Sociocultural context of health and health care delivery

SOCIOCULTURAL CONTEXT OF HEALTH AND

HEALTH CARE DELIVERY

By C.Settley

Learning Outcomes

1. Student should be able to understand the rich diversity of cultures in a multicultural society such as South Africa and throughout the world.

2. Student should be able to apply the sociocultural knowledge in the different health care settings.

South African society: brief historical overview

Social change, social dynamics and transformation in SA

1 of the most noticeable changes made by the new SA Government was the establishment of Chapter 9 institutions. They are:

The Auditor – General

The Commission for Gender Equality

The Commission for the Promotion and Protection of the Rights of Cultural, Religious and Linguistic Communities

The Electoral Commission

The Financial and Fiscal Commission

The Interdependent Communications Authority of South Africa

The Pan South African Language Board

The Public Protector

The South African Human Rights Commission

The Youth Commission

Social change, social dynamics and transformation in SA

The aim was to develop a more equitable healthcare system,

Despite having a well-established economy and being classified as a middle income country, SA has one of the highest income inequalities in the world.

It is a well known fact that poor health is associated with poor socio-economic position.

There is a huge variation in health status and health service access across the country and even between communities who live next to each other.

Population & Demography

Population: a group of people who live in a specific geographical area.

Demography: is a subfield of sociology that examines population size (the absolute numbers of people within a society), and also the structure or composition and the distribution of populations.

Fertility, mortality & migration determines the population size of a specific country or whether the numbers have increased or diminished

- natural increase: most important component of population change

- birth rate: the number of live births for every 1000 members of a population in a given year

- death rate: the number of deaths in a year for every 1000 members of a population

- immigrants: the number of people who moved into a country

- emigrants: those who left (the difference between the two is the immigration rate).

Population change = (births-deaths) + (immigrants-emigrants)

Demographic information

Describes a population Reveals inequalities and problems in society Infant mortality rate Life expectancy Factors that shape death rates and life

expectancy are healthcare practice and socio economic position

Human development index (HDI) Is a measurement of long-term human progress in 3 basic dimensions of

human development:

1- a long and healthy life

2- access to knowledge

3- a decent standard of living

The HDI score varies from 1(a perfect score)to 0.

Therefore nations living in good conditions will have a score of 1, and where poorer it will be closer to 0.

The HDI lists 169 countries, categorised in 4 sections:

1- very high human development

2- high human development

3- medium human development

4- low human development

See table 2.1

Population and health Population size and growth and its consequences such

as: urbanization, air pollution and overexploitation of environmental resources pose challenges to the social structures that must be created in society to support and organize the population. (Urbanisation means an increase in the proportion of people living in urban areas compared to rural areas. An urban area is a built-up area such as a town or city. A rural area is an area of countryside).

There is a relationship between the number of people in a country and both their health and quality of the healthcare services provided

Not only is the number of people important, the other demographic features of a society also influence health and healthcare

Culture In sociological sense: Includes the total way of life of a group

of people. This way of life is shared, it comprises some learning/teaching, and is based on symbols.

The social grouping sharing a way of life can be a nation, a region or even an occupation.

Within a group in which most members share what we call the dominant culture- these being subcultures

We are all born cultureless- and have to be taught our culture by various individuals, such as our parents

This process is called socialisation

All new parents are actively involved in socialisation when they teach their children to talk, walk and behave

Culture Culture must not be confused with society. They are not the

same thing

Culture is an element of society- the most extensive element

It can be described as society’s ‘personality’ and comprises the following aspects of social life: behaviors, norms, values, beliefs and the physical artefacts, i.e. all the objects made by the members of a society.

The latter, tangible products of human society are what we call material culture e.g. cars, televisions, beds, homes, churches, technology, paintings, etc.

Intangible creations or objects of human society (non-material culture), includes knowledge, beliefs, norms, values, symbols and language.

Components of Culture

1) Knowledge and beliefs- the Cognitive Component

2) Value and Norms- the Normative Component

3) Symbols and Language- the Symbolic Component

Components of CultureThe Cognitive Component: Knowledge & Beliefs

Knowledge forms the foundation for social behaviour

Knowledge is a collection of relatively objective ideas and facts about our physical and social worlds

Beliefs are ideas that are relatively subjective, unreliable or not linked to evidence

We acquire our beliefs through the process of socialisation; they help shape how we perceive our surroundings and our personality development

Components of CultureThe Normative Component: Values, Norms and sanctions

Comprises elements necessary for the maintenance of integration and conformity in society

This component specifies the correct ways of thinking and behaving and of defining morality

Values are defined as socially shared ideas or standards about what is good, desirable or important

They represent general criteria for evaluating our own views and actions or those of others

The social rules that determine how we ought to behave arise from the values

Thus, laws against murder clearly reflect the value we place on human life.

Components of CultureThe Normative Component: Value, Norms and Sanctions (continued)

Sometimes the values within a society conflict

Most human populations, no matter how diverse, share at least some consensus over values such as what is good or bad, appropriate or inappropriate

The consensus is often not perfect, but without some degree of value consensus, societies will be characterized by conflict and tension. Some general values respected by most globally:

Achievement

Activism

Freedom

Progress

Materialism

Efficiency


Norms are the social rules that specify how people should behave

They serve to guide people’s actions in particular situations and within particular roles, groups, organizations and institutions

Eg tell us how to act in elevators, how to address our parents, teachers and how to greet people

Norms can be prescriptive: defining how one ought to behave in given situations OR

Norms can be proscriptive: defining how one ought not to behave.

Norms serve to guide people’s actions (E.g. hand shaking)

Although the form of a hand shake may differ, the response is the same

Norms make interactions predictable

Norms vary in their degree of importance


Folkways are norms that designate a society’s customs for routine and casual interaction and for distinguishing between right and rude.

They are weak norms that specify expectations about proper behaviour

Violating folkways are not considered serious- may be considered impolite and inappropriate

Will not be arrested for it


Mores (pronounced mo-rays)

Refers to strongly held norms that specify normal behavior and constitute demands, not just expectations

Violation of mores involves a strong negative societal reaction

In many societies, some such norms are considered so important that they are called laws

Some categories of people are put in charge of enforcing such laws and specific punishment is imposed on violators

E.g. committing murder- brought to justice by laws and police, severely punished by a judge


Norms guide behavior

How does society force people to obey the norms of a society?

Via Sanctions:

Can be positive (reward) or negative (punishment)

Can be informal (enacted by friends/family) or formal (enacted by formal institution)

The process by which are used to make people conform is called social control

Socialization causes us to internalize cultural norms and impose constraints on our own behavior

When we disregard an internalized norm, it results in our experiencing guilt and shame

Components of CultureThe Symbolic Component: Symbols and Language

A symbol is used to represent or stand for something. Can take various forms

Key example: Language. It differs across different cultures. It does more than enable us to communicate. It can determine or influence how we think and it can be a source of thought.

It can be a physical object such as a wedding ring standing for a promise between two people

It can also be a characteristic of an object, like the Aids- awareness ribbon

Or a gesture: a fist raised in the air

Activity on page 38!!!!

Analyzing Culture

Due to different theories on the social phenomena, culture is also being seen through different lenses

The theories help us to understand Assists us to view our own culture more

objectively/scientifically Malinowski (anthropologist in branch of functionalism):

he maintains that cultural phenomena do not develop because people accidently or unintentionally invent them or simply borrow them from others. Rather, they are determined by basic needs and the possibilities of satisfying these. 3 kinds of needs:

Analyzing CultureStructural Functionalism Biological needs: food, shelter, reproduction Instrumental needs: social control, education, political

organization, economics Integrative/symbolic needs: knowledge, religion, art Stable orderly system with interrelated parts that serve

functions Core values Cultural universals: values found in every culture in the

world

Analyzing CultureStructural Functionalism(continued)

Culture functions: to meet the needs of individuals rather than society as a whole

When the needs of individuals- who comprise society are met, the needs of society are also met

The way in which individuals’ needs are served, is that society provides institutions, customary practices and beliefs

Eg for the need of production- the institution of marriage and family has been provided

Eg to ensure order and stability- society has developed laws

Eg as means of intellectual, emotional and pragmatic control of destiny and chance- society has developed magic and religion

Analyzing CultureStructural Functionalism(continued)

Dysfunctions of culture: if a society has multiple subcultures, it leads to a lack of consensus about core values

It is resolved by educating the members of a society on cultural diversity

This is the responsibility of institutions of education and the family

Strengths of the functionalist approach: that it can help explain puzzling cultural practices like magic rituals that are ridiculed as being both ignorant and irrational

Malinowski’s viewpoint: rituals are highly sensible and effective

(study on Trobraid Islanders)

Superstitiousness ….Scientific grounds

Major weakness of the functionalist approach: it overemphasises harmony and cooperation, resulting in cultural conflict being underestimated and the extend of cultural change in society being downplayed

Analyzing CultureThe Conflict perspective Based on the assumption that social life is about competition and struggle

With members of powerful groups seeking to control scarce resources

Acc to this perspective of culture, values and norms help sustain the privileged position of the powerful

Culture thus reflects the interest of the rich and powerful in this perspective

Certain values- such as competitiveness- benefit the powerful like stimulating worker productivity, enabling obtaining larger profits

By believing in competition, the powerless will feel that the powerful are entitled to their riches and privileges

This illustrates the way in which certain ideas are cultural creations are used

A system of ideas that guides the way in which people think and act accordingly, is called ideology (capitalism, communism and apartheid)

A strength of the conflict theory is that it stresses how cultural values and norms may perpetuate social inequalities.

A limitation of the perspective is that it underestimates the extent of integration in society in that it focuses on societal discord and the divisiveness of culture

Analyzing CultureSymbolic Interaction

Describes people as active in that they create, maintain and modify culture during their numerous daily symbolic interactions

This means that one’s culture does not determine one’s behavior; neither are the norms and values static-but dynamic in that we are constantly interpreting and re- them, thus changing them

The strength of the Symbolic Interaction is that it reminds us that despite its structural elements, society consists of people interacting with one another. Alters us to the fact that people who maintain and change culture by means of interaction with others

The aspect is also a point of criticism, because it fails to take into account the larger, macro-level social structures, such as social class- aspects considered by the structural-functionalist and conflict perspective

Concepts related to CultureCultural Universals & Cultural Diversity

Cultural Universals – the commonalities that cultures share. Language, marriages, health systems, religion, economic system, recreation

Cultural Diversity- the differences that cultures share. different ways of looking at things, different ways of dressing, different ways of expressing personality/goodness

Cultural Relativity & Ethnocentrism

Culture: language, values, beliefs, rules, behaviors, artefacts and other characteristics common to or shared by the members of a particular group.

Race: biological term(genetic- hair, etc)

ethnicity: non-biological characteristics that provide members of a group with a sense of common identity such as ancestry, culture, history etc

Ethnocentrism: the practice of judging another culture by the standards of one’s own culture and regarding one’s own as superior.

Cultural relativism: the practice of judging another culture by its own standards

Subcultures

Groups within a group

They develop their own unique symbols, norms and values.

Can be formed around many aspects such as age, occupation, ethnic group and sport interests

A person can belong to various subcultures simultaneously

Have unique traits

Do not oppose the dominate culture of a society (opposite of counterculture)

Members of counterculture are likely to question the morality of the majority group and engage in some or other form of protest activities

Activity on subculture!Page 44

Cultural Change

Culture is not static, but changes over time

Something considered unacceptable behavior years ago, may be acceptable now

Change is inevitable, people resist change often

Cultural Change

3 main sources of influence responsible for change, but also for resistance to change:

1) Forces within a society: Invention: a key process of cultural change e.g. cellphones,

electronic money Culture loss 2) Habit 3) Contact between societies: When societies come into contact with one another; it leads to

change Diffusion- the movement of cultural aspects from one culture

to another Acculturation- when traits replace traditional cultural patterns

Cultural contact & culture and health

Cultural Contact : occurs between cultural groups in the society

Culture and health:

- influences of culture on health and rehabilitation is important

- a good healthcare provider( able to recognize, learn about cultures of his/her patients. Be aware of the fact that people define themselves culturally)

- what should health providers do with such knowledge?

Cultural competence

Cultural competence concepts Cultural Awareness: involves the understanding of the

importance of cultural differences. Also entails being conscious of one’s personal reactions to people who are different

Cultural Sensitivity: which goes beyond awareness and comprises an appropriate attitude towards cultural differences

Cultural Competence: involves having the capabilities of dealing with differences effectively

Cultural Responsiveness: which falls between sensitivity and competence, is the ability to respond to a patient's care needs in a way that matches the patient’s expectations

Cultural Competence is used to encompass all the aspects contained in aspects mentioned

Cultural competence is an important set of skills for all

Vital skill for health care workers Have to be culturally competent to understand

priorities, communicate empathy and acceptance, be responsive to individual and community needs, and work effectively with cultural groups to develop culturally relevant interventions

Must recognize and show tolerance towards pluralistic approach to health

Race & Ethnicity:The social significance of race

Race: A category composed of men and women who share biologically transmitted traits that members of a society deem socially significant.

Sociologists regard race as a social construction in the sense that biological traits are endowed with social meaning.

A race is a group of people who have been singled out on the basis of real or alleged physical characteristics.

There are no biologically pure races. Race is a significant concept only because most

people consider it to be.

Race & Ethnicity:The social significance of race From the definitions it is clear that:

1) Race implies some or other categorisation based on a physical trait; and

2) people decide what that specific trait is and its importance.

It is thus a socially constructed concept.

In most cases it is skin colour; in others, it may be height, facial features, hair texture or eye colour.

i.o.w. theses are social decisions- determined by people and not by biology.

Unfortunately history teaches us that racial classification has largely been made in order to give one group an advantage over another and that is used to rank people in a system of classification that regards one type of group as superior.

Race & Ethnicity:The social significance of race Ethnicity: A shared cultural heritage. This concept refers to people who have

common cultural characteristics and an ethnic identity.

Races may also be analyzed as ethnic categories in many cases.

Because they share a common culture and a common identity, members of an ethnic group are drawn toward one another and feel a sense of "oneness," unity, and shared fate.

Video:Demographic structure of race and ethnicity

Problems in race relations, page 50

1) Prejudice and discrimination 2) Racism of nurses towards patients 3) Strategies for working with diverse clients 4) Racism between colleagues 5) Patients acting in a racist manner towards

nurses

Problems in race relations1) Prejudice and discrimination

Prejudice has to do with the inflexible and irrational attitudes and opinions held by members of one group about another.

Prejudice: For example, a person may hold prejudiced views towards a certain race or gender etc. (e.g. sexist).

Being prejudiced usually means having preconceived beliefs about groups of people or cultural practices.


Discrimination refers to negative behaviors directed against another group, especially on the basis of sex/race/social class, etc.

Eg. World War II - In Germany and German-controlled lands, Jewish people had to wear yellow stars to identify themselves as Jews. Later, the Jews were placed in concentration camps by the Nazis.


Racial discrimination in South Africa. Apartheid (literally "separateness") was a system of racial segregation that was enforced in South Africa from 1948 to 1994. Non-white people where prevented from voting and lived in separate communities.

Age discrimination is discrimination against a person or group on the grounds of age.

Gender Discrimination: In Western societies while women are often discriminated against in the workplace, men are often discriminated against in the home and family environments. For instance after a divorce women receive primary custody of the children far more often than men. Women on average earn less pay than men for doing the same job


Prejudice take the form of a stereotype when an exaggerated description is applied to every person in some category.

Statements such as ‘all whites are….’ or ‘all coloured people……’ are typical of stereotypical thinking.

Prejudice contain an element of judgement. Stereotyping is an oversimplified image or idea held

by a person or group of another. Discrimination involves an act of unfair or unequal

treatment that cannot be hidden.

Problems in race relations2) Racism of nurses towards patients

Racism has been reported in health care in the way that nurses treat their patients.

With regard to patients, race can influence health status when people. This is as a result of inequalities experienced in daily life.

Fear of discrimination may even prevent people from seeking help.


Although the nursing profession is reluctant to admit it, studies have shown that nurses are guilty of racist treatment towards their patients.

It manifests in small ways such as in harmless jokes and gestures (e.g. raised eyebrows).

Kirkham research: established that nurses who manifest resistant care usually relied on stereotypical things when approaching clients and resented the fact that they had to nurse someone from a different race. They believed it caused additional work.


The nurse who offered generalised care, was conscious of the patient’s cultural or racial diversity, but regarded it as a non-issue. Their view was that basic human respect would cover all patients.

Impassioned nurses regarded caring for diverse patients as a positive challenge that they enjoyed. The desire was to learn from their patients. They were eager to learn and accommodate and understand them.


Not all nurses are impassioned nurses. Resistance nursing is unacceptable. Leads to misconduct.

Resistant care Generalist care Impassioned care

Problems in race relations3) Strategies for working with diverse clients

On an individual level: Connect with others. Deal with the family of the patient. Try to accommodate cultural practices as far

as humanly possible. Balance your own expectations.

Problems in race relations3) Strategies for working with diverse clients

Interpersonal and institutional level: The healthcare setting. The role of colleagues. The commitment of the institution. Education.

Problems in race relations4) Racism between colleagues

Step 1 Document any and all incidents of racism that happen to you in the

workplace or that you witness. Write down names, dates, times and detailed descriptions of what occurred. If you have physical evidence, hold on to it in a secure place, such as a locked fireproof box.

Step 2 Report each racist incident that occurs to your supervisor, union steward,

or both. Talk about the incidents with anyone you trust, particularly if they have gone through something similar -- this can help you through an otherwise difficult emotional process.

Step 3 File formal complaints through whatever system is available in your

workplace or union. If necessary, hire a lawyer who specializes in discrimination cases and file a lawsuit. Present the lawyer with all your documentation and evidence of the racist incidents that have occurred.

Problems in race relations5) Patients acting in a racist manner towards nurses

Nurses are often confronted with this. Such attitudes can affect nurses’ morale and

self-confidence. It may even offend them to a point where

they do not want to care for the patient. Read case on page 54.


Actions like this leave nurses feeling hurt and confused about how to act.

They may even lose their temper. In some cases the nurse would try to avoid the patient

or else someone else to take over. Another response is to isolate racist patients as to not

upset the other patients and provide them with a carer of the same ethnic background.

This approach has dangers as it creates a precedent in that patients can demand to be treated by someone of the same background.


Capozzi & Rhodes provide the following advice: - seek help, advice and support. - set limits with patients- remind them that

such comments are inappropriate in the health care setting.

- obtain backup from management. Team approach.

- deal with the problems of racist and abusive behaviour at institutional level. Guidelines.

Race & Health

Erosive health: when race impacts on health when those discriminated against suffer on multiple fronts.

‘ A state of consistent and deliberate decline in the elements that produce well-being. These elements are spiritual, emotional, physical and environmental.

The result of erosive health is due to lack of real tangible involvement and economic political power’.

Reference list

Pretorius, E. Matebesi, Z and Ackermann, L. (2013). Juta’s Sociology for healthcare professionals. Lansdowne, Cape Town, South Africa. Page 9- 24.

http://smallbusiness.chron.com/deal-racism-work-18745.html. Retrieved on 12 July 2015.

http://smallbusiness.chron.com/deal-racism-work-18745.html

http://smallbusiness.chron.com/deal-racism-work-18745.html

Healthcare

Sociocultural context of health and health care delivery