Beyond Trauma: Cultural and Societal Dynamics (Springer Series on Stress and Coping)

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A growing body of research suggests that expectations regarding care differ across cultures Sommer et al. For example, cultures differ in the degree to which pain, limitation in activity, or cognitive impairment is considered an appropriate cause for medical intervention. In the United States, minorities are less likely to use skilled nursing facilities and perhaps more likely to tolerate dementia and old-age disability at home Hinton and Levkoff, ; Whitehouse et al.

The elicitation of home care culture described above can be used to identify subcultures and also differences across cultures. We turn now to some cross-cultural differences identified for expectations of home care.


Ethnic and cultural groups differ in their commitment to family care. African Americans are more likely than whites to endorse the primacy of family care Dilworth-Anderson et al. Similarly, Latinos delay institutionalization relative to whites; a higher cultural value assigned to family care leads to more positive views of family caregiving, which in turn leads to a negative evaluation of skilled nursing facilities as an option for dementia or end-of-life care Mausbach et al. Differences in commitment to family care are based on cultural norms of filial piety or obligation.


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The concept of xiao , or filial piety, is a well-developed element in Chinese culture. However, it is strongly gendered, so that the burden of such care falls on adult daughters or daughters-in-law, not sons Zhan, Norms of filial obligation are heavily influenced by education, with greater acceptability and use of skilled nursing home care evident among more highly educated people.

As minorities advance through the educational and occupational ladders, these differences in recourse to skilled care may lessen. Little information is available for differences among cultural groups in receptivity to home adaptation. Given differences in recourse to institutional placement, as described earlier, cultures with a strong bias toward home care may be more receptive to adaptation of homes to accommodate medical technologies.

However, these households may face other social or community constraints that make it difficult to deliver such technologies. I return to these points below. With norms of filial obligation and positive appraisals of caregiving demands, ethnic and cultural minorities are more likely to report satisfaction in caregiving.

Latina caregivers report lower appraisals of stress and greater perceived benefits of caregiving; they also make greater use of religious coping than white caregivers Coon et al. Similarly, African American caregivers report lower anxiety, greater well-being, and more perceived benefits of caregiving than white caregivers Haley et al. More generally, cultures differ in how well reciprocity between care receivers and caregivers is maintained after the onset of caregiving Becker et al.

A central finding in medical anthropology is the difference between illness and disease Kleinman, Eisenberg, and Good, Clinicians diagnose and treat disease abnormalities in body structure or function , but patients suffer illness, in which symptoms carry social significance and force changes in social function.

Illness depends on social status and systems of meaning used to understand symptoms. Thus, families and health professionals may start with completely different premises when they collaborate to ameliorate disease or manage disability. A striking example is a culture-bound syndrome, susto. It is a folk or culture-bound syndrome to the extent that it is not associated with a particular abnormality in body structure or function recognized by Western medicine. Although it involves fatigue, anxiety, and withdrawal from social roles, it is not simply a psychological disorder. The person with susto views the condition as a spiritual affliction triggered by negative social interaction, speaks of it this way, and as a result seeks treatment from a traditional healer rather than a physician.

Clearly, how people understand symptoms affects how they speak about a condition, to whom they disclose symptoms, when they seek treatment, and who they think can help them. In the case of home care, if expectations for rehabilitation are low or people view disability as inherent to aging, or if they consider incontinence, muscular dyscontrol, or agitation shameful, they may be less likely to involve health care professionals or paraprofessionals.

They may seek to deny or hide the condition. Arranging optimal home care in this case may be complicated and require exquisite skill in bridging cultures.

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Patient and family willingness to seek help, to disclose symptoms, or simply to cooperate in care depends in part on the personal relationships that patients develop with home care providers. Patients are more or less comfortable with different providers and providers are similarly more or less comfortable with different patients, families, or home settings.

Concordance in race or ethnicity may not be the most important factor in such comfort.

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One systematic review did not find concordance in race or ethnicity a significant predictor of receipt of services or satisfaction with care Meghani et al. Such concordance may be more important for more generalized trust in communication with physicians or satisfaction with health services overall Sohler et al. Still, the role of cultural differences and lack of concordance between patients and health care providers should not be underestimated.

In urban centers, such as New York City, it is very common for home health care providers and patients to speak different languages, come from different neighborhoods, and have very different expectations for care. Yet home care paraprofessionals are expected to work in patient homes, to serve to some extent as surrogate family, and to help disabled or critically ill patients function on their own terms. The potential for misunderstanding and frustration is high, as described below. Culture may be relevant for decisions to seek treatment or receive clinical preventive services.

For example, ethnic and racial minorities are less likely to take advantage of preventive health services, such as vaccinations and cancer screening, even when these are available Chen et al. However, it is hard to know how much of this difference in service use is related to aspects of culture such as a different understanding of prevention in late life or differences in the degree to which people view health as a matter of personal agency and how much may be due to the cultural insularity that characterizes many ethnic enclaves.

This kind of insularity may have an important significance for health in ethnic communities organized around religious beliefs. For example, in an orthodox Jewish sample of older women in New York City, the prevalence of mammography, Pap smears, and colorectal cancer screening was low compared with other women of similar age and education. Use of these preventive services was lowest in the orthodox women who reported least exposure to mainstream sources of health information Albert, Harlap, and. Caplan, For ethnic and cultural communities that wish to maintain traditions yet participate in effective disease prevention or home care, it is important that they mobilize community resources, perhaps in partnership with service providers, to develop appropriate delivery of information in culturally acceptable ways.

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Tolerance of disability in families appears to be linked to socioeconomic status SES , with greater tolerance associated with lower SES Murphy, More broadly, consider cultural attitudes toward aging. With each additional decade of life, adults will see not only declines in strength and walking speed and slowing in reaction time but also declines in addictive behaviors and crime, reduction in severe psychiatric disorders, and increased contact with close family Albert and Freedman, American culture stresses the negative features of aging, something to be fought or covered up.

In other cultures, the stress may be on the more positive elements, as among the Samia of Kenya, who boast of aging as a time to sit by the fire and be fed Albert and Cattell, Americans, by contrast, may consider dependence and need for help in old age worse than death Clark, The second level in the social-ecological model is family and social relationships.

Social relationships differ across cultures in the relative priority assigned to individual and family interests. African American caregivers who endorsed family-based justifications for caregiving showed better health outcomes and reported less caregiving stress than caregivers not endorsing these justifications Dilworth-Anderson, Goodwin, and Williams, However, other research suggests that familism can also intensify the stresses and mental health consequences of home care Kim, Knight, and Longmire, ; Rozario and DeRienzis, That is, the disruption of the home and restrictions on other family members inherent in complex home care in which family members may have to maintain equipment, not have friends visit, not be able to leave the home, etc.

In the social-ecological framework described earlier, familism at the level of social relationships may reinforce individual cultural expectations for home care. Whether minority groups use home care services and home-based medical technologies more or less than nonminorities use them depends in part on how these services are defined, how available they are in particular localities and often what kind of state Medicaid waiver policy is in play , and whether differences in SES are adequately controlled.

Because of these differences, studies differ in estimates of the independent role of cultural group or ethnicity in home care utilization. This line of research is most developed for aging services. One review through the s found no differences in home care utilization by race Kadushin, Other studies report lower utilization, for example, among Mexican Americans Crist et al. In New York City, where home care for seniors is generously supported by state and city, Medicaid home care utilization did not differ among whites, African Americans, and Caribbean Latinos Navaie-Waliser et al.

The absence of differences in home care service use by cultural group may or may not mean equal likelihood of use of medical technologies in the home. Here higher levels in the social-ecological framework may become more relevant see Figure Even if families in different cultural groups are equally receptive to adaptation of homes for medical technologies, minority families in less resourced neighborhoods or communities may be less likely to gain access to these technologies.

Likewise, smaller homes or neighborhoods with less reliable infrastructural support may pose additional challenges to adapting homes, even when families are receptive.

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Fonts, L. Martens, and A. Working conditions in mid-life and participation in voluntary work after labour market exit. Traumatology , 14 2 , 20— Long-term Effects of Different Labour Careers. Intergenerational legacies of trauma in police families.

Again, this suggests a need for social-ecological approaches that consider cross-level influences on health care decision making. What about family relationships or culture would lead to potential differences in home care utilization or the adaptation of homes?

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Despite some thought that ethnic or cultural minorities may differ in the recognition of medical symptoms, such as dementia in elders e. Similarly, while poorer mental health anxiety, depressive symptoms, panic syndromes has been reported for a number of different cultural groups in the United States, the greater prevalence is probably due to the challenges of assimilating to a new and often very different society and not. Many differences attributed to culture may actually be artifacts of low access to services or limited knowledge of a disease process.

One study of home care service use by Mexican Americans showed that familism was related to confidence in the services; elders and caregivers who endorsed familism more highly were less convinced of the value of home care and were accordingly less likely to use such services Crist et al. In this analysis, confidence in home care services was an independent predictor of service use and directly related to familism.

Interestingly, Crist and colleagues in this study defined home care use as two or more visits from a provider, not just a single one. Discrimination in experiences with medical providers or more generally may affect receptivity to home care.

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In the Mexican American sample mentioned earlier, experiencing discrimination was associated with less confidence in home care services and lower usage Crist et al. Another question is whether minority and nonminority families receive the same services at home. One study found higher use of physical and occupational therapy among whites and Asians relative to black and Hispanic home health recipients, but this difference was no longer significant with adjustment for case mix Peng, Navaie-Waliser, and Feldman, In a study of home health care of elders discharged from hospitals after a stroke or traumatic brain injury, elders who had private insurance in addition to Medicare were more likely to receive occupational and physical therapy.

Minority families were less likely to have private insurance and for this reason were less likely to receive rehabilitative care Levine et al. Similar factors may be at work for adaptation of homes for medical technologies.