1. SUPPORTING HEALTH COORDINATION, ASSESSMENTS, PLANNING, ACCESS TO HEALTH CARE AND CAPACITY BUILDING IN MEMBER STATES UNDER PARTICULAR MIGRATORY PRESSURE — /SH-CAPAC
Module 3. Foundations for the development of migrant sensitive health systems Unit 1 (1) : Socio-cultural context of refugees and migrants’ health
Prepared by: Anna Szetela; Institute of Public Health, Jagiellonian University Medical College

2. Outline of contents Introduction Cultural adjustment and culture shock
Culture and health/disease perception and reaction

3. Introduction
Why should we include socio-cultural context when dealing with health and healthcare problems?
Over the past decade, available evidence focusing on the impact of culture on health has increased dramatically. This indicates not only a widespread and growing interest in the influence of culture but also the realization of its importance in eliminating health disparities, addressing health literacy, and designing and implementing effective public health interventions. This increasing focus, however, requires a clear understanding of the impact of culture on health.
Iwelunmor, J., Newsome, V., & Airhihenbuwa, C. O. (2014).

4. Cultural adjustment
Emotional reaction a person may have when one moves to a cultural environment which is different from one's own.
4* phases of cultural adjustment:
Honeymoon – initial euphoria, excitment
Culture shock – irritation caused by differences
Adjustment – becoming more familiar with the new culture
Adaptation – feeling like at home
Special situation of refugees.
*the number can be different in different models of cultural adjustment .

5. Culture shock and refugees health
It has often been suggested that refugees are the most disadvantaged of the relocating groups:
Exposition to overwhelmingly stressful premigration experiences in their countries of origin which may strongly affect their subsequent adjustment.
Their migration is involuntary and largely motivated by ‘push’ rather than ‘pull’ factors, which increases the risk of psychological and social adjustment problems.
Their displacement is usually permanent; compared with immigrants and sojourners, refugees are far less likely to be able to return home.
Refugees often come poorly prepared for the crosscultural transition and are frequently under equipped with tangible resources to deal with life in a new culture.
Refugees are likely to originate from cultural backgrounds that are extremely different from those of the receiving countries. .
Ward, Bochner, Furnham 2005.

6. Culture and health/disease perception and reaction
Main areas:
Cultural factors influencing the prevalence of diseases
Cultural factors influencing first contacts with health care
Culture and doctor-patient relationship
Cultural differencies as a barrier in diagnostics, access and treatment

7. Culture and the prevalence of health problems
Culture as a factor causing the health problem.
Culture as a factor reducing the risk of health problem.
What is health problem? What is not? – Culturally differentiated question and answer: different understanding of illness.

8. HEALTH Culture and the prevalence of health problems:
Culture and its role in „health fields”
Health field concept – Marc Lalonde:
Factors belonging to 4 different „health fields” influence our health status.
LIFESTYLE
ENVIRONMENT
HUMAN BIOLOGY
HEALTH
HEALTH CARE ORGANISATION
Based on: Lalonde, 1981.

9. Culture and the prevalence of health problems
The „biggest” field - LIFESTYLE
Culture and the LIFESTYLE category: e.g. relations with other people, alcohol addcition, cigarette smoking, eating/diet, sexual beheviours, help-seeking behaviour.
Personal decisions and habits that are bad, from a health point of view, create self-imposed risks. When those risks result in illness or death, the victim’s lifestyle can be said to have contributed to, or caused, his/her own illness or death. But: these decisions are related to the cultural determinants. .

10. Case study: Oral rehydration therapy in Pakistan.
Activity 1: Culture influencing the decision about contacts with health care
What is health problem? What is not? – Culturally differentiated question and answer: different understanding of illness.
Case study: Oral rehydration therapy in Pakistan.
Read the case study.
Think about other examples of different understanding of health/illness.
Discuss the topic on the forum.
IOM 2014.

11. Culture influencing the decision about contacts with health care
Culture, beliefs play role when taking decision about:
When (if) to contact the doctor,
The choice of the therapy.
Reasearch results show that in some minorities it is the common behaviour to visit the doctor only in the umtimate situation, especially in mental health cases.
Extensive literature in the domain of health care seeking reveals that those from different socio-cultural backgrounds tend to differ in the extent to which they delay seeking medical help. Studies show that being a member of an ethnic minority group can add to delay
IOM 2014.

12. The delay of health care seeking
Cultural differences in delay in health care seeking are attributed to a diverse set of factors, ranging from knowledge and beliefs regarding causes of the disease (etiology related to religion), associated symptoms, curability, and consequences, to trust in physicians.
The delay may be related to a shame and stigmatisation (especially in mental health issues).

13. Culture and doctor-patient relationship
There is growing recognition of the need for culturally safe, patient-centered care in improving the health outcomes of minority populations.
Cultural differences and the inability of health care providers to appropriately address these differences have contributed to high rates of noncompliance, reluctance to visit mainstream health facilities, and feelings of fear, disrespect, and alienation.
Roundtable 2013.

14. Culture and doctor-patient relationship
Some cultural norms heavily regulate gender relationships even in a health care setting such as a hospital. Studies show that female members of some cultural groups may be reluctant to be examined by male physicians and even the anticipation of this happening may contribute to delays in or complete avoidance of health care seeking. In these cultural groups, being examined by a female physician can mitigate the embarrassment. Some Asian women, although they had been in North America for a while and knew the language, indicated that they may choose to access traditional Chinese medicine because the traditional Chinese doctor examines the patient without asking her to take her clothes off.
Uskul 2010. .

15. Cultural differences:
Barriers in diagnostics, access and treatment
Main barriers
Comunication barriers (verbal, non-verbal).
Cultural misunderstandings (e.g. dietary habits in other cultures).
Unknown disease – culture-specific syndrome.
Pathoplasticity - the variability in a symptom’s specific form and content, shaped by events in a patient’s life or culture (e.g. .
Cultural misunderstandings can affect the ability of health professionals to assist their clients or patients in achieving optimal health. For example, health professionals may view clients or patients who are culturally different from themselves as unintelligent or of differing intelligence, irresponsible, or disinterested in their health. This can result in poor health status, marginalization within the health care system, increased risk, and experiences of racism (Roundtable 2013). .

16. Cultural differences:
Communication barriers
Main barriers
Language – miscommunication related to different languages but also different meaning of „the same word” (linguistic differences).
Cultural differences in gestures.
Behaviour of patient and/or staff – related to differents habits, prejudices. .

17. You can use the Unit forum for questions …
Thank you!
You can use the Unit forum for questions …
Pictures: Andalusian Childhood Observatory (OIA, Observatorio de la Infancia de Andalucía) 2014; Josefa Marín Vega 2014; RedIsir 2014; Morguefile 2014.

18. References
Iwelunmor J, Newsome V, Airhihenbuwa CO. Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethnicity & health. 2014;19(1): (retrieved July 24, 2016).
Lalonde M. A new perspective on the health of Canadians. A working document. Minister of Supply and Services Canada (retrieved: July 20, 2016).
Matsumoto D., Juang L. Culture and Psychology. Wadsworth, Cengage Learning, 2013:
Uskul, A. K. (2010). Socio-cultural aspects of health and illness. In D. French, A. Kaptein, K. Vedhara, and J. Weinman, (Eds.). Health psychology. Oxford: Blackwell Publishing. Final draft: (retrieved: July 24, 2016).
Ward C., Bochner S., Furnham A. The Psychology of Culture Shock, Rutledge (retrieved: July 22, 2016).
Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities; Board on Population Health and Public Health Practice; Institute of Medicine. Leveraging Culture to Address Health Inequalities: Examples from Native Communities: Workshop Summary. Washington (DC): National Academies Press (US); 2013 Dec 19. A, Culture as a Social Determinant of Health. Available from: (retrieved July 26, 2016).

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This presentation is part of the project ‘ / SH-CAPAC’ which has received funding from the European Union’s Health Programme ( ). The content of this presentation represents the views of the author only and is his/her sole responsibility; it can not be considered to reflect the views of the European Commission and/or the Consumers, Health, Agriculture and Food Executive Agency or any other body of the European Union. The European Commission and the Agency do not accept any responsibility for use that may be made of the information it contains.