Cultural Attitudes

Black (2000) describes explanatory models and semantic networks used by patients and healthcare workers who may have preconceived ideas about patterns of illness and how that illness should be interpreted and treated. Kleinman (1980) describes five core points used to distinguish notions about episodes of sickness and treatment. He describes these as core clinical functions of how systems of medical knowledge and practice enable people:

• culturally to construct illness as a psychosocial experience

• to establish general criteria to guide the health-seeking process and evaluate the treatment approach

• to manage particular illness episodes by communication, labelling and explanation

• to engage in healthy activities and therapeutic interventions, medicine, surgery, healing rituals and counselling

• to manage the therapeutic outcome and appropriate treatments for the condition.

These five care points or notions about sickness and illness have been described by Kleinman as explanatory models. The clinical process is one way for the individual to adapt to certain worrying circumstances, e.g. abdominal surgery and the possibility of the formation of a stoma. The adaptation premise is reflected in Kleinman's choice of words such as managing, coping, guiding, explaining and negotiating alliances (Young, 1982). Malfunctioning of the body and the psychological processes involved become disease, and the psychosocial disruption becomes illness. Apart from surgery, the first stage of healing is a construction of illness from disease to form a coping function. It may be that a constructional reordering of cultural meaning is all that is necessary in the form of therapy to aid the patient's recovery after surgery.

Culturally, often the use of healers is called upon in non-westernized countries, and these healers have an arcane knowledge and are deemed to have great powers. Their principal social function is to diagnose and prescribe ritual actions to overcome illness or form a prognosis; they name and explain and form explanatory models. As all beliefs are culture bound, little sense can be made of them outside the cultural context. They will also change as the society in which they exist changes and as newer beliefs displace, merge or coexist within the society's older beliefs.

The lay explanatory model is put together in response to a particular episode of illness and is not the same as the individual's general beliefs about illness that his or her society may hold. By contrast, the physician's explanatory model is based on scientific logic and deals with a single cause. Doctor and patient, each using his or her own explanatory model, must agree about the interpretation of each model, the individual's subjective view of the illness and the doctor's view of the disease process. Any problems must be resolved by negotiation so that the patient will comply with the prescribed treatment.

Metaphors of ill health, especially when they are attached to serious conditions relating to the bowel, carry with them a range of associations that can affect how sufferers perceive their condition and how people behave towards them. Bowel movement, for example, is associated with an opening up, allowing entry into the body, the opposite of closing. Assorted words used here are 'empty', 'loosen up', 'unblock', and these suggest that a change has taken place in the internal space of the gut. Having one's bowels emptied is a physical reality associated with internal space and purity - the person is made clean because the bowels are empty. This is often seen when bowel preparation is given before bowel surgery so that the doctor may have unimpeded access to the organ. It is often said that people 'locate' themselves in their bowels and it is considered that the removal of the contents of the bowel may be parallel to removal of self, becoming void, nothing. The very basic personal and private functioning of the individual's bowels in the public domain is also a defining boundary. Young (1982) has suggested that these metaphors of illness emerge at a time when understanding is experiential and empirical. Terminology, folklore and metaphor are all used in semantic networks and make pathways linking the symbolic to the effective, and language links vocal experience to disease (Turner, 1967).

Linguistically, the 'bowels' are used by the British to express collective anger. British people are thought not to pay much attention to their bodies, yet have a fixation about their bowels. To have a bowel action every day is for many a necessity and the bowel is thought to be the cesspool of the unemptied colon. Constipation is defined by many British people as not having their bowels open every day, a belief that goes back to earlier days when it was thought that the intestinal contents putrefy, forming toxins, leading to poisoning of the body. Black (1992), in a small qualitative study, found that people in the research sample often considered that the individual's bowel problem was caused by the contents becoming putrefied, leading to poisoning of the body, as in diverticulitis. Illness episode schedules showed the use of semantic networks and explanatory models in descriptions of why the individual had become ill. One patient considered that his illness was retribution for abuse of his body by eating the wrong food, whereas some thought toxins in the air to be the cause. An Asian patient considered that he had let his inner self go, and the disease had then attacked. If a framework is to be developed to understand the relationship between disease and language, it is important that the disease is observed as a sociohistorical and cultural phenomenon. Into this network the doctor intervenes diagnostically and therapeutically (Good, 1977) and to build a structural theory in body imagery it is important that semantic networks are researched (see Chapter 8).

When epidemiological studies are undertaken, it is often difficult for biomedical researchers to separate cultural, racial, dietary and other factors to give a true picture of what may be causing certain diseases. Chang (1965) noted that the incidence of diverticulitis in the Japanese population in Hawaii was lower than in Europeans in Hawaii. However, in native Hawaiians, who make up 16% of the population, there were only 2% of cases with diverticulitis. Kim (1964) stated that diverticulitis was rarely found in Koreans, and the authors of the previously discussed research (Kyle et al., 1967) found that their enquiries in northern Japan, the Punjab, Nepal and southern Iran concluded that diverticulitis was rarely, if ever, seen in these communities. If, in the preceding group of countries, the populations are considered to be as racially different from each other as they are from Europeans, perhaps the racial factor in epidemiology needs to be investigated.

In Scandinavia, diverticulosis, seen more frequently as the precursor to diverticulitis, is more common in southern Sweden than in its neighbour Finland. It is recognized that Sweden and Finland have good standards of healthcare in western Europe and good standards of living, yet the two countries have different ethnic origins, the Swedish being Nordic and the Finns being from the east Baltic regions (Kohler, 1963).

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