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Population Health for Nurses

21.4 Overview of Cultural Views and Practices

Population Health for Nurses21.4 Overview of Cultural Views and Practices

Learning Outcomes

By the end of this section, you should be able to:

  • 21.4.1 Explain how generalizations and stereotypes impact health outcomes.
  • 21.4.2 Describe various cultural practices and views of the world.
  • 21.4.3 Identify shared cultural beliefs, values, and customs influencing health.
  • 21.4.4 Develop care plans that consider the impact of cultural influences on disease management.

Disregarding cultural elements in clinical practice can lead to low-quality or unsafe care, such as perfunctory or inadequate evaluations, errors in diagnosis, unsuitable treatment plans, or noncompliance by clients and families (Johnson-Lafleur et al., 2023).

Developing cultural awareness as to how people acquire certain practices in their cultures and the role that culture plays in forming individual personal identity, worldview, lifestyle, and health beliefs and practices is essential preparation for Transcultural Nursing, which will revisit Giger and Davidhizar’s transcultural model from the perspective of conducting a cultural assessment.

Cultural Generalizations and Stereotyping

Broad observations about a culture’s shared characteristics or patterns are known as cultural generalizations. These generalizations are not necessarily positive or negative and can describe cultural practices, values, or traditions. For instance, it is a cultural generalization to say that family values are highly emphasized in many Asian cultures or that punctuality is highly valued in some European countries. It is important to recognize that these generalizations are tendencies, not universally applicable traits. They can provide insights into the cultural norms of a particular group and promote cultural awareness and sensitivity, but they should be used thoughtfully and cautiously.

On the other hand, stereotyping involves making oversimplified assumptions about individuals or groups based on their cultural backgrounds. It often results from prejudices, biases, or limited knowledge and leads to the unfair characterization of an entire group based on the actions or behaviors of a few individuals. Examples of stereotyping include assuming that all members of a particular ethnicity are good at math or all people of a certain nationality are loud and aggressive. Stereotyping is damaging and perpetuates harmful biases, leading to discrimination and exclusion of individuals based on their cultural background.

Even though cultural groups may share customs, traditions, and ways of life, there is always diversity and individuality in any culture. Judgments about a particular culture are often based on a limited number of observed characteristics, which can be oversimplified, misrepresented, exaggerated, or distorted. This can lead to false assumptions and stereotyping based on race, gender, religion, or culture, resulting in prejudice, ecological fallacies, and discrimination. As the multicultural population in the United States continues to grow, it is crucial for nurses to recognize and appreciate cultural differences in health care values, beliefs, and customs.

To create a more inclusive and understanding society, it’s important to distinguish between cultural generalizations and stereotypes. Nurses should strive to learn and appreciate the uniqueness and diversity within cultures while recognizing that each person has their own beliefs, values, and experiences that may or may not align with cultural generalizations. By promoting cultural competence and avoiding stereotypes, nurses can minimize misunderstandings and negative interactions.

Cultural Practices and Views of the World

How someone views the world, or their worldview, has a big impact on their health and approach to health care. Different societies and cultures have their own beliefs, values, and attitudes toward health and illness, which affect how they behave, seek health care, and interact with the health care system.

These cultural practices and views are shaped by factors like history, society, religion, and the environment. They affect how people communicate, feel about personal space, organize socially, perceive time, control their environment, and form dietary habits. These concepts are part of the transcultural model developed by Giger and Davidhizar, which is introduced in Transcultural Nursing.

As health care providers, nurses must acknowledge and appreciate the impact of cultural factors on health to deliver effective and culturally sensitive care. This requires nurses to embrace cultural diversity and be receptive to diverse perspectives. By doing so, nurses can broaden their understanding of the world and contribute to a more inclusive and harmonious global community. Providing culturally responsive health care promotes trust, enhances communication, increases treatment adherence, and leads to better health outcomes for individuals from diverse cultural backgrounds.

Communication

Culture influences everything from language and nonverbal communication to communication styles and the values and beliefs that underlie communication. Communication is learned, transmitted, universal, and inclusive of human interaction and behavior. Although two individuals may speak the same language, differences can exist in communication patterns and understandings because of cultural orientation. Culture influences linguistic patterns, how feelings are expressed, and the appropriateness of verbal and nonverbal expressions (Giger & Haddad, 2021).

Verbal communication is associated with languages, including vocabulary and grammatical structure (Halliday, 2006). Language is a form of verbal and written communication and a key component of culture, with different cultures having different languages, dialects, and accents. Language affects what one says and how they say it, so cultural language differences have an impact on how people communicate. For example, some cultures may emphasize formality and politeness in their language use, while others may be more blunt and more direct.

In comparison, body language or motion (kinetic behavior) is an example of nonverbal communication. Nonverbal communication conveys messages without words. Different cultures may use different nonverbal cues to convey meaning or express emotion. In some cultures, direct eye contact may be seen as a sign of respect and engagement. For example, some Haitian Americans use direct eye contact to gain attention and respect during communication. In comparison, others may see this as disrespectful or confrontational. For example, among some Vietnamese Americans and Native Americans, avoidance of eye contact is a sign of respect. Among other cultures, such as Mexican Americans, looking at and admiring a child without touching them can be viewed as giving the child the “evil eye” (Giger & Haddad, 2021). In Buddhist cultures, the head is considered sacred, as it is the highest part of the body, and patting the head is considered rude, while the feet are considered dirty. Table 21.2 lists examples of verbal and nonverbal forms of communication.

Verbal Forms of Communication Nonverbal Forms of Communication
  • Vocabulary
  • Grammatical structure
  • Voice qualities
  • Intonation
  • Rhythm
  • Speed
  • Pronunciation
  • Silence
  • Touch
  • Facial expression
  • Eye movement
  • Body posture
  • Hand gestures
Table 21.2 Forms of Communication

Different cultures may also have different communication styles, such as whether communication is more direct or indirect or whether emotions are expressed openly or kept hidden. These communication styles can impact how messages are received and interpreted by others.

Cultural values and beliefs can influence what is considered appropriate or acceptable to talk about. For example, in some cultures, it may be considered impolite to criticize others openly or to express strong emotions. In others, it may be seen as necessary for honest communication (Giger & Haddad, 2021).

Understanding these cultural differences is essential for effective communication across cultures. Cultural practices affect how people interact with each other. For example, some Alaska Natives seldom disagree publicly with others and may nod yes to be polite, even if not in agreement. In some cultures, it is customary to bow or shake hands when greeting someone, while in others, people may kiss each other on the cheek or give a hug. Among Orthodox Jews and Hasidim, touching, particularly from members of a different sex, is offensive (Giger & Haddad, 2021).

Nurses must be aware of a client’s preferences and practices to avoid miscommunication. Nurses should monitor body language and clients closely to detect meaning.

Space

Space is the setting where communication occurs and includes the space surrounding a person’s body and the objects in the space. An individual’s comfort level is related to inner and outer personal space, which can vary from culture to culture.

Human perception of social and personal space is culturally bound. For example, in Western culture, space is viewed as having four dimensions, or zones: the intimate zone (0 to 18 inches), the personal zone (18 inches to 3 feet), the social zone (3 to 6 feet), and the public zone (6 feet or more) (Figure 21.5) (Hall, 1976). Each dimension or zone has a different purpose. For example, the intimate dimension is associated with comforting, protecting, and counseling. The personal dimension is best illustrated as the “friend zone,” in which communication with less intimate but still familiar companions occurs. Touch is an essential feature of both the intimate and personal dimensions. The social dimension is considered the impersonal business zone and is associated with people working together. Sensory involvement, such as touch, is generally less intense in the social dimension (Giger & Haddad, 2021).

The four dimensions of physical distance between people in western culture are shown as four nested circles. The circles from inner to outer are labled as follows: Intimate Space 0 to 18 inches; Personal Space 18 inches to 3 feet; Social Space 3 to 6 feet; Public Space 6 feet or greater.
Figure 21.5 Western culture has four dimensions of physical distance between people, depending on the situation. Other cultures view personal space differently. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Color can have symbolic cultural implications. For example, in some Asian cultures, white is associated with a funeral, while in some African cultures, red symbolizes death (Giger & Haddad, 2021). The color red may be associated with luck, love, and prosperity in some cultures, while in others it may be seen as a symbol of danger or warning.

Cultural traditions and religious beliefs can also influence color choices. For example, in some African cultures, bright, bold colors are often used in clothing and textiles, reflecting these regions’ vibrant and colorful environments. In Christianity, purple is associated with Lent and is often used in liturgical decorations during this season.

Social Organization

As discussed in Cultural Groups and the Formation of a Cultural Identity, social organization refers to the ways in which groups organize themselves. The social organization of societies influences culture, and the social organization of a cultural group, including family structure and organization, religious values and beliefs, and role assignment, is a part of that group’s culture (Giger & Davidhizar, 2002).

The family is discussed in more detail in Caring for Families. Family structure and organization are culturally bound, which means that culture affects the attitudes, practices, or behaviors of the family.

Family structure and organization and religious values and beliefs inform gender norms and role assignment in group settings. Children are socialized into gender roles. As a social construct, gender roles vary from society to society and can change over time (World Health Organization, 2023, para. 1). Additionally, gender roles are generally associated with a social hierarchy that gives different statuses to different group members. Cultural expectations around gender roles can also impact family organization and function.

Different cultures may have different expectations for family structure, such as the number of generations living together or the role of extended family members. In many cultures, it is common for multiple generations to live together in a single household, while in others, the nuclear family is emphasized.

Often, decisions about health care are made by the family rather than solely by the individual. Family organization can impact how health care decisions are made and who participates in decision-making. Family members can also play a role in communication with health care providers. In cultures where family members are heavily involved in health care decision-making, they may be more likely to accompany the individual to medical appointments and participate in discussions with health care providers.

Time Perception

Cross-cultural research indicates that there are two types of time: clock time, where an external timepiece dictates action and events, and social time, which is governed by the flow of activity or when “the time is right.” The view of social time vs. clock time differs globally (Begic & Mercer, 2017). For example (Giger & Haddad, 2021):

  • Khasi people, an ethnic group in the state of Meghalaya in northeastern India, have an 8-day week.
  • Some Amish people keep slow time, in which they set clocks a half hour ahead when others convert from daylight saving time to standard time.
  • Many people of Asian origin view time as flexible.

Perspectives on time may be oriented to past, present, or future (Begic & Mercer, 2017). Here are a few examples of how different cultures may perceive time (Giger & Haddad, 2021):

  • Past orientation: Some cultures place a strong emphasis on the past and may view time as cyclical or circular rather than linear. These cultures may prioritize traditions and rituals passed down through generations and may view the present and future as interconnected with the past.
  • Present orientation vs. future orientation: Some cultures may have a more present-oriented perspective, focusing on enjoying the moment and responding to immediate needs. Other cultures have a strong focus on planning for the future and investing time and resources in long-term goals.

Cultures may also be influenced by biological rhythms, such as the cycle of day and night. Some cultures may emphasize waking and sleeping at particular times or may have cultural practices tied to natural cycles, such as farming or hunting.

Environmental Control

Environmental control describes an individual’s control over nature and environmental factors. Views of environmental control affect illness and health-seeking behaviors, which are influenced by one’s sense of locus of control. Locus of control (Rotter, 1966) refers to an individual’s beliefs about the extent of their control over the environment and what happens to them. Locus of control can be external or internal:

  • Internal locus of control:
    • Individuals believe that they are responsible for their success/outcomes.
    • Individuals are more likely to take independent action to manage disease symptoms.
  • External locus of control:
    • Individuals believe that external forces, like luck or fate, determine outcomes.
    • Individuals are more likely to depend on others to manage disease symptoms.

Whether the cause of illness is believed to be natural or unnatural further influences health behavior. Natural events are considered an inherent aspect of the world, resulting from causes such as environmental sanitation, personal hygiene, poverty, or biological or psychological factors. They are perceived to have some degree of predictability and to be subject to some element of control (Kahissay et al., 2017). In comparison, unnatural events are viewed as the consequence of disharmony in nature. They are not predictable and are beyond human control (Giger & Haddad, 2021). For example, some cultures may attribute illness to supernatural causes, such as curses or evil spirits, and may use spiritual or religious practices to address these causes (Kahissay et al., 2017).

An individual’s belief about whether an illness has natural or unnatural causes affects the types of cures/treatments they may seek. Alternative therapies are practices intended to promote health that are not represented in traditional Western/modern medical treatment or conventional medical practices. They often represent traditional health practices that are customary to various cultural groups. These therapies can be categorized as energy-based, biologically based, manipulative or body-based, and mind-body-based. These alternative therapies are often embedded in the folk medicine belief system. In many cultures and faiths, alternative therapies and religious practices include blessings from spiritual leaders, healing power, and the use of objects in healing ceremonies.

Folk and traditional beliefs are shaped by culture. For example, traditional Chinese medicine includes practices such as acupuncture, tai chi, moxibustion (burning of herbal leaves on or near the body), cupping (using warmed glass jars to create suction on specific points on the body), and use of herbalists (Figure 21.6).

A therapist holds a fire source in one hand and uses the other hand to apply a suctioned glass cup to the back of a person laying on their stomach.
Figure 21.6 Cupping is an ancient, holistic treatment for various diseases traced back to early Egyptian and Chinese medical practice. (credit: “Cupping” by Alanna Ralph/Flickr, CC BY 2.0)

The rootwork system is a traditional African American folk practice that involves using herbs, roots, and other natural materials to address various health and spiritual concerns. This practice has its roots in African spiritual traditions and was brought to the United States during the period of enslavement of Africans. Rootwork is a holistic practice that encompasses physical, mental, and spiritual health (Mathews, 1987).

Traditional practitioners who deliver care include healers, shamans, and priests. For example, among some Latin Americans, “treatment comes primarily through a variety of healers that include the curandero (healer who uses prayer and artifacts), yerbero (herbalist), espiritista (practitioner of espiritismo, a religious [tradition] concerned with communication with spirits and the purification of the soul through moral behavior), and santero (practitioner of Santería, a religious [tradition] concerned with teaching people how to control or placate the supernatural)” (Giger & Haddad, 2021, p. 110).

A shaman serves as a mediator between the supernatural and the individual. In comparison, the medicine man or woman utilizes traditional techniques to cure disease. Priests perform rituals and ministerial functions as part of particular religions.

Dietary Practices and Nutritional Preferences

The relationship between food and culture is complex and multifaceted. Food is not only a source of nourishment; it also has social, symbolic, and cultural meanings. Food-related traditions and rituals are an essential aspect of many cultures. Holidays and festivals often involve traditional foods and special meals, which can be a way of connecting with one’s cultural heritage and history. Food can also mark important life events such as weddings, funerals, and religious ceremonies.

Cultural practices and beliefs influence what foods are acceptable or desirable and how food is prepared and consumed. Certain foods may be considered taboo or forbidden in some cultures, while in others, they are celebrated and eaten in large quantities. Food can also express cultural or community identity and belonging.

A range of factors, including geography, climate, religion, history, and social norms, shape cultural dietary practices. These practices can vary widely across different regions and communities and significantly impact health. They can also affect health behaviors. For instance, cultural norms may dictate specific dietary restrictions or preferences. These factors can influence the prevalence of obesity, diabetes, and cardiovascular disease.

Some cultures believe that certain nonfood items have medicinal or healing properties. For example, some African and Caribbean cultures believe that consuming clay or dirt (known as geophagia) aids digestion, prevents nausea during pregnancy, and improves overall health (Madziva & Chinouya, 2020). In other cultures, consuming nonfood items such as charcoal, chalk, or ice may be seen as a remedy for various ailments (Sruthi, 2023).

Dietary practices can affect dietary needs and create mineral deficiencies. For example, some Native Americans consume inadequate amounts of protein, calcium, and vitamins A and C. This is due to various factors, including limited access to healthy foods, cultural dietary practices, and historical factors such as the forced removal of Indigenous peoples from their traditional lands and the imposition of Western diets. Traditional Native American diets were often based on locally sourced foods rich in protein, fiber, and nutrients.

Cultural dietary practices are complex and multifaceted. The nurse should approach cultural dietary practices with respect and cultural sensitivity and work with clients to understand their unique dietary needs and preferences.

The Role of Culture in Disease Management

The role of culture in disease management is significant and multifaceted. Culture influences how individuals perceive, experience, and respond to health, illness, and treatment. The box below provides an example of the role culture plays in shaping the health of a South Asian community. Understanding cultural context is crucial for health care professionals to provide effective, client-centered disease management.

The Role of Culture in Shaping Health Beliefs and Practices in the Management of Diabetes

By 2050, around 134 million people in South Asia, including those in India, Pakistan, Bangladesh, and Sri Lanka, will be affected by type 2 diabetes (Hills et al., 2018). Even after considering age, sex, and body mass index (BMI), South Asian immigrants in the United States have a much higher rate of type 2 diabetes (27 percent) than non-Hispanic White individuals in the United States (8 percent) (Hills et al., 2018). When helping individuals of South Asian descent manage diabetes, nurses should be aware of the following culturally influenced health beliefs, behaviors, and practices that may contribute to this difference:

  • Diet and nutrition: South Asian cuisine often includes staple foods like rice, chapati, and lentils, which can be high in carbohydrates. Traditional cooking methods may involve frying or using ghee (clarified butter), which can contribute to a higher intake of unhealthy fats. Cultural preferences for certain foods, spices, and flavors can influence dietary choices, making it essential to address culturally appropriate dietary modifications that balance taste and health needs.
  • Cultural perceptions of health: Cultural beliefs and norms surrounding health and illness can impact diabetes management. Traditional wellness concepts and ideas about the causes and treatment of diseases may differ from Western biomedical perspectives. Understanding these beliefs can help health care professionals tailor interventions and promote health literacy.
  • Family and social support: South Asian communities often prioritize strong family ties and social networks. In diabetes management, family support can be crucial for adopting and sustaining lifestyle changes. Involving family members in education sessions, meal planning, and exercise routines can enhance adherence and overall success in managing the condition.
  • Language and communication: Language barriers can hinder effective communication between health care providers and South Asian clients. Cultural nuances and expressions related to diabetes management may not have direct translations, impacting the delivery and understanding of medical advice. Culturally responsive health care providers or interpreters who understand South Asian cultural contexts can help bridge these communication gaps.
  • Stigma and mental health: Diabetes can carry a stigma in some South Asian communities, leading to emotional and psychological challenges for individuals with the condition. Fear of judgment or discrimination may discourage clients from seeking appropriate health care or openly discussing diabetes-related concerns. Addressing mental health aspects, providing psychosocial support, and creating safe spaces for open dialogue can help individuals overcome stigma.

(See Adhikari & Mishra, 2019; Subhan et al., 2023.)

Culture plays a role in disease management, influencing how individuals perceive, experience, and respond to health and illness. Nurses must approach disease management with cultural sensitivity, humility, and respect to provide client-centered care and improve health outcomes for all individuals. Figure 21.7 illustrates how aspects of culture can affect health behaviors and treatment for a client with type 2 diabetes.

In a diagram, overarching cultural factors influencing client behavior are described in ovals, and these ovals point to a center circle, which is labeled Type 2 Diabetes. Specific cultural influences are described in squares, and arrows point from these squares to show how they affect some of the cultural factors. Cultural factors shown as affecting the treatment plan for Type 2 diabetes are religious practices, language, and communication; family and social support; diet and nutrition; health beliefs and practices; and stigma and mental health. Specific cultural influences include dietary restrictions due to religion, which can affect both religious practices and health beliefs and practices; cultural attitudes that stigmatize diabetes, which affects mental health and health beliefs and practices; and cultural beliefs about health, illness, and the cause of disease, which can affect health beliefs and practices and diet and nutrition.
Figure 21.7 This web of causation shows the many cultural factors that affect client health behaviors and that should inform treatment plans for individual clients. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Understanding and incorporating cultural beliefs, values, and practices into care plans demonstrates cultural competence. This enhances the nurse’s ability to deliver practical, client-centered care that respects and addresses the client’s cultural background. Clients are more likely to adhere to treatment plans that align with their cultural beliefs and practices. By considering cultural factors, nurses can design care plans that are more acceptable and meaningful to clients, leading to better treatment adherence and improved health outcomes.

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