Infrastructure is the interface of a culture with the physical environment; it includes both a population’s biological reproductive patterns that result in births and its material pro- duction system (technoeconomic system) that produces goods such as food and housing.
Population relations with the environment provide energy and resources to sustain human life but that also create exposure to disease. Consequently, cultural-environmental rela- tions affect many aspects of health.
Basic aspects of the infrastructure include food production technologies, transporta- tion facilities, communication systems, utilities (water, electricity, gas, and sewage), industries, and economic systems for the distribution of resources. Human work is basic to infrastructure and economic systems, providing the resources that support existence.
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EXHIBIT 4.1.
Conceptual Framework for Cultural System Health AssessmentsEcological Assessments Physical boundaries (mapping)
Environmental conditions and risks; EPA standards compliance
Contamination and sanitation
Demography and population structures Ethnic composition and distribution Migration, migrants, homelessness Medical and social epidemiology: principal morbidity, mortality
At-risk groups
Immunization, vaccination rates, and programs
Recreational facilities
Nutritional Practices and the Body Concepts of food, diet, and ideal body type Dietary patterns and restrictions
Low-income food support Low-birth-weight incidence Drug-use patterns
Reproduction
Biocultural profi les: ethnic risk factors, especially social and genetic
Reproductive rates and patterns
Sexual practices and prostitution; STD risks and rates
Birth control attitudes and practices; beliefs about pregnancy
Birth practices and breast-feeding Principal mortality and morbidity rates for women and children
Developmental norms and ideals; sexual surgery
Infrastructure
Material goods and economic well-being Land and property ownership
Housing and housing assistance Transportation and communication systems
Industry, markets, and exchange Emergency resources
Economics and Work Median household income Work activities and work risks
Informal economies and undocumented workers
Unemployment rates Welfare resources
Percentage of families, children, and infants below poverty level
Proportion of individuals without health insurance
Household economies and businesses Family Structures and Roles Gender roles; social relationships Attachment patterns
Single-parent prevalence Adolescent birth rates Kinship networks
Domestic violence rates; child abuse cases Adult transition patterns
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Marriage and divorce patterns Care-provision roles and patterns Community Organization
Group defi nitions; intracommunity group divisions
Informal networks Community associations Community expertise
Community structures and groups Community leaders
Political dynamics
Police and criminal justice system activities Social services
Youth organizations and gangs
Community groups with health interests Extracommunity relations
Health Organization and Infrastructure Clinics, hospitals, and emergency departments Ambulance services
Public health facilities
Public health education and outreach Health coalitions, alliances, and organizations Organizational Analysis of Health Institutions
Business environment Values and heroes Rites and rituals Structural networks
Management style and decision making Group Social Psychology
Socialization processes
Acculturation and intercultural confl ict
Self-representations; in-group versus out-group status
Values and norms Cross-gender relations Emotions
Spirituality and religion, especially health implications and support systems
Cultural event analysis: purposes, activities, and actors
Psychocultural dynamics
Education
Health education needs and programs School health programs
Learning styles School quality
High school graduation and dropout rates Literacy rates; illiterate segments
Communication
Home language and dominant language competence
Nonverbal communication; social interaction rules
Social communication: signs, gestures, styles Media services
Health Beliefs and Practices History of relations with biomedicine Perceived accessibility of health providers Health and illness concepts
Lay medical beliefs and practices Folk professional sectors and activities Explanatory Model; Health Beliefs Model Stress management practices
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Consequently, work infl uences diverse cultural institutions and health. Work provides resources for purchasing health care and, in the United States, is the primary source of health benefi ts. Work obligations may preclude seeking health care. Work often consti- tutes a hazardous place, producing many physical, social, and psychological factors that can compromise health.
Reproductive practices structure population dynamics through fertility rates, which affect group size, health conditions, and population growth. Culture infl uences demo- graphic structure and population characteristics: sex ratio, age-distributed mortality, fertility and birth rates, morbidity, mortality, population density, and distribution. These factors, in turn, affect many other aspects of health.
Diet and Nutrition
Diet is a primary context of human relationships to the environment and a fundamental determinant of health and disease. Culture shapes what is eaten, by whom, when, where, with whom, and how. Food can be a contributory factor in the development of disease, such as coronary artery disease, diabetes, and some cancers. Eating is a social event with many health implications. The use of food in social activities expresses relations between individuals and groups. Consequently, food sharing has a variety of implications for health: positive ones such as social support, bonding, and resource sharing and negative ones such as disease risks through shared utensils or unhealthy foods. Cultural concep- tions of foods have a wide range of implications integrated throughout social life. These include interpersonal obligations (e.g., wedding feasts), life events (e.g., birthdays), social rituals (e.g., drinking), and religious and moral judgments regarding permissible diet (e.g., kosher foods).
Because ideas about food are integrated within cultural systems, it is diffi cult to change diet, even when it interferes with health care. To propose therapeutic changes to a diet that will be acceptable requires a knowledge of cultural food practices. Recommended diets for the treatment of conditions are generally based on European American concepts of normal diet and customary foods and seldom include foods in the typical diets of immigrant and minority ethnic groups. Consequently, recommended diets are often not adopted. When cultural food preferences are unknown or not considered, individuals may become under- nourished because of distaste for hospital food. An effective therapeutic dietary change requires an understanding of cultural patterns of food preparation and consumption and the signifi cance of food. Food can have signifi cance as a marker of status, a means of self- gratifi cation, and a compensatory mechanism for psychodynamic conditions. Such social and personal meanings may lead to various forms of malnutrition, manifested in overeating or undereating to meet some secondary or tertiary social goals (e.g., thinness for attraction, obesity as a form of personal protection, or alcohol consumption as a social lubricant).
Foods may be viewed as medicine and are often part of lay treatments of illness. The hot-cold system of illness and healing incorporates foods to balance illnesses, external conditions, or other treatments. Natural products, particularly plant beverages, constitute self-medication. For example, a number of herbal teas used as beverages among Native Americans of the Southwest have been shown to have a variety of anti-diabetogenic properties (Winkelman, 1992b).
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Foods are used as medicine in pregnancy and lactation. Restrictions on diet during pregnancy may favor maternal and neonatal well-being or may prejudice them by restrict- ing the intake of nutrients they need. Infant nutrition is affected by a variety of factors:
Those indigenous to the culture and its patterns of resource use and distribution Cultural norms regarding the nature, frequency, and content of foods provided for infants
Governmental or market infl uences that affect the availability of foods Marketing campaigns encouraging bottle-feeding instead of breast-feeding
Sex, Conception, and Pregnancy
Sexual behavior is biologically based, socially elicited, and culturally shaped; it has many health implications, ranging from the spread of disease to the health of young mothers and their offspring. STDs are associated with promiscuity, extramarital sexual behavior, prostitution, and lower socioeconomic status. Norms affecting premarital sex, homosexu- ality, marriage, extramarital sex, and particular sex practices all have important health implications. So does the process of delivery of babies in the modern world, where bio- medicine has managed to acquire a virtual monopolistic control over legal rights to deliver babies (see the special feature, “Practitioner Profi le: Robbie Davis-Floyd”).
Birth Control All societies regulate conception through diverse means: mores, law, mar- riage, diet, work, medications, and many other cultural practices. When a woman conceives is not merely a matter of individual choice but a product of many infl uences: biological, nutritional, familial, economic, and the cultural value placed on having children. Dietary factors that infl uence the onset of fi rst menses are economic and ecological infl uences on fertility. Cultural concepts about appropriate family size and birth spacing infl uence con- ception. Pregnancy often signals the end of breast-feeding, with dietary implications for the previous child’s health. The acceptability of birth control methods varies cross-culturally, affected by cultural attitudes toward the personal signifi cance of pregnancy. Cultural norms about contact with one’s genitals affect the acceptability of procedures like diaphragms.
People’s desire for large families or a man’s assertion of virility through many children can make control of fertility unwanted. Knowledge of these cultural beliefs is important in directing appropriate birth control methods. Religious beliefs affect birth control attitudes and are a necessary component of culturally sensitive and relevant fertility counseling.
Reproductive Behaviors Pregnancy and birth are profoundly shaped by culture. Cultural responses to pregnancy may produce support, risk factors for mother and child, or con- fl icts with providers. Knowledge of these practices is necessary for bridging patient and biomedical realities through patient and provider education. Biomedical pregnancy prac- tices in the United States involve procedures not customary in other cultures: prenatal examinations, childbirth classes, ultrasonography and fetal monitoring with other obstetri- cal technologies, induction of labor, lithotomy position, and so forth. Ethnomedical models of pregnancy are important for biomedicine and public health because they constitute the
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basis from which people make decisions. Consequently, ethnomedical models are essential to the formulation of culturally relevant programs that address critical divergences from biomedical beliefs. For instance, traditional beliefs about pregnancy and fertility may increase risk during pregnancy (Snow, 1993). Pregnancy taboos—prohibitions on behav- ior during pregnancy—are found throughout the world. Many cultures view pregnant
CULTURE AND HEALTH
Cultural Issues in Mexican American Pregnancy and Prenatal Care
For many women of Mexican origin, beliefs about pregnancy have centered on the traditions of parteras (midwives). Parteras’ ideas about pregnancy and childbirth include food taboos and restric- tions on activities that are often followed as part of the management of pregnancy. Ideas of “hot”
and “cold” conditions and treatments are also important: conditions must be balanced to restore health. Pregnant women are “hot” and must avoid hot foods and hot treatment conditions or neu- tralize these conditions by taking cool substances. The postpartum woman is in a cold state and must be maintained in a warm state and fed hot (or temperate) foods to ensure the fl ow of milk; if the milk becomes cold, it could harm the baby. Restrictions for forty days of convalescence are also derived from parteras’ traditional practices.
Cultural values affect teen pregnancy rates and prenatal care. About half of all Hispanics born in the United States in recent decades were to single mothers, a phenomenon refl ecting cultural values and social circumstances. The relevance of cultural factors in addressing pregnancy risks among Mexican Americans include cultural values concerning children; negative attitudes toward and an ignorance of contraception; the value and status of parenthood; low levels of parental communication with children regarding sex, pregnancy, and contraception; low levels of the use of contraceptives; and social factors affecting access to sex education (Brindis, 1992).
The cultural value placed on children reinforces keeping a pregnancy even outside of mar- riage. Machismo and high mortality among male youth reinforces a mentality in which having a baby is a sign of manhood or womanhood and a means of intergenerational continuity. The lack of sex education refl ects both social and cultural factors. Problems arise in sex education because of low levels of parental communication regarding sex, pregnancy, and contraception and early school dropout. Early school dropout means that sex education is not obtained. Public health information from health service agencies is often ineffective because of language barri- ers, cultural confl icts in learning and instructional styles, and barriers presented by a lack of legal residency. The avoidance of teenage pregnancy requires the involvement of cultural insti- tutions, especially the family and church. Because many Hispanics drop out before fi nishing high school, where sex education is provided, parents must be encouraged to take a central role in the sex education processes. This requires a broader education to assist parents in developing communication skills and relevant knowledge through life education programs that are cultur- ally relevant and sensitive (Brindis, 1992). Communication with parents about sexual matters
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women as being in a vulnerable state or posing a threat to others by her so-called abnormal condition. Understanding cultural taboos regarding pregnancy is important in ensuring the well-being of mother and child. Pregnancy taboos can be in a woman’s favor (e.g., reducing fatty foods or foods with high risks of disease) or may negatively affect the mother and neonate (e.g., food restrictions that deprive them of protein or vitamins).
appears to inhibit teen pregnancy, as does involvement with the church, which tends to delay fi rst sexual intercourse.
Cultural factors affect prenatal care, a signifi cant factor in maternal and neonatal health. The utilization of prenatal health services by Mexican Americans is much lower than that of other groups (Moore and Hepworth, 1994). Mexican Americans were less likely than non-Hispanic whites to initiate fi rst-trimester care, obtain prenatal care, and make postnatal visits for well-baby care. These differences are present even when Mexican Americans have the same access to serv- ices. Predictors of service use included satisfaction with care, lack of transportation problems, and higher social support, advice, and assistance. Low use of care is also affected by income, ineligibil- ity for services, and cultural and language barriers to service satisfaction (Brindis, 1992).
Research on the prenatal beliefs, practices, and patterns of health utilization provide a basis from which to develop prenatal care education for low-income Mexican women (Alcalay, Ghee, and Scrimshaw, 1993). Researchers assessed the effectiveness of mass media campaigns in pro- moting the use of health care services and identifi ed appropriate communication patterns and messages. This provided the basis for designing an intervention that addressed pregnancy-related problems and the appropriate health behaviors. The pregnancy education project used communi- cation interventions based on a variety of persuasion theories that emphasized the personal rele- vance of messages, attitude changes, and new role models.
A signifi cant barrier to prenatal care is a belief that it is unnecessary if a woman feels well.
Women need to know the necessity of prenatal checkups even if they feel well. Information from practitioners does not provide adequate knowledge about appropriate weight gain, the need for iron supplements, the signs of risks during pregnancy, or supplemental dietary needs. Dissatisfaction is a barrier to care. Women’s care-seeking behavior is also inhibited by the lack of their husband’s approval for leaving the house and the inability of a man to accompany his wife because of having to work.
Traditional sex roles and objections by husbands to another man looking at his wife’s private areas are barriers to routine gynecological exams. The hospital and clinical situations where many providers examine the women also make them feel uncomfortable, and they avoid care. Because of the sociali- zation for modesty emphasized in Mexican culture, women may feel particularly strong shame and embarrassment during gynecological or obstetrical exams or in discussing sexual or reproductive issues. Examinations that involve nudity or other lack of personal privacy may result in termination of the doctor-patient relationship. Health care providers sensitive to these cultural factors can adapt by providing greater privacy or by using female personnel for interviews and examinations.
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Birth and Delivery Processes In modern societies, birth processes are managed by bio- medical institutions. But traditional beliefs and practices concerning childbirth persist.
Knowledge of these practices is important for pregnancy, labor, and delivery classes because women use their own cultural beliefs in adapting to medical settings. Traditional practices of birthing while squatting lead women to abandon the gurney and stirrups and seek an area to squat; occasionally, women in a biomedical setting who are following their tradition’s norms by seeking a private area in which to squat are discovered in custo- dians’ closets or in stairwells. Cultural norms regarding the expression of pain are relevant to understanding delivering mothers, their expressions during labor, and the relevance of pain medication or other interventions.
Cultural elements of the biomedical obstetrical practices may confl ict with cul- tural norms about modesty. Perineal shaving and routine episiotomies refl ect cultural practices of biomedicine rather than scientifi cally established procedures. Cultural beliefs about who should be the birth attendant may confl ict with American norms.
Without the recognition of cultural patterns, outreach and marketing strategies may be to no avail (such as recruiting Hispanic men to attend birthing classes to learn to be labor assistants for their wives). Understanding cultural expectations is crucial to the correct assessment of the meaning of others’ involvement or lack thereof. A man’s failure to participate in the birthing process, or even be at the hospital, may refl ect cul- tural expectations rather than a lack of interest in the mother and child. Support for the mother and her newborn also varies widely, ranging from conditions under which oth- ers accept full responsibility for the mother-infant dyad to those where mothers may fi nd little, if any, relief from ordinary responsibilities and little assistance for the care of her newborn.
Differences in delivery expectations between biomedicine and the general culture have contributed to a burgeoning of alternative birthing practices, a popular uprising against biomedicine. The development of modern obstetrical practices led to the adoption of the lithotomic position, with the mother on her back with her feet up in the air in stir- rups. While not conducive to natural labor processes, this was convenient for the physi- cian’s control. The role of culture in birthing practices is evidenced in the changes in the biomedical approach in the recent development of alternative birth centers and the rein- troduction of the nurse-midwife.
Postpartum Taboos Culture shapes a variety of postpartum behaviors affecting the health of newborns and mothers. Cultures have both formal and informal norms regard- ing the behavior of women following birth, including restrictions on activity and foods to protect the mother and newborn. Seclusion is a frequent source of protection, reducing exposure to infectious disease, providing rest and relief from ordinary work, and encour- aging breast-feeding, mother-infant bonding, and healing. Many cultures require new mothers to rest for a month or forty days. Cultural beliefs about activity, diet, seclusion, purifi cation, sex, and protection can favor or prejudice the well-being of mother and new- born. For instance, African Americans often introduce solid food in the fi rst month, a practice considered to be harmful for newborns. Of particular importance are beliefs regarding exposure to temperature extremes, bathing, activity, diet, clothing, and a variety
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