Copyright 2007 Michael Winkelman

Societal Overview: Migrants and Immigration Attitudes Biocultural Ecology: Sociogenic Disease High Risk Behaviors: Lifestyle Nutrition: The Malnutrition Epidemic Workforce Issues Family Roles and Organization Life Cycle Concerns (Pregnancy, Childrearing and Death) Spirituality and World view American Lay Healing Practices American Biomedical Cultural system characteristics

Unconventional Medicine Communication and Medical Relations

Rise of Biomedicine Access Problems in Health Care Delivery

Health care Providers culture Social Interaction Rules

Heritage = history and myth

European American- dominant culture Many national sources immigration Assimilation and Anti-immigration ethos Persistence of white ethnics Education as the socialization medium

Many American health traditions

History of eclecticism Work as Source of Health Care Health Care as an economic burden Anti-Socialized Medicine or Capitalistic medicine?

The Roles of Work in Health and vice versa

Access Issues:

Epidemiology Major causes of death/mortality

Heart 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 related Cancer: environment and lifestyle Pulmonary disease as environmental, lifestyle, drugs Injury as cars, drugs and lifestyle Iatrogenic (hospital acquired) and nosocomial (healer induced) mortality HIV exemplifies sociogenic dynamics

Sociogeniclifestyle and culture

Food and dietary factors, malnutrition Need for low fat/cholesterol and high fiber diets

Obesity, physical activity and life-style Culture and Drug Interactions

Contributory factor to pulmonary disease, accidents, HIV

Sexual behaviors Environmental conditions Medicine



Diet: high-fat and cholesterol, low in fibers Industry inspired food standards in food pyramid Industrial production of non-nutritious foods Reliance on international food sources Additives and xenobiotics Access to foods, nutritional adequacy

Environmental Working Group dirty dozen Fast food nation and advertising images Knowledge of needed foods/nutritionCommercial food production patterns Food rituals and symbolic meanings



Role of health industry in economy Capitalist medicine Occupational hazards and environmental effects OSHA Occ. Safety & Health Ad. Job-related health benefits Culture and Work Issues in medicine

(e.g., nurse roles)

Intercultural work-place relations

Variation in dynamics of family structure affecting health Historical patterns of evangelical, moderate, genteel Nuclear ideal Single-head of household reality, blended families Single parent risks- abuse epidemic Kinship: fictitious; blended and transgendered families "Empty nest syndrome" Gendered Risks Egalitarian gender ideals and realities Family priorities and values Value placed on the protection of children, autonomy New legal approaches and precedents to punishment and discipline Decision-making processesIndividual rights

Cultural behaviors affecting pregnancy

Work, autonomy, feminist revolution Womens 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 Avoidance of smoking, drug use; impt of vitamins & diet

Strong cultural norms for pregnant women

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

Connection with powerful forces both within and outside of herself Power rooted in procreation Feminine qualities and activities given greater respect and value



Graying of America Americans difficulty in dealing with topic of death

Divergent Cultural views of Death

Avoidance and rarity of occurrence for the young (good life expectancy) Medical views of death- failure, end Peoples views of death as religious transition Family obligations to be with the dying person Expectations that HCP will also accommodate family Euthanasia/DNR still often problematic

Death rituals and grief management

General openness the hospice care and end of life advanced directives

Support Strategies

Expectation of HCP support Supporting familys grieving Assist 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 Ethnics Herbal Nutritional Spiritual and Vitalistic

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

Physical places of healing/power of saints

System of meaning and coherence countering doubts from doctors Way of escaping the total domination by biomedicine Countering isolation and despair Forming system of sacred bonds of generosity, love Connecting the sick person to family and friends. Gifts of relics provides support even when not physically present,

Relics as restructuring the dominance of the biomedical system

Saints facilitate choices, doctor, treatmentsor no treatment Saints provide solace and support when the context doesnt Importance of healing and curing distinction

Healing as moving into wholeness Physical, emotional and mental embodiment of peace of Christ Role of forgiveness and reconciliation in healing Social aspects of healing services

The focus on nature and the female goddesses Shamanic roots

Chanting, drumming, dancing, trace, energy healing, massage, herbs Communal ritual healing groups Familiarity with spirits Extraction of harmful intrusions and energies

Health as

Balance and wholeness, connection with spiritual forces Making connections and relationships, with community, nature, cosmos Obtaining energy from the group

Development of modern medicine

Roots in war and Industrial revolution Effects of Rural-urban transformation

public heath and epidemic diseases

The rise of antibiotics

Empowering surgical approaches Expansion of pharmaceutical care

The dominance of capitalist medicine

Primacy of profit motive Impact of multinational corporations

Control of government of public and private sectors of care Health 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 workers comp, abortions, addictions, euthanasia, insanity defense, access to CAM



Return of infectious diseases Persistence of chronic disease Sociogenic disease Misfocus of attention secondary, tertiary versus primary/prevention American lack of cultural awareness Considering cultural features to be personal Lack of cultural care behaviors



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

Kinds of specialist to see for problems

Patient understanding of medical processes Prejudice in services Control by HMOs, Pharmaceutical and Insurance Companies

Decisions regarding nature and quality of care Drive to alternatives

Dissatisfaction with biomedical care culture

Shifting focus of health paradigm

Health promotion, disease preventive and holistic healing Increasing 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 massage spiritual healing diets megavitamin therapy energy healing hypnosis acupuncture

chiropractic imagery commercial weight loss herbal medicine self-help groups biofeedback homeopathy folk remedies

Prayer and exercise included in the original study The 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, depression

1991 study reported 34% of respondents used an unconventional therapy within last year 1997 study reported unconventional use rates ranging from 32% to 54% Used in conjunction with biomedicine Association with more educated segments

Need to ask patients about care practices

Problem with dont ask, dont tell Egalitarian Autonomy Decision making

Need to accept American cultural preferences

Should encourage pain medication where facilitates healing process



Beliefs: Ideology of Materialism, Germs Technology: extreme reliance, lab results Independence and personal responsibility Interaction and Communication styles Hierarchies 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 flattening

Greater sensitivity to leakage

Informality in relations

Importance of greeting style and name formats in respect

Emphasis on personal sharing and disclosure

Need for relationships to enhance patient disclosure

Touch/contact; taboo on touch

sexual harassment concerns versus personalism

Eye contact-cultural directness and honesty

Need for cultural accommodation for politeness

Time orientation timeliness and double standards

Punctuality and polychronic time

Were the greatest or are we?

Need to understand source of limitations, problems Sociogenic Disease Killing ourselves Family and Health Dynamics- changing populations Religious Healing as persistent cultural phenomena Unconventional medicine as cultural response Need for Biomedical Adaptations