Editorial OPEN ACCESS

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Tukuitonga C. Pacific Health Dialog 2018; 21(1):5-7 DOI: 10.26635/phd.2018.901

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Impact of Culture on Health

Colin Tukuitonga

Perceptions of physical and emotional wellbeing differ considerably between and within communities and societies. Ideas about health are, therefore, cultural. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, ethical, and moral practices and values.¹

Good health is the result of complex interactions between individual genetic makeup and the influences of the environment in which the person lives. In general, environmental factors are much more dominant in most cases.

Environmental factors include proximal risks such as tobacco use, poor diets, risky behaviours which are in turn influenced heavily by distal and broader determinants such as social, economic and political factors. Income has been shown to be a major influence on health as it is closely associated with education and social status or class.

Much has been written in New Zealand and internationally on the socioeconomic determinants of health. The World Health Organization (WHO) established the Commission on the Socioeconomic Determinants of Health, which has had a significant influence on how health and wellbeing is characterised.² In 2004, the NZ Public Health Commission published the most authoritative report on the socioeconomic determinants of health in NZ.³ In general, people at the lower end of the socioeconomic spectrum have poorer health status. The wealthy tend to have better health compared with the poor. In response to the rising burden on Non- communicable diseases (NCDs) such as diabetes and heart disease, there is also increasing reference to the ‘commercial determinants’ of health such as the production and consumption of highly processed food items, culminating in the increasing prevalence of obesity and NCDs.

Factors that influence the commercial determinants of health are even more complex because of increasing globalisation, free trade and the relentless pursuit of profit by the private sector.

Health determinants are heavily influenced by the cultural context and environment in which people live and work. Cultural influences not only have a direct effect on health and wellbeing, but also indirectly through its impact of risk factors such as smoking. Health determinants are also multi- dimensional and interconnected. For example, obesity is more prevalent among those in lower socioeconomic groups, which in turn are thought to reflect higher consumption of lower quality food items and reduced levels of physical activity.

Consumption of low quality food items generally reflect the fact that these products are cheaper than healthier food items. In many of these communities, there is predominance of fast food outlets compared with wealthier suburbs. In the case of NCDs, the interconnected nature of the risk factors leads to what is described as an

‘obesogenic’ environment.

What is Health?

The classic WHO definition of health states that “it is a state of complete physical, mental and social wellbeing, and note merely the absence of disease or infirmity.”⁴

This construct has been criticised for failing to take into account the spiritual dimensions of health, especially by indigenous communities, who adopt a socioecological approach to health.

Director-General, Pacific Community (SPC), Noumea, New Caledonia. [email protected]

Citation: Tukuitonga C. Impact of Culture on Health.

PacHealthDialog 2018; 21(1):5-7. DOI:

10.26635/phd.2018.901

Copyright: © 2018 Tukuitonga C. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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6 Pacific people and Maori in NZ have provided

useful and broader definitions of health including Te Marae Ora (Cook Islands) Te Whare Tapa Wha, which includes maki kopapa or taha tinana (physical health), maki vaerua or taha wairua (spiritual health), anau ora or taha whanau (family health) and maki manako or taha hinengaro (mental health).⁵

Socioecological perspectives on health recognise the importance of culture in shaping wellbeing, unlike traditional and conventional models which adopt more technical and somewhat reductionist definitions. Differences in perspectives on health and wellbeing can cause conflict between health care workers who are trained in conventional western settings and health care users.

Increasing awareness of these differences and support provided to health care workers to be more culturally aware would assist interactions and improve health outcomes.

What is Culture?

Culture is a pattern of ideas, customs and behaviours shared by a particular group of people or society. It is constantly evolving. The speed of cultural evolution varies. It increases when a group migrates to and incorporates components of a new culture into their culture of origin.

Pacific people in NZ have kept much of their traditions and customs from their island homes and incorporated many elements from indigenous Maori, European and Asian cultures.

Children and young people often struggle with being ‘between cultures’– balancing the ‘old’ and the ‘new’. They essentially belong to both, whereas their parents often belong predominantly to the ‘old’ culture.⁶

One way of thinking about cultures is whether they are primarily ‘collectivist’ or ‘individualist’.

Knowing the difference can help health professionals with diagnosis and with tailoring a treatment plan that includes a larger or smaller group. Pacific cultures tend be ‘collectivist’ in nature where the health of the individual or closely aligned with the health of the family or whanau.

The influence of culture on health is vast. It affects perceptions of health, illness and death, beliefs about causes of disease, approaches to health promotion, how illness and pain are experienced and expressed, where patients seek help, and the types of treatment patients prefer.⁶ Both health professionals and patients are influenced by their respective cultures. New Zealand and other developed nations’ health system has been shaped by the mainstream beliefs of historically dominant cultures. The

evidence is clear that health care providers from the same ethnic or cultural group tend to achieve better health outcomes.

The closeness and unique relationships between NZ and the Pacific countries contributes to the maintenance of the cultural practices that seem to be increasingly recognised as important to the health and wellbeing as well as socio-economic gains for the countries.

Cultural bias may result in very different health- related preferences and perceptions. Being aware of and negotiating such differences are skills known as ‘cultural competence’ or ‘cultural quotient’ (CQ). This perspective allows care providers to ask about various beliefs or sources of care specifically, and to incorporate new awareness into diagnosis and treatment planning.

Demonstrating awareness of a patient’s culture can promote trust, better health care, lead to higher rates of acceptance of diagnoses and improve treatment adherence.⁶

Pasifika people in New Zealand are often regarded as one homogenous group to simplify government policies and implementation processes. Pasifika people as a group provides strength in numbers at the cost of the reducing the impact of the diversity of cultures based on their island of origins. This diversity of cultures is further enhanced by the increasing intermarriage between Pasifika people and Maori, European (palagi) and Asians as seen in the successive census.

How does Culture impact on Health?

Health is a cultural concept because culture frames and shapes how we perceive the world and our experiences.⁶ Along with other determinants of health and disease, culture helps to define:

• What patients and health care providers believe about the causes of disease. For example, some Pacific patients believe in fatalism, the devil, or a demon as the cause of their condition. They may not accept a diagnosis and may even believe they cannot change the course of events. Instead, they can only accept circumstances as they unfold.

• Which diseases or conditions are stigmatized and why. In many cultures, a mental illness is a common stigma and seeing a psychiatrist means a person is “crazy”. Importantly however, communities having identified the health issues of the person, tend to rally to provide the support structure required to allow the person to function within a safe environment.

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• How illness and pain are experienced and expressed. In some cultures, stoicism is the norm, even in the face of severe pain. In other cultures, people openly express moderately painful feelings. The degree to which pain should be investigated or treated may differ.

• Where patients seek help, how they ask for help, and perhaps, when they make their first approach. Some cultures tend to consult traditional healers first, saving a visit to the doctor for when a problem becomes severe.

• Patient interaction with health care providers.

For example, not making direct eye contact is a sign of respect in many cultures, but a care provider may wonder if the same behaviour means her patient is disrespectful or depressed.

• The degree of understanding and compliance with treatment options recommended by health care providers who do not share their cultural beliefs. Some patients believe that a physician who doesn’t give an injection may not be taking their symptoms seriously.

• How patients and providers perceive chronic disease and various treatment options.

CONCLUSION

As populations become more diverse and societies evolve, health care workers must adapt and be aware of the differences that exist in different groups about their attitudes to health and wellbeing. Furthermore, health care workers need support to ensure that health care interventions are well understood. Attitudes and practices are shaped in large measure by the culture of the individual. The emergence on Pacific Community owned primary health care services in New Zealand is a good development.

More training and support is needed for the health care workforce to better understand cultural influences on health and health care practices.

Competing Interests: None declared Funding: None

REFERENCES

1. Napier A.D., Ancarno C., Butler B., Calabrese J., Chater A., et al. The Lancet Commissions.

Culture and health. Lancet 2014 (384) 9954, 1607-1639.

http://www.thelancet.com/journals/lancet/a rticle/PIIS0140-6736(14)61603-2/fulltext

Accessed on 15 January 2018.

2. Solar O, Irwin A. A conceptual framework for action on the Social Determinants of Health.

World Health Organization 2010 Geneva.

http://apps.who.int/iris/bitstream/10665/4 4489/1/9789241500852_eng.pdf Accessed on 15 January 2018

3. Advisory Committee on Health and Disability.

The Social, Cultural and Economic determinants of Health in New Zealand:

Action to Improve Health. 1998. ISBN: 0-478- 10474-X.

https://www.health.govt.nz/system/files/do cuments/publications/det-health.pdf.

Accessed on 15 January 2018.

4. World Health Organization. About WHO.

Constitution of WHO: principles.

http://www.who.int/about/mission/en/

Accessed on 10 February 2018.

5. Ministry of Health. Maori health models – Te Whare Tapa Wha.

https://www.health.govt.nz/our- work/populations/maori-health/maori- health-models/maori-health-models-te- whare-tapa-wha. Accessed on 10 February 2018.

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