Culture Matters PDF
Culture Matters PDF
Culture Matters PDF
The WHO Regional Office for Europe is one of six regional offices
throughout the world, each with its own programme geared to the
particular health problems of the countries it serves. The European
Region embraces nearly 900 million people living in an area stretching
from the Arctic Ocean in the north and the Mediterranean Sea in the
south and from the Atlantic Ocean in the west to the Pacific Ocean
in the east. The European programme of WHO supports all countries
in the Region in developing and sustaining their own health policies,
systems and programmes; preventing and overcoming threats to
health; preparing for future health challenges; and advocating and
implementing public health activities.
This policy brief has been developed in response to the increasing awareness among policy-makers and the public health community
of the important relationship between culture and health. By exploring the three key public health areas of nutrition, migration
and environment, the policy brief demonstrates how cultural awareness is central to understanding health and well-being and to
developing more effective and equitable health policies. Consequently, it argues that public health policy-making has much to gain
from applying research from the health-related humanities and social sciences.
KEYWORDS
CULTURAL COMPETENCY
CULTURE
HEALTH KNOWLEDGE, ATTITUDES, PRACTICE
HEALTH POLICY
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The mention of specific companies or of certain use. The views expressed by authors, editors, or expert
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endorsed or recommended by the World Health Organization stated policy of the World Health Organization.
This policy brief was developed through the WHO Regional Office for Europe. The cultural contexts of health team of the Division of
Information, Evidence, Research and Innovation, including Claudia Stein (Director), Nils Fietje (Research Officer) and Signe Nipper
Nielsen (Consultant), was responsible for and coordinated its development.
ACKNOWLEDGEMENTS
The WHO Regional Office for Europe wishes in particular to thank the principal author and editor and the six co-authors for
their valuable contributions. In addition, members of the WHO expert group on the cultural contexts of health and well-being
and a number of commentators contributed substantially to shaping and enriching the policy brief with their comments and expertise.
The authors and the WHO Regional Office for Europe therefore thank the members of the expert group on the cultural contexts of
health and well-being as well as the following commentators: Mabel Gracia Arnaiz (Associate Professor, Department of Anthropology,
Philosophy and Social Work, Rovira i Virgili University, Spain), Hakan Ertin (Associate Professor, Department of History of Medicine
and Ethics, Istanbul University, Turkey), Lotte Holm (Professor, Sociology of Food, Department of Food and Resource Economics,
University of Copenhagen, Denmark), Robin A. Kearns (Professor of Geography, School of Environment, University of Auckland, New
Zealand), Agnieszka Maj (Assistant Professor, Department of Social Sciences, Warsaw University of Life Sciences SGGW, Poland), Ilkka
Pietil (Senior Research Fellow, Faculty of Social Sciences, University of Tampere, Finland), Suvi Salmenniemi (Associate Professor
of Sociology, Department of Social Research, University of Turku, Finland), Baktygul Tulebaeva (PhD candidate, Research Assistant,
Department of Social and Cultural Anthropology, Goethe University Frankfurt, Germany), and Catharine Ward Thompson (Professor
of Landscape Architecture, University of Edinburgh, United Kingdom). Thanks also to Jessica Frances Marais, who provided skilful
content and language editing. The Wellcome Trust generously funded the policy brief.
AUTHORS
Co-authors
Michael Depledge (Professor of Environment and Human health, European Centre for Environment and Human Health, University
of Exeter Medical School, United Kingdom)
Michael Knipper (Associate Professor, Institute of the History of Medicine, Faculty of Medicine, Justus Liebig University, Germany)
Rebecca Lovell (Research Fellow, Biodiversity and Health, European Centre for Environment and Human Health, University of
Exeter Medical School, United Kingdom)
Eduard Ponarin (Professor and Director, Laboratory for Comparative Social Research, National Research University, Higher School
of Economics, Russian Federation)
Emilia Sanabria (Lecturer in Social Anthropology, Department of Social Sciences, cole Normale Suprieure de Lyon, France)
Felicity Thomas (Senior Research Fellow, University of Exeter Medical School, and Co-Director of the WHO Collaborating Centre
on Culture and Health, University of Exeter, United Kingdom)
v
Contents
Summary....................................................................................................................................vi
Background............................................................................................................. viii
Policy options............................................................................................................ xi
References.............................................................................................................................. xiii
What is culture?.......................................................................................................... 1
Expanding the evidence base on the cultural
contexts of health and well-being....................................................................2
Policy options.............................................................................................................. 3
Conclusion................................................................................................................................26
References................................................................................................................................. 27
vi Culture matters: using a cultural contexts of health approach to enhance policy-making
Summary
In the WHO European Region, the roll-out of the policy framework
Health 2020 effectively reintroduced well-being as a central concern
for WHO, re-engaging public health with the full complexity of
subjective, lived experience and opening the door to a more systematic
engagement with the cultural contexts of health and well-being. This
shift was reinforced by the adoption of the 2030 Agenda for Sustainable
Development, which provides an additional mandate for seeking to
understand and address cultural contexts. Like Health 2020, the 2030
Agenda asserts that tackling some of the most pressing global problems
health inequities included requires people-centred, whole-of-society
approaches as well as multidisciplinary and multisectoral partnerships.
It calls for a new evidence base that affirms the relevance of cultural
contexts of health and well-being to policy development.
This policy brief, developed through the WHO Regional Office for
Europe together with its expert group on the cultural contexts
of health and well-being, forms part of a larger project aimed at
promoting a culturally grounded approach to enrich policies related to
health and well-being. The project on the cultural contexts of health
and well-being argues that incorporating cultural awareness into
policy-making is critical to the development of adaptive, equitable and
sustainable health care systems, and to making general improvements
in many areas of population health and well-being.
related humanities and social sciences, and from broader public health
and health services research.
Addressing the ways in which values are embodied and lived out in
these and other areas can have a significant impact on health and well-
being outcomes. With this in mind, the policy brief encourages policy-
makers to engage critically and creatively with the material presented
here, and to adopt an inclusive approach to improving health and well-
being policies by taking cultural contexts into account.
viii Culture matters: using a cultural contexts of health approach to enhance policy-making
Executive Summary
Background
1. to make the case for attending to the cultural contexts of health
and well-being;
2.
Develop clear opportunities and guidance for policy-makers to
explore and reflect upon their own cultural conventions and
how these influence perception and decision-making.
3.
Support an expanded evidence base that includes research
from the humanities and social sciences, with a focus on mixed-
methods research on the social and cultural drivers of health
and well-being.
1.
Nutrition: effective policy-making on nutrition means
understanding how cultural contexts impact food choices that
lead to better or worse outcomes, and how food practices can
reinforce or destabilize health and well-being, social trust, and
community resilience.
3.
Migration: effective policy-making on migration and health
means examining how culture mediates both caregiving and
care receiving in cross-cultural and multicultural contexts, and
addressing the urgent need for culturally sensitive assessments
of health and well-being as well as relevant approaches to
health care delivery.
Policy brief, no. 1 xiii
References
1. Beyond bias: exploring the cultural contexts of health and
well-being measurement. Copenhagen: WHO Regional Office
for Europe; 2016 (http://www.euro.who.int/__data/assets/pdf_
file/0008/284903/Cultural-contexts-health.pdf, accessed
13 February 2017).
What is culture?
"It is clear that innovative In addition, vulnerable populations often lack opportunities to
and adaptive mixed- become involved in well-being studies or feel reluctant to do so,
methods research is particularly when their situation leaves them feeling alienated or when
essential to advancing daily survival is a pressing concern. When this is the case, tools for
human health and measuring well-being can unintentionally reinforce power imbalances
well-being." that deny certain groups a voice in the decision-making processes that
affect their lives.
Policy options
1.
Promote an understanding of the interrelationship between
culture and health. This requires a definition of culture that
resists conflation with race or ethnicity, and underscores that
all thought and behaviour is informed by cultures of value
and practice.
4 Culture matters: using a cultural contexts of health approach to enhance policy-making
2.
Develop clear opportunities and guidance for policy-makers to
explore and reflect upon their own cultural conventions and
how these influence perception and decision-making. These
could include a range of self-evaluative workshops, diversity
education training programmes and other activities that build
heightened self-awareness and enhanced communication skills
regarding shared practices and perceptions.
3.
Support an expanded evidence base that includes research
from the humanities and social sciences, with a focus on
mixed-methods research on the social and cultural drivers of
health and well-being. This requires the inclusion of diverse
voices, the development of methods for asserting the place of
lived experience as recognized and valued evidence, and the
integration of qualitative findings into quantitative data sets.
4.
Incorporate subjective definitions, experiences and
measurements into health and well-being policy development
in order to better identify and address the needs of diverse
groups and to better interpret quantitative information.
This requires the development of new vulnerability and
resilience assessment strategies, and could involve the use of
interactive communication platforms to facilitate ongoing
exchanges among researchers, individuals and communities
related to perceptions of health, well-being, illness and
treatment practices.
5.
Identify ethical dilemmas that may arise when systems of
value related to health and health care diverge. This requires
the creation of inclusive public settings (for example, open
policy forums and policy-driven web-based discussions) in
which those with a lesser voice can directly inform policy-
makers about obstacles to adherence and prevention, and/or
the training of new professionals to assess, understand and
represent the health needs of culturally diverse communities.
6.
Support the development of instruments that increase
knowledge of the importance of culture to health and well-
being, and measures for evaluating the cultural competency
of services and policies. Such instruments could include
cultural competency toolkits, training workshops, knowledge
translation platforms and other support mechanisms. Such
Policy brief, no. 1 5
7.
Increase capacity for working intersectorally by introducing
well-being and culture as central elements of a health-in-
all-policies approach. This must be demonstrated through
significant, visible commitment on the part of policy-makers to
a whole-of-society and whole-of-government approach.
8.
Share good practices. A culturally grounded approach to health
and well-being benefits from a multiplicity of perspectives, and
from new settings in which good practices can be shared. As
communities experiment with new strategies and practices,
it will be critical to document and disseminate successful
innovations that are replicable and scalable.
6 Culture matters: using a cultural contexts of health approach to enhance policy-making
Research confirms that the act of receiving food the first behaviour
through which humans learn to create and sustain relationships with
others is infused with meaning and symbolism that emerges socially
and culturally (12). As a concrete vehicle for building relationships, the
"Alimentary health, and shared meal has immeasurable sociological significance (1320). Values
the attempts of policy- related to hunger, satiety, excess, pleasure, satisfaction and restraint
makers to support or are all expressed through the experience of imbibing food with others,
improve it, must be and have direct impacts on food choices and health outcomes. As such,
viewed within the alimentary health, and the attempts of policy-makers to support or
framework of culture." improve it, must be viewed within the framework of culture.
Policy brief, no. 1 7
WHO estimates that 415 million people across the globe currently live with diabetes. 1 To put this number in
perspective, if these people were to form a country, it would be the third-most populated country the world.
Whats more, a single risk factor for diabetes overweight and obesity is a reality for about 2.1 billion
people: 30% of the planets population. If not reversed, diabetes-related mortality and morbidity are predicted
to crush entire health care systems in the next 15 to 20 years. The cost of this epidemic in terms of both
human suffering and economic burden is devastating.
Most of us think of diabetes as principally a clinical illness, and yet, in some countries, more than 90% of
diabetes mortality and morbidity is socially and culturally mediated either by non-diagnosis or by non-
adherence to treatment. According to the
so-called rule of halves, only half of those
living with diabetes have been diagnosed;
among those who are diagnosed, only
half are treated; among those receiving
treatment, only half are adhering to
recommended regimens; and finally, among
those who adhere, only half are achieving
treatment targets. 2
1
WHO Noncommunicable diseases factsheet [website]. Geneva: World Health Organization; 2015 (http://www.who.int/mediacentre/factsheets/fs355/en/, accessed 10 February 2017).
2
Hart JT. Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. Br J Gen Pract. 1992;42(356):11619.
Policy brief, no. 1 11
and often more expensive, and the cooking skills required to prepare
them are vanishing. Entire urban neighbourhoods are now classified
as so-called food deserts areas where affordable and nutritious foods
are no longer accessible without sufficient income and/or access to an
automobile (45).
The implications of these changes for the health and well-being of food
producers themselves are startling. In India, for example, thousands
of suicides are attributed to small-scale farmers inability to afford
the continual purchase of patented, genetically modified seeds and
accompanying pesticides on which their incomes, and depleted soils,
have come to depend (50).
Policy options
1.
Support research for an evidence base that affirms food and
eating as expressions of culture.
4.
Ensure that healthy-eating messaging addresses the
experiential contexts in which people make sense of
nutritional advice and change their behaviours.
The Ashaninka peoples of the Peruvian Amazon believe that if all living beings are not in harmony with
the earth (Aipatsite), humans cannot achieve fulfilment and happiness. The Ashaninka call this form of
harmony living well together (kametsa asaiki), a concept that focuses more on the close relationship of
humans to landscapes than on the distinction between nature and those who inhabit it. 1,2
According to the Ashaninka, real Ashaninka people (Ashaninka sanori) are incapable of becoming the good
people they want to be unless their actions are in harmony with nature. Because the earth is where human
and other beings interact on a daily basis, people are thought to be incapable of growing healthy food,
finding new medicines or building sustainable houses and communities unless they respect its many gifts.
This entails deciding when to stay away from the deepest forests out of respect for the spirits (maninkari)
who they believe lead the souls of the dead to the afterlife. These culturally established protocols of respect
and restraint ensure that certain forests are protected from depletion and overhunting, which in turn
prevents illness and produces long-term well-being among Ashaninka peoples.
Indeed, many indigenous groups across the globe believe that the world can only avoid catastrophic disruption
if humans breathe harmony into it. For such cultures, there can be no hard and fast separation between
humans and the places they inhabit; there is an absolute obligation to sustain the environment because they
are a part of it, and because they themselves cannot survive without being its responsible caretaker.
These highly responsible beliefs about stewardship and balance, however, are challenged by long-term
social disruption, large-scale extraction of, for example, forests, oil and natural gas, and ongoing cycles
of violence against those who protest such mindless destruction. 3 This begs the question: how might
integrating environmental policies with local cultural values encourage deeper commitments to protection
and stewardship?
1
Sarmiento Barletti, JP. It makes me sad when they say we are poor. We are rich!: of wealth and public wealth in indigenous Amazonia. In: Santos-Granero F, editor. Images of public wealth or
the anatomy of wellbeing in Indigenous Amazonia. Tucson: University of Arizona Press; 2015 (139160).
2
Sarmiento Barletti, JP. The angry earth: wellbeing, place, and extractivism in the Amazon. Anthropology in Action 2015;23(3):4353.
3
Survival [website]. London: Survival International; 2017 (http://www.survivalinternational.org/conservation, accessed 10 February 2017).
Policy brief, no. 1 15
The same holds true for communities subject to the persistent noise
and loss of local wildlife from wind farms (73). The decision to replace
more dangerous nuclear power plants with large-scale wind farms
can have a corrosive effect on well-being when rural communities are
forced to accept the presence of turbines in order to offset government-
subsidized energy use in urban and industrial areas. Laudable efforts
to promote more environmentally friendly forms of power generation
may fail when local cultures are not fully considered.
In 2014, Copenhagen was named the Green Capital of Europe. Ninety-six per cent of the citys residents
live within a 15-minute walk to a park or recreation area, and citizens have access to the best network of
urban cycling paths in the world. In addition to being situated within a country that boasts the highest
happiness ratings, strong policy measures support active lifestyles and the city has relatively low levels of
lifestyle diseases. 1
Many cities across the globe have looked to Copenhagen for sustainable models of urban development.
Much of the success of Copenhagens health and environmental policies has been linked to the endorsement
of a culture in which healthy and sustainable lifestyles are highly valued.
However, recent anthropological research shows that these norms and values are not universal among
residents of Copenhagen. Women from low-income communities, for example, may associate certain healthy
and sustainable activities with a particular lifestyle that they feel is difficult to achieve. These residents are
less likely to benefit from the celebrated green spaces within their city.
The lesson from Copenhagen is clear: unless policy-makers strive actively to address issues of social
exclusion, inequalities may persist even in seemingly egalitarian environments.
1
Thomas F. The role of natural environments within womens everyday health and wellbeing in Copenhagen, Denmark. Health Place 2015;35:18795. doi:10.1016/j.healthplace.2014.11.005.
18 Culture matters: using a cultural contexts of health approach to enhance policy-making
Policy options
"For policy-makers focused for and accustomed to serving their health and welfare needs in
on migrant care, there a culturally sensitive manner.
is clearly an urgent need
to prioritize a cultural Such patterns of secondary, internal migration may provide enhanced
understanding of migrant security and well-being for migrants in the short term. Yet, they
populations." may also have adverse consequences in the longer term, as when
a receiving countrys wider population perceives cultural differences
negatively, or when migrants and their children find that isolation
from broad society becomes a key barrier to leading meaningful
lives. Indeed, when migrants feel isolated, the health consequences
are significant: they often present late for clinical care; they tend to
present with already-chronic conditions, rather than conditions that
can be effectively treated or reversed; and they are likely to present
at emergency facilities rather than more affordable, primary-care
settings focused on prevention (85).
Finally, data suggest that migrants who are not well integrated
(those who are both unemployed and undereducated) experience
disproportionately high levels of certain noncommunicable diseases.
In Denmark, for example, where health care registration is mandatory,
rates for certain noncommunicable diseases are still as much as nine
times higher for marginalized, late-presenting migrants as for health-
educated citizens of European descent (86).
Focusing on equity
A 10-year-old girl from a Lebanese family living in Germany was admitted to the hospital with diffuse
stomach pain of unclear origin. Diagnostic tests did not reveal an organic cause for her complaints. Among
physicians and nurses, a discussion evolved about culturally specific perceptions and expressions of pain.
Some alleged that patients from the Mediterranean area are known for their tendency to present with
diffuse complaints and an inappropriate exaggeration of pain. 1 In countries such as Belgium, Switzerland
and Germany, health professionals use the term Mediterranean syndrome to describe what is elsewhere
referred to as culture-bound syndrome. 2,3
During a conversation with the girl and her mother, a medical student learned about the living conditions
and social background of the patient and her family. The girl had been born in Germany. Her parents were
political refugees, but had been waiting for a definite decision about their asylum status for over 10 years.
The student also heard about their constricted living space in a collective accommodation centre, and the
adolescent brothers who disturbed the girls sleep. The girl explained that she had no retreat or quiet space
for study, and that she suffered sleep deprivation and fear about her future. She also had problems in school,
where teachers would repeatedly warn her to work more accurately and to make more of an effort. The
thing is that I know that, she said. Classmates would bully her and shout: You are not even supposed to be
here. But I was born here, the girl explained.
In advanced German, the mother described the gruelling insecurity, the guilt she felt towards the children
and the fear about the uncertain future of the family. The girls father, who had grown up in a wealthy
family and received a university education, was caring for the family as a poorly paid, unskilled worker.
As a result of this conversation, the physicians contacted a social worker known for her expertise in migration
issues and migration laws to work towards a better living situation for the family as well as educational support
for the girl. What was initially assumed to be a culturally specific presentation of pain was discovered to be
a somatization of severe social problems linked to the prolonged asylum process of the child and her family.
1
Strauss L. Gefangen im nirgendwo die geschichte der kleinen patientin Malak und ihrer bauchschmerzen [Trapped in no-mans-land the story of the little patient Malak and her stomach
pain]. In: In wei 2. Giessen: Institut fr Geschichte der Medizin; 2013 (2635) (in German).
2
Ernst G. The myth of the Mediterranean syndrome: do immigrants feel different pain? In Ethn Health 2000;5(2):1216. doi:10.1080/713667444.
3
Van Moffaert M, Vereecken A. Somatization of psychiatric illness in Mediterranean migrants in Belgium. Cult Med Psychiatry 1989;13(3):297313.
Policy brief, no. 1 23
A 16-year-old boy from a Muslim family with Turkish background living in Germany was diagnosed with
osteosarcoma, a severe bone cancer with no options for curative care. The physicians intention to inform
the boy of his condition was met with strong opposition by the family. They explained that, according to
their religion and culture, the patient must not receive this information. For the team of health professionals
in the paediatric oncology department, this was an unbearable situation; telling the truth to a nearly adult
patient and respecting the individuals right to know were essential elements of the health professionals
ethos. The familys staunch resistance to informing the patient about his diagnosis and imminent death
was thus perceived as unacceptable, and yet all attempts by the physicians and other members of the
professional team, including nurses and social workers, to convince the family were rejected. Tension and
distrust between health professionals and the family grew. 1
In an effort to mediate the conflict, a medical anthropologist asked physicians and other informants of
Turkish Muslim background for their opinion on this case. A Turkish physician, who had worked in Germany
for more than 20 years, replied with absolute clarity: We do this in a different way than you do, he said. The
physician went on to describe the surprising opinion that the family was right, that patients should not get
to know the hard truth directly.
Moreover, he drew a clear line between the Turkish and the German way to tell the truth: German
physicians inform the patients directly, with no compassion or sensibility, cold and tough. I have seen
German physicians traumatizing patients and making them feel hopeless. We are used to doing it in
a different way: the patient has to know the truth, but we communicate this in a more sensitive way,
supporting and caring for him, with religious counselling. For us, supporting and taking care of the ill
and the dying individual is most important.
After sharing and discussing this perception with the health professionals, the task of truth disclosure was
commissioned to a local Turkish paediatrician. The tension between staff and family decreased considerably.
A few weeks later, the boy was discharged from the hospital to palliative care at home.
1
Knipper, M. Vorsicht Kultur! Ethnologische Perspektiven auf Medizin, Migration und ethnisch-kulturelle Vielfalt [Caution, culture! Ethnological perspectives on medicine, migration and ethnic-
cultural diversity]. In: Coors M, Grtzmann T, Peters T, editors. Interkulturalitt und Ethik. Der Umgang mit Fremdheit in Medizin und Ethik [Interculturalism and ethics. Dealing with otherness in
medicine and ethics]. Gttingen: Edition Ruprecht; 2014 (5269) (in German).
24 Culture matters: using a cultural contexts of health approach to enhance policy-making
This trust is critical to the creation of a culture for health and well-
being, and for the development of compassionate, effective and
economically viable health care systems for all. To foster it, health
policy-makers and caregivers must reflect critically on their own
perceptions and assumptions, and actively seek to understand the
intersectoral nature of culture, migration, health and well-being.
Additionally, they must ensure that positive changes receive support
at systemic and organizational levels.
Policy options
1.
Implement diversity training across all levels and professions
of health care systems (with a particular focus on leadership
and management staff) to endorse both the ethical and the
economic imperatives for promoting culturally sensitive
health care.
2.
Increase awareness of unconscious stereotyping and of how
cultural practices and related assumptions about others can
lead to the marginalization of perceived outsiders.
3.
Create programmes that educate and empower migrants
to address their health needs preventively and proactively
Policy brief, no. 1 25
5.
Develop inclusive strategies for building social trust and
a culture for health and well-being.
26 Culture matters: using a cultural contexts of health approach to enhance policy-making
Conclusion
"An expanded evidence As outlined in Health 2020 and the 2030 Agenda for Sustainable
base, enriched by Development, incorporating cultural awareness into policy-making
subjective accounts of and policy implementation is critical to the development of adaptive,
personal experience, will equitable and sustainable health care for all. Doing so requires that
offer a more robust set of policy-makers cultivate a nuanced understanding of what culture is,
tools for improving health and strengthen their capacity to identify biases and knowledge gaps
and well-being equitably, that may interfere with effective working practice.
as well as a framework for
further illuminating the This also entails a conscious effort to engage with mixed-methods
working assumptions of research from the health-related humanities and social sciences.
policy-makers, providers Policy-makers must recognize and integrate the extensive body
and the general public." of existing knowledge into their decision-making processes, and
also support the creation of new evidence. An expanded evidence
base, enriched by subjective accounts of personal experience, will
offer a more robust set of tools for improving health and well-being
equitably, as well as a framework for further illuminating the working
assumptions of policy-makers, providers and the general public.
The broad areas of nutrition, the environment and migration offer
important opportunities for meaningful research and engagement
at the level of culture, but this is just the beginning.
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