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Chapter 5

Culture and Diversity Issues in Healthcare

Imagine if you moved to a new country (where you did not speak the native language well) and you needed to go to the doctor’s office. Not only would you likely struggle to communicate your needs with the physician and other staff members, you might find that there are important other cultural differences in beliefs about health or communication behaviors among healthcare providers compared to your country of origin. For example, in some cultures, people attribute illness to spirits or bad luck as opposed to viruses or environmental causes. Culture permeates all aspects of life and it influences our perceptions and experiences of life events, including health-related situations. Culture influences the most fundamental aspects of our existence, such as our assumptions about human nature, the nature of reality, and our relationships to one another and the environment (Gudykunst, 1998; Hofstede, 1984; Schein, 1985). Communication is central to this process because language is defined by, reflects, and transmits culture (Pecchioni et al., 2008).

Culture may best seen as a dynamic (rather than static) concept given that cultural meanings are typically always in a state of flux as individuals adapt to ever-changing environmental conditions, including acculturation, or adaptation from one’s culture of origin to a new culture (Dutta & Basu, 2011). Conceptions of health and illness as well as ways to treat illness vary from culture to culture within the US and around the world. As more and more people from different cultures have immigrated to the US in recent years, there is greater diversity among patients than ever before. Providers can no longer approach healthcare from a single cultural perspective and be effective in treating patients from other cultures in a competent manner. As we will explore in this chapter, culture conceptions of illness and health can be radically different as people from different cultures come together in healthcare settings. Ignoring cultural differences in conceptions of illness and health can lead to a variety of problems between providers and patients, including culturally inappropriate medical decision-making, increased anxiety, fear, and anger, and patient dissatisfaction with overall healthcare. Unfortunately, culture has historically been omitted from health communication studies (Dutta & Basu, 2011). However, this situation has changed in recent years as healthcare providers and health communication researcher have begun to recognize the pivotal role culture plays in health and healthcare. Further, there has been a surge in healthcare consumers’ and providers’ cultural competence, oral and written communication, and numeracy levels becoming increasingly important to achieve adequate health literacy for medical decision-making. The health literacy literature refers to cultural competence as one of the key indicators of being health literate (Kreps, Neuhauser, Sparks, & Villagran, 2008a; Kreps & Sparks, 2008). Kreps and Sparks (2008) define health literacy as involving one’s literacy level, the structure and complexity of the material given, linguistic barriers, differing cultural contexts, and the efficacy of the method in which health messages are communicated. Their recent definition expands on Speros’ conceptualization to include factors external to the consumers, such as information providers’ communication competence. This inclusive definition thus conceives of health literacy as a mutual effort between health information providers and consumers. While there is a general lack of health literacy in many sectors of the population (Fagerlin et al., 2007a), it is particularly disproportionate among certain demographic groups, showing that certain populations are marginalized (Sparks & Nussbaum, 2008).

In addition to the greater use of translators, many healthcare organizations are now implementing intercultural communication training programs. Cultural diversity has become more and more important in healthcare settings among providers and health campaign designers (Dutta, 2007). While healthcare settings have traditionally excluded women and minorities, healthcare provider diversity has increased in recent years. In addition, providers exhibit a great deal of professional diversity due to differences in training and expertise. In recent years, healthcare organizations have attempted to capitalize on the strength of diverse provider perspectives to help solve complex patient health issues through interdisciplinary healthcare teams.

This chapter will explore these issues and a variety of other communication concerns related to culture and diversity within health settings. Specifically, it will examine a variety of topics related to diversity and culture in healthcare, including patient diversity in the US healthcare system, cultural differences in concepts of health and medicine, the need to recognize cultural diversity in healthcare, alternative medicine, social implications of disease, spirituality and health, provider diversity, and interdisciplinary healthcare teams.

Patient Diversity and Issues with Healthcare

The US continues to become more culturally diverse as a nation. Over 55 million people speak a language other than English in the US (US Census Bureau, 2005). Traditionally, most patients in the US healthcare system have been white. However, in the last decade, the population of white Americans grew at about 3.5 percent while other racial and ethnic groups increased by over 43 percent (Ndiwane et al., 2004). By 2030, the population of many minority groups in the US is expected to increase while the population of white Americans is expected to decrease by 10 percent. This presents a number of challenges to healthcare providers, who lack important knowledge about the groups and how to effectively communicate with them (Dutta & Basu, 2011). Currently, people of Latin American origin are the largest minority group in the US with a population of over 20 million, followed by people from various parts of Asia with numbers of over 10 million (US Census Bureau, 2005). In addition, various co-cultures within the US differ in terms of level of education, income, and housing status, all of which impact perceptions of health and access to healthcare services. There are many different problems related to patient diversity that affect quality healthcare and provider–patient communication. For example, many minority groups and recent immigrants often lack access to adequate healthcare, they often cannot afford these services, and/or they receive lower quality of healthcare from providers (Heisler, Rust, Patillo, & Dubois, 2005; Ku & Waidmann, 2003).

The National Cancer Institute (2006) defines health disparities as “differences in the incidence, prevalence, mortality, and burden of cancer and other adverse health conditions that exist among specific population groups in the United States.” Healthcare disparities for immigrants include lack of knowledge about cancer care and research opportunities, and are driven in part by immigration status, cultural, and linguistic differences (Gany, Shah, & Changrani, 2006).

Vulnerable populations often have significant health literacy difficulties and are challenged by intercultural communication barriers to accessing and making sense of relevant health information (Kreps & Sparks, 2008; Sparks, in press). These consumers are often confused and misinformed about healthcare services, early detection guidelines, disease prevention practices, treatment strategies, and the correct use of prescription drugs, which can lead to serious errors and health problems (Kreps & Sparks, 2008).

Members of vulnerable immigrant populations who suffer significant health disparities are desperately in need of culturally relevant, accurate, and timely health information (Kreps, 2005; Kreps & Sparks, 2008). Many vulnerable immigrant consumers in the US are non-native English speakers and encounter serious language barriers and health literacy challenges that necessitate adaptive, culturally sensitive communication strategies to provide them with needed health information (Chew, Bradley, & Boyko, 2004; Hardin, 2005; Kreps, 2006b; Parker & Kreps, 2005).

Moreover, members of many ethnic groups mistrust the healthcare system for a variety of reasons, including historical injustices, such as the mistreatment of Native Americans and African Americans (Ferguson et al., 1998) and the preponderance of Caucasian providers. A number of patients have trouble understanding the English language, and language barriers can lead to many problems such as misunderstandings between providers and patients, misdiagnoses, inappropriate treatments, and poor adherence to suggested treatments for medical problems (Hornberger, Itakura, & Wilson, 1997; Johnson, Roter, Powe, & Cooper, 2004; Rivadeneyra et al., 2000). In addition to language barriers, many immigrants are unfamiliar with the US healthcare system. Given the complexities of managed care, referrals, medical terminology, and many other aspects of the healthcare system, even for people who grew up with it, you can easily understand how an immigrant might find healthcare in the US confusing and intimidating.

Cultural Differences in Concepts of Health and Medicine

Our understanding of the world and our experiences of illness and health are heavily influenced by our day-to-day communication with others. Some communication scholars have argued that people create reality through communication (Gergen, 1999; Pearce, 1995). This is not to say that physical reality is created through communication, but rather that our understanding of reality evolves from interaction with others and is based on and informed by previous interactions. In terms of health, when individuals discuss their conceptions of illness and health again and again, they learn about these concepts through repeated interaction. People who are socialized within a particular culture come to understand illness and health through repeated interactions with others. All cultures have beliefs about illness and health that are passed down from generation to generation (Galanti, 1991; Lupton, 1994).

Perspectives of health and illness in western society are largely dominated by the biomedical model of health, although this is slowly changing to reflect a balance with increases in patient centered care approaches (Sparks & Villagran, 2010). Biomedicine refers to medical practices and beliefs derived from the western scientific tradition, including germ theory, biology, biochemistry, and biophysics, and it is focused primarily on establishing physical causes for illness (Gillick, 1985; Sharf & Vanderford, 2003). However, the biomedical view of health is just one of many cultural conceptions of health around the world and within the US (Galanti, 1991; Spector, 1996). Ethnomedical belief systems are culturally unique beliefs and knowledge about health and disease (Witte, 1991). In addition, Airhihenbuwa and Obregon (2000) argue that communicating about health risks (such as the risk for HIV/AIDS) in ways that are based upon western cultural assumptions, such as privileging the individual over the group or culture as a whole and linear types of thinking (which have their base in the western scientific tradition), are often inadequate when communicating with people from certain regions and cultures, such as South America, Central America, the Caribbean, and Africa. Unfortunately, many providers lack adequate training in understanding the ethnomedical belief systems of their patients from other countries and co-cultures within the US. Ignorance or misunderstanding of these different belief systems can lead to a host of communication problems between providers and patients (O’Hair, O’Hair, Southward, & Krayer, 1987).

Another important issue to acknowledge is the ageism and racism that exist in the medical profession (Pecchioni et al., 2008). For instance, when physicians do not provide older patients with information about clinical trials, even when they think they are acting in the patient’s best interests, they are acting on assumptions that may be unfounded. In fact, the empirical evidence shows that older cancer patients fare well in clinical trials when compared with their younger counterparts. Older patients may well have physical differences from younger patients, but these differences should be established empirically rather than based on limited experience that may be filtered through negative attitudes toward aging (Pecchioni et al., 2008).

Cultural Differences in Attributions of Illness/Health

Many cultures attribute illness to spiritual forces, and this is in direct conflict with the western biomedical model that attributes disease to microorganisms, such as viruses, or to lifestyle influences. For example, some cultures, such as the Hmong from Southeast Asia, often attribute disease to spiritual forces such as malevolent spirits or ghosts who bring ill health, or to the lack of protective spirits of ancestors (Johnson, 2002). Some cultural groups, such as Mexican immigrants, often exhibit strong cultural tendencies toward fatalism when it comes to health issues (Barron, Hunter, Mayo, & Willoughby, 2004), or the belief that health problems are meant to be or caused by God/supernatural forces. Individuals with fatalistic views of health often feel that they have no control over health problems, and they may perceive little personal ability or responsibility for the success or failure of health outcomes. Therefore, individuals from cultures that promote fatalistic views of health may have a more difficult time adhering to biomedical treatments suggested by healthcare providers or making significant lifestyle changes that influence health risks (Lupton, 1994).

The first important step is to acknowledge and be aware of the fact that all patients are not the same. As Pecchioni et al. (2008) recognized, this acknowledgement should extend not just to the physical realm. Most healthcare professionals continue to operate based on the biomedical model of health and illness, in which the body is treated as a machine in isolation from its environment. The biopsychosocial model, however, provides us with a broader lens for examining patient responses to illness because it acknowledges that individuals operate within a web of individual and social roles. Conrad (1987) proposed the use of disease to refer to the physical ailment and illness to refer to the social elements of the disease. Thus, an individual is not his or her diagnosis, but makes sense of that diagnosis within a web of cultural expectations. In this perspective, then, healthcare personnel must identify each patient’s attitudes toward the causes of illness and treatment options, definitions of quality of life, availability of social support, and the like. The body is no longer a machine, but a living organism in communication with its physical and cultural environments (Pecchioni et al., 2008).

Medical procedures that are commonplace in western culture, such as surgery, blood transfusions, and blood tests, are not part of some cultures around the world (such as the Hmong), and these often provoke fear and mistrust among immigrants (Helman, 2000; Smith, 1997). In terms of medical treatment options, some cultures value biomedical solutions to health problems, while others prefer more natural remedies for health problems or spiritual solutions to them. For example, researchers have found that a large number of immigrants from Mexico use herbal medications, massage, and relaxation techniques, which are often suggested by family members or curanderos, traditional Mexican folk healers (Hunt, Hamdi, & Arana, 2000; Keegan, 1996).

Acculturation

Immigrants often change their lifestyle in ways that can affect their health when they come to the US. For example, mainstream US culture often promotes sedentary lifestyles, high fat/high food consumption, smoking, and a variety of other unhealthy behaviors. However, the cultures that many immigrants come from do not promote these lifestyles and diets, and taking on new diets and lifestyles can lead to a variety of health problems. For example, hypertension, diabetes, and substance abuse are becoming more common among immigrants from Southeast Asia and other countries who adopt US mainstream diets and lifestyles (Aldrich & Variyam, 2000; Cobas et al., 1996; Popkin & Udry, 1998). Immigrants may find their ability to continue their traditional diet somewhat difficult to maintain, since some of the traditional foods to which they are accustomed may not be available in the US, and children can become “Americanized,” so that they take on unhealthy lifestyle habits. Moreover, because immigrants from these countries often attribute disease to spiritual forces, they may not understand the connection between lifestyle behaviors and poor health (Helman, 2000; Johnson, 2002).

Informed Consent

In the US patients have the legal right to be fully informed about their health condition, and many Americans perceive this law as ethical and would insist on having full knowledge of their health situation, especially if they were at risk of dying from cancer or high blood pressure. However, beliefs surrounding the issue of informed consent vary by culture, and informed consent should be delivered to people in culturally sensitive ways (Carrese & Rhodes, 1995; Kakai, 2002). For example, the Hmong involve extended family in important decisions, including medical decisions if a family member becomes ill (Johnson, 2002). Moreover, Hmong culture is patriarchal, and decision-making is typically left to the oldest member of the family and male family members, such as a husband or father (Johnson, 2002).

Providers in the US often pressure family members to make decisions about treatment options relatively quickly, but this can lead to problems for a Hmong patient if an older family member (such as a grandfather) or a high-status male family member is not nearby, and other family members may be hesitant to make a decision about healthcare treatment for a family member without consulting this person (Johnson, 2002). In Japan, providers historically concealed terminal cancer diagnoses from patients (Kakai, 2002). Although Japanese physicians have adopted a policy of disclosing terminal cancer diagnoses to patients in recent years, and the majority of Japanese say that they prefer to be informed by their physician if they have cancer (Long, 2000), many individuals still prefer indirect or ambiguous communication from a physician if a family member is diagnosed with cancer (Kakai, 2002). This indirect communication about a cancer diagnosis allows family members to be more hopeful about a loved one’s recovery as opposed to viewing the diagnosis as a “death sentence.” Complicating the issue of informed consent further, medical interpreters are required to interpret information for providers and patients without omitting or changing anything (Dysart-Gale, 2005). This can make it difficult to convey information to patients in a culturally sensitive way, especially if the physician or other provider who is attempting to convey information to the patient through an interpreter has little understanding of the health beliefs of the patient.

Cultural Differences of People Born in the US

Cultural differences in health beliefs and influences on health behaviors do not just affect immigrants in the US. There are many different co-cultures among people who were born in the US, and these co-cultures can influence health beliefs and health behaviors in a variety of ways. Co-cultural differences based on ethnicity, race, or nationality may be even more pervasive in healthcare than ageism because differences extend across the spectrum of care. Ethnic minorities have less access to healthcare, report lower levels of trust in healthcare professionals, delay going to doctors for tests, and are less likely to be offered high-quality care options with cutting-edge technology. This broad spectrum of differences in access make many healthcare experiences quite different depending on one’s co-cultural group, at least in the US (Pecchioni et al. (2008). For example, in the southern US, many people eat foods that are high in calories and fat, such as barbeque, fried okra, and sweet tea (iced tea with large quantities of sugar), because this is often part of traditional Southern cuisine. However, these types of food can have a tremendous impact on health risks, such as obesity, diabetes, high blood pressure, and heart disease, especially if they are not consumed in moderation. Cultural issues implicate certain age groups as well.

The amount of information that the patient is provided also impacts the decision-making (Sparks, 2008). Older patients have been found to ask their physicians fewer questions (Beisecker & Beisecker, 1990) and to receive less information from the physician than younger patients (Street, 1991). patients have a tendency to prefer a communication style that contains less detail and is jargon free, whereas younger and middle aged adults expect more medical information in their messages (O’Hair, Behnke, & King, 1983), and have a number of unique age-related barriers (Sparks & Nussbaum, 2008).

As Sparks & Nussbaum state, the influx of people from varying countries and cultures has also increased demands for healthcare providers who are culturally sensitive to the specific needs of older men and women facing cancer diagnoses. Even in other cultures that practice western medicine, there are differing views as to how much to disclose to patients about their conditions. In the US, we proceed from the assumption and have enshrined as law, the idea that patients have a right to full disclosure of their medical condition. However, Hippocrates was among the first to realize that the mind had an effect on the body. As a result, some medical communities in other cultures consider it good medical practice to lie to patients about their true condition as well as enlist the complicity of the family to perpetuate the prevarication (Sparks & Nussbaum, 2008). All of our communication research points to stereotyping, memory issues, language issues, and intergenerational barriers that present a host of communication problems for older adults within the best of circumstances (Nussbaum, Baringer, & Kundrat, 2003; Sparks, 2003a; Sparks & Nussbaum, 2008), which can ultimately hinder satisfactory healthcare.

Recognizing Cultural Diversity in Health Beliefs

As we have seen, healthcare organizations have witnessed a number of demographic shifts among patients in recent years (Dysart-Gale, 2005). As a result, healthcare workers must learn to communicate effectively with people from other cultures in order to provide competent and quality healthcare (Ulrey & Amason, 2001). In order for healthcare providers to be culturally sensitive, they must have knowledge about the varying cultural beliefs of their patient population, understand and respect the cultural beliefs, attitudes, and values of patients, and be willing to use cultural knowledge when interacting with patients and making decisions about treatment options (Brislin, 1993; Ulrey & Amason, 2001). Providers need to be aware of cultural differences in beliefs about the nature of illness and health as well as the relationship between cultural practices and health.

Learning to communicate more effectively with patients from diverse cultural backgrounds has a number of implications for business-related outcomes within healthcare settings (Voelker, 1995). For instance, as competition between healthcare organizations increases, individual organizations must find ways to attract new patient populations and keep patients satisfied so that they will not go to a competitor to obtain health-related services. Conversely, culturally insensitive or inappropriate communication behaviors on the part of providers can lead to a host of problems, including patient dissatisfaction with healthcare and malpractice lawsuits (Kreps & Thornton, 1992).

A continuing problem in healthcare settings is the assumption that all stakeholders, but particularly patients, share the same perceptions as the host culture. Several studies have offered a view of how Americans perceive themselves and are perceived by others. One such study, conducted by Protocol International, suggested Americans see themselves as efficient, direct, competitive, action-oriented, outgoing, open, and self-reliant. Conversely, people from other cultures saw Americans as abrupt, confrontational, materialistic, pushy, insincere, transparent, and self-centered. Central to competent intercultural communication is having cultural partners who understand the perspective held by each person (Leong & Schneller, 1997). Understanding how healthcare stakeholders view one another is a critical challenge, one that can be overcome with some effort. For instance, American student nurses found that as they learned more about Russian culture, their stereotypes broke down and it was easier for them to understand key cultural aspects that could lead to better healthcare (Heuer, Bengiamin, & Downey, 2001).

Culture helps us to make coherent sense of our mortality, suffering, and death (Greenberg, Solomon, & Pyszczynski, 1997; Lynn, 2000). Such sensitive issues are influenced not just by culture and co-cultural groups, but also by religious beliefs and personal experiences (Lynn, 2000). Ethnic minorities in the US prefer a variety of preferences influenced by their cultural beliefs (Pecchioni et al., 2008). African Americans are reluctant to share their treatment preferences with healthcare providers, but are more likely to prefer life-sustaining treatments than other groups and are less likely to use hospice care or agree to organ donation (Mouton, 2000). Hispanics are also less likely to agree to organ donation or autopsies (Talamantes, Gomez, & Braun, 2000). For both groups, the main reason for not selecting organ donation is the desire to present a whole body to God (Mouton, 2000; Talamantes, Gomez, & Braun, 2000). Further, both Hispanics and African Americans are more inclined to request life-prolonging treatments (Talamantes, Gomez, & Braun, 2000). As we will discuss in more detail later in this chapter, both groups express a desire to allow time for God to work miracles. Among Asian Americans and Pacific Islanders, considerable variability reflects the diversity of their countries of origin, their immigration histories, rural versus urban backgrounds, and education level (Yeo & Hikoyeda, 2000). However, as Asian groups often take a more collectivistic approach to life, issues surrounding illness and death are managed primarily within their co-cultural groups where there is a preference for the family to be involved in all decision-making (Yeo & Hikoyeda, 2000). In general, Asian Americans and Pacific Islanders are more likely to want life support because longevity is more important than quality of life (Pecchioni et al., 2008). In order to provide a whole body to their ancestors, they prefer to avoid autopsy and organ donation (Yeo & Hikoyeda, 2000). Among Native Americans and Alaska Natives, who represent a diverse group with more than 300 federally registered tribes, death is seen as a natural part of the circular pattern of life, so they tend to have more positive attitudes toward dying than most other groups (Pecchioni et al., 2008; Van Winkle, 2000).

Barriers to Providing Culturally Sensitive Healthcare

Unfortunately, many barriers to providing culturally sensitive healthcare exist within the current US healthcare system. Many providers do not have adequate knowledge of how changes in lifestyle from one culture to another can affect the health of immigrants. The majority of hospitals and healthcare facilities in the US today still do not have an adequate number of translators or personnel who understand the ethnomedical belief systems of patients (Schott & Henley, 1996).

As Collins, Villagran, and Sparks (2008) point out, structural and cultural barriers to care are especially problematic for immigrant populations who encounter variance in cultural norms and healthcare delivery systems in their new country. Structural barriers include material phenomena that prevent access to healthcare due to problems such as poverty, lack of transportation, illiteracy, and language difference. Health belief barriers are socially constructed ideas about health and wellness that can either inhibit or enable access to healthcare (Collins, Villagran, & Sparks, 2008).

In addition, as Collins, Villagran, and Sparks (2008) point out, efforts aimed at over­coming barriers to cancer care among Mexican immigrants must address structural and cultural issues that deter patients from seeking treatment. Health literacy efforts to increase prevention can benefit from the cultural notion of bienestar (good God theory) by building on Mexicans’ beliefs about prevention and linking together positive behaviors such as screening, diet, and exercise habits. Emphasizing the balance of integrating healthier foods into the traditional Mexican diet could also help focus prevention measures on cultural ideals of well-being. Health education efforts must also explicitly distinguish between prevention efforts and actual causes of cancer. Such education efforts can enhance the residents’ agency by reducing irrational fears about causing cancer through a toothache or a fight (Collins, Villagran, & Sparks, 2008).

Alternative Medicine

Alternative medicines, such as more holistic forms of medicine, have had a long history around the world and in the US, and many of the practices that are known as western mainstream or orthodox medicine are relatively recent innovations compared to the use of herbal remedies, acupuncture, osteopathy, chiropractics, yoga, massage, guided imagery, and therapeutic touch. Some studies estimate that about 42 percent of the US population, or around 83 million people, have used some form of alternative medicine or holistic therapy, spending an estimated $27 billion on such therapies (Barnes, Bloom, & Nahin, 2008; Eisenberg et al., 1998). Studies also suggest that the majority of individuals who use alternative forms of medicine do not mention it to their physicians and other healthcare providers (Dunn & Perry, 1997). Despite the prevalence and use of alternative forms of medicine, many are hesitant to talk about their use of alternative medicine with providers because of the dominance of mainstream biomedical approaches to health in our culture (Goldner, 1998). US healthcare providers are aware of the growth in popularity of alternative medicines among patients, and there is greater interest among providers in talking with patients about the pros and cons of such approaches (Udani, 1998). For instance, there is concern among many physicians over the possible interaction effects that can occur when a patient is simultaneously using prescription medications and over-the-counter treatments (such as herbal remedies) for the same health problem.

As we saw in Chapter 1, there is a fundamental tension between the biomedical model of health and psychosocial approaches, a tension that includes different perceptions about the efficacy of mainstream medical approaches as opposed to alternative approaches to treating disease and enhancing health. This tension can be seen in the history of medicine within the US. For example, advances in the natural sciences and medical technology during the eighteenth and nineteenth centuries led physicians to begin to distinguish biomedical approaches to medicine from alternative forms of medicine (Schreiber, in press). For example, during this time, herbal remedies were popular treatments for a variety of illnesses, although their efficacy is difficult to document since people did not usually keep records of successes and failures. However, also during this time, there were a variety of traveling “medicine shows” that typically used performers to persuade audiences to purchase somewhat dubious remedies for their ailments (which often contained mostly alcohol).

To distance themselves from what they perceived as questionable approaches to medicine, and to set themselves apart from other types of medical practitioners, biomedical practitioners began to form societies such as the American Medical Asso­ciation and write medical books that detailed biomedical approaches. However, the language they used to make these distinctions often privileged the biomedical approach or talked about more holistic approaches to medicine in derogatory and negative terms, for example describing them as unprofessional, lacking standards, or erratic (Schreiber, in press). As a result, many holistic approaches to health that have value in enhancing physical, psychological, and spiritual health came to be seen as unorthodox, suspicious, and ineffective. Today, many people dismiss homeopathic medicine and other approaches as quackery, and alternative medicine often carries a negative social stigma. Even terms like “alternative medicine,” “complementary medicine,” and “integrative medicine” are not without problems. The word “alternative” carries the connotation of being out of the ordinary, while “complementary” and “integrative” imply that these approaches should be used in conjunction with other, biomedical approaches rather than on their own. Some scholars have argued that these terms help to privilege the biomedical approach to medicine (Schreiber, in press; Wardwell, 1994).

However, holistic medicines may offer some advantages and disadvantages over biomedicine, although what is perceived as an advantage or disadvantage by the patient largely depends on his or her values regarding health, illness, and quality of life (Ho & Robles, 2011). For example, biomedical approaches to a disease such as cancer typically involve the use of chemotherapy, radiology, and surgery. While these procedures offer a number of advantages in terms of destroying cancerous cells and tissue, they also have a great number of side effects. For instance, people who are on chemotherapy often experience fatigue, nausea, hair loss, and a variety of other problems. While one of the authors was conducting research at a cancer center in Memphis, Tennessee, one patient described chemotherapy as like “using an atomic bomb to kill a terrorist hiding in New York City.”

In other words, chemotherapy may help to kill the cancer, but it also destroys a lot of healthy tissue in the process. Holistic approaches may be an attractive alternative to treating disease for individuals facing chemotherapy and other biomedical approaches in that they offer a less invasive type of treatment or one that does not negatively impact their quality of life in a significant way. It should be pointed out that many traditional herbal remedies used for centuries have been adapted by pharmaceutical researchers. For instance, the herb Periwinkle vinca rosea contains insulin that can be used in the treatment of diabetes, and Rauwolfia serpentine is an herb that contains respirine, which is commonly used as a tranquilizer by biomedical practitioners (Airhihenbuwa, 1995).

However, while pharmaceutical companies often use natural ingredients when developing medications, they also frequently develop synthetic versions of chemicals found in nature as well as ways to make these chemicals more concentrated. In addition, because many holistic approaches do not treat disease in an aggressive manner, individuals who are given a good prognosis by their physician for overcoming a disease may consider traditional biomedical treatments along with complementary holistic therapies. Other individuals who are facing a terminal illness and who have been told they may have a relatively short survival time may choose to forgo aggressive biomedical treatments and use holistic approaches to allow for some treatment of symptoms without threatening their overall quality of life.

Spirituality, Culture, and Health

Religion and spirituality are important influences on health beliefs and behaviors, and many health-related practices observed in cultures around the world and within the US are rooted in religious and spiritual traditions. Religion can be conceptualized as “an organized system of beliefs, practices, rituals, and symbols,” and spirituality as “one’s transcendent relationship to some form of higher power” (Thoreson, 1998, p. 415). Egbert, Sparks, Kreps, and du Pré (2008) state that although there is no general agreement regarding how the terms religiosity and spirituality should be defined, scholars largely agree that the terms represent separate, although overlapping, concepts (Koenig, McCullough, & Larson, 2001; Paloutzian & Kirkpatrick, 1995; Parrott, 2004; Thoresen & Harris, 2002). Religion and spirituality have had a profound influence on views of health and illness in many cultures, and they have a number of implications for health communication, although relatively few health communication scholars have examined the impact of religious and spiritual influences on health (Parrott, 2004).

Historically, religiosity has received more scholarly attention than spirituality, especially in relation to health outcomes (Parrott, 2004), however, spirituality is often viewed as a more inclusive term and therefore preferred by many scholars (see e.g. Egbert et al., 2008). In 1967, a classic work by Allport and Ross differentiated between intrinsic (living according to one’s religious beliefs because one truly believes in them) and extrinsic religiosity (using one’s religion to meet needs such as social support, tradition, or status). This differentiation has been maintained by researchers for the past 40 years and has shaped many scholars’ understanding of how religion and religiosity are defined (Egbert et al., 2008). For instance, Koenig, McCullough, and Larson (2001) define religion as “an organized system of beliefs, practices, rituals, and symbols designed (a) to facilitate closeness to the sacred or transcendent (God, higher power, or ultimate truth/reality) and (b) to foster an understanding of one’s relationship and responsibility to others in living together in a community” (p. 18).

Spirituality, on the other hand, is a more expansive conceptualization of divinity. One may be a spiritual person, but not necessarily religious; likewise, being a member of a religion does not by definition make one spiritual. Whereas religion is associated with terms such as formal, behavior-oriented, and doctrine-based, spirituality is better characterized using words such as individualistic, inward-directed, and not doctrine-oriented (Koenig, McCullough, & Larson, 2001). Although both are concepts worthy of discussions related to cancer and aging, the central concept we highlight in this chapter is found in the term spirituality, meaning an individual’s search for meaning in life (e.g. Dreyer, 1994; National Cancer Institute, 2005). Egbert et al. (2008) embrace Koenig, McCullough, and Larson’s (2001) definition:

Spirituality is the personal quest for understanding answers to ultimate questions about life, about meaning, and about relationships to the sacred or transcendent, which may (or may not) lead to or arise from the development of religious rituals and the formation of community. (p. 18)

Spirituality has been identified as a key variable that influences an individual’s response to a cancer diagnosis and sense of identity as expressed in religious ritual practice (Haynes & Smedley, 1999; Lackey, Gates, & Brown, 2001). This is also the case for women diagnosed with a variety of diseases other than cancer. Several studies of illness and wellness in different segments of the larger African American community claim that many believe their degree of health or presence of illness to be God’s will (Abrums, 2000). Hispanic cultural beliefs often align with this notion and often have a low desire for information about terminal illnesses, which is referred to in Spanish as “fatalismo” (see e.g. Collins, Villagran, & Sparks, 2008). Further, Collins, Villagran, and Sparks’ (2008) Hispanic study participants reported avoidance of information about cancer as a means of control and as a demonstration in the power of God. Other members of this population may integrate the prayer process with their sense of familismo, known as the importance of family, or use it as a way to manage information needs. The strategies by which the participants negotiate the tensions between bienestar and “good God theory” illuminate perceptions about personal control in preventing, treating, and surviving cancer (Collins, Villagran, & Sparks, 2008).

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