Sunday, July 26, 2009

The effect of culture on healthcare


In this write-up, I will be analyzing the effects of culture on health care using a specific cultural theory and assessment tool. The cultural theory I will be using is Leininger’s cultural care theory and the culture I will be exploring is the Igbo Culture.

The Igbo culture

The Igbo people usually called ‘Ibo’ by non-Igbos are situated in the southeast region of Nigeria in West Africa. The area is divided by the Niger River into two unequal sections – the eastern region which is the larger part, and the Midwestern region. The global health case study states that ‘According to Nigeria’s National Census (1991), the Igbo cultural group accounted for 25 million of the 88.9 million people in the country’ .The population reference bureau updates that Nigerian population had increased to 140 million in 2006, and the southern states of which the Igbos constitute a large part of accounted for 65 million. The Igbos speak the Igbo language, and the y have two major religions : Christianity and traditional religion. Christianity is the belief in Jesus as the son of God, and Lord, while their traditional religion is the worship of idols, believing that many of the idols are small gods that point to ‘Chukwu’ meaning the big God. The Igbos are known to value education, hence in present day igbo culture, the minimum education one would have is The high school certificate.
Their staple food is ‘Garri’ which is processed from cassava. It could be drunk as a cereal, or baked into cakes. But the most common way of eating it is to make it as a dough, and eat it with different kinds of soups. Mostly vegetable packed soups. Other staple foods are Rice and Yam, to name a few. The cultural practices of the Igbos include: ‘The new yam festival’ which is usually celebrated around October of every year when the new yam is harvested; ‘Igba Nkwu Nwanyi’ meaning pouring wine for the bride. This is the name given to their costly marriage ceremony, where the groom has to spent the savings of a long period to get married. This usually contributes to the longevity of the Igbo marriages, if unfaithfulness is noted or other conflicts, and the lady decides to go home to her parents, another ceremony is performed. This practice has helped couples to resolve their differences on time before it gets out hand. Of course there are several other practices which the scope of this paper will constrain me to write.

The health beliefs of this ethnic group in relation to health and illness include the following:

- That most illnesses are caused by one’s enemies who submitted their names to evil sprits.
- That some illnesses are a reward of one’s evil doing in the past.
- That evil spirits could be appeased to cure mysterious illnesses.
- That health is a gift from God (Chukwu) and should be maintained by good food, so the eating of fruits and vegetables is usually the norm, as these vegetables are mostly grown from family gardens and are not bought in the market. Even if they are bought, they are very affordable.
- That husbands should stick to their wives sexually to prevent ‘Nsi Nwanyi’ meaning myserious illness gotten from women. This is the common name for sexually transmitted diseases.
- The use of local herbs to cure illnesses which have been proven to be effective over the ages.

The specific health and illness needs of the Igbo people include:

- Lack of portable drinking water: Water is usually bought from some rich people that installed bore-hole systems. The public tap water which is the main source of water supply is not usually maintained by the government because of misappropriation of funds. This water problem is usually worse during the dry season, because during the rainy season. The source of water supply is usually Rainfall.

- Most families are low income earners and the staple foods which are garri, yam and rice are usually costly. So under nourishment is usually a problem which could be solved by the assisted nutritional services like food stamps or free food programs.

- The main disease or illness suffered by this group is Malaria. But there have been many resources and curative measures available, so mortality from malaria is almost a thing of the past.

- According to a global health case study, ‘Agriculture is a heritage occupation and remains quite traditional with small sized farms, and rain-fed crop production. All crops cultivated are used as food. Nonetheless, both protein-energy and micronutrient deficiencies are a public health problem’.

- Over-crowding is a major problem as people are over crowded in cars, schools, and living places. This usually aids in the transmission of infectious diseases easily.

- Majority of the Igbo people suffer from and die from stroke since healthcare is not affordable for early diagnoses of the illness. And to make it worse, when somebody slumps on the way in a real village setting, no help is called for as it is believed that the evil spirits tormenting the individual would start tormenting the helper. This is recently improving with the continuous health education on heart attacks, and strokes.

Road traffic accidents (RTA) is one of the major causes of death in this area, because of lack of proper driving regulations. A health education research supports this by stating that ‘Data taken from admissions records to the hospital and private clinics (the three facilities which treat accidents) show a similar dominance of RTAs. All entries relating to unintentional injuries were extracted for 1 year, from March 1993 to March 1994. Ninety-nine entries were recorded, of which 63 were injuries caused by RTAs’.

Their ways of meeting healthcare needs include the following:

- Since there is no health insurance, and health delivery is usually based on availability of cash payment by the patient, people usually go to the hospital when they are really sick. This aids in a high rate of mortality level because in some cases, the illnesses are at their end stage.

- Thanks to the government of the Igbo people that both over the counter drugs and prescriptions drugs can be gotten over the counter even with no prescription. And medications are sold relatively cheap, far cheaper than that what hey are sold here in the United States. Hence antibiotics, anti-malarial drugs, and most common diseases can be easily bought, and one follows the dosage on the drugs. If not for this, millions of people would have died because they could not afford hospital bills.

- Many deliveries are done by experienced traditional midwives or people that have have some background in healthcare, and this is done either in their homes, or in their some small private clinics. This reduces the cost of child birth, and pregnant mothers are usually referred to the hospitals if their pregnancy is complicated. The negative effect is that many babies are lost, and some mothers do not make it to the hospital.

- Apart from traditional midwives helping in deliveries, they also help in circumcision of males. There are also herbalists that are known and proven to use herbs to cure illnesses.

- Some herbs like ‘Akum, shut up!’ are grown by most people in their back yard. ‘Akum’ means malaria, shut up is an English language. This herb is very bitter, but when soaked in water and drunk, cures malaria. Keep in mind that malaria is the commonest illness in this culture, although the fatality has greatly reduced because of availability of its cure in various ways.

Some areas of conflict between cultural practices and the healthcare delivery system include the following:

- The strong belief that one’s illness is caused by one’s enemies prevents people from seeking healthcare delivery, because it is believed to be useless in such cases. Many people die because of this belief.

- The smuggling in of herbal preparations into the hospitals usually affects real assessment of the success of the treatment plan. Usually nurses make it a routine to search patients’ surroundings to make sure that there are no hidden preparations.

- Some people do not want to be blamed for not going to the hospital, so they go, but cheek their medications, and throw them away when the nurse leaves the room, fake recovery after a few two or three days from admission, and go home. This could either be from believing in a non-scientific origin of the illness, or other personal beliefs.

- It is usually a thing of pride to have a non-eventful pregnancy, which is crowned by a vaginal delivery of the baby. Hence many women try everything they can to have vaginal delivery to maintain their ego, as people who have not gone through normal delivery and gone through the pains of childbirth are not ‘real women’. Some end up losing their babies or their lives in the process of being ‘real women’.

- The interesting aspect is that the healthcare professional in this area also have their origin from the same area. There have been many cases where the doctor or the nurse suggested to the relatives to take the patient home, and the sickness is termed spiritual.

Leininger’s cultural care theory application

Leininger states that ‘caring’ is the best description of ‘nursing’ and ‘refers it to a feeling of compassion, interest and concern for people’ (Leininger, 1970) .She objects the use of environment as a concept “instead of ‘environment’ Leininger uses the concept ‘environmental context’, which includes events with meanings and interpretations given to them in particular physical, ecological, sociopolitical and/or cultural settings.” (Leininger 1991). This makes the care more individualized and the specific environment of the individual patient is properly taken into consideration in his care; the incidents preceding his illness, and his own interpretations of the illness are carefully put into consideration without ethnocentrism.
Leininger projects the use of Ethnohistory which ‘refers to the past events and experiences of individuals or groups, which explain human life ways within particular cultural contexts over short or long periods’ The collection of this data helps the nurse to better understand the reason for the patient’s beliefs, and know how to inculcate them into his/her care. Take for instance someone in the Igbo culture, that had a threat two days back from an enemy of submitting his name to evil spirits, or bewitching him with witchcraft, and then today has this mysterious pain that would not go even with narcotics. This individual tells the nurse that his pain cannot go with narcotics or any scientifically produced medication, Ordinarily, the nurse would think he is crazy or does not know what he is saying, but if ethnohistory is collected, and the patient tells the nurse of previous occasions where the witch had threatened people and the had the same kind of pain which never stopped until he told them when it would stop, which came to pass, then the nurse would better understand what she is dealing with.

Leininger projects two care systems that should be taken into consideration. They are:

• ‘ professional care systems refer to formally taught, learnt and transmitted professional care, health, illness, wellness and related knowledge and practical skills that prevail in professional institutions
• lay care systems refer to culturally learnt and transmitted knowledge and skills used to provide assistive, supportive, enabling or facilitative acts towards or for another individual or group to improve a human lifeway, health condition or to deal with handicaps and death.’(Leininger, 1995)
I want to say here, that in the case of this culture in question, professional care system would mean the scientific knowledge we have learnt in school about health, while the lay care systems should be applied alongside the professional care to totally care for the individual.
Leininger’s culture care theory has strong tools and suggestions in culturally based care. The only weakness I see in this theory, is that there is so much emphasis on the patient’s culture, that if one is not careful, professionalism may be compromised.
In conclusion, Leininger’s cultural care theory perfectly fits into every culture, including the Igbo culture because it comes down to the level of the patient, respecting his/her values, which in turn relaxes the patient, and instills confidence and more co-operation in care.