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Culture , Health and Illness. Prof.Dr .Selma KARABEY.
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Culture, HealthandIllness Prof.Dr.Selma KARABEY
“Ifyouwishtohelp a communityimproveitshealth, youmustlearntothinklikethepeople of thatcommunity. Beforeasking a group of peopletoassumenewhealthhabits, it is wisetoascertaintheexistinghabits., howthishabitsarelinkedtooneanother, whatfunctionstheyperform, whattheymeantothosewhopracticethem” (Paul, 1955)
Culture • The sum of values and traditional ideas transmitted to individuals in a communityover a period of time, or patterns of behavior acquired or learnedand transmitted by human groups. • Culture includes how people behave,think, and communicate their values, ideas, customs, attitudes, beliefs, andmores (Huff & Kline, 1999; Tischler, 1993).
Culture • Sharedideas, meanings, andvalues • Sociallylearned, not geneticallytransmitted • Patterns of behaviorthatareguiededbysharedideas, meanings, andvalues • Oftenexists at an unconscious • Constantlybeingmodifiedthrough “livedexperiences” (Institute of Medicine, 2002)
Health • The physical, mental, social, and spiritual well-being and fitness that individualsenjoy. • Health is not just freedom from disease but is multidimensionaland is to a large extent culturally defined. • Health may be defined as the quality of a person’s physical, psychological,and sociological functioning in a variety of personal and social situations(Bedworth & Bedworth, 1992).
Illness Illnessrefers • to what the person feels is wrong and not what a doctor says or discovers isamiss (Bond & Clark, 2002; Crane & Martin, 2002).
Disease • The failure of an organism to adequately or appropriately counteractstresses or stimuli, which can be biological, behavioral, or environmental,resulting in sickness or disability.
Peoplemixupdifferentmedicalsystem! • A 16-countrystudy of communityperception of health, illnessandprimaryhealthcarefoundthat in all 42 communitiesstudied, peopleusedboth Western biomedicalsystemandindigeniouspractices. • Experience has shownthathealthprogramsthat fail torecognizeandworkwithindigenousbeliefsandpracticesalso fail toreachtheirgoals.
ExamplesfromTurkey • Use of “taharet bezi” • Incision of forehead in jaundice. • Drinkingurine in urticaria.
Dualism • Another school of thought among the ancient Greeks, however, proved tobe more influential. • The philosophy of dualism considered the body as part ofthe material world and therefore subject only to physical laws. • In contrast,mind was non-material, much like the soul and not subject to physical laws. • Consequently, for the dualists, the body is like a machine and physical illnessor health is a function of physical causes. Interpersonal relationships, socialcontext, and socialization were seen as distal, minor players in the competitionbetween physical health and illness. • Dualistic philosophy dominated Western thought for centuries.
SocialandPsycologicalFoundations of HealthandIllness • The idea that social factors play a role in physical health and well-being isnot a new one. • Hippocrates, the father of medicine, observed that the social relationshipbetween patient and physician was important for recovery. • However, an empirically based approach that focused on the role ofsocialpsychologicalprocessesforetiology, prevention, treatmentandadaptationto physical illness was only pioneered in the 1950s and did not gatherfull-steamuntilthe 1970s.
HASTALIK & RAHATSIZLIK(Disease & Illness) • If it is recognized in biomedicine, theillnessthatpersonfeelswould be diagnosed as “disease. • Althoughillnessexists, but ifdisease can not biologicallydetected, then, bybio-medicine, it is diagnosed as “psycho-somatic”. • Thissituation is realfortheclient, but forphsycian? • InTurkey, pschologicalillnessesareexpressedthrough body languageespeciallyamongwomen.
CULTURE & MENTAL ILLNESS& MEDICALIZATION • Approachtothementalilnesses is different in variouscultures. • Inourculture, peoplewhohavemoderatementalillnesswould be tolerated. • Peoplewhohavebeendiagnosed, whohavegotmedicineandclinicaltreatment in western cultures can maintainsocial life andwork. • “Yaramaz” kidsin ourculturemayhaveobligedtolong-life druguse as thediagnosis of “AttentionDeficiencySyndrome” in USA.
MEDICALIZATION • Perhaps, it is an expression of commonand “normal” condition as a disorder. • Post-traumaticStressDisorder:Itwasdefined in theAmericansoldierscomingbackfromtheVietnam War. • It is a “fictive” disorderaccordingtosomestudies of medicalanthropology. • On theotherhand, insurancecompanies in USA onlymake a payment in theconditionsdefined as disorders.
Western MedicineFails!!! • Itoveremphasizestobiology. However, themostimportantcurrenthealthproblemsdepend on humanbehaviorand life style (e.g. COPD, diabetese, Cerebrovascularaccidents, Ischeamicheartdisease).. • Itfocuses on disorders. Preventionandpromotion of healthare not priorities of modern, western medicine.
Western MedicineFails!!! • Itacceptsonlyitself. Itignorestheconditionsthose can not be defined in it. • Itignoresthepersonalrequestsanddecisions of people/patients. • Itrefusestheapproachesbesides western medicineandstigmatizethem as “unscientific” • Western medicinefocuses on thehealthproblemsdefinedbyrichcountries.
Itshould be consiedered: • De factoapproacheswouldextremelychangeand be relativeaccordingtothe time, region, conditions, institutionsandpeople. • Therearepyshological, socialandculturaldimensions of everyhealth/illnessbehavior. Ifonly it is wellunderstood, then, it would be developedappropiateapproachestothepeopleandculture. • Forthat, medicinehighlyneedstosocialscience.
SocialSciencesthatexamineculturalandbehavioralparameters • Anthropology • MedicalAnthropology • Psycology • SocialPsychology • HealthPsychology • Sociology • MedicalSociology
Peoplehaveit up to their noses with conflicting medical advice. • So they junk all the advice and return toeatingjunkfood. • In a studyconducted in Washington, morethantwo-thirdsof the respondents asserted that the government should not tell people whatto eat, and many complained about low-fat diets. • More importantly, peopleevidencing high “nutrition backlash” ate more fat and fewer servings of fruitsandvegetables. (Patterson et al., 2001).
Turkey is gainingweighttoo! TÜİK, Sağlık Araştırması, 2012TurkStat, HealthSurvey, 2012
Risk Behaviors • Risk behaviors cluster inpatterns that in combination influence a person’s risk ofdisease. • Sedentary life-style in industrial societies: • taking little exercise, • eating foods of poornutritional value, • consuming caloric drinks and • smoking cigarettes.
Risk Behaviors • While these factors donot determine disease in an inevitable sense, they placethe person at elevated risk of obesity, high bloodpressure, and subsequently of cardiovascular disease aswell as impairment of musculoskeletal health. • Otherunhealthful behavioral patterns include the connectionsamong smoking behavior,malnutrition, and drug taking,and those among alcoholism, aggression, violenceand suicide. • Each of these patterns is reinforcedby membership in a social milieu that brings similarpeople together, as well as by individual personal traits. • Each pattern also trends to correspond to personal valuesand beliefs, which form the connection betweenbehaviorandculture.
TheTermanCohort • The best means of ascertaining healthylifestyles and understanding health-promoting life pathways is through longtermlongitudinalstudy. • TheTerman Life CycleStudybeganin 1921–22 when most of the 1,528 participants were in elementaryschoolin the San Francisco and Los Angelesareas. • Continued until the present, it is the longest study of a singlecohort ever conducted, and the only such major study with rich data collectedregularly throughout the life-span (from childhood to late adulthood anddeath.
TheTermanCohort • Data havebeencollected and refined on the subjects’ social relations, education, personality,habits, careers, families, mental health, life stress, physical activities, and physicalhealth; death certificates and coded dateandcause of death. • The study was originally focused on addressing suchissues as whether bright children were introverted eggheads. • The average birth date was 1910. • The data are collected prospectively, without any knowledge ofthe eventual health outcome, thus avoiding several common sources of biasin the data collection phase of such studies.
TheTermanCohortNeglect of Precursors and Complex Causal Pathways,Including Self-selectionintoEnvironments • Just as phototropicplants move towards a source of light, some individuals grow towards morefulfilling and health-promoting spaces while other individuals remain subjecttodarker, health-threateningenvironments. • There is self-selection or pull into risk conditions. • That is, peopleseek out healthier or unhealthier situations as a function of personality andpre-existingstress.
MarriageandDivorce • Numerous epidemiological studies have found that married individuals, especiallymarried men, have a significantly lower mortality risk than single anddivorced individuals. • Results confirmed that consistently married people (especially men) livelonger than those who are single due to marital breakup • Inconsistently married men had a relativehazard of mortality of almost 1.4 (40 percent greater risk), and separated ordivorced men had a relative hazard of 2.2.
Divorce • Men who experienced marital dissolution and remarriedwere at higher risk prior to age 70, and then their relative mortality riskdeclines (Tucker et al., 1999). • Strong advice to “get married” (for social support) ironicallymay increase rather than decrease one’s risk, since one cannot face the stressof divorce if one has not married. • Part of the relationship between marital history and mortality risk inthe Terman participants may be explained by childhood psychosocial variables,which were associated with both future marital history and mortality risk (Tucker et al., 1996).
Precursors • What are these lifelong pathways that the adults with a consistent and stablemarriagearetraveling? • Where have they come from, bothpsychologically and socially? • Individuals who were divorced or remarriedreported (retrospectively) that their childhoods were significantly more stressfulthan those who got and stayed married. (They scored highly on such itemsas “marked friction among family members during childhood.”)
Familystress (particularlyparentaldivorce) is known to predict unhealthy behaviors such as smoking and druguse in adolescence as well as poor psychological adjustment. • Divorce of one’s parents during childhood can certainly affect one’s futuremental health. • There is good longitudinal evidence that children of divorce,especially boys, are at greater risk for observable behavior and adjustmentproblems. • Death of a parent had very little effect, consistent withother research indicating that parental strife and divorce is a greater influenceon subsequent psychopathology than is parental death (Tennant, 1988)
Terman participants who were impulsivechildren, grew up to be both less likely to be consistently married and morelikelytodieyounger. • Childhoodimpulsivity and parental divorce predicted marital instability, and these arealso predictive of earlier mortality. • These variables explain some of the mortalitydifferential between consistently and inconsistently married participants.
As a key determinant ofhealth: Personality Sociability: • A large amount of evidence establishes that people with variouspersonal and community ties, usually termed social support, are generallyhealthier • It thus seems sensible that more sociable peoplewould be healthier, and that development of sociability in children and adolescentsshould be encouraged. • This conclusion again neglects precursors andcomplex causal pathways, including self-selection into environments.
Itturnsout that there is little evidence that sociability itself predicts health and longevity. • Sociability was strongly related to Extraversion but also significantlycorrelatedwithAgreeableness. • The Terman children who were rated bytheir parents and teachers as popular, fond of large groups and social activities,and so on did not live longer than their unsociable peers. • There was simply no evidence that sociable children were healthier or lived longer across many decades. • In fact, sociable children were somewhatmore likely to grow up to smoke and drink.
Conclusion • First, we need to examine individual lifepatterns. Rather than taking a piecemeal approach, rather than educatingpeople about endless lists of things not to do, it may prove more efficient andeffective to launch people onto healthy life paths, and intervene intensivelyonly for those few people at special high risk. • Second, we need greater focus on the social context – the person in thesituation, andsituationselection. • Third, we need to consider cultural changes, both in the medical cultureand in the broader societal culture.
PublicPolicy CommunityFactors InstitutionalFactors InterpersonalFactors IntrapersonalFactors Ecological Model of HealthBehaviour
PredisposingFactors • Knowledge • Beliefs • Values • Attitudes • Confidence • Capacity Genetics • Enabling Factors: • Availability of health resources • Accessibility of health resources • Community/government laws, priority and commitment to health • Health related skills Specific behaviour by individuals or by organizations Health Environment (conditions of living) • Reinforcing factors: • Family • Peers • Teachers • Employers • Health providers • Community leaders • Decision makers Fig. Thisportion of thePrecede-Proceed Model includesadditionallinesandarrowstooutline a theory of causalrelationshipsandorder of causationandfeedbackloopsforthethreesets of factorsinfluencingbehaviour. Inadditiontothelinesshown, an arrowfrom “enablingfactors” to “environment” wouldelaboratetheecologicalaspect of factıorsthatinfluencebehaviourindirectlythroughchanges in theenvironment. (Kreen&Kreater, 2005, p.149, withpermission)
Tanıl Bora diyor ki; Nice zamandır Diyarbakır’da fakirin derdiyle meşgul olan Dr. Mahmut Ortakaya yıllar önce Ankara’da bir tıp kongresinde, “benim halkım artık kanser olmak istiyor” diyordu, başta verem, Kürt halkının çağın çoktan geride bıraktığıhastalıklardan çektiklerini dile getirirken. Ben de naçizane, dünyanın bütün halkları adına, konuşan hekim istiyorum! İnsanınkolunu tutan, gözüne bakan, yanağını okşayan, Mahmut abi gibi hekimleri istiyorum Evet, sağaltan, yapabildiğince iyi edenve mutsuzluğu da tedavi eden hekimliğin sırrı, konuşmadadır.
Memduh Şevket Esendal’ın Tıp Öğrencisi Oğluna Öğütleri (1930’ların sonu, 40’ların başı): “Şunu da bil ki, adam doktor olunca çok bir şey bilmiş olmaz. Hekimlik birçok bilgilerin satırbaşlarınıbilmek demektir. Alt tarafları keşif olunmamış ki? Kansere tutulmamak için ne yapmalı? Hiç belli değil. Tutulunca ilacınedir? Bilinmiyor. Mikroplar ve beden mukavemeti? Bir karanlık iş? Yalnız adamlar doktoru, biliyor sanırlar ve doktor bundan istifade ederek onları avutur! Gene ölecek olur ancak doktor da avutacağınıavutur. Hekimliğin adam gövdesi ve onun sağlığıhakkında insanlığınneler bilmediğini öğrenmek olduğuna inan! Ancak adamın nabzınıtutmak, ona bir güler yüzle bakmak, onu dinlemek bu zavallı adamlara bir büyük yardımdır.”
“Hekim olmanın birinci şartı, üstü başıtemiz ve çok nazik ve sevimli olmaktır. Kaba saba, pis, eşek hekim olmaz. Hekim,yüreği acıyan, yüzü gülen, kendisi samimi olan adamdır. Bunu herkes kendine yakıştırıp yapmalı. Açgözlü, paragözlü hekim beş para etmez. Para kendiliğinden gelir. Az geldiği olursa, çok geldiğide olur.” “Bu hekimlikte sana iki sözüm, şu iki şeyi tutmaktır: ‘Biliyorum’ deyehastayı muayene etmemezlik etme. Kızıp hastaya kötü muamele etme. Senden eyilikumarak gelmiş adamıincitmek olmaz, isterse yalancıve yapmacık olsun.”
