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Cultural Views of Health and Illness
- 1. Culture and Health Dr. Preeti Dugg Solanki UCMS, Delhi 112/1/2017
- 2. Plan of Presentation • Introduction: Anthropology • What is culture? • Why culture matters? • Cultural views of health, illness and healers • Culture bound syndromes • PEN -3 Model • Cultural competence • Examples of various cultural practices • Recommendations 2
- 3. Behavioral sciences Social psychology Sociology Social anthropology 3 Deals with the study of human relationships and of human behavior for a better understanding of the pattern of the human life. Concerned with psychology of the individuals living in human society.. deals with the effect of social environments on persons , their attitudes and motivations
- 4. Anthropology Social Physical Medical Cultural 4 Study of development and various types of social life Study of total way of life of contemporary primitive man , his ways of thinking ,feeling and actions Study of human evolution, racial differences , inheritance of bodily traits ,growth and decay of human organism Deals with the cultural component in the ecology of health and illness
- 5. Custom • A traditional practice or usual way of doing something followed by a social group or people. i. Folkways : informal rules and norms that, while not offensive to violate, are expected to be followed. ii. Mores : informal rules that are not written, but, when violated, result in severe punishments and social sanction upon the individuals, such as social and religious exclusions.* *Source: Boundless. “Folkways and Mores.” Boundless Sociology Boundless, 26 May. 2016. Retrieved 04 Jan. 2017 from https://www.boundless.com/sociology/textbooks/boundless-sociology-textbook/culture-3/the-symbolic-nature-of-culture-30/folkways-and-mores-198-4919 6
- 6. Culture “that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities acquired by man as a member of society” (Tylor, 1871). “conventional understandings, manifest in act and artefact”. (Robert Redfield) 7
- 7. • Shared ideas, meanings, and values. • Socially learned, not genetically transmitted. • Patterns of behavior that are guided by these shared ideas, meanings, and values. • Often exists at an unconscious level. • Constantly being modified through “lived experiences”. 8
- 9. 10
- 10. Cultural perspectives Insider perspective (emic in anthropology): • shows the culture as viewed from within. • refers to the meaning that people attach to things from their cultural perspective. Outsider perspective (etic in anthropology): • refers to the same thing as seen from the outside. • rather than meaning, it conveys a structural approach, or something as seen without understanding its meaning for a culture. 11
- 11. 12
- 12. These perspectives allow us: • to look at health, illness, and prevention and treatment systems from several perspectives. • to analyze the differences between these perspectives. • to develop approaches that will work within a cultural context. 13
- 13. “Further awareness for cooperation so that health and culture can be developed in a mutually supportive manner which will benefit all people in all countries.” Joint Declaration , WHO & UNESCO 14 “1996 : Year of Culture and Health”
- 14. Cultural Views of Health, Illness and Healers • A condition that is endemic in a population may be seen as normal and may not be defined as illness. • E.g.. Malaria in Africa, Schistosomiasis in Egypt. • There are generalizations about culture specific health beliefs and behaviors and that generalizations cannot be assumed to apply to every individual from a given culture. 15
- 15. 16
- 16. Body balances • The concept of hot and cold is one of the most pervasive around the world, particularly important in Asian, Latin American, and Mediterranean cultures. • In the hot and cold belief system, a healthy body is seen as in balance between the two. Illness may be brought on by violating the balance, such as : washing the hair too soon after childbirth (cold may enter the body, which is still hot from the birth) eating hot/heavy foods at night breastfeeding while upset (the milk will be hot from the emotions and make the baby ill). 17
- 17. • Energy balance is particularly important in Chinese medicine, where it is referred to as chi. When the balance is disturbed, there are internal problems of homeostasis. • Dislocation: From the outsider perspective, a depression in the fontanelle can be indicative of dehydration, often due to diarrheal disease but from the insider perspective, it is referred to as a cause of the disease (caida de mollera) in Mexico and Central America. 18
- 18. Emotional • Illnesses of emotional origin are important in many cultures. • Sorrow ,envy, fright, and stress are seen as causing illnesses. • Envy is believed to cause illness because people with envy could cast the evil eye on someone they envied, even unwittingly, or the envious person could become ill from the emotion (Reichel-Dolmatoff & Reichel-Dolmatoff, 1961). 19
- 19. 20 • “Culture-bound” syndrome • Prevalent among many Latino groups in North and Central America. • It is thought to be caused by a traumatic experience and affected individuals experience a variety of symptoms, including severe anxiety, difficulty sleeping, and a loss of interest in life. • Susto appears to be a cultural expression for distress and is linked to emotional stress and depressive symptoms. *Weller, Catalina S. C, Triana A.Susto. The Encyclopedia of Clinical Psychology. 2015. 1–3. Susto(“fright” or “fright sickness”)
- 20. Supernatural • Evil eye is a widespread concept, in which someone can deliberately or unwittingly bring on illness by looking at someone with envy, malice, or too hot a gaze. • Belief in soul loss is widespread throughout the world and can be caused by things such as fright, bewitching, the evil eye, and demons. It can occur in adults and children. Mostly treated through rituals to retrieve the soul. 21
- 21. 22
- 22. 23
- 23. Food • Food can cause illness through its role in the hot and cold belief system, through spoiled foods, dirty foods, raw foods, and combining the wrong foods. • E.g. Sweets are implicated as a cause of worms in children, and children who eat mud or dirt may get ill. Foods eaten at the wrong time of day, such as “heavy” foods at night. 24
- 24. * S.C.M. Scrimshaw and E. Hurtado, Rapid Assessment Procedures for Nutrition and Primary Health Care: Anthropological Approaches to Improving Program Effectiveness (RAP), 1987, p. 26. 25
- 25. Types of healers Indigenous: Midwives Shamans Curers Spiritualists Witches Sorcerers Priests Diviners Herbalists Bonesetters Massagers Pluralistic : Injectionist Indigenous health workers Western-trained birth attendants Traditional chemists/herbalist Storekeepers and vendors Western Biomedical Pharmacists Nurse-midwives Nurses Nurse practitioners Physicians Dentists Other health professionals Other Medical Systems Chinese medical system i. Practitioners ii. Chemists/herbalists iii. Acupuncturists Ayurvedic practitioners Taoist priests 26
- 27. Culture bound syndromes • Culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations (American Psychiatric Association, 1994) • No objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures. • Recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. 28
- 28. Majority of CBS share the following characteristics: Categorized as a disease in that culture Widespread familiarity in that culture Unknown in other cultures No objectively demonstrable biochemical or organ abnormality Treated by folk medicine/ traditional healers 29
- 29. In India, common culture bound syndromes are Dhat Syndrome Gilhari syndrome Possession Syndrome Compulsive spitting Koro Culture-bound suicide (sati, santhra) Ascetic syndrome Jhinjhinia 30
- 30. 31 Case study-2 • Detailed phenomenological analysis revealed that there exists a strong cultural belief that dog bite may evolve into a puppy pregnancy even in the human male. • Psychiatric status showed that there was a clear association of obsessive-compulsive disorder in two cases, anxiety-phobic locus in one and three showed no other mental symptom except this solitary false belief and preoccupation about the puppy pregnancy.
- 31. Model of common cultural health beliefs 32
- 32. PEN-3 Model • Framework developed to “centralize culture in health promotion interventions” • It has been used to address a multitude of health issues (e.g., HIV, smoking, nutrition) with complex clinical and cultural contexts that affect health behaviors and health outcomes. • Use of the PEN-3 model allows researchers to examine cultural practices that are crucial in explicating the mechanisms of positive health behaviors, while acknowledging unique cultural practices that have a neutral impact on health and distinguishing negative factors that are likely to have an adverse influence on health behaviors.* 34 *Airhihenbuwa C. A conceptual model for culturally appropriate health education programs in developing countries. Int’l. Quarterly of Community Health Education, Vol. 11 (1) 53-62, 1990-91
- 33. Person Extended family Neighborhood Positive Exotic Negative Predisposing Enabling Nurturing Health education Educational diagnosis for health behavior Cultural appropriateness for health behavior PEN-3 Model 35
- 34. 36 • 16 women aged 19 to 25 years and 20 women aged 45 to 60 years participated. • Six focus-group sessions were conducted with 6 participants per group.
- 35. Ethnocentrism & Cultural relativism Ethnocentrism refers to seeing your own culture as best. In the context of cross- cultural understanding, ethnocentrism poses a barrier if people approach a culture with the attitude that it is inferior. Cultural relativism in anthropology refers to the idea that each culture has developed its own ways of solving the problems of how to live together; how to obtain the essentials of life, such as food and shelter; how to explain phenomena; and so on. No one way is viewed as better or worse; they are just different. 37
- 36. Cultural competency Definition : Cultural competence is defined as awareness of the cultural factors that influence another’s views and attitudes, and an assimilation of that awareness into professional practice*. ( Lancet Commission ) 38*Napier A.D, Ancarno C, Butler B, Calabrese J et al. Culture and health .The Lancet. 2014; 384: 1607–39
- 37. Why we need cultural competency • To respond to current and projected demographic changes. • To eliminate long standing disparities in health status of people of diverse racial, ethnic and cultural backgrounds. • To improve the quality of services. • To enhance the workplace environment. • To decrease the likelihood of liability / malpractice claims. 40
- 38. • On the organizational level, there are five essential elements that contribute to a culturally competent system (Cross, Bazron, Dennis, & Isaacs, 1989). • The system should i. value diversity ii. have the capacity for cultural self-assessment iii. be conscious of the dynamics inherent when cultures interact iv. institutionalize cultural knowledge v. develop programs and services that reflect an understanding of diversity between and within cultures. 41
- 39. Case study-3 42 First visit • C/o frequency, nocturia, hesitancy and suprapubic pain for several months • Antibiotic for prostatitis. Second visit • C/o boggy, tender prostate, moderately increased BP and a normal urinalysis. • Different antibiotic for prostatitis. Third visit •Spanish- speaking provider •Explained continued symptoms •Loss of job •History of previous accident •Took herbal remedies •Diagnosed with a urethral stricture. • 35-year-old Mexican male. • Immigrant • Limited English proficiency
- 40. 43 • Language and patterns of communication are key components of culture and can be obstacles in providing good medical care . • This case demonstrates that seeking care at physicians' offices and hospitals may be viewed as a last option by patients. • Patients may seek advice from several sources-including family members, friends, and as in this case, an herbalist. • Additionally, many medical symptoms are self diagnosed and self-treated. • Recognizing that the patient had strong beliefs, acknowledging these beliefs, and incorporating them improved patient satisfaction and trust.
- 41. Examples of various cultural practices affecting health 44
- 42. Jogini culture : HIV in India 45 • Jogini is the name for a female sexually exploited temple attendant and is used interchangeably with Devadasi in the state of Andhra Pradesh, India. • Twice more likely to be HIV positive than other women who are used for sexual intercourse in India. • Their rate of mortality from HIV is 10 times the total mortality rate for all women in India. • The four states in India with the most Jogini also have the highest prevalence of HIV.
- 43. Chhaupadi culture 46 Traditional practice wherein menstruating women have some restrictions, such as restrictions to consumption of milk products; restricted access to public water sources; not being allowed to touch men, children, cattle, living plants, or fruit bearing trees; and having to live outside the home such as in an animal shed.
- 44. • Anemia and underweight of women was 2-fold higher and child health status was poor in Chhaupadi-affected areas in comparison with the national average. • Reproductive health problems like severe bleeding, backache, and lower abdominal pain are worsening during Chhaupadi stay. • Negative health behaviors such as smoking and alcohol consumption were seen during their Chhaupadi stay. • Genital infections due to lack of menstrual hygiene , uterus and cervical problems due to heavy working, and recurrent infection of human papillomavirus are the major consequences due to Chhaupadi stay. • Undernutrition due to some food barriers. 47
- 45. Female genital mutilation • Female genital mutilation (FGM) comprises all procedures that involve the partial or total removal of external genitalia or other injury to the female genital organs for non-medical reasons.* • It is still being reported in 30 countries in Africa and in a few countries in Asia and the Middle East. • Over 200 million girls and women worldwide are living with the effects of FGM. • Every year some 3 million girls and women are at risk of FGM and are therefore exposed to the potential negative health consequences of this harmful practice (4). 48 *Eliminating female genital mutilation: an interagency statement. Geneva: World Health Organization; 2008.
- 46. 49 • The self-reported prevalence of female genital mutilation was 70.3%, while it was 58.6% according to clinical examination of the women’s genitalia. • The most common age at which mutilation was performed was 4–7 years (60.2%). • The common reasons for practicing female genital mutilation were cultural tradition (46.7%) and dictate of religion (38.9%). • More than one third (36.6%) of the women support the practice and 34.5% have intention to mutilate their daughters.
- 47. • Culture should be better defined. • Culture should not be neglected in health and health-care provision. • Culture should become central to care practice. • Agency should be better understood with respect to culture. • Training cultures should be better understood. • Competence should be reconsidered across all cultures and systems of care. • New models of wellbeing and care should be identified and nourished across cultures 52*Napier A.D, Ancarno C, Butler B, Calabrese J et al. Culture and health .The Lancet. 2014; 384: 1607–39 Recommendations
- 48. 54 Thank you…!! ‘’It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” William Osler
Notes de l'éditeur
- Sociology deals with the study of human relationships and of human behavior for a better understanding of the pattern of the human life. Social psychology is concerned with psychology of the individuals living in human society.. deals with the effect of social environments on persons , their attitudes and motivations. Social anthropology is study of development and various types of social life.
- Let's return to that example of meeting someone. What if the person you're meeting doesn't respond the way you'd expect? Perhaps he will refuse to shake your hand, get your name wrong, or interrupt you. You may think he is rude or come away from the interaction with a bad impression of the person. He is breaking the rules of social interaction - in other words, he is violating your culture's folkways. For the most part, our reactions to such violations are mild. We may come away from the person with a bad impression, but we will not be calling the police to report his behavior. This is where folkways differ from mores. While both fall under the umbrella of 'social norms', violations of mores are met with severe punishments from society. The reactions to violation of social norms, including folkways and mores, are called sanctions.
- Learned behavior which has been socially acquired. it focuses not only on shared understandings, but also on practices that are based on those understandings and that make sense of beliefs held in common with others. Culture, therefore, does not equate solely with ethnic identity, nor does it merely refer to groups of people who share the same racial heritage. Redfield’s definition is also helpful because it does not imply that all members of a group that share languages, practices, and overt expressions of belief automatically share a given value, nor that local ideas can be readily translated across or even within a given group.
- Lived experiences are defined as the experiences that people (and sometimes groups of people) go through as they live their lives. These experiences modify their culturally influenced beliefs and behaviors. This means culture is not static on either the group or individual level, because people are constantly changing. This concept helps allow for cultural change as people migrate to a new setting (community, region, or country), as people acquire additional education and experiences, and as conditions change around them (e.g., armed conflicts, economic changes in a country or region, political changes).
- concepts of insider and outsider perspectives are useful for examining when we are seeing things from our point of view and when we are trying to understand someone else’s view of things. Disease is the outsider view, usually the Western biomedical definition. It refers to an undesirable deviation from a measurable norm. Illness, on the other hand, means “not feeling well.” Thus it is a subjective, insider view.
- Guatemalan villages where these beliefs prevailed, researchers learned that mothers believed that worms were normal and were not a problem unless they became agitated. In their view, worms live in a bag or sac in the stomach and are fine while so confined. Agitated worms get out and appear in the feces or may be coughed up. Mothers also believed that worms are more likely to become agitated during the rainy season because the thunder and lightning frightened them. From an outsider perspective, this makes sense: Sanitation is more likely to break down in the rainy season, so there is more chance of infection and more diarrheal disease, which will reveal the worms. The dilemma for the health workers was to get the mothers to accept deworming medication for their children, because most of the time worms were perceived as normal. If the health workers tried to tell the mothers that their beliefs were wrong, the mothers would reason that the health workers did not understand illness in a Guatemalan village and would reject their proposal. The compromise was to suggest that the children be dewormed just before the rainy season, in order to avoid the problem of agitated worms. It worked.
- And the importance of cultural factors to many differnet aspects of international heatlh was officialy recognized in 1996 by the WHO n UNESCO who declared it the year of culture n health.
- Foods (often following the hot/cold theories) and acupuncture are among the strategies used to restore balance (Topley, 1976).
- Biologically susto doesn’t have a defined mechanism, however it seems to be a psychosomatic condition that is manifested in a culture that accepts it as a legitimate syndrome.
- this diagram of treatments, were key in expanding the orientation of the Central American diarrheal disease program. The program had intended to focus the distribution of oral rehydration solutions (ORS) in the clinics, but the insider perception was that you usually only take a child to the clinic for the worst form of diarrhea, dysentery. Instead, the most common treatment consisted of fluids in the form of herbal teas or sodas with medicines added. Often, storekeepers and pharmacists were consulted. It made sense to provide the ORS at stores and pharmacies as well as at clinics, so that all diarrheas were more likely to be treated
- Indigenous practitioners are usually of the culture and follow traditional practices. Pluralistic healers are those who mix the two traditions, Western biomedical practitioners are an important source of care, but they may also be expensive or hard to access from remote areas.
- The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions
- Dhat syndrome is a syndrome in which nocturnal emissions lead to sever anxiety and hypochondriasis, often associated with sexual impotence. Patient usually presents with various somatic, psychological and sexual symptoms. Possession syndrome: Diagnosable under Dissociative disorders. Patient is possessed usually by ‘spirit/soul’ of deceased relative or a local deity. Majority of these patients are females who otherwise don’t have any outlet to express their emotions. Treatment includes careful exploration of underlying stress which precipitated the possession attack. Antidepressants and anxiolytics are helpful in certain cases. Koro: Seen in northeastern states like Assam • Fear of genitalia retracting into abdomen leading ultimately to death and Seen in both sexes. Person applies external retractors to the genitalia in form of clamps, chains etc. to avoid it retracting back. Ascetic syndrome:Appears in adolescents and young adults, Characterised by social withdrawal, severe sexual abstinence, practice of religious austerities, lack of concern with physical appearance and considerable loss of weight Gilhari :Characterised by patient complaining of small swelling on the body changing its position from time to time as if a gilhari (squirrel) is tavelling in the body Jhin Jhinia: Occurs in epidemic from in India • Characterised by bizarre and seemingly involuntary contractions and spasms Santhara/Sallekhana : voluntarily giving up life by fasting unto death over a period of time for religious reasons to attain God/ Moksha
- P-Person. Health education is committed to the health of every person. As a result, individuals should be empowered to make informed health decisions. E-Extended Family. Health education is concerned with not only the immediate nuclear family, but also with extended kinships. Such focus on extended family should also take into account family lineage. N-Neighborhood Health education is committed to promoting health and preventing disease in neighborhoods and communities. Involvement of community members becomes critical in providing culturally appropriate health programs. P-Predisposing. These are knowledge, attitudes, values, and perceptions that may facilitate or hinder personal motivation to change. For example, if there is a cultural belief that consuming sweet items (e.g., sugar) causes diarrhea it will be a serious challenge to promote oral rehydration solutions (ORS), which contains sugar, as a therapy for diarrhea. E-Enabling. Societal, systematic, or structural influence or forces that may enhance or be a barrier to change, such as availability of resources, accessibility, referrals, skills, types of services (e.g., traditional medicine). N-Nurturing. These are reinforcing factors that a person may receive from significant others. Examples include attitudes and behavior of health and other personnel, peers, feedback from extended family kinship, employers, government officials. P-Positive Behavior. These are behaviors that are known to be beneficial and must be encouraged. This is very critical in program success and sustainability. E-Exotic Behavior. These are unfamiliar practices and/or behaviors that have no harmful health consequences; therefore, one must not attempt to change them. An example is wearing of amulets around a child’s neck to ward off evil spirit. In fact, some physicians have actually used this practice on their paediatrics patient with the instruction that only they (the physician) can take them off. This helps to guarantee that the parent will return for a follow-up visit. Public Health should address “what is” and not “what ought to be.” Therefore one must refrain from moralizing behaviors that are unfamiliar. N-Negative Behavior. These are behaviors that are harmful to health and, therefore, health providers should attempt to change them. An example is unprotected (against disease or unwanted pregnancy) sexual intercourse.
- Ethnocentrism is "my culture's the best in every way." Cultural relativism is "Every culture is equally valid, so you have no right to impose your culture's values on other cultures. This is a natural tendency, because the survival and perpetuation of a culture depend on teaching children to accept it and on its members feeling that it is a good thing.
- 3. The delivery of high-quality primary health care that is accessible, effective and cost efficient requires health care practitioners to have a deeper understanding of the socio-cultural background of patients, their families and the environments in which they live. Culturally competent primary health services facilitate clinical encounters with more favorable outcomes, failure to follow instructions because they conflict with values and beliefs may raise a presumption of negligence on the part of the provider.
- These five elements must be manifested in every level of the service delivery system. They should be reflected in attitudes, structures, policies, and services.
- There were no bilingual providers or interpreters at the previous medical encounters. lack of translation resulted in the physician's decreased understanding of symptoms and delayed diagnosis, and the patient's prolonged suffering, increased frustration, and loss of employment. In this case, rather than disregarding the practices and beliefs of the patient, the physician contacted the herbalist who was instrumental in maintaining the patient's compliance with the therapeutic regimen.
- The Jogini can be traced back to medieval South India. It appears that at that time a woman would become a Jogini in order to upkeep the services of the temple Their roles would include sweeping the temples, carrying the utensils for worship and dancing for the gods. Towards the end of this period, a schism appeared between the ‘clean’ and ‘unclean’ castes, and each group began to take on certain roles. According to the state government of Andhra Pradesh, there are 16 799 Jogini. One-third of the districts across Andhra have no surveillance. It is estimated that 50% of the Jogini in Andhra are unreached by this data. Many of these women are suffering from sexually transmitted infections due to high-risk sexual activity. They r youngest and the age of onset of sexual activity is also earlier than women used for sexual intercourse in India. Also dey tke average 2.6 more clients per week than the average sexually exploited woman. All of these factors contribute to the fact that Jogini are more likely to be HIV positive than the average woman used for sexual intercourse in India. Furthermore, Jogini have an AIDS-associated mortality rate of 2.44/100 person-years, which is 10 times higher than the national mortality rate among women in India. There have been many attempts to stop Jogini practice. The states of Karnataka and Andhra Pradesh enacted the Devadasi (Prohibition of Dedication) Acts during the 1980s. The Karnataka Devadasis Act was adopted by the State Legislature in 1982 and made it illegal to dedicate a Jogini (Andhra Pradesh Act was adopted in 1988). There is a fine of 5000 rupees (US $82) and up to a 5-year prison sentence. The fine and jail sentence are applicable to any person found to be involved in dedications.As of 2009, there have been 45 cases and one conviction in Karnataka. In Andhra Pradesh, there have been seven cases and no convictions. the incidence of mental health problems among Jogini women is high—92% of Jogini women report depression and 57% report that they have attempted suicide.
- Chhaupadi culture in Nepal is that threat wherein menstruating women have to live outside of the home in a shed-like dwelling. A number of taboos and sociocultural restrictions still exist concerning menstruation, which intimidate women and makes their life difficult. These studies and reports indicate that Chhaupadi might be a major cultural factor that is responsible for women’s poor health status. Anemia and underweight (body mass index <18) of women was 2-fold higher and child health status was poor in Chhaupadi-affected areas in comparison with the national average because small children live together with their mothers in Chhaupadi during the menstruation period. Reproductive health problems like severe bleeding, backache, and lower abdominal pain are worsening during Chhaupadi stay and some of the women fall prey to negative health behaviors such as smoking and alcohol consumption throughout their Chhaupadi stay.20 Genital infections due to lack of menstrual hygiene, undernutrition due to some food barriers, and uterus and cervical problems due to heavy working, and recurrent infection of human papillomavirus are the major consequences due to Chhaupadi stay.21 Chhaupadi itself does not cause any disease or illness, but it facilitates an unsafe menstruation period. As a result, it increases reproductive tract infection for women due to poor hygiene (limited access to water) and maternal malnutrition (some food restriction), and after continued use it increases behavioral problems (due to isolation, substance abuse, and stigmatization).
- . because small children live together with their mothers in Chhaupadi during the menstruation period.
- FGM is practised for a variety of sociocultural reasons, varying from one region and ethnic group to another. The primary reason is that it is part of the history and cultural tradition of the community. In many cultures, it constitutes a rite of passage to adulthood and is also performed in order to confer a sense of ethnic and gender identity within the community. social acceptance is a primary reason for continuing the practice. safeguarding virginity before marriage, promoting marriageability (i.e. increasing a girl’s chances of finding a husband) ensuring fidelity after marriage preventing rape providing a source of income for circumcisers Some communities believe that FGM is a religious requirement, although it is not mentioned in major religious texts such as the Koran or the Bible. In fact, FGM predates Islam and is not practised in many Muslim countries, while it is performed in some Christian communities (5).
- revalence of female genital mutilation among Muslim Kurdish women in Erbil city is very high; although, most cases are of type I. There is clear lack of knowledge about the health consequences of female genital mutilation and a relatively important segment of women support this practice. Custom or tradition and dictate of religion are the main reasons for this practice that need further in-depth exploration.
- 1. Culture is not merely defi ned by national, ethnic, or racial affi liation. Culture consists of conventional understandings manifest in actions, institutions, and things. 2. The systematic neglect of culture in health is the single biggest barrier to advancement of the highest attainable standard of health worldwide (availability, accessibility, acceptability, and quality). The cultural practices of individuals and groups served should be better understood and acknowledged so that care systems can adjust practices in the interest of promoting wellbeing and reducing waste. 3. Sensitisation to the norms and values of those who use care services is essential if professionals are to improve adherence. Health-care providers cannot usefully present information to patients if patients do not understand the merits of adherence to treatment within their existing values and concerns. 4. Patients should therefore be educated on how they can empower themselves within their local cultures and the cultures of care that serve local needs. 5. The training of caregivers needs to change substantially. Medical hierarchies and medicine’s hidden curriculum of prestigious imitation (hierarchical attitudes, values, and perspective taught implicitly to caregivers) should be openly acknowledged so that clinical students and staff can spend less time reporting to superiors and more time engaging with patients and understanding their needs. Teaching communication skills should not be optional (conveying implicitly or explicitly to students of health care that such training is less valued). 6.
- We practice medicine most often from a medicocentric point of view. In our role as physicians, the tradition of medicine and the medical culture often override our own individual cultures when caring for patients. Training to augment our ability to care for our increasingly diverse society should be integrated in medical schools, residency programs and continuing medical education for practicing physicians. We must be willing to participate in lifelong learning that helps integrate the principles of biomedicine with the many beliefs and values of our patients. We can accomplish this by improving communication, knowledge, and negotiations to reach an agreement for the best medical care possible.