Copyright 2007 Michael Winkelman

Societal Overview: Migrants and Immigration AttitudesBiocultural Ecology: Sociogenic DiseaseHigh Risk Behaviors: LifestyleNutrition: The Malnutrition EpidemicWorkforce IssuesFamily Roles and OrganizationLife Cycle Concerns (Pregnancy, Childrearing and Death)Spirituality and World view American Lay Healing PracticesAmerican Biomedical Cultural system characteristics

Rise of BiomedicineAccess Problems in Health Care Delivery

Unconventional MedicineCommunication and Medical Relations

“Health care Providers culture”Social Interaction Rules

Heritage = history and mythEuropean American- dominant cultureMany national sources – immigrationAssimilation and Anti-immigration ethosPersistence of “white” ethnicsEducation as the socialization medium

Many “American” health traditionsHistory of eclecticism

The Roles of Work in Health and vice versaWork as Source of Health CareHealth Care as an economic burden

Access Issues: Anti-Socialized Medicine or Capitalistic medicine?

Epidemiology– Major causes of death/mortalityHeart disease (cardiovascular diseases)

Cancer

Lung diseases, especially obstructive pulmonary

Accident/Injury (largely vehicular)

Diabetes

Stroke

HIV

All basically Sociogenic diseases= derived from lifestyle

CVD, Diabetes, stroke as diet and activity relatedCancer: environment and lifestylePulmonary disease as environmental, lifestyle, drugsInjury as cars, drugs and lifestyleIatrogenic (hospital acquired) and nosocomial(healer induced) mortalityHIV exemplifies sociogenic dynamics

Sociogenic—lifestyle and cultureFood and dietary factors, malnutritionNeed for low fat/cholesterol and high fiber diets

Obesity, physical activity and life-styleCulture and Drug Interactions

Contributory factor to pulmonary disease, accidents, HIV

Sexual behaviorsEnvironmental conditionsMedicine

Diet: high-fat and cholesterol, low in fibersIndustry inspired food standards in food pyramidIndustrial production of non-nutritious foodsReliance on international food sourcesAdditives and xenobiotics’’

Environmental Working Group “dirty dozen”Access to foods, nutritional adequacy

“Fast food nation” and advertising imagesKnowledge of needed foods/nutrition-Commercial food production patternsFood rituals and symbolic meanings

Role of health industry in economyCapitalist medicineOccupational hazards and environmental effects– “OSHA” Occ. Safety & Health Ad.Job-related health benefitsCulture and Work Issues in medicine

(e.g., nurse roles)Intercultural work-place relations

Variation in dynamics of family structure affecting healthHistorical patterns of evangelical, moderate, genteelNuclear idealSingle-head of household reality, “blended families”Single parent risks- abuse epidemicKinship: fictitious; blended and transgendered families"Empty nest syndrome"

Gendered RisksEgalitarian gender ideals and realities

Family priorities and valuesValue placed on the protection of children, autonomyNew legal approaches and precedents to punishment and disciplineDecision-making processes—Individual rights

• Cultural behaviors affecting pregnancy– Work, autonomy, feminist revolution– Women’s independence and the declining birth rate

• Abortion controversy• Sexual values affecting health• Developmental Values and Adolescence

– Autonomy and Sexual Risks• The Graying of America

Extensive control of fertility–falling behind replacement population growth

Strong cultural norms for pregnant womenAvoidance of smoking, drug use; impt of vitamins & diet

Expectation for fathers' participation prenatal classes and birthing processesHome Birth Movement: Birth as natural, spiritual

Connection with powerful forces both within and outside of herselfPower rooted in procreationFeminine qualities and activities given greater respect and value

Graying of AmericaAmericans difficulty in dealing with topic of death

Avoidance and rarity of occurrence for the young (good life expectancy)

Divergent Cultural views of DeathMedical views of death- failure, endPeople’s views of death as religious transition

Death rituals and grief managementFamily obligations to be with the dying personExpectations that HCP will also accommodate family

General openness the hospice care and end of life advanced directives

Euthanasia/DNR still often problematic

Support StrategiesExpectation of HCP supportSupporting family’s grievingAssist in expression grieving interpersonally and with support referrals

• The general cultural beliefs or world view– Materialism vs. Spirituality

• Predominance of Judaeo-Christian traditions, especially Protestantism

• Limited concepts of religious freedom, limits to tolerance

• General belief that religion and spirituality have a role in health

• Expectation HCP will address religious concerns, including praying with patients

• Patient reliance on religious healing practices including prayers', amulets, support groups and a variety of rituals

Eclectic: Native American and EthnicsHerbalNutritionalSpiritual and Vitalistic

American SpiritualismsCatholic and Protestant Healing Traditions, Paganism, Wicca and Shamanic Re-Inventions

Physical places of healing/power of saintsSystem of meaning and coherence countering doubts from doctorsWay of escaping the total domination by biomedicine

Relics as restructuring the dominance of the biomedical system

Countering isolation and despairForming system of sacred bonds of generosity, loveConnecting the sick person to family and friends. Gifts of relics provides support even when not physically present,

Saints facilitate choices, doctor, treatments—or no treatmentSaints provide solace and support when the context doesn’t

Importance of healing and curing distinctionHealing as moving into wholenessPhysical, emotional and mental embodiment of peace of ChristRole of forgiveness and reconciliation in healingSocial aspects of healing services

The focus on nature and the female goddesses Shamanic roots

Chanting, drumming, dancing, trace, energy healing, massage, herbsCommunal ritual healing groupsFamiliarity with spiritsExtraction of harmful intrusions and energies

Health as Balance and wholeness, connection with spiritual forcesMaking connections and relationships, with community, nature, cosmosObtaining energy from the group

Development of modern medicineRoots in war and Industrial revolutionEffects of Rural-urban transformation

public heath and epidemic diseasesThe rise of antibiotics

Empowering surgical approachesExpansion of pharmaceutical care

The dominance of “capitalist medicine”Primacy of profit motiveImpact of multinational corporations

Control of government of public and private sectors of careHealth as biggest business 13% GDP

Highest cost worldwide Lack of coverage, mal-distribution of resources

Infant mortality rates 26th internationally

Medicine as social control Growing legal roles of medicine (certificates)Expansion of areas of care (addiction, diet, stress)Increased control over treatment (prescriptions, tests, services)Impacts on other aspects of life through worker’s comp, abortions, addictions, euthanasia, insanity defense, access to CAM

Return of infectious diseasesPersistence of chronic diseaseSociogenic diseaseMisfocus of attention

secondary, tertiary versus primary/preventionAmerican lack of cultural awareness

Considering cultural features to be personalLack of cultural care behaviors

Work, private and security netFind appropriate providers, available, able/willing to receive patient

Kinds of specialist to see for problemsPatient understanding of medical processesPrejudice in servicesControl by HMOs, Pharmaceutical and Insurance Companies

Decisions regarding nature and quality of careDissatisfaction with biomedical care culture

Drive to alternatives

Shifting focus of health paradigmHealth promotion, disease preventive and holistic healingIncreasing personal responsibility

“Unorthodox medicine“ – “medical practices that are not in conformity with the standards of the medical community . . .[and] not widely taught at U.S. medical schools or generally available at U.S. hospitals” (Eisenberg et al. 1993: 246).

relaxation techniques chiropractic massage imagery spiritual healing commercial weight lossdiets herbal medicinemegavitamin therapy self-help groupsenergy healing biofeedbackhypnosis homeopathyacupuncture folk remedies

Prayer and exercise included in the original studyThe 1997 study added aromatherapy, naturopathy and chelation therapy.

Massage, relaxation techniques & chiropractor Treatments especially for chronic conditions

Back pain, renal failure, cancer, arthritis, AIDS, gastrointestinal or digestive problems, eating disorders, anxiety, headaches, and chronic pain, insomnia, depression1991 study reported 34% of respondents used an unconventional therapy within last year1997 study reported unconventional use rates ranging from 32% to 54%Used in conjunction with biomedicineAssociation with more educated segments

Need to ask patients about care practicesProblem with “don’t ask, don’t tell”

Need to accept American cultural preferencesEgalitarianAutonomyDecision making

Should encourage pain medication where facilitates healing process

Beliefs: Ideology of Materialism, GermsTechnology: extreme reliance, lab resultsIndependence and personal responsibilityInteraction and Communication stylesHierarchies and Power

English as informal "official language“Need for translators, interpreters

Emphasis on verbal communication styles Need to read behavioral, emotional, “non-verbal”

Emotional expression – control and flatteningGreater sensitivity to “leakage”

Informality in relationsImportance of greeting style and name formats in respect

Emphasis on personal sharing and disclosureNeed for relationships to enhance patient disclosure

Touch/contact; taboo on touchsexual harassment concerns versus personalism

Eye contact-cultural directness and honestyNeed for cultural accommodation for politeness

Time orientation – timeliness and double standardsPunctuality and “polychronic time”

“We’re the greatest” – or are we?Need to understand source of limitations, problems

Sociogenic Disease – “Killing ourselves”Family and Health Dynamics- changing populationsReligious Healing as persistent cultural phenomenaUnconventional medicine as cultural responseNeed for Biomedical Adaptations