Discuss the influence of social and cultural factors on health.

Social Sciences and Culture in Health

• The key concepts:
• Culture — the learned, shared and transmitted body of knowledge, belief, values and behaviour of a group; it is learned rather than inherited, and therefore can change
• Norms, values, customs, taboos and rituals
• Socialisation — the process by which a person acquires the culture of their group
• Social stratification — the hierarchical arrangement of society by class, caste, gender, occupation and wealth, which determines access to every resource including health care
• The family — joint, nuclear and three-generation; its functions of reproduction, socialisation, economic support, care of the sick and elderly, and emotional support
• The family is the unit of health care in practice, since illness behaviour, diet, contraception and care-seeking are family decisions rather than individual ones — which is why counselling the patient alone frequently fails
• The sick role (Parsons) describes illness as a social status with rights and obligations:
• Rights — exemption from normal social role obligations, and from responsibility for the condition
• Obligations — to want to get well, and to seek competent help and cooperate with it
• Its value is in explaining secondary gain and conflicts over certification and sickness absence; its limitation is that it fits acute illness and fits chronic illness and disability poorly, where the person cannot get well and exemption becomes permanent
• It also fits stigmatised conditions poorly, where the person IS held responsible — as with HIV, alcohol dependence, lung cancer in a smoker and mental illness
• Illness behaviour is the sequence by which a person interprets symptoms and decides to act, and it varies greatly by culture, gender, class and previous experience
• The distinction between disease and illness is central and examinable — disease is the biomedical pathology the doctor diagnoses; illness is the person’S experience of being unwell; and sickness is the social role and recognition
• They can occur separately — hypertension is disease without illness, since the person feels perfectly well; and many symptoms are illness without demonstrable disease
• The practical importance of this distinction is large — the doctor treats the disease while the patient came about the illness, and dissatisfaction arises when the second is never addressed
• It also explains adherence failure in hypertension and diabetes, since a person who feels well is being asked to take a tablet that may make them feel worse, to prevent something they cannot perceive
• Cultural factors influencing health, with Indian examples:
• Food beliefs — "hot" and "cold" classifications of foods, which determine what is given or withheld in illness, pregnancy and after delivery
• Restriction of diet during illness and in diarrhoea, when continued feeding is what is needed
• Withholding colostrum as impure, and delaying the first feed
• Food taboos in pregnancy, which restrict exactly the diet most needed
• Women eating last and least
• Beliefs about causation — evil eye, spirit possession, divine punishment, and the humoral balance of hot and cold
• Practices around childbirth — delivery by an untrained attendant, application of substances to the cord, bathing the newborn immediately, and postnatal seclusion
• The use of traditional healers, frequently as the first resort
• Stigma attaching to leprosy, tuberculosis, HIV, mental illness, epilepsy, disability and infertility
• The correct approach to cultural practices is the point of the whole topic:
• Classify practices as beneficial, neutral, uncertain or harmful
• Promote the beneficial ones actively — prolonged breastfeeding, oil massage of the infant, postnatal rest and family support in illness
• Leave the neutral ones alone, since attacking a harmless custom wastes credibility that will be needed for a harmful one
• Change only the harmful ones, and do so with respect, using local leaders and offering an acceptable substitute rather than only a prohibition
• Never ridicule a belief, since ridicule ends the relationship and the person simply stops telling you what they do
• The commonest error of a young clinician is to attack every unfamiliar practice at once, which achieves nothing except the loss of the trust needed for anything