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. 

Narrative and Health

     Going through the readings, I obtain a general idea that at the personal level, narratives can be described as telling a story of the lived experience of the teller. Furthermore, I think in health care narrative also is formed at other levels. Specifically, at the interpersonal level, the interpretation of physicians towards patients’ stories, and co-constructing meaning in dialogue are narratives too. For example, I think the presentation of doctors’ prescription, including suggestion of changing life style, might be one kind of co-constructing narrative, which is based on hearing the narratives of patients. The narrative is a result of an interaction in which both of the actors are engaging. In addition, at the societal level, different social positions of physician and patient shape divergent narrative. They both tell stories with the sense of their positioning which is linked to the ethnicity. To understand the narrative, we need to understand the positional context. Locate ourselves within the story to obtain a meaningful sense.

     Basically, narrative is a way to make sense of the world. The process of constructing a narrative allows people to impart meaning to the life change, to address disorder. Thus, it seems that narrative is used to make sense of the disturbance in the life brought by the illness. The plot of narrative varies across tellers. Narrators arrange a set of events in their own particular ways, forming different development, and different results. The process involves different values and cultural norms. An individual may interpret some details as important parts that others may neglect. For example, I remember in an interview on SSB I conducted recently, the Chinese participant narrated her experience of consumption of SSB focusing on the concept of “moderation”. She described that she was aware to restrict the intake of SSB within the extent of moderation – neither too much, nor too less – even thought when she had strong desire to drink SSB. This perception is associated with the “moderation” ethos in Confucian thought. Moderation here means a harmony condition between ritual (Li) and desire, avoiding indulgence. Culture constitutes a structure of customs, ideas, and norms that offers individuals patterns for responding to the world. The selection of events in the narrative usually represents the teller’s personal idea of the issue.

     I was reminded of one question that how patients with painful experience construct narrative? Do they encounter difficulties? What if the narrative is absent for people without power? How is narrative created by power? And how is the narrative creating power? The process of narrative enables an individual to organize events in a coherent pattern and integrate thoughts. It provides people a sense of control over the chaotic, obscure, and silent life. Constructing stories lead to less rumination. On the other hand, painful experiences in some cases may not be put into a narrative form and therefore result in negative feelings and emotions. It might happen especially when patients have no access to narrate or without power, and awareness to tell others’ their stories and experiences. Illness is an event that creates chaos to the everyday life. If constructed, illness narrative plays a role in asserting responsibility of patients and producing a clear picture which reassesses identity, reevaluating their own position in the world. Maybe that is one avenue in which narrative creates power.

      Narrative is a basic mean of individual interaction. We communicate with other through telling stories in the daily life. It is a natural and acceptable way of communicating information and knowledge. Therefore, not only health professionals need to understand the ethical narratives of patients, but also we can use narrative approaches to promote health behaviors change. I am thinking that maybe different types of stories can be used for different goals. For example, tell culturally common stories to pervasive in a cultural atmosphere. Hence, narratives are not merely a personal method, but an attempt to engage with other actors to co-construct narratives within positional context, understanding the power structures that uphold them. Providing support for development of narratives, I think, also might be an important way to increase confidence and awareness of the marginalized. 

Culture, Structure, and Health

     The term “American Dream” mentioned in Benoit’s article (2005) attracted my attention. The idea of American Dream essentially claims that all human are equal, and everyone can succeed and live a happy life through hard work. However, I think actually the American Dream is not attainable for everyone due to the existing inequality rooted in class, gender, race, age, and religion. But the Dream reflects the ethos of the United States. In American’s culture, personhood is established through individual effort. A morality is playing a role here. Thus illness can be viewed as a moral fault that is resulted by failed self-improvement. It reminded me an interview we conducted. When I asked the participant what influenced her choice of Sugar Sweetened Beverage (SSB), she said she would feel guilty if she consumed SSB. She believed health problems would occur if she consumed too many. In her value system, health is a personal business. The narrative is rooted in the structure of meanings and roles. It is very different from Chinese culture. For example, compare the American Dream with the “Chinese Dream”, the American Dream pursues individual honor, whereas the Chinese Dream aims to achieve country prosperity. The Chinese Dream was created by Chinese dominant power, the Communist Party, who is intended to maintain dominance through control people to strive for community interest, rather than individual benefit. The Chinese Dream is a part of ideology that is instilled into the mind of Chinese people. Powerful actors have the ability to shape the contexts where problems locate and influence people’s behavior. Therefore, the ways in which people in different culture construct the disease meanings are distinct. There is an example in the book “postcolonial disorders”. Chinese provincial government viewed HIV throughout epidemiological categories that associated with group rather than individual risk behaviors to HIV. For instance, the Han, which is the dominant ethnic group in China, believes that the Tai ethnic group has a characteristic of sexual promiscuity, and it result to the Tai group members’ higher risk and susceptibility of sexually transmitted infections. Hence, this interpretation of sexual risk places blame in ethnic groups or marginalized communities. I am thinking whether this is the structure that produces violence through restricting resources to borderlands and “hard-to-reach populations”. In other words, this distinct characteristic of Tai ethnic group, even though it is “perceived” by the dominant group, becomes a source of discrimination, and suffering. Thus I think listening to cultures and the narratives of structural violence could identify resource needs and the cause of suffering in the community, in order to promote social change.

     With regard to the “hard-to-reach populations”, I also was thinking there is a wall between the “reachable populations” and the “hard-to-reach populations”. The reachable populations enjoy most of the basic resources, such as food, money, and materials, but in the meantime, hard-to-reach populations endure pain of inadequacy of resources. Why? It is because they are in the other side of the thick wall, no one sees their situation, and no one hears their voices as well. The wall is built by the structure, the culture, and all of these cause inequality in race, gender, and socio-economic status. Interestingly, I think it is like a vicious circle. Culture is a constructor of meanings, values, and roles within which the community exists, and it also can become a barrier of the existence of the community. The web of violence that is knitted by the structure is covering over the head of the “hard-to-reach populations”. They are suffering, struggling, striving, and hovering. They need support and direction, and their nature of suffering requires to be understood. As mentioned earlier, there is a circle. Cultural difference is a start of meaning making process, and a cause of inequality as well. To jump out of the circle, we need to put culture in the center, recognize the differences the structure leads to, identify effective methodology for resistance the structural violence and make efforts to achieve social change.
     However, how can the "silent" voices be heard? It is indeed a larger question as we discussed. Generally, I think the marginalization is caused by the (1) marginalized communities' ignorance, they have little motive to change their situation and they do not take active action; and (2) intentional discriminate or oppress result from political, economic and cultural factors; and (3)inappropriate or insensitive intervention, their voices are not heard. To change the marginalized community's situation, I assume that the ways may include resisting to discriminate, and develop programs that are sensitive to the experience of the marginalized community. Initially, I am thinking about some potential avenues. First, provide communicative platform for whom need to express their needs; Further, create ethical dialogue by sensitive and respectful identification, in order to urge more willingness among marginalized groups; Third, I think conducting a research itself is also a process of raising their awareness to shout their voices out. The projects can be empowering for the participants, because the research induces them to reflect on and evaluate their experiences.

Culture and Suffering

     Suffering refers to human experience of enduring specific problems, load, and wounds towards the body and mind in different forms (Kleinman, 1997). The aim of healthcare always is to alleviate suffering. Understanding suffering is essential in health care practice. The meanings of suffering are culturally different. I think the reason may be that suffering is an aspect of inner experience, a reaction to misfortune in life. The interaction between individuals and the society is influenced by cultural values, which involves subjective self-consciousness.

     I was impressed with the assumption in Dickson’s article (2003) that Korean culture affects the way in which people respond to pain, as well as face suffering. It is true, at least according to my own experience that Korean women have unusual pressure in Korean society which is male-dominated, because they are expected to look after all the families, including three generations in some cases. In addition, older age in Korean culture means respectable states and honor. All of these distinct meanings make Korean women perceive pain differently. Sometimes pain and illness become their secret, which are hided in front of their families. What’s more, they would experience through the process of struggling, striving to decrease pain, and then tolerating the pain by themselves, because they view pain as an inevitable part of aged life. In this way, physicians could improve healthcare and pain management through considering patients’ cultural beliefs.

     I also was reminded that there is a question of balance between time and effectiveness. How could healthcare practitioners provide effective service within limited time and resource? They usually have inadequate time, or money to explore the cultural characteristics of the patients. In my opinion, it is essential, at least, for health care providers to keep the culturally sensitive perception in mind. It means physicians should notice patients’ cultural background and take it into account in diagnosis and therapy.

     Human life is filled with suffering and desire, pain and joy. Suffering is unendurable since it conflicts with the desire of goodness. Thus human are usually fighting with good and evil. It is a process of resistance, bearing and struggling with the distress of pain of body and spirit. Therefore, I am thinking whether suffering could be a power that inspires people to seek human’s desire. When people are suffering a certain kind of pain or sickness, they usually struggle to reduce the pain, to pursue “good” states that is consistent with their expectation.

     Then, I was enlightened by the point that to prevent this resistance, political violence is used to create hopelessness through suffering. Undoubtedly, dominant power needs to suppress criticism in order to maintain the domination. As we mentioned earlier, suffering can produce energy to resist, as well as sense of helplessness which result in silence. That is also the way in which dominant system keeps power and control. Human trauma can lead to silence of people. Silencing exists in the context of access to power. The dominant social actors have more chance to construct the priorities of the healthcare system. On the other hand, the voices of marginalized communities always are mute, who are hard to access to the health care resources and basic materials of life. They have no access to express their voices, and as time goes by, they lose the hope and desire to shout their voices out. They are numb, and physicians and policy maker as well. However, the voices of marginalization should be heard and represented in policy to accomplish social change.

     It also reminded me that in a society which is controlled by absolute dominant actors, it is more difficult to find out and address the challenging that marginalized people encounter. Sometimes dominant power creates a “safe” atmosphere on the surface and ignores the voice of marginalization. I am thinking the problem in China. It is likely that people who are marginalized believe no one can help except themselves. What they can do is to “climb up” to “dominant society” and gain the power to change their life through higher education and all the efforts, despite many people still are struggling in the dark. Unfortunately, little research and attentions are paid in suffering of marginalized communities. It is partly caused by abnormal state of the society. The society is supposed to be “in harmony”. The poorer and marginalized people are victim of sacrifice. What do we researchers do in the context? To heal it, I think, is to figure out a balance between the center of power and marginalized individuals. What it means is to explore how the dominant policy systems influence suffering and lead to further change through the research of culture. 

Culture, Health, & Pain

     I am enlightened by the assumption that pain is a universal experience, as well as an inner experience, which means although all people experience pain similarly, there are differences in people’s perception of pain and expectation of how others respond to their pain. That is because pain is not only understood in biological aspect but also it is sensitive, emotional, and cognitive (Kleinman et al., 1992). Biological, psychological, and social factors intertwine in the response, expression and management of pain. It reminds me the influence of culture on pain experience.

     Culture difference in pain-related behavior, I think, is likely to derive from social contexts, since the way that an individual interpret and understand pain depends on his or her past experience. The relation between pain and culture combines science and philosophy together. Pain is defined differently using their own languages and idioms in various cultural groups. For example, to patients from Asian cultures, they are often stoic facing pain. Why people in Asian cultures have high pain tolerance? It is probably linked to cultural beliefs of self-management. Even though an individual feels pain, it is a habit to make it unobvious and hide it. Asian patients view it as an improper social manner to complain pain openly. I think this cultural value arises from traditional Asian cultures which assert that harmony in interpersonal communication is important.

     Undoubtedly, it is essential to deliver culturally competent care. However, how do clinicians measure patients’ pain, in order to conduct appropriate health care? What about self-report? But different words are used to describe pain in different culture, and many of them are too abstract to understand. Language is limited in conveying pain experience. And how do clinicians understand patients’ narratives about personal pain experience? There is neither easy way, nor assured way, I am afraid. In addition, it is not necessarily true that everyone from a culture will perform the “typical” or expected behavior in this culture when suffering pain. Thus developing a critical reflexive awareness is needed in health care. Still, we should keep in mind that culture is a framework that directs patients’ behavior. An individual’s experience of pain may rely on his or her cultural belief, past experience, and unique characteristics. Every patient is a unique unity. By careful listening and probing each patient’s feeling and experience, health care providers may discover what is happening.

     In many cultures, interestingly, people often believe illness and pain are caused by evil spirit or punishment from a higher power such as God. In this case, patients might refuse pain medication because they think it is God’s desire and God will help him to bear it. Additionally, it is a common saying in Chinese culture, that as long as you can suffer the pain that you encounter, you will obtain spiritual growth. Hence for health care professionals it may be not wise to judge their beliefs. Conversely, they need to anticipate patients’ needs and values, and initiate conversation with patients, to negotiate an appropriate treatment for patients within their cultural and religions contexts. Never take for granted, and be rigorous when exploring deeper origins. 

"The Name of the Disease"

    The documentary "The Name of the Disease" opens another window to me, narrating the voices of patients who have less power in the poor region of rural Rajasthan, India. It is fantastic to touch a picture of another world. In this world, patients and their family believe the disease is due to evil spirit; in this world, “doctors” can heal every disease, and anyone can be a “doctor”; in this world, the name of the disease is “who knows”. I don’t know why I am sick, what the name of the sick is, and how to cure the sick. “I don’t know what to believe” may be meaning “I have to believe everything I hear”. Thus no matter bhopa, or official doctor, no matter science, or ghost, as long as I can access it, as long as I can afford it, I need to have a try. The people here have the original desire – to be alive. How do they live without resource, without knowledge, without support? They are struggling within the poverty, inequality, and hopelessness. Honestly, while watching this documentary, I don’t feel anything except empathy. I hope it is a good start to be a good researcher.

Culture, Modernist Paradigm, and Health

    The individual is a cell of society. The whole atmosphere of society may influence what an individual think, what an individual do. With regard to the influence of social force on individual health behavior, the instance of sati highly impressed me. The symbolic meanings of sati in a culture could “persuade” or restrain a widow’s self-destruction unconsciously. In some cultures, sati is symbolized as a representation of dignity, loyalty and purity of women. What does a widow do when she is suffering from the depression due to her husband’s death in such an atmosphere? Sometimes women are pushed to step on the way of sati by social power. As modern society changes, on the other hand, what if sati is considered as an irresponsible and hasty behavior?

    As Nandy (1988) claimed, people keep their social and political dominance through making themselves rational in social change. Human learn from the patterns, cause, and rules of nature to understand how to dominate it. Culture of a group, a community, a region, and a country is reinforced by social power. Social force can push people to perform a certain behavior by building rational environment. “Rationality” would change across different social contexts and cultures. Rationality gives people reasons to believe, to act. Rational behavior in a culture is one that is not just reasoned, but also is aimed to achieve a goal. However, it varies as the context varies. One “rational” behavior may be “irrational” in another culture. Religious practice may be one kind of manifestation.

    Thus, every behavior has its reason to exist. So does health-related behavior. Patient-centered communication therefore plays a vital role in understanding patients’ social contexts among diverse groups. Physicians need to elicit what patients are thinking, what is their expectation, all of which are depending upon their cultural identities. It is required for physicians to be sensitive to recognize patients’ problems, their misunderstanding caused by patient-physician cultural differences. Besides, in order to engage with the patient, I think the attitude of empathy is a core element in patient-physician communication. Empathy is a process of understanding and anticipating the feelings and experiences of another. Physician puts himself in patient’s places, giving him cues of what he should do in a certain setting. It enables the physician to accurately fulfill patients’ needs. Specifically, the patients are willing to talk more about their concerns and symptoms, helping the physician get known more information about their physical and psychological states and respond to patients’ need appropriately. It leads to more accurate diagnosis. 

Culture, Experience, & Identity

    

    Disease and illness are experienced by patients, existing in the human’s body as a physical condition from the clinician’s perspective, whereas for the patients who are suffering from the illness, the disease is a part of the self as a mental state and simultaneously a physical issue as well (Good, 2005). Illness experience, I think, involves patient’s subjectivity and is given meanings through the cognitive representations and images that developed after understanding their illness condition. Pain, as an essential part of illness experience, is also subjective, which feeling is hard to be measured (Jackson, 1992).

    As two parts in medical systems that possess different medical knowledge and perspectives, Physicians and patients have different ways to translate signs and categorize symptoms; therefore misinterpretations and misunderstanding are normal in health communication. On the other hand, the distinction between so call reality and subjective illness experience increases the difficulty of management pain in health care. In different institutions where produce the ideology of the systems they are engaging in, how do physicians understand the subjective illness experience of patients? Even for patients themselves, they have confusion about pain problems. The confusion is caused by pain’s features of invisibility, subjectivity, and stigma. Pain can not be observed, hard to be described, and the extent that people can endure is different. For instance, in many cultures, boys and men are supposed to hide and bear their pain in silence. They may have difficulties when expressing their pain experience in the process of discourse with physicians.

    Indeed, patients and physicians have trouble understanding each other. Narratives in their relationship are effective tools toward shared decision-making, meaning efforts to describe pain and experience in details. By open conversation with patients, physicians could find out patients’ interests and needs, in which process consideration of role of culture is important. Health practitioners encounter challenges when translating between objective medical theories and local cultural forms of knowledge, which are culturally diverse.

    The ways in which we perceive self – identity – are developed in daily behaviors we perform in the context that culture offers, are associated with our constructing and interpreting meanings of health and disease, and influence the relationships with others in health care systems, in cultural communities. For example, a person who see himself or herself as a follower of a religion tend to adapt to the ritual procedures and healing tradition practice in the religion. Religion practice is a process of fulfilling the needs of connecting with one’s culture, with the past, and origins of the religion. I was enlightened by the assumption of Airhihenbuwa (1995) that we should emphasize the political aspects of culture when dealing with the identity and distinction within the contexts of power and agency. Culture is political. It is based on the foundation of the institutions where people engage in, such as agencies, families, religions, and schools. Cultural identity is established, developed, and changed by different contexts. Thus an individual may identify with sorts of cultures, for example, the social group they participant, the religion they follow, the companies they work in. The degree to which a person identifies with a certain culture may influence his or her health behaviors and outcomes.

Culture: Epistemology & Ontology

    

    The important role of culture has attracted increasing attention as a factor influencing healthcare and health communication, as well as a consideration of developing effective health communication programs and intervention (Airhihenbuwa, 1995). So what is culture? Why does it matter in health communication? I can’t agree more with the point argued by Bauman (1999) that culture is a set of things that people keep in mind guiding their perceiving and interpreting events, the world, and themselves, in order to act in a way acceptable to the members in the same group. Culture is mirrored in a group’s norms, values, beliefs, and patterns of communication. For instance, cultural groups have their unique ways to overcome challenges, according to their shared values and norms, such as would be the case if a cultural group uses traditional practice to promote a certain disease. Thus consonance between health care intervention and the cultural traits of target group increases acceptance of health programs. That’s why health intervention and programs aim to be culturally sensitive and meet cultural groups’ psychosocial needs.

    The culture-centered approach introduced in Dutta’s book Communicating health (2008) deepened my understanding of health and health communication that are constrained and developed within cultural contexts and values. The contexts of culture endow health communication with health meanings of how group members interpret and understand health and illness. These meanings may enable or limit their health behaviors. For example, alterations to the genitals of male and female are defined differently (Darby, 2004). Female genital alteration (FGA) is considered as a harmful surgery to female, which damages their integrity. On the other hand, male genital alterations (MGA) are called circumcision, which seems to be less serious. In this way, male genital mutilation is always ignored whereas female genital mutilation is recognized. The distinct definitions raise some questions in my mind. Whether these meanings of genital alteration are associated with sexual function in society? Is circumcision is discriminatory? What is the standard? Are there double standards? I think there are. They are probably caused by the potential medical and physical benefits of MGA as Darby claimed. However, these “benefits” also could be the products of cultural norms. A cultural group dedicates to seeking evidence proving their customs are reasonable, in order to be accepted by the members. Moreover, a cultural practice may be viewed as a violation of human rights in other culture’s perspective.

    Therefore, the study of culture is essential in understanding health communication. As the culture-centered approach (CCA) proposed, there are also three key concepts upholding the construction of culture: structure, culture, and agency. These concepts and their interplay remind me that the voice of marginalized groups is mute. They have difficulty to access services, lack capacity to engage in health behavior. As a researcher, what I am intended to do is to understand their culture contexts, address the structures that constrain their behaviors, and enable cultural members to perform beneficial health related actions. The epistemology and ontology of culture is the first lesson, the first entrance, and the first illumination on the long way.

Introductions

My independent study "Culture and Health" is coming! 

Be more independent and strict!

I am on the way..