2- Several researchers have used an iceberg to illustrate the different elements or components of culture- It has also been suggested that we use a duck swimming across a pond to illustrate this point—the duck may be calm on the surface, but you know those little legs and feetand working hard to propel the bird through the water- It is much the same with culture. Some of the hidden parts carry the heavier load of the workAbove: geography, generation, socioeconomic status, language, literacy, beliefs and values, status, facial expressions, gestures, religious rituals, paintings, literature, gender, holiday customs, foods, music, styles of dressBelow: gender, communication preferences, ideas about control, sense of self, obligation, definitions of “fair,” comfort with ambiguity, perspectives on time, face or honor, status, feelings about power differencesWhat is not here?This discussion will address culture in a broader sense – we are looking not just at race and ethnicity, which are only components of culture, not the whole of it
3Do you think health care is a right or a privilege? Why?
4Answers from Others…A persons overall health should determine his cost for care. Everyone should pay their own way for health care benefits because some people are sicker than others or have diseases that cost so much to support.A more local economic argument…
5Answers from Others…A population that is sick cannot be productive and benefit the economy. We end up paying more if we don’t provide health care to all. It is not a far leap to consider that improving health care access may be profitable to society as well as improve the health of individuals.The more global economic argument…
6Answers from Others…It is a privilege because people abuse rights when they take advantage of society. Unhealthy lifestyle choices and unwillingness to get health care is favored by the poor people and minorities. People visit the emergency room mainly for convenience. This privilege should be limited or cut. You get what you pay for!“Us” versus “them”…
7Answers from Others…Health care is a privilege because there are many factors that the individual controls themselves, such as practicing good nutrition and getting enough exercise. These are choices.The middle class perspective…
8Answers from Others…Resources and opportunities are not necessarily available to everyone in equal measure. In large part because of these inequities, I believe the right of individuals to health care carries a responsibility to contribute to the health of others, whether they be family members, friends, or strangers in the communityStarting to encompass social determinants and interrelatedness…
9Answers from Others…I wonder if we as a nation have done enough to prevent disease in the first place. Health care is a right of every citizen, and we need to do more to help the community be healthier.Moving past “us” and “them” to “we”…
10Answers from Others…I cannot understand how health care can be thought of as a privilege. The asymmetry of information in healthcare is greatly magnified. In a developed country, this is clearly unacceptable, unethical, and reflects a complete lack of morality with respect to the fundamental right to health.An ethics-based perspective…
11Third SpaceIn sociology, anthropology, communication, and education research you will find the term third space
12Third SpaceFirst space: one created by the majority and imposed on the minoritySecond space: one minority groups view as their actual cultureThird space: a part of both the first and second spaces, that allows people to detach from existing parameters and examine the world with new eyesThis is what we will attempt to create during the time we spend together—a space in which we examine a topic and its components, elements, or aspects from new eyesIn this presentation, we will use the term “minority” in a broad sense – it will mean anyone outside or different from the majority
13What is the mission of the public health system?
14Mission“To fulfill society’s interest in assuring conditions in which people can be healthy.”Institute of Medicine, 1988What does this mean?The IOM, in The Future of Public Health, named this the mission of the public health system.
15Culture and Beliefs Culture affects attitudes On what beliefs or attitudes was/is United States culture built – in general?How does history affect our beliefs?Much of our attitude about health and health care results from our cultural beliefs – again, in a broad senseUS beliefs: individualism, puritanism, paternalism, … these are not the only important beliefs in our system, but they are some of the biggestPaternalism is the notion that people in authority should help others “for their own good”One huge piece in the United States is individualism, so let’s spend some time on it
16Individualism v Collectivism Individualism: cultures tend to include loose ties between individuals, and everyone is expected to look after him or herself and immediate familyCollectivism: people are born into, raised by, and expected to demonstrate lifelong loyalty to strong, cohesive in-groups in which everyone is responsible for everyone(Hofstede, 2001)
17Individualism v Collectivism IdentificationSelfGroupPriorityGoal of individualSelf-sufficiencyInterdependenceDx between individualsMuchLittleAssociated withMen, UrbanWomen, RuralEmphasisInitiative, achievementBelongingMarriagesMay involve childrenMust involve childrenPurpose of educationLearning how to learnLearning how to doIndividualist—Norms- People may choose to join groups, but group membership is not essential to identity- Everyone has a right to a private life- Guilt cultures, modern societies- Children should take care of themselves as soon as possible- Extravert behavior- Methods for coping with stress are problem-focused- Science and technology are treated matter-of-factly- Education for everyone- People tend to have more control over their job/working hours, work more hoursCollectivism—Norms- Private life is invaded by institutions and organizations to which one belongs- Family provides protection in exchange for lifelong loyalty- Marriages must include children- Introvert behavior- The purpose of education is learning how to do- Methods for coping with stress are emotional- Science and technology are treated as magic- Education for the elite- People tend to have less control over their jobs/working hours, fewer hours worked
18School & Work Has anyone ever done a group project at work or school? How did it go?How much do you enjoy work in which you must depend on other people to get the job done?What if this was the norm?
19How is it different at home? Do you consider your kids and spouse when making decisions?What does that mean?What if you had to also consider your parents, siblings and their spouses and kids, grandparents, in-laws, aunts and uncles, cousins and their spouses…?Would your decisions be different?This is just one, relatively minor, example of using a more collectivist mindset – think about how your behavior and decisions would change if you needed to function this way all of the time, in every aspect of your life.This is a difficult concept to grasp – it is very difficult to shift between these particular mindsets
23What are the Outcomes?Do Americans who struggle financially have the same opportunities to be as healthy as others?Are they more vulnerable to poor health due to circumstances?
24Factors of HealthAmerica leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on EarthYet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and JordanScientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctorWhere people live, learn, work and play has an enormous impact whether they stay well in the first placeAmerica leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on Earth. Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan. It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to see a doctor when they’re sick. The second is to build preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a test. The third is to stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it. Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. It’s time we expand the way we think about health to include how to keep it, not just how to get it back.Copyright 2010 Robert Wood Johnson Foundation
25Factors of Health Three key ingredients to health Ensure that everyone can afford to see a doctor when they’re sickBuild preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a testStop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drinkCopyright 2010 Robert Wood Johnson Foundation
26Factors of Health Social Social norms and attitudes Availability of resourcesAccess to opportunitiesAccess to health careQuality of education and job trainingOpportunities for recreational and leisure- time activitiesTransportation optionsPublic safetySocial supportCultureSocial norms and attitudesExposure to crime, violence, and social disorderSocioeconomic conditionsResidential segregationLanguage/LiteracyAccess to mass media and emerging technologiesThis list is from Healthy People 2020, and includes not-health factors that can significantly affect health(US DHHS, 2012)
27Factors of HealthIn the entire city of Detroit—an area of nearly 150 square miles—there are dozens of “convenience stores” but only five grocery stores. An apple a day may keep the doctor away, but you have to be able to buy an apple.Copyright 2010 Robert Wood Johnson Foundation
28Factors of Health Physical Natural environment, such as green space or weatherBuilt environment, such as buildings, sidewalks, bike lanes, and roadsWorksites, schools, and recreational settingsHousing and community designExposure to toxic substances and other physical hazardsPhysical barriers, especially for people with disabilitiesAesthetic elementsHealthy People 2020 separates out these physical determinants that also affect health(US DHHS, 2012)
29Key Factors 1. Economic Stability 2. Education Poverty Employment statusAccess to employmentHousing stability2. EducationHigh school graduation ratesSchool policies that support health promotionSchool environments that are safe and conducive to learningEnrollment in higher education(US DHHS, 2012)
30Key Factors 3. Social and Community Context 4. Health and Health Care Family structureSocial cohesionPerceptions of discrimination and equityCivic participationIncarceration/Institutionalization4. Health and Health CareAccess to health servicesAccess to primary careHealth technology(US DHHS, 2012)
31Key Factors 5. Neighborhood and Built Environment Quality of housing Crime and violenceEnvironmental conditionsAccess to healthy foods(US DHHS, 2012)
32Equality v Equity What is equality? What is equity? Are they the same thing?
33Equity v EqualityEquality: fairness in proportion - ensuring everyone has similar access, an equal pieceEquity: fairness in distribution, everyone has access that is appropriate and necessary to their needs – everyone gets what they need regardless of the size of the pieces – equity may also be likened to equality of outcomes
35Socioeconomic StatusSocioeconomic Status: the social standing or class of an individual or group; often measured as a combination of education, income, wealth, and occupationThis is an official definition of socioeconomic status, but what does it mean?We will come back to this in a little while…(American Anthropological Association, 2007)
36Poverty Is all poverty the same? What does “poverty” mean? What does it mean to live in poverty?
37Poverty Economic Social Cultural Political (UNESCO, n.d.) Poverty undermines human rightsEconomic: the right to work and have an adequate incomeSocial: access to health care and educationPolitical: freedom of thought, expression, and associationCultural: the right to maintain one's cultural identity and be involved in a community's cultural life(UNESCO, n.d.)
38PovertyGenerational Poverty: families living in poverty for two or more generationsSituational Poverty: people or families who fall into poverty due to lack of resources to address a specific eventHow are these different?
39Poverty“Poverty is a peculiar, insidious thing: a cause whose effects often cause the original cause, or an effect whose causes are caused by the effect”(Shipler, 2004, p 53)
40Mistakes & Achievements Personal mistakes have larger consequencesPersonal achievements yield smaller returnsMiddle class: every 3 monthsPoverty: every weekWhat does this mean?Mistakes: people who live in poverty have less buffer from government, less agility to move around – fewer optionsAchievements: poor have less control, less scope of control, so achievements tend to be smaller and have lesser impactalso, things for which poor people work the hardest – feeding the kids – are not appreciated as much as things for which wealthier people work – like opening a plantThere is a crises every 3 months for middle class families, on average, and once a week for those living in poverty.(Shipler, 2004)
41PovertyWe’re not just talking about the rich versus the poor. On Average, middle class Americans live shorter lives than those who are wealthy.We have to take responsibility for our lives and decisions. But all Americans should have an equal opportunity to make the decisions that allow them to live a long, healthy life, regardless of their level of income, education, or ethnicity.Copyright 2010 Robert Wood Johnson Foundation
42Related SkillsWhat skills do you need to work in a fast- food restaurant?What skills do you need to work in a C- suite?How are these skills obtained or built?Who teaches them?Does anyone not know what a “C-suite” is? It refers to the CEO, CFO, CNO, etc – the executives(Shipler, 2004)
43Learning/Education If you do not have a roof over your head If you do not know with whom you are livingIf you do not know whether there will be food for dinnerAre you going to worry about classwork?(Shipler, 2004)
44Socioeconomic Class How many social classes are there in the US? Are there different mindsets that go with each class?What might be similar?What might be different?
45We can’t eradicate illness, but we can foster health. Health begins with healthy relationships, healthy communities, and healthy jobs, which protect us from the stress of everyday life.We are social by nature, and when the ties that bind begin to unravel, so does our health.Health begins at home in our families, with a loving relationship between parents and their children, where kids can expect to be safe, nurtured and protected.Health begins with healthy communities, with safe streets, freedom from violence, and parks where kids can play.Health begins with a good education, where children learn not only how to read, write, and prepare for fulfilling, prosperous life, but how to treat each other with dignity and respect.And health begins with safe jobs and fair wage, where people derive a sense personal satisfaction from their work and connection to their co-workers.No institution alone can restore a healthy America that nurtures families and communities. That will require leadership, and a partnership of business, government, and civic and religious institutions.We can’t eradicate illness, but we can foster health. And health begins with healthy relationships, healthy communities, and healthy jobs, which protect us from the stress of everyday life. That’s one prescription that doesn’t require a co-pay.Copyright 2010 Robert Wood Johnson Foundation
46We need a few good volunteers… Line of Inequity…
47Some StatisticsPeople in the highest income group live an average of 6.5 years longer than those in the lowestPeople in the middle class will die an average of 2 years sooner than those at the topLow income people are 50% more likely to have heart disease than the wealthyMiddle class people are 20% more likely to have heart disease than the wealthy(California Newsreel, 2008)
48Some StatisticsChildren living in poverty are about 7 times more likely to be in poor or fair health as those in the topMiddle class children are twice as likely to be in poor or fair health as the wealthyRates of illness for poor people in their 30’s and 40’s are comparable to those of wealthy people in their 60’s and 70’s(California Newsreel, 2008)
49Some StatisticsIf they get sick, 47% of US private sector workers must choose between staying home or losing a day’s payThe US is the only industrialized nation that does not require employers to provide paid sick leaveThe US is the only industrialized country in which paid vacations are not required by law1 in 4 American workers receive NO paid holidays or vacations(California Newsreel, 2008)
50Current Efforts: Federal National Partnership for Action to End Health DisparitiesAwareness—increase awareness of the significance of health disparities, their impact on the nation, and the actions necessary to improve health outcomesLeadership—Strengthen and broaden leadership for addressing health disparities at all levelsHealth System and Life Experience—Improve health and healthcare outcomesCultural and Linguistic Competency—Improve cultural competency and linguistic competencyResearch and Evaluation— Improve coordination and utilization of research and evaluation outcomesThe NPA also includes some structures to ensure continuing communication and collaboration among established partners and ongoing efforts to recruit additional partners.One of those is the Regional Health Equity Council (RHEC) structure…
51Current Efforts: Nebraska People are People are People: Increasing Your CQCommunity Health Worker CoalitionOHDHE Strategic PlanPromote chronic disease prevention, maternal child health promotion, reduction of obesity, and improve physical activity and nutritionEnhance awareness of health disparities and advance CQEstablish coordinated data collection, evaluation methods and outcomes, and provide relevant statistical dataExpand and sustain statewide community partnerships and collaborationEncourage full racial and ethnic minority engagementEnhance collaboration/coordination and technical assistance efforts regarding tribal health
52What are you/your organization doing? How do you fit in?
54ReferencesAmerican Anthropological Association. (2007). Race: Are we so different? Retrieved fromCalifornia Newsreel. (2008). Unnatural causes: Is inequality making us sick? Retrieved fromHentoff, N. (1999, November). Expelling ‘Huck Finn.’ The Washington Post. Retrieved from hentoff p.htmHofstede, G. (2001). Cultures consequences: Comparing values, behaviors, institutions, and organizations across nations. Thousand Oaks, CA: Sage Publications.Institute of Medicine. (1988, January 1). The future of public health. Washington, DC: National Academies Press.Shipler, D. K. (2004). The Working Poor: Invisible in America. New York NY: Knopf.United States Department of Health and Human Services. (2012). Healthy people Retrieved from
55More informationNebraska Office of Health Disparities & Health Equity