Page 120 - Cultural Competence in Health Education

98 Cultural Competence in Health Education and Health Promotion

I sought a less specific clinical framework than biomedicine provides and one that was

consistent with my experience of spirituality in the clinical arena. The most practical
help for using spirituality in a culturally responsive way has come to me from two
divergent sources: family nursing research and cultural anthropology.
Family nursing theory provides an understanding of context and suggests ways to
intervene. Family households, whatever their composition, produce health through a
dynamic process of interactions with the complex contexts in which they are embed-
ded. They do this in ways that are unique but also culturally consistent, using mean-
ingful patterns of routines and rituals that can either enhance resilience or threaten
well - being. Several pieces of research by Denham (1997, 1999a, 1999b, 2002) describe
this in great detail. For Denham, routines are patterned activities that structure fami-
lies through the processing of information, knowledge, and experience. Rituals are

activities with significant meaning, satisfying symbolic forms of communication acted
out over time, that relate to family identity and call upon existing strengths and resources
to meet needs. Family health routines are often characterized by highly ritualized indi-
vidual health practices that include patterned member interactions. Time as cycles
(days, seasons, events, developmental stages) is critical to this creative process of
health routine enactment. Awareness of this research should encourage health educa-
tors to reevaluate their selection of target audiences, keeping family in mind, and to
consider how they might contribute to the creative development of rituals and routines
that are culturally consistent but also unique to each family.
Moving to the realm of cultural anthropology, Kinsley (1996) discusses a cross -
cultural perspective on health, healing, and religion. He notes that traditional cultures

tend to perceive the world as filled with life and to attribute to all natural objects a soul
or animating essence; human beings, especially, are believed to possess a soul or souls

that underlie and define their life. Beliefs in these cultures about the ultimate causes of
sickness stem from moral and theological thought. Disharmony in the relationship
(broken taboos, willful or accidental offense or injury) between the sick person and
another being (deity, ancestor or ghost, another living person) is posited as the ulti-
mate cause. Therefore seeking and promoting harmonious relationships is expected to
produce health. The immediate causes of sickness are seen to relate closely to the spe-

cific disease process and include soul loss, object intrusion, spirit intrusion, disease
sorcery, and breach of taboo. These ideas might sound absurd to the biomedical mind,
but when Kinsley (1996, p. 8) compares them to losing the will to live, germ theory, or
not acting like oneself anymore, their general applicability becomes readily apparent.
Dossey (1998) speaks to the same lingering on of “ primitive ” ideas in modern medi-
cine in his eloquent essay about the “ evil eye. ” Health educators need to consider the
quiet presence of these enduring beliefs in populations that appear to be acculturated,
even within the dominant culture. When these are quietly present as health beliefs,
they will exert their power over behavioral choices even though remaining unvoiced.
Astute practitioners learn to look for and identify these enduring ancient beliefs and
then work with them, without ever trying to make them go away.
If remnants of these disease causation beliefs persist, what about the expectations
of health care providers as healers? Often the priest and physician have been the same

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