Behavioral Objectives
After reading this chapter, the nurse will be able to:
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Recognize relevant cultural factors that affect health-seeking behaviors related to environmental control.
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Recognize relevant cultural factors that affect illness behaviors related to environmental control.
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Identify various types of cultural folk health practices and the effect on health-seeking behaviors.
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Recognize the relationship between external locus of control and fatalistic or health-seeking behaviors.
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Recognize factors affecting external locus of control for persons in selected cultural groups.
Environmental control refers to the ability of an individual or persons from a particular cultural group to plan activities that control nature. Environmental control also refers to the individual’s perception of ability to direct factors in the environment. This definition in itself implies that the concept of environment is broader than just the place where an individual resides or where treatment occurs. In the most practical sense, the term environment encompasses relevant systems and processes that affect individuals ( ).
Systems are organized structures that may influence and be influenced by individuals. Processes may be viewed as organized, purposeful patterns of operation. Processes generally include the dynamics and interactions among families, groups, and the community at large. On the basis of these definitions, it is evident that the environment and humans have a reciprocal relationship in the sense that humans and the environment are constantly exchanging matter and energy. When this exchange has purpose and is goal directed, the interaction and exchange processes are considered functional and useful. However, when the exchange has no purpose and lacks goal direction, a dyssynchronous relationship occurs ( ).
In the broadest sense, health may be viewed as a balance between the individual and the environment. Health practices such as eating nutritiously, subscribing to preventive health services available in the community, and installing hazard- and pollution-control devices are all believed to have a positive effect on the individual, who in turn can positively affect the environment ( ).
Complex systems of health beliefs and practices exist across and within cultural groups. In addition, variations, whether extreme or modest, to cultural beliefs and practices are found across ethnic and social class boundaries and even within family groups. Today the most widely accepted approach to health care is the biomedical model. This model emphasizes biological concerns, which are considered by those who support this model as more “real” and significant than psychological and sociological issues ( ).
Today in modern Western society, health care practitioners remain primarily interested in abnormalities in the structure and function of body systems and in the treatment of disease. According to , the biomedical approach is culture-specific, culture-bound, and value-laden. The biomedical model represents only one end of a continuum. At the opposite end of the continuum is the traditional model, which espouses popular beliefs and practices that diverge from medical science ( ). Persons who subscribe to beliefs encompassed in the traditional model have varying health beliefs and practices, including folk beliefs and traditional beliefs that are also shaped by culture ( ).
Distinction between Illness and Disease
During the past few decades, scientists and anthropologists began to make a distinction between the terms illness and disease . The individual experiences that relate to illnesses do not necessarily correlate with the biomedical interpretation of disease. Illness can be defined as an individual’s perception of being sick. On the other hand, disease is diagnosed when the condition is a deviation from clearly established norms based on Western biomedical science ( ; ). Illness can and does occur in the absence of disease; approximately 50% of visits to physicians are for complaints without a definite basis. According to , illness is culturally shaped in the sense that it is individually perceived. In other words, how one experiences and copes with disease is based on the individual’s explanation of sickness. Disease is described in detail in medical–surgical nursing textbooks. However, nurses need to remember to incorporate both personal and cultural reactions of the client to illness, disease, and discomfort to give culturally appropriate nursing care.
Just as culture influences health-related behavior, it also has a profound effect on the expectations and perceptions of sickness that shape the labeling of sickness and on how, when, and to whom communication of health problems occurs ( ). The astute nurse must keep in mind the fact that perceptions of health and illness are shaped by cultural factors. As a direct result of cultural shaping, individuals vary in health care behaviors, health status, and health-seeking attitudes ( ; ; ; ).
The term health care behavior is defined as the social and biological activities of an individual that are based on maintaining an acceptable health status or manipulating and altering an unacceptable condition ( ). The term health status, on the other hand, is defined as the success with which an individual adapts to the internal and external environment ( ; ). Thus, health care behavior influences health status, which in turn influences health care behavior. Because health care behavior and health status are reciprocal in nature, they both can be affected by sociocultural forces, such as economics, politics, environmental influences, and the health care delivery system itself ( ).
Cultural Health Practices Versus Medical Health Practices
Cultural health practices are categorized as efficacious, neutral, dysfunctional ( ), or uncertain.
Efficacious Cultural Health Practices
According to Western medical standards, efficacious cultural health practices are beneficial to health status, although they can differ vastly from modern scientific practices. Because efficacious health practices can facilitate effective nursing care, nurses need to actively encourage these practices among and across cultural groups. Nurses must keep in mind that a treatment strategy that is consistent with the client’s beliefs may have a better chance of being successful. For example, persons from cultural groups who subscribe to the theory of hot and cold, such as some Mexican Americans, may actually benefit from this particular belief. Individuals who subscribe to this theory may avoid hot foods in the presence of stomach ailments such as ulcers, a practice that is consistent with the bland diet used in a medical regimen for the treatment of ulcers. Thus scientific health care practices may be blended with efficacious cultural health practices.
Neutral Cultural Health Practices
Neutral cultural health practices have no effect on the health status of an individual. Although some health care practitioners may consider neutral health practices irrelevant, the nurse must remember that such practices may be extremely important because they might be linked to beliefs that are closely integrated with an individual’s behavior ( ). In , several examples of neutral practices were cited, including “the ritual disposal of the placenta and cord,” interpretation of signs in the cord, avoidance of sexual activity during various stages of pregnancy, certain hygiene practices, and avoidance of exposure to luminous rays of the moon during a lunar eclipse. Many Southeast Asian women believe that sitting in a door frame or on a step while they are pregnant will complicate labor and delivery. In waiting and examination rooms, these women avoid areas near doors. These women may also think that overeating or inactivity during pregnancy will cause a difficult delivery and that sleeping late or during the day will have the same effect. Hill tribeswomen (Hmong and Mien) avoid contact with scissors and knives because they fear sharp instruments may cause cleft lip or abortion. There is a general belief among these women that reaching overhead for something or working too hard may cause miscarriage or birth defects ( ; ). Although these practices require no planned nursing interventions, the astute nurse must recognize their significance and respect the client’s right to subscribe to and practice such beliefs.
Dysfunctional Cultural Health Practices
Dysfunctional cultural health practices are harmful. An example of a dysfunctional health care practice found in the United States is the excessive use of such items as overrefined flour and sugar. The nurse must be aware of practices that are dysfunctional and should work to establish educational training programs that help individuals identify dysfunctional health practices and develop beneficial practices. A dysfunctional health care practice was noted among women of various racial, ethnic, and cultural groups in British Columbia in Canada ( ). Findings from this study noted that implementation of a population-based cervical cytology screening program in British Columbia that began in 1955 decreased the mortality from invasive squamous cervical cancer by more than 70%. However, the mortality from cervical cancer, despite the implementation of this innovative program, remained high among the Canadian Native population (Inuits, Indians, Métis). In fact, the mortality was four times higher among Canadian Native women than among their non-Native counterparts ( ). Although approximately 85% of the women in the general population complied with screening recommendations, the compliance by Canadian Native women was approximately 30% less. Whether this underparticipation by Native woman resulted from beliefs and attitudes or from lack of availability of resources was not determined.
Uncertain Cultural Health Practices
In 1994, developed a cultural assessment system that included a category of cultural health practices with unknown effects. Classified as uncertain, these practices included such things as swaddling a newborn infant to maintain body temperature and using an abdominal binder for mother and infant to prevent umbilical hernias.
The nurse must remember that in most instances health practices do not fit perfectly into one category or another. According to , health practices are subjectively evaluated as more or less beneficial or harmful when they are compared with the alternative practices available to the user.
Values and Their Relationship to Health Care Practices
Values may be viewed as individualized sets of rules by which people live and are governed. They serve as the cornerstone for beliefs, attitudes, and behaviors. Cultural values are often acquired unconsciously as an individual assimilates the culture throughout the process of growth and maturation. It is important for the nurse to recognize that because cultural values are believed to exist almost solely on an unconscious level, they are the most difficult to alter. Cultural values therefore have a pervasive and profound influence on the individual ( ).
Value Orientations
defined value orientations as “complex but definitely patterned principles which give order and direction to the ever-flowing stream of human acts and thoughts as they relate to the solution of common human problems.” Kluckhohn and Strodtbeck also proposed that it is entirely possible for an individual to hold a value orientation different from the rest of the same cultural group. However, they concluded that despite differences in value orientation within a cultural group, dominant value orientations can be identified for most persons of a particular cultural group.
In their classic work, compared the way people in different cultural groups organize their thinking about such things as time, personal activity, interpersonal relationships, and their relationship to nature and the supernatural. They developed an orientation framework that includes temporal, activity, relational, people-to-nature, and innate human nature orientations.
Temporal Orientation
Temporal orientation refers to the method by which persons from particular cultural groups divide time. Time is generally divided into three frames of reference: past, present, and future. According to and , most cultures combine all three orientations, but one is more likely to dominate than another.
Activity Orientation
Activity orientation refers to whether a cultural group is perceived as a “doing”-oriented culture, which is oriented toward achievement, or as a “being”-oriented culture, which values “being” and views people as an important link between generations. In other words, the “doing”-oriented culture values accomplishments, whereas the “being”-oriented culture values inherent existence.
Relational Orientation
Relational orientation from a cultural perspective distinguishes interpersonal patterns. More specifically, relational orientation refers to the way in which persons in a culture set goals for individual members. Relational orientations are found in three modes: lineal, individualistic, and collateral.
Lineal Mode.
When the lineal mode is dominant within a particular cultural group, the goals and welfare of the group are viewed as major concerns. Other major concerns are the continuity of the group and the orderly succession of the group over time. Cultures that are perceived as subscribing to the lineal mode view kinship bonds as the basis for maintaining lineage.
Individualistic Mode.
Cultures in which the dominant mode is individualistic value individual goals over group goals. Thus, each individual is responsible for personal behaviors and ultimately is held accountable for personal accomplishments.
Collateral Mode.
When the collateral mode is dominant in a cultural group, the goals and welfare of lateral groups such as siblings or peers are of paramount importance. Examples are found in Russia and in Israel, where the goals of individuals are subordinate to those that affect the entire lateral group.
People-to-Nature Orientation
People-to-nature orientation implies that people dominate nature, live in harmony with nature, or are subjugated to nature. The conceptual framework of people dominating nature is based on the view that humans dominate nature and further indicates that humankind can master or control natural events. When people live in harmony with nature, there is an integration among them, nature, and the universe. When the view that humans are subjugated to nature is held, a philosophy of fatalism is adopted; that is, fate is considered inevitable, and individuals perceive themselves as having no control over nature or their future—they consider themselves powerless to guide personal destiny. An example is the belief held by some Appalachian people that “If I’m going to get cancer, I’m going to get it,” so that taking preventive measures to avoid cancer would be of no benefit. This fatalistic attitude, however, is not completely consistent because most Appalachian people will go to a physician or hospital if they believe they are extremely ill.
Innate Human Nature Orientation
The innate human nature orientation distinguishes an individual’s human nature as being good, evil, or neutral. Some cultural groups view human beings as having a basic nature that is either changeable or unchangeable. For example, an individual may be viewed as evil and unchangeable, evil but changeable, or neutral (subject to both good and negative influences).
Locus-of-Control Construct as a Health Care Value
The locus-of-control construct, which originated in social learning theory, is defined as follows:
When a reinforcement is perceived as following some action but not being entirely contingent upon (personal) action then in our culture it is typically perceived as a result of luck, chance, and fate, as under the control of powerful others, or unpredictable because of the great complexity of the forces surrounding [the individual]. When the event is interpreted in this way by an individual, this is labelled as a belief in external control. If a person perceives that the event is contingent upon his own behavior or his own permanent characteristics, we have termed this a belief in internal control. ( )
This definition presupposes that individuals who believe that a contingent relationship exists between actions and outcomes have internal feelings of control and thus act to influence future behaviors and situations. Individuals who believe that efforts and rewards are uncorrelated, and who thus have external feelings of control, view the future as the result of luck, chance, or fate, and are less likely to take action to change the future. The locus-of-control construct can be applied to a variety of phenomena, including the weather, preventive health, curative health actions, and feelings of well-being. For example, individuals who believe that a contingent relationship exists between compliance to preventive and treatment regimens and health have an internal locus of control and are likely to respond positively to affect the future and thus promote good health. On the other hand, individuals who believe that compliance behaviors and health are unrelated have an external locus of control and have little motivation to develop behaviors that could affect the future and enhance good health. concluded that the locus of control does not in itself represent a behavior trait and can be modified by interaction with others.
While the locus-of-control construct originates in social learning theory ( ), it is essential to note that believed that locus of control is often too general and tends to collapse good and bad events. However, in contrast, noted that thousands of researchers have scientifically examined the locus-of-control construct. In fact, , in summarizing the multitude of investigations on the locus-of-control construct, noted that, compared with the external, the internal is often resistant to such factors as social pressure and is frequently dedicated to the pursuit of excellence. While has been quick to add a disclaimer that internality is not necessarily good, the remainder of the research indicates that in a responsive environment, individuals who have an internal locus of control have been able to benefit from such beliefs ( ). noted that his 1966 monograph had been cited more than 4700 times in the literature, thereby giving credence for its validity as an applicable construct. Some cultural experts in nursing, such as , espouse the usefulness of the locus-of-control construct to understand individuals from diverse cultural backgrounds.
The astute nurse should recognize that persons who subscribe to an external locus of control tend to be more fatalistic about nature, health, illness, death, and disease. For example, some Hispanics, Appalachians, and Puerto Ricans are reported to have an external locus of control. Some American Indians, Chinese Americans, and Japanese Americans or Japanese Canadians are said to be more or less in harmony with nature; therefore, their cultural beliefs fall outside the locus-of-control construct. However, northern European Americans and African-Americans are reported to fall within both the internal and the external locus-of-control construct ( ). The nurse can help the client modify behaviors that fall within the realm of the external locus-of-control construct by showing the effects of certain behaviors on illnesses, health, and disease and thus promote the development of an internal locus of control.
Folk Medicine
Folk medicine, or what is commonly referred to as “Third World beliefs and practices,” is often called “strange” or “weird” by nurses and other health professionals who are unfamiliar with folk medicine beliefs ( ; ). In reality, whether or not something seems “strange or weird” depends on familiarity with the beliefs. In most instances folk medicine practices do not seem strange or weird once health care providers become familiar with them.
The astute nurse must distinguish between practices that are familiar and practices that are desirable, since becoming familiar with something does not imply acceptance. In this situation, tolerance becomes a two-way process: people who subscribe to folk medicine practices need not feel compelled to abandon these beliefs and practices when they become familiar with modern medicine, and health care practitioners should not feel compelled to abandon modern medical practices when they become familiar with folk medicine practices.
An individual’s worldview largely determines beliefs about disease and the appropriate treatment interventions. For example, a belief in magic may lead to the assumption that a disease is a result of human behavior and that a cure can be achieved by magical techniques. A religious belief may lead to the assumption that the disease is a result of supernatural forces and that a cure can be achieved by appealing to supernatural forces. The scientific view may lead to the assumption that the disease is a result of the cause-and-effect relationship of natural phenomena and that a cure is achieved by scientific medicine ( ).
Folk Medicine Beliefs as a System
The folk medicine system classifies illnesses or diseases as natural or unnatural. This division of illnesses or diseases into natural and unnatural phenomena is common among Haitians, persons from Trinidad, Mexicans and Mexican Canadians, African Canadians, and some Southern White Americans ( ).
Distinction between Natural and Unnatural Events
The simplest way to distinguish between natural and unnatural illnesses is that, according to this belief system, natural events have to do with the world as God made it and as God intended it to be. Thus, natural laws allow a measure of predictability for daily life. Unnatural events, on the other hand, imply the exact opposite because they upset the harmony of nature. Unnatural events can therefore be viewed as events that interrupt the plan intended by God and at their very worst represent the forces of evil and the machinations of the devil. Unnatural events are frightening because they have no predictability. They are outside the world of nature, and so when they do occur, they are beyond the control of ordinary mortals.
Germane to the tendency to view phenomena in terms of opposition, such as good versus evil and natural versus unnatural, is the belief held by some folk medicine systems that everything has an exact opposite. For example, some African Canadians who subscribe to a folk medicine system believe that for every birth there must be a death, for every marriage there must be a divorce, and for every person with good health there must be someone with bad health. This belief is so encompassing that such individuals believe that every illness has a cure, every poison has an antidote, every herb has a healing purpose, and so forth ( ). Because of this belief, some cultural groups do not accept the chronicity of such diseases as acquired immunodeficiency syndrome (AIDS), herpes, or syphilis.
Herbal medicine continues to enjoy a “rebirth” ( ). noted that 34% of all U.S. citizens use herbal products in some way. In 1990, they spent $13.7 billion on “unconventional” therapy, with 75% of this cost being out-of-pocket. Canadians are also participating in this resurgence with an increased use of herbal medicines ( ).
In 2007, the number of what is now termed natural medicines in some circles had increased again dramatically. Natural medicines also include vitamins, dietary supplements, and alternative medicines. In fact, the use of dietary supplements and alternative medicines continues to gain popularity among health-seeking consumers. Today, more than 40% of all U.S. residents have tried some type of alternative medication, whereas 50% of U.S. residents 35 to 49 years of age have tried alternative medicines. It fact, it has been reported that in the United States:
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106 million people use vitamins and minerals.
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44.6 million people use herbal remedies.
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24.2 million people use specialty dietary supplements ( ).
Distinction between Natural and Unnatural Illnesses
Illnesses are generally classified as natural or unnatural, which affects the type of cure or practitioner sought. All illnesses can be viewed as representing disharmony and conflict in some particular area of life and thus tend to fall into two general categories: natural illnesses as environmental hazards and unnatural illnesses as divine punishment.
Natural Illnesses as Environmental Hazards.
Natural illnesses in the folk medicine belief system occur because of dangerous agents, such as cold air or impurities in the air, food, and water. Natural illnesses are based on the belief that everything in nature is connected and that events can be both interpreted and directed by an understanding of these relationships. Sympathetic magic, the basis for popular folk medicine beliefs and practices, can be divided into two categories: contagious and imitative magic. At the root of contagious magic is the premise that the parts do represent the whole. Many witchcraft practices are based on contagious magic, including such practices as an evildoer obtaining a lock of the victim’s hair or shavings from the victim’s skin to do harm. Imitative magic, on the other hand, is based on the premise that like will follow like. For example, a knife under the bed will cut labor pains. To assist the client in preventing natural illnesses, the nurse must comprehend the direct connections between the body and natural phenomena, such as the phases of the moon, the position of the planets, and the changing of the seasons. Because in this belief system good health is contingent on these phenomena, it is imperative that one be able to read these signs if the body is to remain in harmony with nature.
Unnatural Illnesses as Divine Punishment.
Unnatural illnesses are believed to occur because a person has become so grave a sinner that the Lord withdraws his favor. In fact, illnesses may be attributed to punishment for failure to abide by the proper behavior rules given to man by God ( ). The cause of unnatural illnesses, for those who subscribe to these beliefs, is based on the continual battle between the forces of good and evil as personified in God and the devil. Evil influences may be blamed for any unnatural illness, which may range from nightmares to tuberculosis to cancer ( ). An example of a person subscribing to this belief is a diabetic African-American woman who consistently refuses to inject herself with insulin because she believes her illness is the direct result of punishment by the devil for her sinful youth. However, unnatural illnesses are also believed to result from witchcraft. Witchcraft is based on the belief that there are individuals who have the ability to mobilize unusual powers for good and evil.
Comparison of the Folk Medicine System and Other Medical Systems
To develop an understanding of folk medicine as a system, the system itself must be examined, along with the ecological model, the Western medical system, alternative therapies, and religious systems. Every medical system is based on the philosophy of survival of the human organism. According to the classic work of Thomas , both folk practices and Western medical practices are social systems with interdependent parts or variables that include beliefs, attitudes, practices, and roles associated with the concepts of health and disease and with the patterns of diagnoses and treatments.
All medical systems have an adaptive nature. As such, the term medical system can be defined as the pattern of cultural tradition and social institutions that evolves from deliberate behavior to improve health status, regardless of the outcome of a particular behavior ( ).
To achieve good health, an individual must develop an idea of what constitutes disease, with its counterpart conditions of pain and suffering. Once an individual adopts a philosophy of health, various health roles are delineated. These health roles require specific health care practitioners who are duly initiated into the rites of practice. Practitioner status may be granted by medical societies or, in the case of folk medicine practices, by supernatural forces. The body is an integral part of each individual; therefore, all medical systems use body parts or excreta for diagnostic purposes. In addition, folk medicine practices, in most cases, prescribe medicine to rub into the skin, to irrigate the body, or to anoint the sick.
Ecological Model.
The ecological model is closely related to the folk medicine system. defined ecology as having three foci: (1) biological, or the branch of biology that deals with the relationship between organisms and the environment; (2) social, or the relationship between people and institutions and the interdependence between the two; and (3) cultural, or the relationship between culture and the environment, which also includes culture and societies in the environment. Ecological dimensions of health care can assist the nurse in providing plausible explanations as to why certain individuals contract specific diseases and why other individuals do not. Over the past decade, health care practitioners have become increasingly concerned with the ecological dimensions of race and ethnic minority group health problems such as AIDS and sickle cell anemia.
Western Medical System.
In contrast to the folk medicine system, which attempts to explain illness in terms of balances between an individual and the physical, social, and spiritual worlds, is the Western medical system of diagnoses and scientific explanations for illness. Western medical practices focus on preventive and curative medicine, whereas folk medicine practices focus on personal rather than scientific behavior. In the folk medicine system, it may make all the sense in the world to burn incense and to avoid certain individuals, cold air, and the “evil eye.” According to , one person’s religion is another person’s magic, witchcraft, or superstition. However, it is very difficult for health care professionals to see these entities as directly relevant to medical practice or to recognize that for some cultural groups, religion is the equivalent of a science.
Although many differences in focus can be seen when Western and folk medicine health practices are compared, some of these differences may not be that significant. For example, Western medical relationships are generally dyads, such as physician–client, physician–nurse, and nurse–client relationships, whereas folk medicine networks are generally multiperson health care networks that may consist of parents, other relatives, and nonrelatives as health caregivers. However, today multiperson health care networks are no longer dismissed by Western health care practitioners as irrelevant and thus dysfunctional. In fact, multiperson networks are slowly being incorporated into the Western medical system of health care.
Ethnic diets are an important aspect of human ecology, and health care providers are beginning to incorporate the use of ethnic diets into practice and to understand their significance. A person, regardless of ethnic group, must consume enough food to meet nutritional requirements for energy, fat, protein, vitamins, and minerals to keep the body functioning. noted that very little is known regarding the range of human variability both among and within human populations, particularly regarding common parameters such as nutritional requirements, physiological response to malnutrition, and digestive capabilities. It is perhaps this lack of knowledge that has in the past resulted in Western-oriented health care providers prescribing diets unacceptable to persons from diverse and multicultural backgrounds. In fact, some individuals from diverse cultural backgrounds may have physical incompatibility with certain Western foods. Therefore, the nurse must consider factors regarding ethnic diets and other such folk practices when developing care plans for culturally specific nursing care.
Alternative Therapies.
In 1990, 36% of Americans, approximately 61 million people, used one or more nonmedical forms of therapy to treat illness. Most of these individuals used these alternative therapies without informing their health practitioner ( ). In contrast, William LaValley, founder of the Nova Scotia Medical Society’s Complementary Medicine Section, estimates that 25% of the Canadian population sought health care from alternative practitioners ( ). Other presenters at the reported that 18% of patients seen at the Calgary human immunodeficiency virus (HIV)/AIDS clinic and 27% of those seen at the University of Calgary gastroenterology clinic had tried alternative therapies. Some 44% of physicians from Alberta indicated that they made referrals to practitioners of alternative therapies, even though only 10% considered themselves informed on the subject ( ). Although Western medicine tends to focus on illness care, alternative therapy addresses the whole patient ( ). In alternative therapy, symptoms are seen as the tip of the iceberg and the body’s means for communicating to the mind that something needs to be changed, removed, or added to one’s life ( ). In alternative therapy, the mind and the body are seen as a whole. Acupuncture, holistic healing, therapeutic touch, aromatic therapy, meditation, guided imagery, and a variety of other techniques prevail as feasible alternative therapies ( ). Practitioners of alternative therapies include therapeutic touch experts, homeopaths, naturopaths, massage therapists, and reflexologists ( ). According to , scientists working in the new field of psychoneuroimmunology have demonstrated the existence of intimate links between parts of the brain concerned with thought and emotion and the neurological and immune systems. Based on these discoveries, concluded that thought can become biology. Although the scientific value of alternative, or complementary, therapies is yet to be proved, there is a psychological component that allows the client to have a sense of control. For this reason, nurses should be well informed about nontraditional methods ( ).
Over the past 20 years the use of complementary therapies increased from 36.3% in 1990 to 46.3% of the U.S. population by 1997 and remained stable from 1997 to 2002 ( ). The increasing prevalence of Alzheimer’s disease in an aging U.S. population with concomitant behavioral symptoms of dementia (BSD), coupled with the numerous side effects experienced when medications are used to ameliorate these symptoms, has resulted in the current recommendations for nonpharmacological treatments (NPTs) for BSD. Several of the therapies that demonstrate efficacy for alleviating BSD in Alzheimer’s disease are complementary therapies such as aromatherapy ( ) and calming interventions such as therapeutic touch ( ; ; ; ). Research studies conducted by and reviewed by show a moderate effect for therapeutic touch on BSD. In a randomized, double-blind, three-group experimental interrupted design, examined the effect of therapeutic touch on BSD nursing home residents with dementia. Fifty-seven residents 67 to 93 years of age who exhibited BSD were randomized to one of three groups (experimental, placebo, control) within each of three special care units within three long-term care facilities. Direct behavioral observation was completed every 20 minutes from 8:00 a.m. to 6:00 p.m. for 3 days preintervention and for 3 days postintervention by trained observers who were blind to group assignment. The intervention consisted of therapeutic touch given twice daily for 5 to 7 minutes for 3 days between 10:00 a.m. and 11:30 p.m. and between 3:00 p.m. and 4:30 p.m. The main outcome variable was overall BSD including six specific behaviors: restlessness, escape restraints, tapping, searching, pacing, and vocalization. Findings from this study using analysis of variance (ANOVA) (F 3.331, P = 0.033) and Kruskal-Wallis ( X 2 = 6.661, P = 0.036) indicated a significant difference in overall BSD, restlessness, and vocalization when the experimental group was compared with the placebo and control groups. Therapeutic touch significantly decreased restlessness and vocalization when the experimental group was compared with the control group, whereas the placebo group indicated a decreasing trend in BSD. In a similarly designed study, found that therapeutic touch decreased BSD in the experimental group compared with the control group ( P = 0.03), with a significant difference in morning cortisol (P = <0.001). At a time when cost containment is a consideration in health care, therapeutic touch is a complementary therapy that is noninvasive, readily learned, and able to provide an alternative for selected persons with BSD.
Religious Systems.
Some religious groups have elaborate rules concerning health care behaviors, including such things as the giving and receiving of health care. Religious experiences are based on cultural beliefs and may include such things as blessings from spiritual leaders, apparitions of dead relatives, and even miracle cures. Healing power based on religion may also be found in animate as well as inanimate objects. Religion can and does dictate social, moral, and dietary practices that are designed to assist an individual in maintaining a healthy balance and, in addition, plays a vital role in illness prevention. Examples of religious health care practices include illness prevention through such acts as the burning of candles, rituals of redemption, and prayer. Religious practices such as the blessing of the throats on St. Blaine’s feast day are performed to prevent illnesses such as sore throats and choking. Baptism may be seen as a ritual of cleansing and dedication, as well as a prevention against evil. In addition to its meaning as dedication to God’s will and a preparation for death, anointing the sick is related by some religious and cultural groups to recovery and may be performed in the hope of a miracle. Circumcision is also a religious practice in that it may be viewed as having redemptive values that may prevent illness and harm ( ; ).
It is important for the nurse to learn to distinguish between a shaman and a priest. A shaman derives power from the supernatural, whereas a priest learns a codified body of rituals from other priests and from biblical laws. In traditional folk medicine systems, some of the most significant religious rituals are those that mediate between events in the here and now and events in the hereafter or “out there” in the netherworld ( ).
Another example of a religious system is the Amish movement. For the Amish, religion and custom are inseparable and blend into a way of life ( ). Religious considerations determine hours of work, occupation, means, destination of travel, and choice of friends and mates. The Amish value the importance of working with the elements of nature rather than mastery over these elements. Closeness to soil, animals, plants, and weather is valued. Salvation is viewed as obedience to the community ( ). The Amish have the belief that the human body was created by God and should not be tampered with. Some Amish believe that although medication may help, it is God who heals ( ).
Many Amish have been increasingly influenced by special health food interests, vitamins, and food supplement industries ( ). Folk medical practices and opposition to health care seem to be dominant in some family systems ( ). hypothesized that there is a relationship between the concept of family culture and health behavior. Clusters of family cultures serve as basic socializers of health ( ). Friendshaft, a concept that crosses distinct church lines, produces distinct patterns of behavior and personality in the Amish community related to choice of type of physician. It also influences choice of curative diet therapy, folk remedies, and family coding of preference of treatment in reference to the presumed cause of symptoms ( ; ).
Death and Dying and End-of-Life Decision Making across Cultures
Some researchers have noted that grieving and death rituals vary across cultures and for the most part are often heavily influenced by religion ( ; ). It is essential to remember that how and to what extent rituals regarding death and dying are practiced will certainly vary and will depend on the country of origin and level of acculturation into the mainstream of U.S. society. also noted that the duration, frequency, and intensity of the grief process by various cultural groups is often also based on the manner in which death is experienced and on the family cultural beliefs ( ).
Cultural Beliefs and Advanced Directives.
The U.S. health care system is based on three values:
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Life is sacred and should be preserved at all costs.
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Autonomous decision making should be maintained at all times.
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Above all, it is important that no individuals suffer needlessly ( ).
Autonomy in Decision Making and Truth Telling about Death and Dying.
In the United States, the value of autonomous decision making is valued by many persons from diverse cultures ( ). found that when it comes to decision making in the case of the terminally ill, some Korean Americans and Mexican Americans subscribe to a family-centered model of decision making as opposed to a patient-centered model. For example, they noted that some Korean Americans may seek to avoid the unnecessary suffering of a loved one, particularly if they believe that more negative results would occur if a loved one were told of an unfavorable prognosis. In this case, the family serves as a group decision maker. Examples of other cultural groups that may subscribe to such beliefs include some Japanese Americans and Hispanic individuals ( ; ).
Findings from one study suggested that Mexican Americans and Korean Americans are significantly less likely than Whites and African-Americans to believe that a family member should be told of a diagnosis, particularly a diagnosis such as metastatic cancer ( ). In fact, Koreans (47%) and Mexican Americans (65%) were significantly less likely than Whites (87%) and African-Americans (88%) to believe that a loved one should be told of a diagnosis such as metastatic cancer. A surprising finding from this study ( ) was that Korean Americans (28%) and Mexican Americans (41%) tended to hold an overriding belief that loved ones should not be allowed to make decisions about life-supporting measures as compared with 56% of Whites. In fact, some researchers suggest that among Mexican Americans there is a belief that the dying should be protected from knowing the prognosis. Yet when it comes to the decision of quality over quantity of life, some cultural groups also vary in this regard. For example, noted that some African-Americans are about only half as likely as their White counterparts to opt for pain medications that might improve the quality of their lives at the expense of the length of life, even if it means that the physiological pain might be constantly present. On the other hand, Whites are more likely to refuse such life-sustaining measures as intubation than their Hispanic or African-American counterparts ( ).
The astute nurse who works with persons from diverse cultural backgrounds must be cognizant of the variations not only in the beliefs about death and dying but also about such keys issues as advanced directives, truth telling, and autonomy in decision making.
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