Chapter 2: Theories and Models related to Multicultural health.

Theories of Health and Illness

• Theories about health and illness address the beliefs and practices about how to maintain health and the causes of illness.

• These ideas, beliefs and attitudes are socially constructed and deeply ingrained in people’s cultural experience, and they can have profound effects on medical care.

• These beliefs influence prevention efforts, care given, how patients cope (including how they understand and response to diagnosis and symptoms), and how they live their lives (lifestyle and etc).

• Illness causation theories include diet-based, rewards and punishments, taboos, exposure to germs, hot-cold balance, yin-yang balance and more.

• Treatments can include witchcraft to more biomedical western techniques.

Personalistic

• Personalistic systems emphasize illness caused by intentional intervention of a agent who may be a supernatural being or a human being with powers.

• Behaviors are often linked to the illness and is argued by a disturbed natural equilibrium. Without equilibrium, illness occurs.

• Illness can also be INFLICTED on others as a punishment or malicious actor. An dead person can retaliate as not doing certain traditions or an witch can curse someone.

• Latin American and Asian cultures often have personalistic systems.

Naturalistic Theories

• Naturalistic theories of disease view health as a state of harmony between person and their environment; when balance is upset, illness results.

Humoral pathology

• Humoral pathology was developed and become basis of both ancient Greek and Roman medicine. Important also in Latin America and Asia.

• Humoral system is an ancient belief based on the idea that our bodies have four important fluids or humors:

  • Blood → Associated with liver, spring, air and hot and wet weather.

    • Linked to Sanguine (cheerful, confident and optimistic).

  • Phlegm → Associated with brains and lungs, winter, water and cold and wet.

    • Linked to Phlegmatic (calm, sluggish and apathetic).

  • Black Bile → Associated with Spleen, Fall, Earth, and cold and dry weather. 

    • Linked to Melancholic (bitter, envious, and melancholic) temperament.

  • Yellow Bile → Associated with Gallbladder, Summer, Fire and Hot and dry complexion.

    • Linked to Choleric (easily angered) temperament.

• Treated with discovering complexion imbalances and rectifying them with cold remedies and vice versa.

Ayurvedic

• Ayurvedic medicine is an ancient naturalistic approach to health used in India and other parts of the world.

  • Ayurvedic → life pain and knowledge.

• In the Ayurvedic system, illness is caused by vital energies being imbalanced. These vital energies express living and non-living matter (prana).

• Three primary principles are present that govern every human body.

  • Doshas: Derived from the five elements: earth, air, water, fire, and space. Dosha regulate all actions of the body.

  • Prakriti: Genetically-based concept which categorizes the population into several subgroups based on phenotypic traits, emphasizing how individual constitutions influence health and wellness across different cultures.

  • Chakras: Energy centers of the body associated with organs of the body, with primal forces below.

    • Prana: Breath of life; vital energy that sustains all living beings, and plays a crucial role in the balance of body and mind, reflecting the interconnectedness of physical health and spiritual wellbeing.

    • Agni: Spirit of light and fire; represents metabolic processes within the body, essential for transformation and digestion, and symbolizes the importance of balance in health across various cultural practices.

    • Soma: Manifestation of harmony; embodies the relationship between the physical body and the mind, emphasizing holistic approaches to wellness that integrate traditional and modern healing practices.

  • This system links all three concepts together. When we breath we take in life-force, and move the energy through the body via respiratory and circulatory system.

  • Chakra acts as the wheels of life; these wheels pull in vital life force energy. There are seven major chakras and many minor chakra centers. They are associated with a major gland or organ.

    • Plays a integral in emotional state.

Vitalistic Medicine

• Vitalistic system defined as the concept that bodily functions due to vital principle or “life force” which is distinct from forces explainable by laws of chemistry and physics.

• Imbalances in vital force (which lead to disease) is related to polar opposites: yin (female, dark, cold) and yang (male, light, hot) in which one combines interaction of body fluids and energy channels / medians.

• In China Vital force is referred to as “chi”, while in Ayurveda system it is “prana”.

Biomedical Theory / Allopathic Medicine

• Biomedical medicine (aka allopathic medicine) is based on the mechanical view of the body: When the machine breaks illness occurs.

• Spirituality and biomedical theory keep a separate role as it is viewed as non-scientific approach.

• Allopathic medicine is most known to Westerns and follows a biological approach to healing; ex: Patient has high blood pressure → Allopathic system gives them medicine.

• Fundamental core value is that diagnosis and treatment should be based on scientific data as the understanding of disease processes relies heavily on empirical evidence and research, which guides medical professionals in selecting appropriate interventions.

• Germ theory and antibiotic research heavily promoted biomedical theory is now a cornerstone of modern medical practice, influencing how diseases are understood and treated across various cultural contexts.

• Theoretical construct about cause of illness is bio-medicine, and a variety of trained healthcare professionals work in this paradigm.

Holistic Medicine

• Holistic Approach (alternative medicine or complementary medicine) has a long history and has been rapidly growing in popularity world-wide.

• Holistic Medicine → approach to maintaining and resuming health that takes body, mind, and spiritual being into consideration.

  • Variety of therapies such as massage, prayer, herbal remedies and more.

• Providers include professionals such as homeopaths, naturopaths, acupuncturists, and hypnotherapists.

Cultural Competence

• Cultural competence occurs when an individual or organization has ability to function effectively within cultural context of beliefs, behaviors, and needs of the patients of community it servers.

• “A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.”

• Continuum of cultural competence

  • Cultural destruction → Cultural incapacity → Cultural blindness → cultural pre competence → cultural competence → cultural proficiency.

• To be culturally competent: Know your own worldviews, avoid stereotyping and be sensitive to differences and understanding them.

Cultural Competence Models

1. Cultural Awareness → Process of conducting an self-examination of your own biases towards other cultures and exploring your own cultural background and differences.

2. Cultural knowledge → Process in which a person seeks and obtain objective information on a culture’s worldviews and traditions, as well as garner information about predisposed risks of that ethnic group/culture.

3. Cultural skill → The ability to conduct a cultural assessment to collect relevant cultural data regaining the client.

4. Cultural encounter → Process that encourages the health care professional to directly engage in cultural interactions with clients from culturally diverse backgrounds to influence their own beliefs.

5. Cultural desire → Motivation of health care professional to “want to” rather than “have to” engage in process of becoming culturally aware.

The Purnell Model for Cultural Competence

• Begun in 1991 when Purnell discovered the need for students and staff to have a frame-work for learning about each other cultures.

• Outlying rim represents Global Society; Second rim represents Community; Third rim represents Family; Innermost rim represents the Individual.

  • Global Society / Outer Rim: World communications and politics; conflicts and warfare; just natural stuff.

  • Community / Second Rim: Cultural norms and values within a specific local area.

  • Family / Third Rim: Two or more people emotionally involved with each other.

  • Person / Fourth Rim: Behavior and emotional well-being, including individual health practices and personal beliefs that influence health outcomes.

Sunrise Model

• Developed by Madeleine Leininger, it represents a cultural care theory structure. It mixes/describes anthropological and nursing beliefs and principals.

• Cultural care worldview model begins with the flow from Cultural & social structure dimensions into Environmental context & ethnohistorical then into Individuals, families, groups, communities & institutions.

  • Cultural & Social → Tech, Religious/Philosophical, Kinship, cultural values, Political/legal, economic and education factors.

  • Environmental context includes the physical and social environments that shape health behaviors and access to healthcare.

• From Individuals, families, groups, communities and institutions, we integrate and apply generic/folk systems, nursing care, and professional systems to give culturally congruent nursing care.

• Cultural Care Prevention/Maintenance → Assistive, supporting, facilitative actions that enable individuals and communities to maintain and enhance their health through culturally sensitive practices.

• Cultural Care Accommodation or negotiation → Assitive actions that modify or adapt care practices to meet the cultural needs or preferences of the patient, ensuring that their values and beliefs are respected in the healthcare setting.

• Cultural care patterning or restructuring → Actions that involve reconfiguring or redesigning care practices to align with the cultural patterns of individuals and communities, ensuring that health interventions are relevant and effective.

Worldview

• Worldview → A set of cultural assumptions and beliefs that express how people interpret and explain their life experiences.

• Worldview includes relationships with nature, social structures, ethical reasoning and cosmology.

• Culture is built upon worldviews that shape the values, norms, and practices of a community, influencing how health is perceived and approached across different cultures.

• People’s worldviews are built upon cultural and religious backgrounds and has profound health implications.

  • Fatalism → Predetermined fate ideology… death is expected and may not believe medical intervention as a means to alter their destiny.

Temporal Relationships

• Temporal relationships → People’s worldviews in reference to time.

• Vary upon culture to culture; In the West, time is often viewed linearly, emphasizing progress and future planning. Eastern cultures see things as cyclical.

• Orientated timing of cultures/people:

  • Past Orientation: These people focus on their historical experiences and traditions, often valuing lessons learned from previous generations over future aspirations.

    • Seen in Asian cultures.

  • Present Orientation: Indigenous and African cultures exhibit this. Present-orientated people are more unwillingly to engage in long-term planning.

  • Future Orientation: This perspective is characterized by an emphasis on future goals and aspirations, where individuals prioritize planning ahead and setting long-term objectives, often found in Western cultures.

• Proxemics or space: This concept refers to the use of personal space in communication, which varies significantly across cultures.

  • Certain cultures may exhibit far or close proximity in their interactions, which can influence relational dynamics and communication effectiveness in multicultural health contexts.

  • Other forms of communication like staring can be respected or be aggressive.

Social Relationships

• Locus of control → the degree to which individuals believe they can influence the events that affect them, which can be a significant factor in understanding health behaviors and outcomes.

  • Internal Locus of Control → Free will belief; individuals feel empowered to take actions that directly impact their health and well-being.

  • External Locus of Control → Fate belief; individuals feel that are subject to outside forces direct their lives.

Individualism

• Individualism → the focus is on the self rather than the group.

• Autonomy is prioritized and everyone has a responsibility for themselves.

• Conflict, uniqueness and personal expression are highly valued.

• Direct action, behavior regulation and achievements are also valued.

Collectivism

• Collectivism → People are socialized to see themselves as part of larger group such as a family or a community.

  • An individual’s identity is determined by their relationship within a group. Decisions are made for the GROUP and not the person.

  • Healthcare / illness is an FAMILY matter not an individual matter.

Worldview and Health Decisions

• Euthanasia → “Good Death” in Greek; It is the act of self mercy killing or the choice to end one's life in order to alleviate suffering, often within the context of terminal illness.

  • Compassion or murder or suicide?

• Karma (& rebirth) → Karma is the philosophical concept that actions have consequences that may affect one's current life and future lives, thereby influencing health decisions and perspectives on illness within various cultures.

  • Ahisma → Ahimsa is a principle of nonviolence and respect for all living beings, deeply rooted in Hinduism and Buddhism, which may guide individuals in making health decisions that prioritize compassion and ethical considerations.

  • Reincarnation → Reincarnation is the belief that the soul is reborn into a new body after death, a concept prevalent in several religions such as Hinduism and Buddhism, influencing attitudes towards health, illness, and the value of life.

• Advance directives → legal documents that enable people to convey their preferences for medical treatment in situations where they may be unable to communicate their wishes, reflecting their values and beliefs about healthcare.

  • Living Will → Set of instructions that document a person’s wishes about medical care to sustain life.

  • Durable power of attorney → Document that names your healthcare representative for yourself when you are unable to speak.

Worldview and Response to Illness

• Biomedical worldview → a perspective that focuses primarily on biological factors and excludes psychological, environmental, and social elements from considerations of health and illness.

• Mind-body integration → the concept that emphasizes the interconnectedness of mental and physical health, acknowledging how emotional states can influence physiological well-being.

• Certain cultures cope with expression of emotions, some avoid talking about it. Asian cultures suppress their feelings and emotions while African Americans express their concerns.

• Some cultures shun chronic illness and disability as punishment.

  • Stoic → a philosophical approach that encourages the endurance of pain or hardship without the display of feelings and without complaint, often found in various cultures where emotional restraint is valued.

  • Emotive → an approach that emphasizes the expression and acknowledgment of feelings as an essential part of coping and healing, commonly observed in cultures that prioritize open communication about emotional well-being.

  • European American culture had boys be reprimanded for crying or expressing vulnerability, reinforcing a stoic ideal that equates masculinity with emotional restraint. Same with Asia cultures.

    • In contrast, many Hispanic and Latino cultures often promote emotive expressions, suggesting that openly sharing emotions can foster stronger community bonds and support systems.