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Homework answers / question archive / We have discussed many topics and ideas about culture and health over the semester

We have discussed many topics and ideas about culture and health over the semester

Health Science

We have discussed many topics and ideas about culture and health over the semester. In a 2-3 page paper (or slightly longer) reflect on the following:

  1. How has your thinking about culture and health changed as a result of this class? Give specific examples.
  2. How do you see yourself using the principles taught in this class to help achieve health equity, justice in health, or promoting inclusive health? Consider how you think about what these terms mean and what this looks like for you. This could range from teaching your friends about being culturally competent to pursuing a career to help improve the health of marginalized populations.
  3. using Arial font, 11 pt. and 1-inch margins all around. Please use APA format to cite any material other than your own that you use in your paper. Be sure to edit your paper for spelling, grammar, and writing clarity. You will be graded on the appropriateness, completeness (i.e., did the student address and support each question in the prompt?) and thoughtfulness of your responses, as well as spelling, grammar, and writing clarity.

CHAPTER 5 Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Religion, Rituals, and Health Nothing is so conducive to good health as the regularity of life without haste and without worry which the rational practice of religion brings in its train. —James J. Walsh To prevent disease or to cure it, the power of truth, of divine Spirit, must break down the dream of the material senses. —Mary Baker Eddy Key Concepts Spirituality Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Religion Rituals Shrines Animal sacrifice © Click Bestsellers/Shutterstock, Inc. and © Ms.Moloko/Shutterstock, Inc. Learning Objectives After reading this chapter, you should be able to: 1. Describe the role religion plays in people’s lives. 2. Explain how religion influences health behaviors and the rationale behind these choices. 3. Describe ways that religion can have positive and negative effects on physical and mental health. 4. Describe religious differences in birthing and death rituals. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. 5. Explain the difference between spirituality and religion. Have you ever prayed for a loved one or yourself when ill? If so, you fall within the majority of Americans. In 2007, almost 50% of adults said they had prayed about their health during the previous 12 months, up from 43% in 2002 and 14% in 1999 (Wachholtz & Sambamoorthi, 2011). Thirty-six percent of Americans surveyed reported that they had experienced or witnessed a divine healing of an illness or injury (Pew Forum on Religion & Public Life, 2008). Spirituality, religion, and health have been related in all population groups since the beginning of recorded history (Koenig, 2012). In earlier times, physicians were often clergy, and for hundreds of years religious organizations were responsible for licensing physicians (Koenig, 2012). Belief in the ability of the supernatural to heal surfaced in shamanism thousands of years ago. Recorded history describing spiritual healing includes Egyptian belief in the healing power of a particular holy site and Greek and Roman temples built to the healing gods. These types of practices are still known today. Shamanic traditions continue today in Africa, Central and South America, and among some American Indian tribes, and Christians continue to make pilgrimages to holy sites that are believed to heal, such as the Sanctuary of Our Lady of Lourdes in France. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Spirituality is often described as a belief in a higher power, something beyond the human experience. For many people, spirituality is a means of living with, confronting, or otherwise addressing universally mysterious events and occurrences. These events include birth, death, health, personal challenges, and tragedies. Scientific research has determined that spiritual practices positively influence health and increase longevity. However, there is disagreement as to the mechanism of these benefits. Closely related but distinctive is religion, which is the acceptance of the specific beliefs and practices of an organized religion. Religion is generally an organized approach to practicing a form of spiritual belief in and respect for a supernatural power or powers, which is regarded as a creator or a governing framework of the universe and is supported by personal or institutionalized systems grounded in belief and worship. Although many people find spirituality in the form of religious practice, religion and spirituality are conceptually different. A person may be spiritual without being religious, or may be both. Research has shown that both spirituality and religious beliefs have positive effects on health. Those who practice Eastern religions seek to refine the life force within themselves, and they attempt to find meaning and purpose in life through these efforts. Practitioners of Western Christianity may focus more on faith and belief in external guidance and salvation from a supreme being, a god, or gods. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Although much human conduct is related to spiritualism that goes beyond practicing formal religious teachings, these two concepts flow universally throughout all cultures. However, most of the research has focused on health and religion, as opposed to health and spirituality, primarily because religion is associated with behaviors that can be quantified (e.g., how often one prays or attends a place of worship), it can be categorized by type of religion, and there is more agreement about its meaning. Religion has a significant role in the United States and in the health. It has an impact on social lives and health behaviors and, hence, on physical and mental well-being. Religion and rituals overlap, but not all rituals are related to religion. Rituals such as baptism and the burning of ghost money when a person dies (a tradition in China) are related to religious practices, but other rituals are not tied to religion, such as drinking tea at 3 o’clock in the afternoon every day. The chapter begins with a discussion of religion and then moves into rituals, but the separation is not definitive. We discuss how religion in America influences health. Then we focus on rituals related to health. Because these topics have such a vast scope, only a few religious practices within the United States are discussed. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Religion in the United States Spirtualism was part of the indigenous populations when the Europeans first arrived in what would become the United States. The conquering Spanish brought their Catholic priests not only for their own guidance but also to impose Christian beliefs on the natives. To a large extent the United States was established by people of strong religious beliefs, including Protestants from Europe seeking a place to practice their beliefs free from religious conflict with other European religions including Catholicism. In part because of the successful establishment of religious colonies, the United States has become “The Land of the Free,” drawing immigrants from all over the world. The result is that almost every religion is represented and practiced somewhere in the United States. In the 2011 Gallup poll, about 91% of the U.S. population reported a belief in God or a universal spirit (Newport, 2011). In 2008, 65% of Americans had reported that religion is an important part of their daily lives (Newport, 2009). Religion and race/ethnicity are linked, but it is important not to assume a person’s religion is based on his or her ethnicity (see Table 5.1). It also is not safe to assume that a person strictly adheres to the practices of a religion. Adherence to religious practices exists on a continuum, with some strictly adhering to all of the guidelines and others having looser ties. TABLE 5.1 Religious Groups in the United States by Denomination, 2015 Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Data from Muslims from “Muslim Americans: Middle Class and Mostly Mainstream,” Pew Research Center, 2007. For more information, please see the detailed tables in the Full Reports section. Source: Pew Research Center (2015). Comparisons. Retrieved from Religion and Health Behaviors Lifestyle represents the single most prominent influence on our health today. As a result, the United States is seeing the need for more emphasis on prevention and behavior modification. People with religious ties of any kind have been shown to engage in healthier behavioral patterns, and these positive lifestyle choices lead to improved health and longer lives. Why do people with stronger religious ties have better health? The answer includes several possible factors, such as proscribed behaviors, closer social relationships, and improved coping mechanisms. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Health behaviors encouraged or proscribed by particular religions are one possible explanation for how religion can positively affect health. Some religions prohibit tobacco, alcohol, caffeine, certain sexual practices, and premarital sex, and some encourage vegetarianism. Social relationships are another potential explanatory factor for the connection between religion and improved health indicators. Social ties can provide both support and a sense of connectedness. Many churches and temples offer workshops, health fairs, and craft fairs, which provide social interactions. Social relationships also are tied to coping mechanisms because they provide support in multiple forms during times of stress. For example, financial support may be provided to people who have incurred a tragedy, such as a disability, loss of job, or a house fire. Religious organizations also conduct fundraisers for families who have experienced a death or personal tragedy in the family. Churches and temples assist elders by providing transportation or taking food to the homebound. Friendships and a sense of purpose also are methods of support. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Dietary Practices Dietary practices have a long history of being incorporated into religions around the world. Some religions prohibit followers from consuming certain foods and drinks all of the time or on certain holy days; require or encourage specific dietary and food preparation practices and/or fasting (going without food and/or drink for a specified time); or prohibit eating certain foods at the same meal, such as dairy and meat products. Other religions require certain methods of food preparation and have special rules about the use of pans, plates, utensils, and how the food is to be cooked. Foods and drinks also may be a part of religious celebrations or rituals. The restriction of certain foods and beverages may have a positive impact on the health of those engaged in such practices. For example, restricting consumption of animal products, such as beef and pork or all animal products, may reduce the risk of health problems. Many religions, such as Hinduism and Buddhism, practice or promote vegetarianism, and these diets have been shown to have several health effects, such as the reduction of heart disease, cancer, obesity, and stroke. Some religions help prevent obesity through beliefs that gluttony is a sin, only take what you need, and the need for self-discipline. Table 5.2 presents a list of religions, their related dietary practices and restrictions, and the rationale behind them. Religions may incorporate some element of fasting in their practices. In many religions, the general purpose for fasting is to become closer to God, show respect for the body (temple) that is a gift from God, understand and appreciate the suffering that the poor experience, acquire the discipline required to resist temptation, atone for sinful acts, and/or cleanse evil from within the body (Advameg Inc., 2008). Fasting may be recommended for specific times of the day; for a specified number of hours; on designated days of the week, month, or year; or on holy days. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. TABLE 5.2 Religions and Their Related Food and Substance Practices and Restrictions and Related Rationales Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Source: Adapted from Advameg Inc. (2008). Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. During times of fasting, most but not all religions permit the consumption of water. Water restriction can lead to a risk of dehydration. Some fasters may not take their medication during the fast, which may put their health at risk. Prolonged fasting and/or restrictions from water and/or medications may pose health risks for some followers. Because of these health risks, certain groups are often excused from fasting. These groups include people with chronic diseases, frail elderly, pregnant and lactating women, people who engage in strenuous labor, young children, and people suffering from malnutrition. Did You Know? Most Hindus prefer to die at home. If that cannot occur, then certain rituals are to be performed at the hospital. Examples include assisting the patient with facing east and lighting a lamp near the patient’s head. Often family and friends will be present, singing hymns or chanting mantras from sacred scriptures. Holy ash or sandalwood paste is applied on the forehead after the patient dies. Members of the family may want the body to face south as that symbolizes facing the god of death. A few drops of holy water are trickled into the mouth, and the incense near the head of the deceased remains burning. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Use of Stimulants and Depressants In addition to foods, some religions prohibit or restrict the use of stimulants. A stimulant is a product (including medications), food, or drink that stimulates the nervous system and alters the recipient’s physiology. Stimulants include substances that contain caffeine, including some teas, coffee, chocolate, and energy drinks. Caffeine is prohibited or restricted by many religions because of its addictive properties. A depressant slows down the nervous system. Alcohol is an example. Many religions also restrict spices and certain condiments, such as pepper, pickles, or foods with preservatives because they are believed to be harmful by nature and favor the natural taste and effect of foods (Advameg Inc., 2008). Some religions prohibit the use of stimulants and depressants, but others use them during ceremonies. For example, Roman Catholics, Eastern Orthodox Christians, and certain Protestant denominations use wine as a sacramental product to represent the blood of Christ in communion services (Advameg Inc., 2008). Rastafarians introduced marijuana into their religious rites because they consider it to be the “weed of wisdom,” and they believe it contains healing ingredients (Advameg Inc., 2008). American Indians use tobacco and the hallucinogenic peyote as part of their spiritual ceremonies. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Cigarette Smoking The influence of religion and spirituality is most evident in its “effects” on cigarette smoking. At least 137 studies have examined relationship between religion and spirituality and smoking, and of those, 123 (90%) reported statistically significant inverse relationships (including three at a trend level), and no studies found either a significant or even a trend association in the other direction. Of the 83 methodologically most rigorous studies, 75 (90%) reported inverse relationships with religion and spirituality involvement. Not surprisingly, the physical health consequences of not smoking are enormous. Decreased cigarette smoking will mean a reduction in chronic lung disease, lung cancer, all cancers (30% being related to smoking), coronary artery disease, hypertension, stroke, and other cardiovascular diseases (Koenig, 2012). Exercise Level of exercise and physical activity also appears linked to religion and spirituality. Koenig (2012) located 37 studies that examined this relationship. Of those, 25 (68%) reported significant positive relationships between religion and spiritual involvement and greater exercise or physical activity, whereas 6 (16%) found significant inverse relationships. Of 21 studies with the highest quality ratings, 16 (76%) reported positive associations and 2 (10%) found negative associations (Koenig, 2012). Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Religion and Health Outcomes As a result of religion’s effects on health behaviors, it is not surprising that religion has been shown to have positive effects on both physical and mental health. Over the last several decades, a notable body of empirical evidence has emerged that examines the relationship between religion or religious practices and a host of outcomes. Most of the outcomes have been positive, but it is important to note that religion does not always have favorable effects on health. Religion has sometimes been used to justify hatred, aggression, and prejudice (Lee & Newberg, 2005). Religion can be judgmental, alienating, and exclusive. Religious conflict is perhaps the greatest controllable threat to health and well-being in the modern era. Though raised as a Christian, during World War II, Adolph Hitler intentionally murdered 6 million Jews. Jews and Muslims repeatedly attack one another, keeping the Middle East in a constant state of tension over the last 50 years. Islamic extremists have declared war on Christian believers and used explosives on subways in Spain, crashed jetliners into high rises in New York, and used modern media to display multiple and serial beheadings while ostensibly practicing their religion. Threats of Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. nuclear proliferation and potential use of “dirty” nuclear weapons have been driven by religious conflict. Religion also may have a negative impact on health through the failure to conform to community norms. Open criticism by other congregation members or clergy can increase stress in social relationships. Feelings of religious guilt and the failure to meet religious expectations or cope with religious fears can contribute to illness. In some cases, parents’ reliance on religion instead of traditional medical care has led to children’s deaths. Also, people may not participate in healthy behaviors because they believe that their health is in God’s hands, so their behaviors will not change God’s plan. This is referred to as a fatalistic attitude. In terms of positive effects, an abundance of research supports religion’s constructive effect on health outcomes. Koenig (2012) found that religion and spirituality were related to lower levels of depression and anxiety and an improved ability to cope with adversity. Studies of health behavior have found that higher levels of religious involvement are inversely related to alcohol and drug use, smoking, sexual activity, depressive symptoms, and suicide risk (Koenig, 2012; Williams & Sternthal, 2007). These studies also found that spirituality and religion are positively related to immune system function. A review of 35 studies of the relationship between religion and healthrelated physiological processes found that both Judeo–Christian and Eastern religious practices were associated with reduced blood pressure and improved immune function; moreover, Zen, yoga, and meditation practices correlated with lower levels of stress hormones and cholesterol and better overall health outcomes in clinical patient populations (Williams & Sternthal, 2007). In an important publication, Duke University researcher Harold Koenig and colleagues Michael McCullough and David Larson (2000) systematically reviewed much of the research on religion and health. This lengthy and detailed review of hundreds of studies focuses on scholarship from refereed journals. In sum, the review demonstrates that the majority of published research is consistent with the notion that religious practices or religious involvement are associated with beneficial outcomes in mental and physical health (Johnson, Tompkins, & Webb, 2008). These outcome categories include hypertension, mortality, depression, alcohol use or abuse, drug use or abuse, and suicide. Reviews of additional social science research also confirm that religious commitment and involvement in religious practices are significantly linked to reductions not only in delinquency among youth and adolescent populations but also in criminality among adult populations. Part of the following information is a summary of the findings from an extensive literature review conducted by Johnson, Tompkins, and Webb (2008). This information is reprinted with permission from the Baylor Institute for Studies of Religion. Hypertension Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. As of 2012, nearly 1 in 3 adults (about 67 million) had high blood pressure, also known as hypertension (Centers for Disease Control and Prevention, 2012b). Though there is strong evidence that pharmacologic treatment can lower blood pressure, there remains concern about the adverse side effects of such treatments. For this reason, social epidemiologists are interested in the effects of socioenvironmental determinants of blood pressure. Among the factors shown to correlate with hypertension is religion. Epidemiological studies have found that individuals who report higher levels of religious activities tend to have lower blood pressure. Johnson, Tompkins, and Webb’s (2008) review of the research indicates that 76% of the studies found that religious activities or involvement tend to be linked with reduced levels of hypertension (see Table 5.3). TABLE 5.3 Results of Religion and Health Outcomes Studies The data represent the percentage of published studies that were reviewed. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Baylor Institute for Studies of Religion. Koenig (2012) found that at least 63 studies have examined the relationship between religion and spirituality and blood pressure, of which 36 (57%) reported significantly lower blood pressure in those who are more religious or spiritual and 7 (11%) reported significantly higher blood pressure. Mortality A substantial body of research reveals an association between intensity of participation in religious activities and greater longevity. Studies reviewed for the report done by Johnson, Tompkins, and Webb (2008) examined the association between degree of religious involvement and survival (see Table 5.3). Involvement in a religious community is consistently related to lower mortality and longer life spans. Johnson, Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Tompkins, and Webb’s (2008) review of this literature revealed that 75% of these published studies conclude that higher levels of religious involvement have a sizable and consistent relationship with greater longevity (see Figure 5.1). This association was found to be independent of the effect of variables such as age, sex, race, education, and health. In a separate analysis, McCullough and colleagues conducted a meta-analytic review that incorporated data from more than 125,000 people and similarly concluded that religious involvement had a significant and substantial association with increased length of life (as cited in Johnson et al., 2008). In fact, longitudinal research in a variety of different cohorts also has documented that frequent religious attendance is associated with a significant reduction in the risk of dying during study follow-up periods ranging from 5 to 28 years. Cancer Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. At least 29 studies have examined relationships between religion/spirituality and either the onset or the outcome of cancer (including cancer mortality). Of those, 16 (55%) found that those who are more religious or spiritual had a lower risk of developing cancer or a better prognosis, although 2 (7%) studies reported a significantly worse prognosis. Of the 20 methodologically most rigorous studies, 12 (60%) found an association between religion or spirituality and lower risk or better outcomes, and none reported worse risk or outcomes. The results from some of these studies can be partially explained by better health behaviors (less cigarette smoking, alcohol abuse, etc.), but not all. Effects not explained by better health behaviors could be explained by lower stress levels and higher social support in those who are more religious or spiritual. Although cancer is not thought to be as sensitive as cardiovascular disorders to psychosocial stressors, psychosocial influences on cancer incidence and outcome are present (Koenig, 2012). Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. FIGURE 5.1 Research examining the relationship between religion and health outcomes (total of 498 studies reviewed). Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Baylor Institute for Studies of Religion. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Mental Health Religion can be helpful or problematic when it comes to mental health. Generally, religion is helpful in providing explanations and practices that can support individuals in understanding and dealing with distress. However, religion also can be a contributor to distress and the onset of mental illness when individuals are confronted with distress that seems to demonstrate the failure of religious beliefs (Pargament, 2013). Religion has been used to justify unhealthy and lethal behavior, for example, when a woman says God told her to kill her three children. Bad judgment and mental illness are no excuse to blame religion, but unhealthy acts do occur in the name of religion. Depression Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Approximately 1 in 10 adults in the United States reports depression (Centers for Disease Control and Prevention, 2012a). Over 100 studies that examined the religion– depression relationship were reviewed by Johnson, Tompkins, and Webb (2008), and they found that religious involvement tends to be associated with less depression in 68% of the articles (see Figure 5.1). People who are frequently involved in religious activities and who highly value their religious faith are at reduced risk for depression. Religious involvement seems to play an important role in helping people cope with the effects of stressful life circumstances. Prospective cohort studies and quasi-experimental and experimental research all suggest that religious or spiritual activities may lead to a reduction in depressive symptoms. These findings have been replicated across a number of large, well-designed studies and are consistent with much of the cross-sectional and prospective cohort research that has found less depression among more religious people (see Table 5.3). Suicide Suicide was the 10th leading cause of death for all ages in 2010 (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2010). A substantial body of literature documents that religious involvement (e.g., measured by frequency of religious attendance, frequency of prayer, and degree of religious salience) is associated with less suicide, suicidal behavior, and suicidal ideation, as well as less tolerant attitudes toward suicide across a variety of samples from many nations. This consistent inverse association is found in studies using both group and individual-level data. In total, 87% of the studies reviewed on suicide found these beneficial outcomes (see Figure 5.1). However, with increasing use of suicide bombers as agents of religious practice, such as the U.S. World Trade Center attacks and individuals boarding U.S. – bound airplanes with explosive material in shoes, this area may need further review. Constructive peaceful religious practice has apparently proven to mediate isolated Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. suicide behavior. But what is the prognosis for religion that encourages suicide? Promiscuous Sexual Behaviors Out-of-wedlock pregnancy is associated with poverty, higher infant mortality rates, increased risk of contracting sexually transmitted diseases, and other issues. Studies in the Johnson, Tompkins, and Webb (2008) review generally show that those who are religious are less likely to engage in premarital sex or extramarital affairs or to have multiple sexual partners (see Table 5.3). In fact, approximately 97% of the studies that were reviewed reported significant correlations between increased religious involvement and lower likelihood of promiscuous sexual behaviors (see Figure 5.1). None of the studies found that increased religious participation or commitment was linked to increases in promiscuous behavior. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Drug and Alcohol Use In 2011, an estimated 22.5 million Americans aged 12 or older—or 8.7% of the population—had used an illicit drug or abused a psychotherapeutic medication (such as a pain reliever, stimulant, or tranquilizer) in the past month (National Institute on Drug Abuse, 2014). Both chronic alcohol consumption and abuse of drugs are associated with increased risks of morbidity and mortality. Johnson, Tompkins, and Webb (2008) reviewed over 150 studies that examined the relationship between religiosity and drug use (n = 54) or alcohol use (n = 97) and abuse. The vast majority of these studies demonstrate that participation in religious activities is associated with less of a tendency to use or abuse drugs (87%) or alcohol (94%). These findings are consistent regardless of the population under study (children, adolescents, or adults) or whether the research was conducted prospectively or retrospectively (see Table 5.3). The greater a person’s religious involvement, the less likely he or she will be to initiate alcohol or drug use or have problems with these substances if they are used (see Table 5.3). Only four of the studies that were reviewed reported a positive correlation between religious involvement and increased alcohol or drug use. Interestingly, these four tended to be some of the weaker studies with regard to methodological design and statistical analyses. Delinquency There is growing evidence that religious commitment and involvement helps protect youth from delinquent behavior and deviant activities. Recent evidence suggests that such effects persist even if there is not a strong prevailing social control against delinquent behavior in the surrounding community. There is mounting evidence that religious involvement may lower the risks of a broad range of delinquent behaviors, including both minor and serious forms of criminal behavior. There is also evidence Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. that religious involvement has a cumulative effect throughout adolescence and thus may significantly lessen the risk of later adult criminality. There is growing evidence that religion can be used as a tool to help prevent high-risk urban youths from engaging in delinquent behavior. Religious involvement may help adolescents learn prosocial behavior that emphasizes concern for other people’s welfare. Such prosocial skills may give adolescents a greater sense of empathy toward others, which makes them less likely to commit acts that harm others. Similarly, when individuals become involved in deviant behavior, it is possible that participation in specific kinds of religious activities can help steer them back to a course of less deviant behavior and, more important, away from potential career criminal paths. Research on adult samples is less common but tends to represent the same general pattern—that religion reduces criminal activity by adults. An important study by T. David Evans and colleagues found that religion, indicated by religious activities, reduced the likelihood of adult criminality as measured by a broad range of criminal acts (as cited in Johnson et al., 2008). The relationship persisted even after secular controls were added to the model. Further, the finding did not depend on social or religious contexts. A small but growing body of literature focuses on the links between religion and family violence. Several recent studies found that regular religious attendance is inversely related to abuse among both men and women. As can be seen in Figure 5.1, 78% of these studies report reductions in delinquency and criminal acts to be associated with higher levels of religious activity and involvements. In sum, Johnson, Tompkins, and Webb’s (2008) review of the research on religious practices and health outcomes indicates that, in general, higher levels of religious involvement are associated with reduced hypertension, longer survival, less depression, lower level of drug and alcohol use and abuse, a reduction in promiscuous sexual behaviors, reduced likelihood of suicide, lower rates of delinquency among youth, and reduced criminal activity among adults. As can be seen in Figure 5.1, this substantial body of empirical evidence demonstrates a very clear picture: People who are most involved in religious activities tend to fare better with respect to important and yet diverse outcome factors. Thus, aided by appropriate documentation, religiosity is now beginning to be acknowledged as a key protective factor, reducing the deleterious effects of a number of harmful outcomes. Religion and Well-Being Well-being has been referred to as the positive side of mental health. Symptoms for well-being include happiness, joy, satisfaction, fulfillment, pleasure, contentment, and other indicators of a life that is full and complete (Johnson et al., 2008). Many studies have examined the relationship between religion and the promotion of beneficial outcomes (see Table 5.4). Many of these studies tend to be cross-sectional in design, but Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. a significant number are important prospective cohort studies. As reported in Figure 5.2, Johnson, Tompkins, and Webb (2008) found that the vast majority of these studies, some 81% of the 99 studies reviewed, reported some positive association between religious involvement and greater happiness, life satisfaction, morale, positive affect, or some other measure of well-being. Koenig (2012) found that out of the 256 studies he reviewed, 79% of them found only a positive relationship between religion and spirituality and well-being and three studies showed a significant inverse relationship. The vast number of studies on religion and well-being have included younger and older populations as well as African Americans and Caucasians from various denominational affiliations. Only one study found a negative correlation between religiosity and wellbeing, and this study was conducted in a small, nonrandom sample of college students. TABLE 5.4 Results of Religion and Well-Being Outcomes Studies The data represent the percentage of published studies that were reviewed. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Baylor Institute for Studies of Religion. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. FIGURE 5.2 Research examining the relationship between religion and well-being outcomes (total of 171 studies reviewed). Source: Johnson, Tompkins, & Webb (2008). Reprinted with permission from The Baylor Institute for Studies of Religion. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Hope, Purpose, and Meaning in Life Many religious traditions and beliefs have long promoted positive thinking and an optimistic outlook on life. Not surprisingly, researchers have examined the role religion may or may not play in instilling hope and meaning or a sense of purpose in life for adherents. Researchers have found, on the whole, a positive relationship between measures of religiosity and hope in varied clinical and nonclinical settings. In total, 25 of the 30 studies reviewed (83%) document that increases in religious involvement or commitment are associated with having hope or a sense of purpose or meaning in life (see Figure 5.2). Similarly, studies show that increasing religiousness also is associated with optimism as well as larger support networks, more social contacts, and greater satisfaction with support. In fact, 19 out of the 23 studies reviewed by Johnson, Tompkins, and Webb (2008) conclude that increases in religious involvement and commitment are associated with increased social support. Koenig (2012) reviewed 40 studies on the relationship between hope and religion and Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. spirituality. Seventy-three percent (n = 29) reported significant positive relationships with hope; none of these reported the inverse. Koenig (2012) identified six studies with the highest quality, and of those six, half found a positive relationship. Self-Esteem Most people would agree that contemporary American culture places too much significance on physical appearance and the idea that one’s esteem is bolstered by his or her looks. Conversely, a common theme of various religious teachings is that physical appearance, for example, should not be the basis of self-esteem. Religion provides a basis for self-esteem that is not dependent upon individual accomplishments, relationships with others (e.g., who you know), or talent. In other words, a person’s self-esteem is rooted in the individual’s religious faith as well as the faith community as a whole. Of the studies Johnson, Tompkins, and Webb (2008) reviewed, 65% conclude that religious commitment and activities are related to increases in self-esteem (see Figure 5.2). Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Educational Attainment The literature on the role of religious practices or religiosity on educational attainment represents a relatively recent development in the research literature. In the last decade or so, a number of researchers have sought to determine whether religion hampers or enhances educational attainment. Even though the development of a body of evidence is just beginning to emerge, some 84% of the studies reviewed concluded that religiosity or religious activities are positively correlated with improved educational attainment (see Figure 5.2). Educational attainment is relevant to health because those with a higher education tend to have higher socioeconomic status, and hence, better health status. To summarize, a review of the research on religious practices and various measures of well-being reveals that, in general, higher levels of religious involvement are associated with increased levels of well-being, hope, purpose, meaning in life, and educational attainment. As can be seen in Figure 5.2, this substantial body of evidence shows quite clearly that those who are most involved in religious activities tend to be better off, which is one of the critical indicators of well-being. Just as the studies reviewed earlier (see Table 5.3 and Figure 5.1) document that religious commitment is a protective factor that buffers individuals from various harmful outcomes (e.g., hypertension, depression, suicide, and delinquency), there is mounting empirical evidence to suggest that religious commitment is also a source for promoting or enhancing beneficial outcomes (e.g., well-being, purpose, or meaning in life). This review of a large number of diverse studies leaves one with the observation that, in general, the effect of religion on physical and mental health outcomes is remarkably positive. These findings have led some religious health care practitioners to conclude that further collaboration between religious organizations and health services may be desirable (see Box 5.1). Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. BOX 5.1 Clinical Implications of the Relationship Between Religion, Spirituality, and Health There are many practical reasons for addressing spiritual issues in clinical practice. Here are eight important reasons for doing so, and there are others as well. First, many patients are religious or spiritual and have spiritual needs related to medical or psychiatric illness. Studies of medical and psychiatric patients and those with terminal illnesses report that the vast majority have such needs, and most of those needs currently go unmet. Unmet spiritual needs, especially if they involve spiritual struggles, can adversely affect health and may increase mortality independent of mental, physical, or social health. Second, religion and spirituality influence the patient’s ability to cope with illness. In some areas of the country, 90% of hospitalized patients use religion to enable them to cope with their illnesses and over 40% indicate it is their primary coping behavior. Poor coping has adverse effects on medical outcomes, both in terms of lengthening hospital stay and increasing mortality. Third, religious and spiritual beliefs affect patients’ medical decisions, may conflict with medical treatments, and can influence compliance with those treatments. Studies have shown that religious and spiritual beliefs influence medical decisions among those with serious medical illness, and especially among those with advanced cancer or HIV/AIDs. Fourth, physicians’ own religious or spiritual beliefs often influence medical decisions they make and affect the type of care they offer to patients, including decisions about use of pain medications, abortion, vaccinations, and contraception. Physician views about such matters and how they influence the physician’s decisions, however, are usually not discussed with a patient. Fifth, as noted earlier, religion and spirituality are associated with both mental and physical health and likely affect medical outcomes. If so, then health professionals need to know about such influences, just as they need to know if a person smokes cigarettes or uses alcohol or drugs. Those who provide health care to the patient need to be aware of all of the factors that influence health and health care. Sixth, religion and spirituality influence the kind of support and care that patients receive once they return home. A supportive faith community may ensure that patients receive medical follow-up (by providing rides to doctors’ offices) and comply with their medications. It is important to know whether this is the case or whether the patient will return to an apartment to live alone with little social interaction or support. Seventh, research shows that failure to address patients’ spiritual needs increases Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. health care costs, especially toward the end of life. This is a time when patients and families may demand medical care (often very expensive medical care) even when continued treatment is futile. For example, patients or families may be praying for a miracle. “Giving up” by withdrawing life support or agreeing to hospice care may be viewed as a lack of faith or lack of belief in the healing power of God. If health professionals do not take a spiritual history so that patients and their families feel comfortable discussing such issues openly, these situations may go on indefinitely and consume huge amounts of medical resources. Finally, standards set by the Joint Commission and Medicare require that providers of health care show respect for patients’ cultural and personal values, beliefs, and preferences (including religious or spiritual beliefs). If health professionals are unaware of those beliefs, they cannot show respect for them and adjust care accordingly. Source: Koenig (2012). Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. What Do You Think? Health care professionals should take a patient’s religion and spirituality into consideration, but to what extent should a health care professional’s beliefs be taken into consideration? If a pharmacist has religious beliefs against abortion, should he or she be required to fill prescriptions for the emergency contraceptive? If a pharmacist works in Oregon, where doctors are, by law, permitted to write lifeending prescriptions for dying patients, should a pharmacist who believes that such a practice is murder be required to fill that prescription? Should a faith-based hospital be able to prohibit providing an abortion? Would your answer be different if it was the only hospital in a large rural region so women wanting an abortion would have to travel for 5 hours to reach a clinic? Should the rural hospital be able to prohibit providing an abortion if the life of the mother is threatened? Rituals A ritual is a set of actions that usually is structured and has a symbolic value or meaning. The performance of rituals is usually tied to religion or traditions, and their forms, purposes, and functions vary. These include compliance with religious obligations or ideals, satisfaction of spiritual or emotional needs of the practitioners, to ward off evil, to ensure the favor of a divine being, to maintain or restore health, as a demonstration of respect or submission, stating one’s affiliation, obtaining social acceptance, or for the pleasure of the ritual itself. A ritual may be performed on certain occasions, at regular Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. intervals, or at the discretion of individuals or communities. It may be performed by an individual, a small group, or the community, and it may occur in arbitrary places or specified locations. The ritual may be performed in private or public, or in front of specific people. The participants may be restricted to certain community members, with limitations related to age, gender, or type of activity (hunting and birthing rituals). Rituals are related to numerous activities and events, such as birth, death, puberty, marriages, sporting events, club meetings, holidays, graduations, and presidential inaugurations. Handshaking, saying hello and good-bye, and taking your shoes off before entering a home are also rituals. These actions and their symbolism are neither arbitrarily chosen by the performers nor dictated by logic or necessity, but they either are prescribed and imposed upon the performers by some external source or are inherited unconsciously from social traditions. Many have practical roots. Shaking hands originated as a gesture to assure each person that neither was carrying a weapon, and taking off shoes before entering a home helps keep it clean. The biomedical system contains numerous rituals, including its own language filled with scientific terminology, jargon, and abbreviations (e.g., MRI, CAT scan). There are formal rules of behavior and communication, such as how physicians should be addressed and where the patient should sit. There are rituals such as hand washing, how to perform a physical examination, how to make a hospital bed, and how to document information in medical records. The values and expectations include being on time for your appointment and adhering to the treatment regimen. People who are unaccustomed to this culture and these rituals can experience difficulty with them, and this includes maneuvering through the complex health insurance system, which is laden with unfamiliar rituals and rules. This can be particularly challenging if English is the patient’s second language and if the patient did not come from a place with a similar system, such as socialized medicine. In addition to rituals within health care systems numerous rituals are related to health. These rituals are discussed here to help prompt people who are working in health care to ask about, be sensitive to, and not be surprised about these key differences. Objects as Rituals People wear various items to maintain their health. These may include amulets that may be worn on a necklace or strung around the neck, wrist, or waist. For example, people from Puerto Rico may place a bracelet on the wrist of a baby to ward off the evil eye. In addition to being worn, amulets may be placed in the home. For example, items such as written documents, statues, crosses, or horseshoes may be hung on the home to protect the family’s health as well as other factors. It is important to ask about removing these objects first because removal may cause great stress and concern for the person. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Shrines For centuries people have described certain places as being holy or magic, as having a concentrated power, or having the presence of spirit. Ancient legends, historic records, and contemporary reports tell of extraordinary, even miraculous, happenings at these places. Different sacred sites have the power to heal the body, enlighten the mind, increase creativity, develop psychic abilities, and awaken the soul to a knowing of its true purpose in life. Shrines are located at some of these sacred sites. A shrine was originally a container, usually made of precious materials, but it has come to mean a holy or sacred place. Shrines may be enclosures within temples, home altars, and sacred burial places. Secular meanings have developed by association, and some of the associations are related to health and healing. People visit numerous shrines that represent health to maintain or restore health. Some examples of these shrines are Our Lady of La Leche, Our Lady of San Juan, and St. Peregrine. These shrines can be associated with healing for a specific disease or condition or with healing in general. Animal Sacrifice Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Animal sacrifice is not only practiced for food consumption but also is believed to be needed for one to build and maintain a personal relationship with the spirit. It is also believed that it brings worshippers closer to their Creator or spirit and makes them aware of the spirit in them. Sacrifices are performed for events such as birth, marriage, and death. They are also used for healing. Animals are killed in a way similar to a kosher slaughter. Animals are cooked and eaten following most rituals, except for some healing and death rituals in which the animal is not eaten because it is believed that the sickness is passed into the dead animal. Birthing Rituals The birth of an infant is a life-altering event that is surrounded by many traditional and ancient rituals. These rituals are often related to protecting the health of the child, which includes protecting him or her from evil spirits. The rituals are related to events prior to, during, and after the birth. Because the rituals are so numerous, we have listed the general variations, but the list is not exhaustive. Prior to birth: Food restrictions Wearing of amulets The fulfilling of food cravings Exposure to cold air Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Avoidance of loud noises or viewing certain types of people (i.e., deformed people) During labor: How the placenta is discarded Silent birth (some cultures require that no words or sounds are spoken by the woman and/or family members) People present during labor Utilization of a midwife Place of delivery Medications used After birth: Breastfeeding Amulets (placed on the baby, crib, or in the newborn’s room) Female and male circumcision Baptism Animal sacrifice Cutting of child’s lock of hair Bathing of baby Food restrictions When the naming of the baby occurs Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Rubbing the baby with oils or herbs Acceptance of postpartum depression Woman’s and child’s confinement period Death Rituals Responses to death vary widely across cultures. Although some cultures may perform the same or similar rituals, they may have different meaning among the cultures. The rituals, in part, are related to beliefs about the meaning of life and life after death. Is death the end of existence or a transition to another life? Rituals play a role in behaviors, such as how people discuss death, respond to death, handle the deceased’s body, the behaviors that occur at the funeral, and the mourning process. Some general variations include: Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. The method of disposing of the body Open versus closed casket The length of the mourning process and appropriate behavior Dress, including colors, at the funeral ceremony and afterward Food restrictions or traditions Appropriate emotional responses The role of the family Use of prayer What is buried with the body Rituals engaged in before, during, and after the ceremony (e.g., burning of ghost money or candles, use of flowers) Animal sacrifice Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Summary Religion plays a major role in the lives of Americans. It shapes our health behaviors and has been shown to have an overall positive effect on health behaviors. Religion also guides people when making difficult and sometimes life-altering decisions. With technological advances, medical decisions can be complicated. Some people find the answers within their religion, but many people within religious sectors have differences in opinions. It is important for health care professionals not to assume someone’s religion based upon their ethnicity and not to assume that everyone strictly adheres to the religious practices. In this chapter we have described how important religion is in the lives of Americans as well as the reasons religion can influence health behaviors and decisions. In addition, some reasons people who are religious may have positive health habits and outcomes as well as the potential negative effects of religion were discussed. The chapter ended with a discussion about rituals that are related to health. Many of those rituals are tied to religious beliefs, and health care professionals should make an effort to adhere to these rituals. Review 1. Provide examples of how religion shapes health behaviors and the rationale behind them. 2. Explain some of the positive and negatives effects religion can have on health Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. outcomes. 3. Provide examples of medical decisions that are made based on religion and the rationale behind them. 4. Explain issues that health care professionals should take into consideration related to beginning- and end-of-life transitions. Activity Select a religion that you are interested in learning more about. Write a three-page paper about the practices and beliefs of that religion that are related to health. Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Case Study This case focuses on a Hasidic Judaism patient with cystic fibrosis and her family. Hasidic Judaism, sometimes referred to as Hasidic, refers to members of a Jewish religious movement founded in the 18th century in eastern Europe that maintains that God’s presence is in all of one’s surroundings and that one should serve God in one’s every deed and word. As you read through this study, pay particular attention to the multiple cultural and religious factors that influence this child’s medical management. Judy Cohen is 6 years old. Much of her life in the Hasidic Jewish community revolves around the neighborhood synagogue, her extended family, and their Hasidic Jewish community. She lives with her parents and four siblings in a house packed closely against her grandparents’ house next door. The Cohen house is awash in the smells of Mrs. Cohen’s cooking, the sounds of Yiddish prayer and conversation, and the laughter of children. The Cohens speak English fluently, but they prefer to speak their native language. They speak English only when necessary. Judy’s mother stays home to care for Judy and her four siblings, ages 3, 7, 9, and 10 years. Judy’s father, Mr. Cohen, works for a family business. When the father is not working, he is usually praying, socializing, and consulting with the rabbi at the synagogue. When she was 12 months old, Judy was diagnosed with cystic fibrosis (CF), which is an inherited chronic disease that affects the lungs and digestive system. At the time, the medical team that specialized in CF recommended that her siblings have sweat tests, which is the test used for diagnosing cystic fibrosis. Judy’s parents declined because they believed that their children’s health was in God’s hands. Judy’s condition was stable then, and she and her mother attended regularly scheduled appointments with the CF team. Judy’s father, although he was concerned, did not usually come to Judy’s appointments. Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. When Judy was 18 months old, she went to the clinic with an increased cough and weight loss. The team recommended that she be hospitalized. Judy’s parents initially declined but agreed a week later after her cough had worsened. At age 4 years, Judy again went into the hospital for pneumonia. Mr. and Mrs. Cohen reluctantly agreed to the hospital admission. When Judy appeared to be responding to the intravenous antibiotics, her parents convinced the medical team to allow Judy to complete her regimen of antibiotics at home. When she was home, the family did have their daughter complete the course of antibiotics that was recommended, but they refused visiting nurse services because they did not want the neighbors to know about Judy’s illness. When Mrs. Cohen became pregnant with her fifth child, the medical team strongly suggested that she go for genetic counseling and possibly testing. After discussing the issue with their rabbi, Mr. and Mrs. Cohen decided not to have genetic testing. Again, they believed that “whatever will be, will be” and that the unborn child’s health was in God’s hands. Today, Judy went to the clinic for a routine follow-up appointment. This is her first visit since beginning school. Her respiratory status is good, but she is having more frequent stools. After being questioned, Mr. and Mrs. Cohen admit that they do not want the school to give Judy the required enzymes, which are recommended so that she can digest her food. They have not told anyone at the school that Judy has CF. There are several issues to consider about this case: What are the various ways in which religious beliefs can affect the understanding of illness? How did the Cohens’ Hasidic belief system affect Judy’s treatment? Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. What are some of the main tenets of Hasidic Judaism? Do you believe that the Cohens should have been required to have genetic testing done? Do you think the Cohens mishandled Judy’s illness? Source: Cross Cultural Health Care (2003). References Advameg Inc. (2008). Religion and dietary practices. Retrieved from Centers for Disease Control and Prevention. (2012a, April 20). An estimated 1 in 10 U.S. adults report depression. Retrieved from Centers for Disease Control and Prevention. (2012b, September). Getting blood pressure under control. Retrieved from Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2010). Web-based Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. Injury Statistics Query and Reporting System (WISQARS) [online]. Retrieved from Cross Cultural Health Care (2003). Cross cultural health care-case studies. Retrieved from Johnson, B. R., Tompkins, R. B., & Webb, D. (2008). Assessing the effectiveness of faith-based organizations: A review of the literature. Waco, TX: Baylor University. Koenig, H. G. (2012). Religion, spirituality, and health: The research and clinical implications. Psychiatry. Retrieved from Koenig, H. G., McCullough, M. E., & Larson, D. B. (2000). Handbook of religion and health. New York: Oxford University Press. Lee, B. Y., & Newberg, A. B. (2005). Religion and health: A review and critical analysis. Zygon, 40, 443–468. National Institute on Drug Abuse. (2014, January). DrugFacts: Nationwide trends. Retrieved from Newport, F. (2009, January 28). State of the states: Importance of religion. Retrieved from Newport, F. (2011, June 3). More than 9 in 10 Americans continue to believe in God. Retrieved from Pargament, K. I. (2013, March 22). What role do religion and spirituality play in mental health? Retrieved from Pew Forum on Religion & Public Life. (2008, February). 2008 U.S. Religious Landscape Survey. Retrieved from Pew Research Center. (2015). Comparisons. Retrieved from Wachholtz, A., & Sambamoorthi, U. (2011). National trends in prayer use as a coping mechanism for health: Changes from 2002 to 2007. Psychology of Religion and Spirituality, 3(2), 67–77. Retrieved from Copyright © 2016. Jones & Bartlett Learning, LLC. All rights reserved. Williams, D. R., & Sternthal, M. J. (2007). Spirituality, religion and health: Evidence and research directions. The Medical Journal of Australia. Retrieved from Ritter, Lois A., et al. Multicultural Health, Jones & Bartlett Learning, LLC, 2016. ProQuest Ebook Central, Created from aul on 2020-05-05 09:47:48. 1 Culture, Health Promotion, and Cultural Competence R O B E R T M . H U F F, M I C H A E L V. K L I N E , A N D D A R L E E N V. P E T E R S O N Chapter Objectives On completion of this chapter, the health promotion student and practitioner will be able to Copyright © 2014. SAGE Publications. All rights reserved. • Define and discuss the concepts of health education, health promotion, and disease prevention as these relate to working with multicultural population groups • Define and discuss at least five common terms associated with working with diverse population groups, including the terms culture, ethnicity, acculturation and assimilation, ethnocentrism, and cultural competence • Identify and discuss at least five potential barriers to multicultural health promotion and disease prevention activities designed for diverse cultural groups A ctivities for promoting health and preventing disease in any population, whether directed at individuals, groups, or communities, are a formidable task. Such endeavors require an organized effort characterized by an understanding that culture and cultural forces, among other social forces, are powerful determinants of health-related behaviors. Culture, in any group or subpopulation, can exist as a total or partial system of interrelationships of human behavior guided and influenced by the organization and the products of that behavior. Indeed, the beliefs, ideologies, knowledge, institutions, religion, Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. 3 Copyright © 2014. SAGE Publications. All rights reserved. 4 and governance, as well as nearly all activities (including efforts to achieve health-related behavior change), are affected by the forces of culture. Culture is a dynamic, fluid, ever-changing, and complex force in the lives of individuals, groups, and communities. And it is this complexity that has made it difficult to formulate a universally accepted definition of culture. Kreuter, Lukwago, Bucholtz, Clark, and Sanders-Thompson (2003) note that no single definition of culture is universally accepted. But there is “general agreement that culture is learned, shared, and transmitted from one generation to the next, and it can be seen in a group’s values, norms, practices, systems of meaning, ways of life, and other social regularities” (p. 133). The definition of culture will be dealt with in greater depth later in the chapter. It is also important, where possible, to be aware that ethnic and cultural factors may be connected with a target group’s vulnerability to certain communicable and chronic diseases and other health-related problems. Such knowledge can provide the planner with many clues during the assessment process. Students and practitioners should be aware that many of a target group’s health risk factors are amenable to behavior change, thus reducing risk. Efforts to promote health and prevent disease within culturally different ethnic subgroups, as in any target group, will entail influencing the health behavior of individuals, families, groups, or communities. This will require identifying and changing those factors that are associated with accomplishing the desired health-related behavior. Also, these efforts probably will require some type of sustained collaboration between the public, private, and voluntary sectors and the people most directly affected by a defined health concern or problem. Cultural considerations ultimately may determine whether a particular population or target group will choose to participate in health promotion and disease prevention (HPDP) programs. There will be the need for FOUNDATIONS a continuing communication between these stakeholders that establishes and maintains working relationships characterized by mutual understanding, trust, and respect (see Hodge, Hodge, & Palacios, Chapter 16, this volume, for a discussion reflecting this process). There are many settings in the community where activities are conducted for promoting health and preventing disease in a population. These include a myriad of work sites, schools, health care program sites, and the community itself. Comprehensive health promotion activities at a work site consisting of a large, culturally diverse employee population may, for example, carry out employee-risk assessments (including screenings and appraisals) as well as establish and maintain an appropriate variety of educational programs, services, and activities to reduce or eliminate identified areas of health risk. In this setting, a work site must carry out culturally sensitive and effective interventions that meet the needs of their employees. This sensitivity must be carried over in the group as well as in one-to-one counseling or educational encounters. Awareness and sensitivity to cultural diversity, then, must be reflected in the planning, design, implementation, and evaluation phases of such a complex undertaking. This chapter will distinguish between the concepts of health promotion and health education and briefly examine the implications and impact of culture at these two overlapping levels. We will also provide an overview of culture, particularly as cultural differences affect HPDP efforts, and discuss current paradigms that have been proposed to improve practitioner skills in working in multicultural health care settings. Finally, we will describe potential barriers to effective multicultural HPDP efforts. HEALTH PROMOTION AND DISEASE PREVENTION The terms health promotion and disease prevention, when used in this text, encompass Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. Culture, Health Promotion, and Cultural Competence a similar range of interests and concerns as expressed long ago in the Joint Committee on Health Education Terminology (1991) report. The committee defined HPDP as “the aggregate of all purposeful activities designed to improve personal and public health through a combination of strategies, including the competent implementation of behavior change strategies, health education, health protection measures, risk factor detection, health enhancement, and health maintenance” (p. 102). Central to this conceptualization, it should be noted, is the need to achieve different levels of outcomes (e.g., individual, family, group, organization, community) through a combination of health promotion and health education strategies and intervention activities. Another ageless definition of health promotion is “any planned combination of educational, political, regulatory, and organizational supports for actions and conditions of living conducive to the health of individuals, groups, or communities” (Green & Kreuter, 1991, p. 432). Explicit in this definition is the need for interventions that respond to a broad level of community concern relating to stimulating, establishing, and sustaining an appropriate combination of educational, organizational, and political support needed to facilitate actions aimed at achieving desired community health outcomes. These definitions of health promotion provided above serve the purpose of this text well because they are valid in today’s context; they are succinct, readily understandable, multidimensional; and they focus on the reality and need for several different levels of specific and needed program activities and outcomes (e.g., individual, family, group, organization, community) in HPDP program planning. Health education has been defined as “any planned combination of learning experiences designed to predispose, enable, and reinforce voluntary behavior conductive to heath in individuals, groups, or communities” (Green & Kreuter, 1991, p. 432). Intervention efforts 5 from this particular vantage point concentrate on facilitating the voluntary acquisition of specific health-related knowledge, attitudes, and practices associated with achieving specific health-related behavior changes. Health education is mentioned here because health promotion emerged out of health education and designates a broader level of outcome than does health education. However, health education is considered a primary instrumentality for achieving health promotion outcomes. For example, the focus of health education interventions in a cervical cancer education and screening program targeting African-American women living in a specific geographical area may be concerned with making educational programs more available and accessible to this group. Such programs can enable the target group to develop skills for carrying out defined voluntary screening behaviors related to reducing the risk of this life-threatening disease. However, the planning of interventions and related activities at this level, then, usually focus on reaching only one target group among the many possible groups of women at risk and in need of specified educational programs. On the other hand, the planning of strategies and interventions at the health promotion level goes beyond a single cervical cancer education program focus. For example, interventions may focus on the need to establish and sustain a more accessible and equitably distributed system of women’s health screening and education programs for enhancing the overall health of all poor and underserved women in that particular community. The complexity of health promotion program efforts requires a greater scope of coordination, participation, commitment, and expense than does the cervical cancer education and screening aimed at a single target group. Indeed, many community participants representing a diversity of public, private, and voluntary agencies, organizations, and institutions will need to be involved in this endeavor. Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. 6 Health promotion efforts also may be conducted at a broader community level and may seek health and health-related behavior changes or social outcomes through ecological or environmental approaches intended to result in permanent structural changes or supports in the form of policies, regulations, and expanded access to resources affecting people where they work and live (Green & Kreuter, 1991, 2005; Green, Richard, & Potvin, 1996; McLeroy, Bibeau, Steckler, & Glanz, 1988; Richard, Potvin, Kischuk, Prlic, & Green, 1996). It is seen, then, at one level, health education programs, for example, might concentrate on facilitating the voluntary acquisition of specific health-related knowledge, attitudes, and practices for reducing the specific target group’s health risk for certain chronic or communicable diseases. It is important to recognize that interventions designed to achieve change on only the individual level will not be as effective as those that can achieve broader change on the community level. Thus, program efforts at other levels (i.e., the health promotion level) may seek social or environmental changes (supportive structures) for reducing population health risk. These changes are in the form of new risk-reducing policies, laws, and regulations and new or increased organizational or structural arrangements that encourage, enable, and reinforce the acquisition and practice of certain health-related behaviors (Green & Kreuter, 1991, 2005). HPDP programs, through their assessment and diagnosis processes of community needs (discussed in Chapters 6 and 7 of this volume), must be able to identify at-risk target groups in the community and specifically the kinds of disease prevention efforts (by particular target group) that need to be included in their health promotion activities. The following identifies the specific focus and types of activities generally conducted under the different levels of disease prevention: FOUNDATIONS (1) the primary prevention level (providing specific protection that prevents the onset of the disease itself or reduces exposure or risk levels to the disease processes, e.g., immunizations against a variety of childhood diseases, disease screening, smoking prevention and cessation programs, HIV/ AIDS education and screening programs); (2) the secondary prevention level (providing activities related to early diagnosis and prompt treatment of a disease that is already present, (e.g., syphilis, HIV/AIDS, gonorrhea, diabetes, cervical cancer); and (3) the tertiary level of prevention (activities implemented through treatment and rehabilitation efforts to minimize disability after the damage has been done from existing illness (e.g., alcoholism, diabetes, cirrhosis of the liver, chronic obstructive pulmonary disorder, emphysema, high blood pressure) (Turnock, 2001). Finally, the focus of all HPDP efforts must of necessity include an awareness and sensitivity to culture and the many cultural differences reflected in the population to be targeted. And within their own cultural milieu, all planning participants (e.g., planners and community participants) need to recognize that any HPDP interventions contemplated must consider the personal experiences, knowledge, health practices, and problem-solving methodologies that are acceptable within the framework of the individual, group, or community to be targeted. HEALTH PROMOTION AND CULTURE Promoting health and preventing disease is a challenging goal that, to many, might seem straightforward, logical, and highly scientific. After all, we know about germ theory, diseases of lifestyle, medications, radiation, surgery, and other Western approaches to preventing and/or diagnosing and treating health problems in the general population. However, this process is not always what it seems. Indeed, there are many different ways of perceiving, Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. Culture, Health Promotion, and Cultural Competence understanding, and approaching health and disease processes across cultural and ethnic groups with which health practitioners need to become better acquainted. Cultural differences can and do present major barriers to effective health care intervention. This is especially true when health practitioners overlook, misinterpret, stereotype, or otherwise mishandle their encounters with those who might be viewed as different from them in their assessment, intervention, and evaluation-planning processes. There is not a day that goes by that we are not exposed to a variety of sights, sounds, and tastes reflecting influences coming at us from a multitude of sources including the news media, our work settings and contacts in the community, and the foods we choose to eat. From these, we form opinions, make judgments, and take actions perceived to be appropriate to the situation and setting in which we find ourselves. When these choices involve our efforts to improve the health of the many “publics” we encounter in our health care roles, our perceptions of how these publics relate to and respond to our efforts may be colored by our own ethnocentric views of the world. In turn, our publics may view us in a similar manner. That is, whereas we might view a client as delusional if the individual comes to us for help and tells us he or she has been seeing a traditional folk healer because they believe someone has put a “hex” on him or her, that client might view us as ignorant and inexperienced when we offer him or her counseling and medication as the treatment for the problem. In both cases, cultural beliefs and practices born out of years of enculturation and socialization in divergent worldviews have gotten in the way of the communication and treatment possibilities. Brislin and Yoshida (1994) note that health care professionals’ lack of knowledge about health beliefs and practices of culturally diverse groups and problems in intercultural 7 communication has lead to significant challenges in the provision of health care services to multicultural population groups. They also observed that the cultural diversity of the health care workforce itself could present problems that can disrupt the provision of services because of competing cultural values, beliefs, norms, and health practices in conflict with the traditional Western medical model. For example, Putsch (1985) describes a situation in which an elderly Navaho patient with a mild senile dementia has returned for an outpatient visit after several long hospitalizations. He greets his physician in Navaho, shakes hands, and embraces him. He then turns to greet the nurse’s aide, who will act as an interpreter, and extends his hand to her. She flees from the room visibly frightened. When later questioned about her behavior, she relates that she had been warned by her mother never to shake hands with gray-haired people because they might “witch you.” She also noted that she knew about this man through her husband’s family and that he was “no good” (p. 3346). In exploring cultural differences in more detail, a discussion of what we mean by culture, ethnicity, acculturation, and other related terms will help set the scene for how these may affect our ability to assess, plan, implement, and evaluate HPDP programs for a variety of multicultural population groups. CULTURE The term culture has been defined in many ways over the years and continues to be a concept that is hotly debated among anthropologists even today. In 1871, E. B. Tylor defined culture as “that complex whole which includes knowledge, belief, art, morals, law, custom and any other capabilities and habits acquired by man as a member of society” (quoted in Bock, 1969, p. 17). Stein and Rowe (1989) define culture as “learned, nonrandom, systematic behavior that is transmitted from Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. 8 person to person and from generation to generation” (p. 4). Kagawa-Singer and Chung (1994) describe culture as “a tool which defines reality for its members” (p. 198) and note that within this perception of reality, the individual’s purpose in life emerges through a process of socialization in which he or she learns the appropriate beliefs, values, and behaviors shared by society. Thus, culture is seen as both integrative and functional in that the beliefs and values transmitted to the individual provide a sense of identity as well as the rules the individual must follow to enable his or her culture to survive over time (KagawaSinger & Kho, Chapter 12, this volume; Tseng & Streltzer, 2008). Kagawa-Singer (2012) also notes that it is unclear what the actual contribution of culture is to health outcomes and that “culture is rarely defined or appropriately measured” (p. 356). She suggests that, for researchers working with diverse population groups, better operationalizing what they mean by the term will lead to more scientifically relevant and better results for the communities they are studying. Slonim (1991) identifies five basic criteria for defining a culture: having a common pattern of communication, sound system, or language unique to the group; similarities in dietary preferences and preparation methods; common patterns of dress; predictable relationship and socialization patterns between members of the culture; and a common set of shared values and beliefs. No matter how it may be defined, culture can be seen as a dynamic template or framework a society uses to view, understand, behave, and pass on its culture to each succeeding generation. Culture helps specify what behaviors are acceptable in any given society, when they are acceptable, and what is not acceptable. It also provides some guidance for dealing with the basic problems of life (Rani, 2007). Anderson and Fenichel (1989) caution, however, that this cultural framework is only a set of tendencies or possibilities for behavior, and individuals FOUNDATIONS within any given society are essentially free to choose from all the available possibilities within this frame. What do the above issues have to do with HPDP? Consider, if you will, what possible barriers one might encounter if he or she were designing a health program for a community primarily composed of first-generation Hmong who were recent immigrants to the United States. Certainly, language could be a problem, but so too could the many cultural differences at nearly every level, from the basic nuances of communication to the significant differences in their worldview of what constitutes health and disease, from cause and prevention to treatment and cure. In fact, the Hmong health belief system is primarily based on the supernatural, and much of their traditional treatment is based on spiritual appeasement (Brainard & Zaharlick, 1989; Fadiman, 1997; Kalantari, 2012). A failure to understand and appreciate these “differences” would have serious implications for the success of any HPDP effort. Even with this caveat, we must also recognize that culture groups are fluid, dynamic, and change over time in response to the environments they exist in. Thus, first generation peoples will differ from second, and second from third and so forth. This makes it imperative that health promoters/health care practitioners carefully assess before designing interventions or treatments in order to ensure that what they do is effective, relevant, and appropriate to those they are working with. ETHNICITY Ethnicity relates to the sense of identity an individual has based on common ancestry, national, religious, tribal, linguistic, or cultural origins. It generally implies that there are shared values, lifestyles, beliefs, and norms among those claiming affiliation to a specific ethnic group (Henderson, Spigner-Littles, & Milhouse, 2006; Nunnally & Moy, 1989; Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. Culture, Health Promotion, and Cultural Competence Office of Minority Health, 2001; Paniagua, 1994; Spector, 2013). Ethnic identity provides a sense of social belonging and loyalty for the individual and often is used by others outside the ethnic group to identify or label “difference” (Kagawa-Singer & Chung, 1994; Kagawa-Singer & Kho, Chapter 12, this volume). Unfortunately, ethnicity also is used to stereotype diversity in human populations and frequently leads to misunderstanding and/or distrust in all sorts of human interactions. In fact, the use of an ethnic label by someone outside the ethnic group may lead to a partial or complete shutdown of the learning curve for both parties in this process. For example, it can be seen that once the stereotype has been identified, one or both parties often cease to look beyond the stereotype to find out who each really is. Slonim (1991) distinguishes between culture and ethnicity but notes that they tend to overlap with respect to how they are defined and used. She notes that culture is concerned with symbolic generalities and universals about social and family groups, whereas ethnicity is concerned with one’s sense of identification and belonging to a specific reference group within any given society. Ethnicity, then, helps shape the way we think, relate, feel, and behave within and outside our reference group and defines the patterns of behavior that provide an individual with a sense of belonging and continuity with his or her ethnic group over time. Ethnicity is a word that often is used in the same breath as the term race. It is important, however, not to confuse ethnicity with race, the latter of which is a biological term used to describe ethnic groups on the basis of physical characteristics such as skin color or shape of the eyes, nose, and mouth (Helman, 2007; Montague, 1964; Rani, 2007; Tseng & Streltzer, 2008). Nelson and Jurmain (1988) note that race is an ancient concept that in more recent times has been used by scientists to place human populations into “racial” 9 categories for purposes of classification. This form of classification, although convenient, ignores the issue of genetics, which is concerned with heredity and biological variation in all living things. Nelson and Jurmain regard the term race as a sociocultural concept rather than a biological one. Thus, people often are classified along racial lines regardless of their genetic traits, and these racial categories have long been used as a basis for promoting discrimination, hatred, and divisiveness among human groups all around the world. Disreali (1849) commented that “The difference of race is one of the reasons why I fear war may always exist; because race implies difference, difference implies superiority, and superiority leads to predominance” (The Quotations Page, 2013). In this book, the term race is not used to describe the various multicultural groups discussed. The exceptions are where contributors are reporting epidemiological data presented by federal, state, or local health agencies that gather and report health statistics using race as a variable. The editors prefer the terms ethnic, multicultural, and culturally diverse. They believe that these terms reflect a more accurate description of human populations. For the health practitioner, reframing the term race to multicultural, ethnic, or culturally diverse may serve to promote a greater sensitivity to the challenges, potentialities, and rewards of working with diverse cultural groups in HPDP activities. ACCULTURATION AND ASSIMILATION Acculturation is a term used to describe the degree to which an individual from one culture has given up the traits of that culture and adopted the traits of the dominant culture in which he or she now resides (Celenk & Van de Vijver, 2011; LaFromboise, Albright, & Harris, 2010; Lazarevic, Pleck, & Wiley, 2012; Wallace, Pomery, Latimer, Martinez, & Salovey, 2009). Locke (1992) identifies four levels of acculturation: the “bicultural” Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. 10 individual, who can function equally well in his or her own culture and the dominant culture; the “traditional” individual, who holds on to most, if not all, of his or her traits from his culture of origin; the “marginal” individual, who seems not to have any real contact with traits from either culture; and the “acculturated” individual, who has given up most of his or her traits of origin for those of the dominant culture. Locke notes the importance of assessing the degree of acculturation when working in a multicultural setting, as there is a natural tendency on the part of many culturally diverse individuals to resist acculturation. This resistance can lead to significant misunderstandings and the inability to establish meaningful and mutually beneficial working relationships between the health care practitioner and those he or she may be seeking to help or influence. An example might be the practitioner who encounters a Latina mother with a newborn who feels that the child is ill because of the mal de ojo (evil eye), that is, the belief that a sudden change in the emotional or physical health of an infant or young child is caused by the jealousy (or admiration) of a person with powerful eyes (de Paula, Lagana, & Gonzales-Ramirez, 1996). A failure to recognize the significance of this problem for the patient, and the prescribing of a treatment that seems out of order in the mind of the mother, might result in her not following through or even engaging in an active way in the clinical encounter. Enculturation is a similar process as acculturation yet is also different. While acculturation is concerned with taking on the traits of a new culture one has moved into, enculturation has to do with learning and practicing the culture one is born into. That is, the language, behaviors, food practices, religion, dress, social and gender roles, and other values, beliefs, and mores of the family and society in which they are reared. Of importance here also, is that a child undergoing enculturation within his or her family will FOUNDATIONS also be undergoing acculturative forces from outside the family. This can, and often does, lead to a culture clash between the child and his or her parents and other relatives. Assimilation is a closely related process to acculturation and is viewed as the social, economic, and political integration of a cultural group into a mainstream society to which it may have emigrated or otherwise been drawn (Casas & Casas, 1994). Generally, for assimilation to occur, there must be at least some minimal acculturation with respect to the language, values, laws, customs, and other major features of the dominant society. As Locke (1992) notes, however, there may be a genuine resistance and rejection of many of the values of the dominant culture with only a minimal level of cultural assimilation into mainstream society. Like acculturation, then, the level of an ethnically diverse client’s assimilation into mainstream society might need to be assessed by the health practitioner to better understand and perhaps predict how well that person will accept and/or participate in HPDP recommendations and behaviors. One has only to pay a visit to areas of his or her city where recent immigrants have settled or where there is a long-established but insular population characterized by the maintenance of the culture-of-origin behaviors, including language, customs, food practices, and other social conventions that keeps its members isolated from mainstream society. ASSESSMENT OF ACCULTURATION The measurement of acculturation levels in the clinical setting has been the focus of a number of investigators studying a diversity of multicultural groups (Celenk & Van de Vijver, 2011; Cuellar, Harris, & Jasso, 1980; Hoffman, Dana, & Bolton, 1985; Lazarevic et al., 2012; Mendoza, 1989; Milliones, 1980; M. Ramirez, 1984; Smither & RodriguezGiegling, 1982; Suinn, Rickard-Figueroa, Lew, & Vigil, 1987). Paniagua (1994) comments Health Promotion in Multicultural Populations : A Handbook for Practitioners and Students, edited by Robert M. Huff, et al., SAGE Publications, 2014. ProQuest Ebook Central, Created from aul on 2020-05-05 10:33:18. Copyright © 2014. SAGE Publications. All rights reserved. Culture, Health Promotion, and Cultural Competence on the variety of acculturation scales that can be used, depending on the ethnic group in which one is interested, and describes the Brief Acculturation Scale suggested by Burnam, Hough, Karno, Escobar, and Telles (1987). This scale uses three variables: generation in the United States, preferred language, and preferences for whom the individual most often socializes with. The assumptions underlying these variables hold that (a) the longer the individual is exposed to the dominant culture or the younger the individual is at the...

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