way in which individuals perceive themselves as sexual human, in my understanding, it may also be socialized into the private relationship with others, as well as desires, and expectations. It would vary across cultures and contexts.

     I was enlightened by the assumption that sexually transmitted infections (STIs) are constructed through gender power relations and gender stereotype (Shefer, & Strebel, 2002). The balance state of power between male and female is always playing crucial role in sexuality and sexual practices. In the context where men are the dominant actors, women usually are lack of right and power to make decision on sexual matters. For instance, in the issues of condom use, contraception, pregnancy, and reproduction, female always are the victims. Why women are more vulnerable to unprotected sex, to HIV transmission, to malfunction? Perhaps it is partly due to the unbalance of gender power. Women have little resource and opportunity to decide for their own needs. They have to tolerant for men’s desire, because women depend on men to survive in some cultural context.

     As I was reading the article written by Schoepf (2001), the point, that spread of AIDS infections is influenced by political economy, social relations, reminded me of an example of sexuality in Japan. The government of Japan prohibits the use of oral contraceptives, because the government believes it would decrease the motivation of condom use for Japanese and increase the risk of transmission of AIDS. That might be an important explanation of why Japan has a comparably lower incidence of AIDS, even though in the society men are on the absolutely dominant position, even though men who are married usually seek pleasure from multiple partners. 

     I am thinking that culture should be utilized as a tool of engaging people in acceptable change practice with regard to health behavior, rather than merely as a barrier or a problem. Cultural lens potentially provides clear picture of people’s ways of thinking and behaving. The issues of sexuality are culturally sensitive to different degree in diverse social contexts. For health providers, I think respect is the basis for sexual matters, as well as sensitivity, rather than judging patients wearing colored glass of stereotype.

Culture, Health, and Resistance

     The ultimate goal of human is survival. However, the life is not easy, which is potentially full of risk, pain, struggle, and resistance. I am impressed by the term of “awakening” (Mallory, 2000). When people are awakening? Inspiring by knowledge of survival and evaluation of risk, people make practical decision and make changes to fit in the current situations, letting the life transform towards good. People always have the natural motivation to seek advantages and avoid harm. I was thinking, however, what people will do facing challenges and violence? Do people respond to the violence differently in different cultures? Female might be a specifically interesting issue in this case. Women in diverse cultures are situated in diverse positions. Cultural scenery draws different pictures for women in different roles, such as of mother, wife, daughter. The problem is that, in some culture, women have little access to obtain understanding of the risk and survival. How are women able to make subsequently behavior changes if they even do not realize the violence, let alone respond to it? Additionally, I think what elementary requirements for survival are as women perceived also vary as cultures vary. It reminds me of Maslow’s hierarchy of needs (Maslow, 1943). Basically, the need for physiological necessaries, including food, water, and sleep is in the first level (Maslow, 1943). So what if women determine they have to tolerant some risks in order to achieve these basic needs? They might be helpless when the life is lack of food and money because of economic constraints, feeling powerless to resist the violence. How do they pursue higher level of health, security, morality and family needs when the basic living needs are not accomplished? How are they able to make decision for themselves without power? Moreover, how is it different as a woman in the cruel world? Women historically are suffering from gender inequality in social roles and lived experience. They are struggling with and striving to resist more violence than men consistently, although it depends on different social settings. For health care practitioners, what can they do? What should they do? I assume it is more than an ethical issue. The lived experiences of women, as well as marginalized population, are the outcome of intertwining of structural process, power flow, and cultural system, I think. Thus a deeper understanding of these interactions would facilitate health care quality.

     Although it has been claimed that the order and the importance of Maslow’s hierarchy of needs vary across cultures in different regions (Tang, 1997), I think its basic assumption is reasonable in some circumstances. However, I agree with the statement in Martyn’s paper (2001), which claimed that parents who are under oppressing tend to communicate information to resist the power and violence with their children. Resistance is linked to challenging constraints from dominant power, issues of freedom, and empowerment. People not are merely bearing the risk, but also have the potential ability to negotiate, struggle with and resist the dominant roles, endeavoring to make social changes, and being empowered by power. How to be empowered through resistance? Initially, I was thinking perhaps involvement and take action of resistance make people gain control over their life. Also, people would feel they master the skills of survival required within a certain context, which helps with establishing a clearer identity based on the social roles. In this sense, people are able to resist the violence associated with the political and economic situation and feel empowered. Power is not stable. It is produced through discourse, I believe. Thus resistance would promote the flow of power and offer an alternate way to communicate and challenge the authority of powerful actors. However, the real challenge is that mere willingness to resist violence is not enough (Basu & Dutta, 2008). People are lack of partners. Who would help and support the marginalized? Maybe it is not political leaders, who have own political concerns. What can we researchers do? The first idea comes out is providing an opportunity for participation in making decision. And with more difficulty, create hope, confidence and trust for people for an ideal future. We are standing in the river, inevitably complying with the flow, but also resisting the flow, in order to maintain control over ourselves, and determine our own direction.

Reference

Basu, Ambar and Dutta, Mohan J. (2008).
Participatory Change in a Campaign Led by Sex Workers: Connecting Resistance to Action-Oriented Agency. Qualitative Health Research, Jan 2008; vol. 18: pp. 106 - 119.

Mallory, C., & Stern, P. (2000). Awakening as a change process among women at risk for HIV who engage in survival sex. Qualitative Health Research, 10, 581-594.

Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50(4), 370–96.

Tang, T. L., & West, W. B. (1997). The importance of human needs during peacetime, retrospective peacetime, and the Persian Gulf War. International Journal of Stress Management, 4(1), 47–62.

Alternative Ways of Healing and Knowing

     When mainstream scientific methods do not work for patients, what would they do? When both conventional medical treatment and alternative medicine are available to patients, which therapeutic practice would they choose to seek help? I think it is largely relevant with cultural interest. Health, ideally, is a condition in accordance with our expectation and values. On the other hand, illness is a disturbance of this expectation. In this sense, how do people shape individuals’ expectation? I assume it maybe the outcome of historical purpose and culture cultivation. It suddenly comes to me that the term of “culture” is made up of “cultivation” and “nature”. Alternative medical traditions offer patients sense of trust and safe, because it comes from cultural ritual, corresponding with the ways of thinking and making meaning of patients. Culture not merely establishes belief pattern, but also have a function of sedatives which enable patients calm down. It is likely that cultural values are the foundation of human development, consistently playing a role on people’s growth over time. They are like the embrace of a mother, emotionally and cognitively upholding patients.

     As to alternative medicine, Traditional Chinese medicine (TCM) might be a classical example. The view of the world and the body in TCM has its conceptual root. The human body is viewed as an entity in which organs and other parts function variously and interdependently. In this case, health and disease refer to balance or imbalance of the functions, yin and yang energy, either within the body or between the human body and environment. The practice of TCM includes the use of acupuncture, diet, herbal remedies, physical movement, and massage. Likewise, I found Ayurveda also stresses the concept of balance and harmony. This ancient ways of healing emphasizes the mind-body-spirit connection. The phase “flower power” in Zimmerman (1992) is interesting. Based on what I have read, I think it means gentleness of the practice – such as healing through meditation, yoga and diet, together with strong power to manage violence in patient’s humeral system. Thus, these traditional ways of healing represent the cultural heritage of China and India. I was thinking some questions. Whether they would be, could be, or should be utilized in global health care system? Are they meaningful and beneficial to patients from diverse cultures as well? Are these unconventional medicines weird to other cultural group, or novel? Why western medicine is more popular in global society, because it is “scientific”?

     In addition, spiritual concern is another alternative way of knowing that requires notice. Patients who have spiritual beliefs tend to contribute healing to God’s will. Thus building connection between physicians and God facilitate adherence of patients. Various ways of healing and knowing bring complication to physicians and caregivers’ work. They need to obtain deeper understand of patients’ religious beliefs and cultural beliefs, and identify patients place which belief as chief concern. So, how to be more sensitive to these ways of knowing? I think physicians should learn appropriate ways to help patients from other cultures feel comfortable; be perceptive of patients’ cues; learn how to identify patients’ agenda and underlying motivation and expectation. Human are complex entities. Patients are complex further, since they are the population who are suffering from disorder and pain. The interior struggle is obscure, and even unrevealed. Furthermore, cultural norms make their ways of knowing more elusory. This is a long way to explore, and a fantastic journey to enjoy as well.

Culture, Health, and Ways of Knowing

     The dominant culture controls, oppresses and forms traditional ways of knowing and being, being an important impact on human health status, hope and expectation. Ways of knowing are as diverse as the cultures and the ways to knowledge understanding are not easily transformed. I found the issue of the naming of child in a family, mentioned in Airhihenbuwa’s book, is very interesting. Similarly, the naming has cultural meaning in China as in Africa. The name is a symbolic link of history with life of people. Chinese parents design the name of children aiming to place their aspiration, purpose and hope, especially involving health. For example, hoping children will be healthy, parents name children “Kang” (means health), or “Qubing” (far away from disease); female names are usually using flowers names, such as “Lan” means orchid with parents’ hope of beauty; to respect history or religion, people use “Xin” (belief) or “Mu” (revere) in their name; “Zhong” (loyalty) reflects a expected social ethos. Furthermore, according to the birth date and time of the child, it is speculated what element (Five Elements: metal, wood, water, fire, earth) the child lacks or conflicts with in the life. In this case, a corresponding word is added in the name to enable the five elements balanced, in order to keep the child healthy. The naming of children is a symbol of the attempt of family to follow the cultural ritual and reproduce themselves, making meanings within cultural meanings, to respond to the world. Thus, how this cultural issue is related to health? As Airhihenbuwa claimed, I agree that the survival of children depends on the survival of the family. The naming mirrors the role of children in the context of family, which is an aspect of expectations of parents. The expectations are shaped based on the perceived social structure and norms that people understand.

     The assumption that saying distress at menopause for Japanese women is inappropriately explained as natural and inevitable in both biomedical and psychosocial perspectives, which is proposed by Lock (1992), reminds me a question. How do we, researchers, or practitioners change their existed ways of knowing and being to improve patients’ health outcome? Or how do we deal with their ways of knowing? I think, may be the first step, before indigenous people actively engage in developing healthier life, is to acknowledge, face, and cure the wounds resulted from historical trauma, colonization, and inequality in health, as well as life experience. A sensitive identity is needed here, with respect, beneficence, and trust for each one in practice. Stepping to a further road, how to encourage health-related behavior change? Basically, I think there are some elements playing positive roles: awareness of the problem, skills to evaluate the environment and examine information, support of social network including family, friends and professionals, and more importantly, strengthened self-esteem, which increase the passion and willing to promote health status. Individuals obtain ability and power through acquiring the skills to deal with and manipulate the forces that influence the individual, although in fact it is very difficult, since sometimes people even are not conscious. It is the result of politics, economy, and culture forming the ways of knowing and wellbeing of indigenous people together. Indigenous people need to gain access to learning and being understood in a comfortable and respectful way.