Cultural influences and diabetes health care

Abstract

Health care planning requires understanding of the underpinning culture of the people. How do people from different cultures and social groups explain the causes of ill health and the types of the treatment they believe in, and whom do they contact if they require any help? They may have different expectations of the health care system and of what a doctor can or cannot do. At times, coming from a different culture, it is difficult to recognise the body language and personal expectations of patients. In his article ‘Cultural aspects of diabetes mellitus in Sudan’ in this issue of Practical Diabetes International (pages 226–229), Dr Awad Ahmed discusses some of the important issues among the Muslim communities in Sudan. But it unveils only the tip of the iceberg regarding cultural variations among South Asian communities on the whole and the impact on planning health care delivery pathways. It is well established that there are gaps in knowledge and sensitivity when dealing with patients from diverse cultures.1 This may lead to miscommunication through false generalisation and stereotyping.2 Knowledge of cultural variations not only empowers health care providers but it means a lot to patients' perceptions and beliefs. Anthropologists have provided many definitions of culture. Taylor's3 widely accepted definition of culture is: ‘The complex whole, which includes knowledge, beliefs, art, morals, law, custom and any other capabilities and habits acquired by man as a member of the society.’ Cecil Helman4 describes culture as ‘A set of guidelines that is inherited by an individual as a member of the particular society and that tells them how to view the world, how to experience it emotionally and how to respond in it, its relation to other people, to supernatural forces or gods and to natural environment.’ It also provides people with the pathway to transmit the above guidelines to the next generation by the use of symbols, language, art and rituals. Hence culture could be seen as an ‘inherited lens’ through which an individual perceives and understands the world they live in and understands how to live within it. While growing up in society, one gradually acquires the ‘cultural lens’ of the society. This shared perception of the world is an essential element of the continuity of cultural groups. The American anthropologist Edward Hall5 suggests that there are three different levels of culture, ranging from the explicit manifest culture visible to outsiders, such as social rituals, traditional dress and festive occasions, to a much deeper level including underpinning rules and assumptions known to individuals or the members of cultural groups but rarely shared with outsiders and taken for granted. Manifest culture is a public façade presented to the world, a series of implicit assumptions, beliefs and rules, which constitute a group's ‘cultural grammar’ and is easy to observe and change. The deeper level of culture is hidden, stable and difficult to change. Anthropologists studying the social-culture end of the spectrum assert beliefs and practices relating to ill health often linked to beliefs about the origin of a much wider range of misfortune, i.e. accidents, interpersonal conflicts, natural disasters, crop failure, theft and loss, etc. In some societies, the whole range of those misfortunes are blamed on supernatural forces, on divine retribution or on the malevolence of witches or sorcerers. Thus cultural background plays an important influence on many different aspects of people's lives including their beliefs, behaviour, perception, emotions, rituals, diet, dress, body image and particularly attitudes towards ill health, pain and other misfortunes. An individual's age, gender, size, body image and experience, educational, socio-economical and social class, economical stability, social support network and environmental factors, etc. may also influence their health beliefs, all of which have important implications for health and health care. Therefore, it is hard for one to conceptualise how people react to illness, death, or other misfortune without understanding the type of culture they have grown up in or acquired, through which they perceive and interpret their world. The role of culture should be seen in its particular context, which is made up of historical, economical, social, political and geographical elements. It means that the people's culture is influenced by many other factors at one point in time and should not be seen in isolation. Black's report (1982)4 clearly demonstrated the role played by economic factors in the causation of ill health. Health could be correlated social class, and those with low income and lower social class had more illness in comparison with their fellow citizens in affluent areas. It is also well accepted that diabetes does not discriminate in the community. It affects people from all ages in every population and the risk of developing diabetes increases with age. Diabetes can have a devastating impact on the physical, psychological and mental well-being of individuals and their families. Diabetes is more prevalent among less affluent people, and more deprived groups may have a one and half times greater risk of diabetes. There is a four to five times higher prevalence of diabetes among South Asians and up to three times higher prevalence among Afro-Caribbeans in UK.6 Reflecting on Black's report, one could argue that the higher prevalence could be correlated with socio-economical status and the acquired lifestyle of people in UK in addition to their genetic predisposition. The Delivery Strategy of National Service Framework (NSF)6 and the GP contract7 have important implications for the delivery of health care sensitive to individuals and local needs especially for people with diabetes in the UK. These documents also emphasise the need for clinical governance to be local and the delivery mechanism to be safe and of a high quality. The GP contract goes one step further, ensuring a high quality of care and outcomes in the community at large. Therefore, understanding the underpinning cultural diversities is pivotal in planning health care in any country with global movement of communities over the years. People from different communities enriched with their own culture are living in every part of the world. UK is no different from any other country and has its share of communities from different parts of the world. The last OPCS Census Report (1991)8 showed that there are 1431348 people of South Asian decent living in UK. The majority of these people (823821) are from India, 449646 are from Pakistan, and 157881 from Bangladesh, etc. There are nine well-recognised communities of South Asian decent in the world, and there are also various other subsections. These communities differ in their communication and culture. They have different languages, religious obligations, religious practices, eating habits, social customs, birth and death rites, etc. Their beliefs restrict the therapeutic and non-therapeutic interventions they choose to adopt. This may lead to long-standing complications because of inadequate concordance with management strategies of chronic diseases such as diabetes. It is beyond the scope of this article to expand on these beliefs in detail. Moreover it is very difficult for people from different cultures to be sensitive to individual needs without the background knowledge. It appears that some of the traditional health care paradigms have to move forward in order to deliver quality health care, to empower health care professionals, carers and of course patients, and to encourage the culture of self-management. One also needs to look into methods of information gathering and processing, perhaps with the helps of link workers or support workers, as well as road mapping pathways that will deliver health care sensitive to the individual's needs.