- Email: [email protected]
Cultural Concepts of Women’s Health and Health-Promoting Behaviors
CLINICAL ISSUES
Cultural Concepts of Women’sHealth and Health-PromotingBehaviors ~~
Rachel E. Spector, RN, PhD, CTN
Cultural diversity is the reality of the 199Os, and the United States is becoming the most ethnically diverse society in the world. The needs and responses of many different racial and ethnic groups are competing for recognition, and nurses must learn how to meet the health care needs of this multicultural society. This article explores cultural concepts relating to women’s health and health-promoting behaviors in the context of this social change. It explores demographic change, concepts of heritage consistency, traditional health beliefs, and traditional healthpromoting behaviors.
C
ultural diversity is a reality today, and the United States is becoming the most ethnically diverse society in the world. A s we enter the 21st century, nurses are perched on the cutting edge of enormous demographic, social, and cultural change. Many of these changes will play a dramatic role in the delivery of nursing care to a given woman and her family. There is an ongoing social explosion occurring in the United States, caused by the profound forces of demographic change that are catapulting this nation into a universal nation. This change originated during the mid- 1960s with a social explosion that resulted in a surge of group consciousness. First blacks, then Hispanics, Asian-Americans, Native Americans, and white ethnic groups began to assert their cultural group identity. The rejuvenation of ethnic identity eroded the melting pot myth and the belief that an American culture would decrease group awareness. The needs and responses of many different racial and ethnic groups are competing for recognition; we must learn how to meet the needs of this multicultural society and begin to change the way we address the complex issues related to health and nursing care. This article explores cultural concepts that are related to women’s health and health-promoting behaviors
in the context of this social change. I t presents an overview of: 1. demographic change; 2. concepts of heritage consistency; 3 . traditional health beliefs; and 4 . traditional health-promoting behaviors
Demogrtzpbic Cbange It has been said that “demography is destiny” (Hodgkinson, 1986, p. 273). There are two major ways for analyzing the impact o f demographic change on the scope of nursing education and practice. O n e way is to compare the 1980 census with that of 1990. In 1980, the overall population of the United States (226.5 million people) was 79.7% white (nopHispanic); 11.5% black (non-Hispanic); 0.6% Native American; 1.5% Asian/Pacific Islander; and 6.4% Hispanic ( U . S . Bureau of the Census, 1981). In 1990, the population was 75.6% white (nonHispanic), 11.7% black (non-Hispanic), 0.7% Native American, 2.8% Asian/Pacific Islander, and 9% Hispanic ( U . S. Bureau of the Census, 1991). Of note is the decrease in the white population and the increase in Asian/ Pacific Islanders and Hispanics. Another way to view this demographic change is to analyze recent immigration trends. In 1992, 810,635 immigrants arrived in this country. I t was the second largest influx of immigrants in 70 years. The largest numbers of immigrants were from Mexico (91,332), Vietnam (77,728), the Philippines (59,179), the Republics of the former Soviet Union (43,590), and the Dominican Republic (40,840) (“Immigration to US,” December 14, 1993). The Immigration and Naturalization Service is expecting that between 800,000 and 900,000 immigrants will come here each year under the immigration laws that were passed in 1990 (“Immigration to US,” December 14,1993). The United States has an emerging majority population comprised of non-Europeans who are native born or
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immigrated here from all over the world. Thus, it is imperative for health-care providers and nurses t o understand the traditional health beliefs a n d health-promoting behaviors o f the people w h o comprise the majority of these new Americans.
Heritage Consistency There are numerous ways of analyzing the role that culture plays in women’s health-care practices; o n e way is in the context of heritage consistency. Heritage consistency, a theory originally developed in 1980 by Estes and Zitzow t o develop a means o f assessing and counseling Indians (Native American) with alcoholism within a cultural context, encompasses “the degree t o which one’s lifestyle reflects his/her tribal culture” (p.2 ) . T h e theory has been expanded in an attempt to study t o what degree any person’s lifestyle reflects his/her traditional culture, be i t European, Asian, African, o r of Spanish origin. T h e value characteristics, such as spoken language o f preference, food preferences, name, schools attended, neighborhood ties, and social activities, indicate that heritage consistency exists o n a continuum, and an individual can possess value characteristics o f a heritage-consistent (traditional) and a heritage-inconsistent (acculturated) nature. The concept includes a determination of one’s cultural, ethnic, and religious background (Spector, 1991). Heritage consistency encompasses three broad concepts: Culture: the sum total of socially inherited characteristics of a human group that comprise everything that o n e generation can tell, convey, o r hand d o w n to the next (Fejos, 1959) and a “metacommunication system” wherein not only the spoken words have meaning, but everything else as well (Hall, 1988, p . 1 4 ) . Ethiricity the condition of belonging to a particular ethnic group. Included in the characteristics of an ethnic group are migratory status; race, language, and dialect; religious faith o r Faiths; ties that transcend kinship, neighborhood, and community boundaries; shared traditions, values, and symbols; literature, folklore, and music; food preferences; settlement and employment patterns; s p e cial political interests; an internal sense o f distinctiveness; and an external sense of distinctiveness. There are at least 106 different ethnic groups in America and more than 170 Native American tribes o r nations (Thernstorm, 1980). Religioiz: the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe; a system of beliefs, practices, and ethical values (Abramson, 1980). Religion provides the person a frame of reference and a perspective with which t o organize information. Ethnicity and religion are related, and one’s religion often is the determinant of ethnic group. There are three other concepts interwoven with this theory: Sotializatzoir; the process of being raised within a
242 J 0 G .Y ,I’
culture and acquiring the characteristics of the given group. Education is a form of socialization. Acculturatioii: a model of second culture acquisition; the phenomena an individual experiences when s h e lives within or between cultures (LaFromboise, Hardin, 8r Gerton, 1993). Assimilation: t h e process by which an individual develops a n e w cultural identity. Assimilation is becoming in all ways like the members o f t h e dominant culture (LaFromboise et al., 1993). In reality, assimilation is not always possible.
People who have maintained a strong sense of their heritage may hold on to traditional health beliefs.
I t has been observed by this author in several research studies that people w h o have maintained a strong sense of their heritage may hold o n to traditional health beliefs. T h e subsequent health-promotingbehaviors may stem from traditional folk health practices. “Traditional,” o r homeopathic, refers to health beliefs that are derived from ancient beliefs and health-promoting behaviors derived from ancient methods o f maintaining health, preventing changes in health status, and restoring health. “Modern,” or allopathic, health beliefs are those that are derived from the scientific beliefs of the present time and involve t h e use of technology and other forms of current health care. When o n e speaks of beliefs, it is important to differentiate between allopathic health care that e m braces all methods of proven therapy, including modern health care, and homeopathic beliefs, which generally are derived from ethnocultural folk traditions and often are at odds with the allopathic system (Spector, 1991).
cross-Cultu raI HeaIth Beliefs Imagine healthas a three-dimensional phenomenon, that of body (the physical self), mind (the feelings, attitudes, and behavior that o n e has, which often are culturally determined and immersed and intertwined in the conception of health and illness [Jalali, 19881, and spirit (the “who I am-unified and alive, it is expressed through my body, my thinking and so forth” [Stoll, 1989, p. 61). These dimensions must be kept in balance, both within the person and within the environment. Thus, health is the bala n c e of these three dimensions, each dimension being carefully cared for, yet totally related to the other two dimensions. T h e health-promoting behaviors are the actions that are used in each of these dimensions to maintain health, prevent illness, and restore health (Fig. 1).
Volume 24. Number 3
Cultural Concepts in Clinicul Cure
1
i
Heallh
Prevention of
Maintenance
Illness
Proper clolhing Special foods I d l e 1 Iocd combinations
M
Concenlralion
I
N D
Silence Reading Religion
1
Restoration of Health
Traditfonal folk remedles
Herbal Leas
Symbolic clolhing
Massage
Avoid cerlain people
Relaxation
Family aCliVilIeS Religious cusloms
Prayer
Exorcism Teas Prayer Medilalion
‘Superslition’ Medilalion
Traditional beliefs regarding the causation of illness differ vastly from the modern model of epidemiology.
Heallng Evil Eye Exorcism Symbolic objects
Health Beliefs There are numerous traditional health beliefs observed among the different ethnocultural groups that comprise the American population. For example, among women who have maintained traditional belief systems, there tend to be culturally based or folk beliefs that determine the definitions of health and illness. Women who are of an Asian origin (from China, the Philippines, Korea, Japan, or Southeast Asia) may view health as the “balance of yin and yang” (Spector, 1991, p. 173) and illness as the imbalance; those of African, Haitian, or Jamaican origin may view health as “harmony with nature” (Spector, 1991, p. 190) and illness as disharmony with nature; those from Hispanic countries may see health as the “balance of hot and cold” (Spector, 1991, p. 214) and illness as the imbalance; Native Americans may view health as the ability to “live in harmony with nature” (Spector, 1991, p. 237) and illness as living in disharmony with nature; and traditional people of European origin may have a philosophy that sees health as “feeling good and able to d o your duty” (Spector, 1991, p. 267) and illness as feeling bad. The word “may” is used when describing these philosophies and behaviors to prevent any kind of stereotyping. There are individual differences within a given group of people and among groups. However, there also are some discernible commonalties, especially the sense of balance and harmony within the self and
one’s relation to the environment, in the connotation of the terms health and illness. Traditional Epidemiology The traditional or folk methods of health maintenance, illness prevention, and treatment of illness rest in the woman’s ability to understand the cause of a given illness. The traditional beliefs regarding the causation of illness differ vastly from the modern model of epidemiology. To more fully appreciate the richness of the methods used to maintain health and prevent and treat illness, it is important to have an awareness of what may be deemed the causation of illness. “Traditional epidemiology” includes the following.
Traditional agents include hexes, spells, and the evil eye. The evil eye is a concept that manifests itself among numerous cultural, religious, and ethnic populations. The belief in the evil eye is one of the oldest held beliefs; it asserts that there is a power that emanates from the eye or mouth that strikes a victim, usually a child, with an injury, illness, or other misfortune. This belief helps to explain misfortune (Spector, 1991). Traditional hostfactors include such phenomena as soul loss and spirit possession (the ability to provoke the envy, hate, and jealousy of a friend, acquaintance, or neighbor, and the religious and social behavior of the person). Traditional environmentalfactors include air quality (ma1 aire or bad air) and such natural events as a solar eclipse.
Traditional Health-Promoting Behaviors Health-promoting behaviors stem from beliefs about the cause of illness. They most often are pragmatic, inexpensive, and common activities. There is little scientific knowledge of their efficacy because when they are effective, modern medical help is not sought. Traditional Practices of Health Maintenance The health-promoting behaviors that may be used to maintain the health of the person include maintaining balance of the body by wearing proper clothing, e.g., traditional women from Germany may wear shawls to protect themselves from drafts. Another example is eating the proper diet-women from Southeast Asia may eat rice daily. The maintenance of mental health may consist of activities that include sports, concentration, supports,
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reading, and arts and crafts. O n e example of this is the activities, such as sports, commonly played in all societies. Spiritual health is maintained in the traditional ways by silence, prayer, and meditation. Traditional Practices of Preventing Illness Traditional practices of prevention developed from the folk beliefs about the causes o f illness. People avoided those who were known to cause or transmit hexes and spells, and many elaborate methods were developed to prevent the envy, hate, and jealousy of others. Countless methods evolved over generations and exist today to protect people from the evil eye. Every effort is made by the host to avoid situations in which behavior, be it social or religious, is compromised. The following are examples of traditional practices used in the prevention of illness. 1. The use of protectioe/reIigioiCs objects. Various protective objects may be worn, carried, or hung in the home. Amulets are objects with magical powers, such as charms, worn on a string or chain around the neck, wrist, or waist to protect the wearer form the evil eye or the evil spirits. These spirits could be transmitted from one person t o another or may have supernatural origins. Amulets have been found to exist in societies all over the world and are associated with the protection of man from trouble (Budge, 1978). In addition to amulets, there are talismans, “consecrated religious objects,” that people may use (Spector, 1991, p. 126). Talismans are believed to possess extraordinary powers, and they may be worn on a rope around the waist or carried in a pocket or purse. The evil eye also may be prevented by touching an infant when it is admired (Puerto Rican belief) or by drawing a circle around an infant’s bed and spitting on the child three times (Eastern Europe). 2. The use of substances. This practice employs the use of diet and consists of many different ObServdnCeS. I t is believed that the body is kept in balance or harmony by the type of food that one eats, and there are numerous food taboos and combinations that are prescribed in traditional belief systems. People from many ethnic backgrounds eat raw garlic o r onion in an effort to prevent illness. Garlic or onions also may be worn on the body or hung in the home. 3. The use of religious practices. Religion strongly affects the way that people choose t o prevent illness, and it plays a strong role in rituals that are associated with prevention. I t dictates social, moral, and dietary practices
Many people believe that illness is prevented by the adherence to religious codes, morals, and practices, and they view illness as a punishment for breaking a religious code.
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that are designed to keep a person in balance and healthy and plays a vital role in a person’s perception of the prevention of illness. Many people believe that illness is prevented by the strict adherence to religious codes, morals, and practices, and they view illness as a punishment for breaking a religious code. Traditional Ways of Restoring Healtb Folk Medicine. Folk medicine is related to other types of medicine that are practiced in our society. I t was derived from earlier theories of academic medicine and has coexisted, with increasing tensions, with modern medicine. There is ample evidence that the folk practices of ancient times have only in part been abandoned by modern belief systems; many of these beliefs and practices continue to be observed. There are two varieties of folk medicine: Natural folk medicine, which is the use of the natural environment (herbs, plants, minerals, and animal substances) to treat illnesses, and 2. Magicoreligious folk medicine, which is the use of charms, holy words, and holy actions to treat illnesses (Yoder, 1972). There also are traditional healers within a given cultural community who women may consult before they seek health-care services or during the course of treatment. 1.
A wide variety of substances may be ingested for the treatment of maladies. Frequently, the active ingredients of these traditional remedies are unknown. If a woman is believed to use these remedies, an effort must be made to determine what she is taking and the remedy’s active ingredients. The active ingredients often can be antagonistic or synergistic to the prescribed medications. When this is the situation, the medi-cation may have no effect or a severe overdose may ensue. Substances also may be used to restore the body’s balance; they may be introduced into the body in other ways. An example of this is the Asian practice of coining. A substance, usually Tiger Balm, is rubbed over the body in certain areas, usually the back or the arm, with a coin to release “wind” and restore the body’s balance. Illness also is treated with the use of religious beliefs, practices, and objects. The wearing of religious medals, carrying of prayer cards, or performance of sacrifices are not unusual practices. There are strong beliefs in religious healing, and the active use of traditional healers continues. There are countless rituals that must be adhered to during the dying process, such as the Catholic ritual of the anointing of the sick (Spector, 1991) when a believer is extremely ill or is dying. There are numerous other religious practices that must be performed at the moment of, or just before, death that require the active participation of family members. In some ethnocultural groups, ritual anointing of the body and washing is necessary; others, such as gypsies, believe that the person should die close to the earth and thus request that the person be placed on the floor to die. The practice within
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Cultural Conceph in Clinicul Cure
many hospitals of isolating a family member from the rest of the group is not necessary and may cause m o r e harm than good.
Conclusion Nursing education a n d practice are grounded in modern European philosophies of health and health-promoting behaviors. Given the demographic changes that are rapidly turning this nation into a universal society, it is imperative that nursing develop frameworks that are multicultural in nature. T h e theory and practice of multicultural nursing will provide an educational and a practice framework for broadening nurses’ understanding of cultural concepts that are health related and will describe the beliefs, practices, and issues that are part of the lived traditional philosophies and experiences of people from diverse cultural backgrounds. Culture, through a series or w e b o f symbols, is learned, and it serves as the medium o f our individuality and personhood and the medium of social relationships. Culture occurs simultaneously in a person’s head (meaning) and in their environment (behavior). With a knowledge and understanding of multicultural nursing, t h e nurse is able to appreciate the total diversity of our society. The change t o multicultural nursing is a process, o n e that will take time to develop. It often will require the grasp of ideas that may run contrary to allopathic beliefs. I f the nurse is to b e the advocate a n d caregiver to diverse peoples, s h e or h e must be willing to develop this understanding and to support women w h o choose to follow the health care norms of their personal traditional world.
References Ahranison, P. (1980). Religion. In S. Thernstorm (Ed.), The Hari8ard encjclopedia of American ethnic groups (pp. 869-875). Cambridge, MA: Harvard University Press. Budge, E. A. W. (1978). Amulets a n d superstition. New York: Dover.
Estes, G., CG Zitzow, D (1980). Heritage consistency as a consideration in counseling Natiiw Americans. Dallas, TX: National Indian Education Association Convention. Fejos, P. (1959). Man, magic, and medicine. I n I . Goldstone (Ed.), Medicine a n d anthropology (p. 43). New York: I n ternational University Press. Hall, E. T. (1988). Introduction. In M . Matsumoto (Ed.), The unspoken waj’ (p. 14). Tokyo: Koclansha International. Hodgkinson, H . L. (1986). Reform? Higher education? Don’t be absurd! Higher Education, 273. Immigration to US in 1992 soars I5 percent to 810,635. (1993, December 14). The Ijoston Globe, p. 22. Jalali, B. (1988). Ethnicity, cultural adjustment and behavior: Implications for family therapy. In 1.. Comas-Diaz CG E. H. Griffith (Eds.), Cross-cultural mental health (p. 9). New York: John Wiley CG Sons. LaFromboise, T., Hardin, 1.. K., CG Gerton, J. (1993). Psychological impact of blcUhrJliSm: Evidence and theory. Psychotogical Hulletin. 114(3),397. Spector, R. E. (1991). Citltirral ditlersitj~it1 health a n d illness (3rd ed.). N o w a l k , CT: Appleton d Img. Thernstorm, S. (Ed.). (1980). 7be Haruard encyclopedia of American ethtiic groups (p. vii). Cambridge, MA: Harvard University Press. U S . Bureau o f the Census. (1981 ). Cirrre?itpopulatiotli reports, 1980: General social a n d economic characteristics. Part I : United States summary (PC80-I -C1). Washington. DC: U S . Government Printing Office, pp. 1-13. IJ. S. Bureau o f the Census. (1991 ) . Currentpopulation reports, 199:Census ofpopulation a n d housing, summarypopulatioti a n d housing characteristics, United States. Washington, DC: U S . Government Printing Office, p. 59. Yoder, D. (1972). Folk medicine. In R. H. Dorson (Ed.), Folkloreandfolklije (pp. 191-193). Chicago: Universityof Chicago Press.
Addressf o r correspondence: Rachel E. Spector, RN, PhD, CTN, Boston College School of Nursing, Cbestnut Htll, MA 02167. Rachel E. Spector b a n associate professor In the Department of Community Health at the Boston College School of Nursfng, Chestnut Htll. MA.
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Cultural Concepts of Women’sHealth and Health-PromotingBehaviors ~~
Rachel E. Spector, RN, PhD, CTN
Cultural diversity is the reality of the 199Os, and the United States is becoming the most ethnically diverse society in the world. The needs and responses of many different racial and ethnic groups are competing for recognition, and nurses must learn how to meet the health care needs of this multicultural society. This article explores cultural concepts relating to women’s health and health-promoting behaviors in the context of this social change. It explores demographic change, concepts of heritage consistency, traditional health beliefs, and traditional healthpromoting behaviors.
C
ultural diversity is a reality today, and the United States is becoming the most ethnically diverse society in the world. A s we enter the 21st century, nurses are perched on the cutting edge of enormous demographic, social, and cultural change. Many of these changes will play a dramatic role in the delivery of nursing care to a given woman and her family. There is an ongoing social explosion occurring in the United States, caused by the profound forces of demographic change that are catapulting this nation into a universal nation. This change originated during the mid- 1960s with a social explosion that resulted in a surge of group consciousness. First blacks, then Hispanics, Asian-Americans, Native Americans, and white ethnic groups began to assert their cultural group identity. The rejuvenation of ethnic identity eroded the melting pot myth and the belief that an American culture would decrease group awareness. The needs and responses of many different racial and ethnic groups are competing for recognition; we must learn how to meet the needs of this multicultural society and begin to change the way we address the complex issues related to health and nursing care. This article explores cultural concepts that are related to women’s health and health-promoting behaviors
in the context of this social change. I t presents an overview of: 1. demographic change; 2. concepts of heritage consistency; 3 . traditional health beliefs; and 4 . traditional health-promoting behaviors
Demogrtzpbic Cbange It has been said that “demography is destiny” (Hodgkinson, 1986, p. 273). There are two major ways for analyzing the impact o f demographic change on the scope of nursing education and practice. O n e way is to compare the 1980 census with that of 1990. In 1980, the overall population of the United States (226.5 million people) was 79.7% white (nopHispanic); 11.5% black (non-Hispanic); 0.6% Native American; 1.5% Asian/Pacific Islander; and 6.4% Hispanic ( U . S . Bureau of the Census, 1981). In 1990, the population was 75.6% white (nonHispanic), 11.7% black (non-Hispanic), 0.7% Native American, 2.8% Asian/Pacific Islander, and 9% Hispanic ( U . S. Bureau of the Census, 1991). Of note is the decrease in the white population and the increase in Asian/ Pacific Islanders and Hispanics. Another way to view this demographic change is to analyze recent immigration trends. In 1992, 810,635 immigrants arrived in this country. I t was the second largest influx of immigrants in 70 years. The largest numbers of immigrants were from Mexico (91,332), Vietnam (77,728), the Philippines (59,179), the Republics of the former Soviet Union (43,590), and the Dominican Republic (40,840) (“Immigration to US,” December 14, 1993). The Immigration and Naturalization Service is expecting that between 800,000 and 900,000 immigrants will come here each year under the immigration laws that were passed in 1990 (“Immigration to US,” December 14,1993). The United States has an emerging majority population comprised of non-Europeans who are native born or
J O C N N
241
CLI.VIC.4 L
I S S I ’ E S
immigrated here from all over the world. Thus, it is imperative for health-care providers and nurses t o understand the traditional health beliefs a n d health-promoting behaviors o f the people w h o comprise the majority of these new Americans.
Heritage Consistency There are numerous ways of analyzing the role that culture plays in women’s health-care practices; o n e way is in the context of heritage consistency. Heritage consistency, a theory originally developed in 1980 by Estes and Zitzow t o develop a means o f assessing and counseling Indians (Native American) with alcoholism within a cultural context, encompasses “the degree t o which one’s lifestyle reflects his/her tribal culture” (p.2 ) . T h e theory has been expanded in an attempt to study t o what degree any person’s lifestyle reflects his/her traditional culture, be i t European, Asian, African, o r of Spanish origin. T h e value characteristics, such as spoken language o f preference, food preferences, name, schools attended, neighborhood ties, and social activities, indicate that heritage consistency exists o n a continuum, and an individual can possess value characteristics o f a heritage-consistent (traditional) and a heritage-inconsistent (acculturated) nature. The concept includes a determination of one’s cultural, ethnic, and religious background (Spector, 1991). Heritage consistency encompasses three broad concepts: Culture: the sum total of socially inherited characteristics of a human group that comprise everything that o n e generation can tell, convey, o r hand d o w n to the next (Fejos, 1959) and a “metacommunication system” wherein not only the spoken words have meaning, but everything else as well (Hall, 1988, p . 1 4 ) . Ethiricity the condition of belonging to a particular ethnic group. Included in the characteristics of an ethnic group are migratory status; race, language, and dialect; religious faith o r Faiths; ties that transcend kinship, neighborhood, and community boundaries; shared traditions, values, and symbols; literature, folklore, and music; food preferences; settlement and employment patterns; s p e cial political interests; an internal sense o f distinctiveness; and an external sense of distinctiveness. There are at least 106 different ethnic groups in America and more than 170 Native American tribes o r nations (Thernstorm, 1980). Religioiz: the belief in a divine or superhuman power or powers to be obeyed and worshipped as the creator(s) and ruler(s) of the universe; a system of beliefs, practices, and ethical values (Abramson, 1980). Religion provides the person a frame of reference and a perspective with which t o organize information. Ethnicity and religion are related, and one’s religion often is the determinant of ethnic group. There are three other concepts interwoven with this theory: Sotializatzoir; the process of being raised within a
242 J 0 G .Y ,I’
culture and acquiring the characteristics of the given group. Education is a form of socialization. Acculturatioii: a model of second culture acquisition; the phenomena an individual experiences when s h e lives within or between cultures (LaFromboise, Hardin, 8r Gerton, 1993). Assimilation: t h e process by which an individual develops a n e w cultural identity. Assimilation is becoming in all ways like the members o f t h e dominant culture (LaFromboise et al., 1993). In reality, assimilation is not always possible.
People who have maintained a strong sense of their heritage may hold on to traditional health beliefs.
I t has been observed by this author in several research studies that people w h o have maintained a strong sense of their heritage may hold o n to traditional health beliefs. T h e subsequent health-promotingbehaviors may stem from traditional folk health practices. “Traditional,” o r homeopathic, refers to health beliefs that are derived from ancient beliefs and health-promoting behaviors derived from ancient methods o f maintaining health, preventing changes in health status, and restoring health. “Modern,” or allopathic, health beliefs are those that are derived from the scientific beliefs of the present time and involve t h e use of technology and other forms of current health care. When o n e speaks of beliefs, it is important to differentiate between allopathic health care that e m braces all methods of proven therapy, including modern health care, and homeopathic beliefs, which generally are derived from ethnocultural folk traditions and often are at odds with the allopathic system (Spector, 1991).
cross-Cultu raI HeaIth Beliefs Imagine healthas a three-dimensional phenomenon, that of body (the physical self), mind (the feelings, attitudes, and behavior that o n e has, which often are culturally determined and immersed and intertwined in the conception of health and illness [Jalali, 19881, and spirit (the “who I am-unified and alive, it is expressed through my body, my thinking and so forth” [Stoll, 1989, p. 61). These dimensions must be kept in balance, both within the person and within the environment. Thus, health is the bala n c e of these three dimensions, each dimension being carefully cared for, yet totally related to the other two dimensions. T h e health-promoting behaviors are the actions that are used in each of these dimensions to maintain health, prevent illness, and restore health (Fig. 1).
Volume 24. Number 3
Cultural Concepts in Clinicul Cure
1
i
Heallh
Prevention of
Maintenance
Illness
Proper clolhing Special foods I d l e 1 Iocd combinations
M
Concenlralion
I
N D
Silence Reading Religion
1
Restoration of Health
Traditfonal folk remedles
Herbal Leas
Symbolic clolhing
Massage
Avoid cerlain people
Relaxation
Family aCliVilIeS Religious cusloms
Prayer
Exorcism Teas Prayer Medilalion
‘Superslition’ Medilalion
Traditional beliefs regarding the causation of illness differ vastly from the modern model of epidemiology.
Heallng Evil Eye Exorcism Symbolic objects
Health Beliefs There are numerous traditional health beliefs observed among the different ethnocultural groups that comprise the American population. For example, among women who have maintained traditional belief systems, there tend to be culturally based or folk beliefs that determine the definitions of health and illness. Women who are of an Asian origin (from China, the Philippines, Korea, Japan, or Southeast Asia) may view health as the “balance of yin and yang” (Spector, 1991, p. 173) and illness as the imbalance; those of African, Haitian, or Jamaican origin may view health as “harmony with nature” (Spector, 1991, p. 190) and illness as disharmony with nature; those from Hispanic countries may see health as the “balance of hot and cold” (Spector, 1991, p. 214) and illness as the imbalance; Native Americans may view health as the ability to “live in harmony with nature” (Spector, 1991, p. 237) and illness as living in disharmony with nature; and traditional people of European origin may have a philosophy that sees health as “feeling good and able to d o your duty” (Spector, 1991, p. 267) and illness as feeling bad. The word “may” is used when describing these philosophies and behaviors to prevent any kind of stereotyping. There are individual differences within a given group of people and among groups. However, there also are some discernible commonalties, especially the sense of balance and harmony within the self and
one’s relation to the environment, in the connotation of the terms health and illness. Traditional Epidemiology The traditional or folk methods of health maintenance, illness prevention, and treatment of illness rest in the woman’s ability to understand the cause of a given illness. The traditional beliefs regarding the causation of illness differ vastly from the modern model of epidemiology. To more fully appreciate the richness of the methods used to maintain health and prevent and treat illness, it is important to have an awareness of what may be deemed the causation of illness. “Traditional epidemiology” includes the following.
Traditional agents include hexes, spells, and the evil eye. The evil eye is a concept that manifests itself among numerous cultural, religious, and ethnic populations. The belief in the evil eye is one of the oldest held beliefs; it asserts that there is a power that emanates from the eye or mouth that strikes a victim, usually a child, with an injury, illness, or other misfortune. This belief helps to explain misfortune (Spector, 1991). Traditional hostfactors include such phenomena as soul loss and spirit possession (the ability to provoke the envy, hate, and jealousy of a friend, acquaintance, or neighbor, and the religious and social behavior of the person). Traditional environmentalfactors include air quality (ma1 aire or bad air) and such natural events as a solar eclipse.
Traditional Health-Promoting Behaviors Health-promoting behaviors stem from beliefs about the cause of illness. They most often are pragmatic, inexpensive, and common activities. There is little scientific knowledge of their efficacy because when they are effective, modern medical help is not sought. Traditional Practices of Health Maintenance The health-promoting behaviors that may be used to maintain the health of the person include maintaining balance of the body by wearing proper clothing, e.g., traditional women from Germany may wear shawls to protect themselves from drafts. Another example is eating the proper diet-women from Southeast Asia may eat rice daily. The maintenance of mental health may consist of activities that include sports, concentration, supports,
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reading, and arts and crafts. O n e example of this is the activities, such as sports, commonly played in all societies. Spiritual health is maintained in the traditional ways by silence, prayer, and meditation. Traditional Practices of Preventing Illness Traditional practices of prevention developed from the folk beliefs about the causes o f illness. People avoided those who were known to cause or transmit hexes and spells, and many elaborate methods were developed to prevent the envy, hate, and jealousy of others. Countless methods evolved over generations and exist today to protect people from the evil eye. Every effort is made by the host to avoid situations in which behavior, be it social or religious, is compromised. The following are examples of traditional practices used in the prevention of illness. 1. The use of protectioe/reIigioiCs objects. Various protective objects may be worn, carried, or hung in the home. Amulets are objects with magical powers, such as charms, worn on a string or chain around the neck, wrist, or waist to protect the wearer form the evil eye or the evil spirits. These spirits could be transmitted from one person t o another or may have supernatural origins. Amulets have been found to exist in societies all over the world and are associated with the protection of man from trouble (Budge, 1978). In addition to amulets, there are talismans, “consecrated religious objects,” that people may use (Spector, 1991, p. 126). Talismans are believed to possess extraordinary powers, and they may be worn on a rope around the waist or carried in a pocket or purse. The evil eye also may be prevented by touching an infant when it is admired (Puerto Rican belief) or by drawing a circle around an infant’s bed and spitting on the child three times (Eastern Europe). 2. The use of substances. This practice employs the use of diet and consists of many different ObServdnCeS. I t is believed that the body is kept in balance or harmony by the type of food that one eats, and there are numerous food taboos and combinations that are prescribed in traditional belief systems. People from many ethnic backgrounds eat raw garlic o r onion in an effort to prevent illness. Garlic or onions also may be worn on the body or hung in the home. 3. The use of religious practices. Religion strongly affects the way that people choose t o prevent illness, and it plays a strong role in rituals that are associated with prevention. I t dictates social, moral, and dietary practices
Many people believe that illness is prevented by the adherence to religious codes, morals, and practices, and they view illness as a punishment for breaking a religious code.
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that are designed to keep a person in balance and healthy and plays a vital role in a person’s perception of the prevention of illness. Many people believe that illness is prevented by the strict adherence to religious codes, morals, and practices, and they view illness as a punishment for breaking a religious code. Traditional Ways of Restoring Healtb Folk Medicine. Folk medicine is related to other types of medicine that are practiced in our society. I t was derived from earlier theories of academic medicine and has coexisted, with increasing tensions, with modern medicine. There is ample evidence that the folk practices of ancient times have only in part been abandoned by modern belief systems; many of these beliefs and practices continue to be observed. There are two varieties of folk medicine: Natural folk medicine, which is the use of the natural environment (herbs, plants, minerals, and animal substances) to treat illnesses, and 2. Magicoreligious folk medicine, which is the use of charms, holy words, and holy actions to treat illnesses (Yoder, 1972). There also are traditional healers within a given cultural community who women may consult before they seek health-care services or during the course of treatment. 1.
A wide variety of substances may be ingested for the treatment of maladies. Frequently, the active ingredients of these traditional remedies are unknown. If a woman is believed to use these remedies, an effort must be made to determine what she is taking and the remedy’s active ingredients. The active ingredients often can be antagonistic or synergistic to the prescribed medications. When this is the situation, the medi-cation may have no effect or a severe overdose may ensue. Substances also may be used to restore the body’s balance; they may be introduced into the body in other ways. An example of this is the Asian practice of coining. A substance, usually Tiger Balm, is rubbed over the body in certain areas, usually the back or the arm, with a coin to release “wind” and restore the body’s balance. Illness also is treated with the use of religious beliefs, practices, and objects. The wearing of religious medals, carrying of prayer cards, or performance of sacrifices are not unusual practices. There are strong beliefs in religious healing, and the active use of traditional healers continues. There are countless rituals that must be adhered to during the dying process, such as the Catholic ritual of the anointing of the sick (Spector, 1991) when a believer is extremely ill or is dying. There are numerous other religious practices that must be performed at the moment of, or just before, death that require the active participation of family members. In some ethnocultural groups, ritual anointing of the body and washing is necessary; others, such as gypsies, believe that the person should die close to the earth and thus request that the person be placed on the floor to die. The practice within
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many hospitals of isolating a family member from the rest of the group is not necessary and may cause m o r e harm than good.
Conclusion Nursing education a n d practice are grounded in modern European philosophies of health and health-promoting behaviors. Given the demographic changes that are rapidly turning this nation into a universal society, it is imperative that nursing develop frameworks that are multicultural in nature. T h e theory and practice of multicultural nursing will provide an educational and a practice framework for broadening nurses’ understanding of cultural concepts that are health related and will describe the beliefs, practices, and issues that are part of the lived traditional philosophies and experiences of people from diverse cultural backgrounds. Culture, through a series or w e b o f symbols, is learned, and it serves as the medium o f our individuality and personhood and the medium of social relationships. Culture occurs simultaneously in a person’s head (meaning) and in their environment (behavior). With a knowledge and understanding of multicultural nursing, t h e nurse is able to appreciate the total diversity of our society. The change t o multicultural nursing is a process, o n e that will take time to develop. It often will require the grasp of ideas that may run contrary to allopathic beliefs. I f the nurse is to b e the advocate a n d caregiver to diverse peoples, s h e or h e must be willing to develop this understanding and to support women w h o choose to follow the health care norms of their personal traditional world.
References Ahranison, P. (1980). Religion. In S. Thernstorm (Ed.), The Hari8ard encjclopedia of American ethnic groups (pp. 869-875). Cambridge, MA: Harvard University Press. Budge, E. A. W. (1978). Amulets a n d superstition. New York: Dover.
Estes, G., CG Zitzow, D (1980). Heritage consistency as a consideration in counseling Natiiw Americans. Dallas, TX: National Indian Education Association Convention. Fejos, P. (1959). Man, magic, and medicine. I n I . Goldstone (Ed.), Medicine a n d anthropology (p. 43). New York: I n ternational University Press. Hall, E. T. (1988). Introduction. In M . Matsumoto (Ed.), The unspoken waj’ (p. 14). Tokyo: Koclansha International. Hodgkinson, H . L. (1986). Reform? Higher education? Don’t be absurd! Higher Education, 273. Immigration to US in 1992 soars I5 percent to 810,635. (1993, December 14). The Ijoston Globe, p. 22. Jalali, B. (1988). Ethnicity, cultural adjustment and behavior: Implications for family therapy. In 1.. Comas-Diaz CG E. H. Griffith (Eds.), Cross-cultural mental health (p. 9). New York: John Wiley CG Sons. LaFromboise, T., Hardin, 1.. K., CG Gerton, J. (1993). Psychological impact of blcUhrJliSm: Evidence and theory. Psychotogical Hulletin. 114(3),397. Spector, R. E. (1991). Citltirral ditlersitj~it1 health a n d illness (3rd ed.). N o w a l k , CT: Appleton d Img. Thernstorm, S. (Ed.). (1980). 7be Haruard encyclopedia of American ethtiic groups (p. vii). Cambridge, MA: Harvard University Press. U S . Bureau o f the Census. (1981 ). Cirrre?itpopulatiotli reports, 1980: General social a n d economic characteristics. Part I : United States summary (PC80-I -C1). Washington. DC: U S . Government Printing Office, pp. 1-13. IJ. S. Bureau o f the Census. (1991 ) . Currentpopulation reports, 199:Census ofpopulation a n d housing, summarypopulatioti a n d housing characteristics, United States. Washington, DC: U S . Government Printing Office, p. 59. Yoder, D. (1972). Folk medicine. In R. H. Dorson (Ed.), Folkloreandfolklije (pp. 191-193). Chicago: Universityof Chicago Press.
Addressf o r correspondence: Rachel E. Spector, RN, PhD, CTN, Boston College School of Nursing, Cbestnut Htll, MA 02167. Rachel E. Spector b a n associate professor In the Department of Community Health at the Boston College School of Nursfng, Chestnut Htll. MA.
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