Student should be able to understand the rich diversity of cultures in a multicultural society such as South Africa and throughout the world. Student should be able to apply the sociocultural knowledge in the different health care settings.

1. SOCIOCULTURAL
CONTEXT OF HEALTH
AND HEALTH CARE
DELIVERY
By C.Settley

2. Learning Outcomes
 1. Student should be able to understand the
rich diversity of cultures in a multicultural
society such as South Africa and throughout
the world.
 2. Student should be able to apply the
sociocultural knowledge in the different
health care settings.

3. South African society: brief historical
overview
 Social change, social dynamics and transformation in SA
 1 of the most noticeable changes made by the new SA Government was the
establishment of Chapter 9 institutions. They are:
 The Auditor – General
 The Commission for Gender Equality
 The Commission for the Promotion and Protection of the Rights of Cultural,
Religious and Linguistic Communities
 The Electoral Commission
 The Financial and Fiscal Commission
 The Interdependent Communications Authority of South Africa
 The Pan South African Language Board
 The Public Protector
 The South African Human Rights Commission
 The Youth Commission

4. Social change, social dynamics and
transformation in SA
 The aim was to develop a more equitable healthcare system,
 Despite having a well-established economy and being classified as a
middle income country, SA has one of the highest income inequalities
in the world.
 It is a well known fact that poor health is associated with poor socio-
economic position.
 There is a huge variation in health status and health service access
across the country and even between communities who live next to
each other.

5. Population & Demography
 Population: a group of people who live in a specific geographical area.
 Demography: is a subfield of sociology that examines population size (the absolute
numbers of people within a society), and also the structure or composition and the
distribution of populations.
 Fertility, mortality & migration determines the population size of a specific
country or whether the numbers have increased or diminished
 - natural increase: most important component of population change
 - birth rate: the number of live births for every 1000 members of a population in a
given year
 - death rate: the number of deaths in a year for every 1000 members of a
population
 - immigrants: the number of people who moved into a country
 - emigrants: those who left (the difference between the two is the immigration
rate).
 Population change = (births-deaths) + (immigrants-emigrants)

6. Demographic information
 Describes a population
 Reveals inequalities and problems in society
 Infant mortality rate
 Life expectancy
 Factors that shape death rates and life
expectancy are healthcare practice and socio
economic position

7. Human development index (HDI)
 Is a measurement of long-term human progress in 3 basic dimensions of human
development:
 1- a long and healthy life
 2- access to knowledge
 3- a decent standard of living
 The HDI score varies from 1(a perfect score)to 0.
 Therefore nations living in good conditions will have a score of 1, and where
poorer it will be closer to 0.
 The HDI lists 169 countries, categorised in 4 sections:
 1- very high human development
 2- high human development
 3- medium human development
 4- low human development
 See table 2.1

8. Population and health
 Population size and growth and its consequences such as:
urbanization, air pollution and overexploitation of
environmental resources pose challenges to the social
structures that must be created in society to support and
organize the population. (Urbanisation means an increase in the proportion of
people living in urban areas compared to rural areas. An urban area is a built-up area such as
a town or city. A rural area is an area of countryside).
 There is a relationship between the number of people in a
country and both their health and quality of the
healthcare services provided
 Not only is the number of people important, the other
demographic features of a society also influence health
and healthcare

9. Culture
 In sociological sense: Includes the total way of life of a group of
people. This way of life is shared, it comprises some
learning/teaching, and is based on symbols.
 The social grouping sharing a way of life can be a nation, a region or
even an occupation.
 Within a group in which most members share what we call the
dominant culture- these being subcultures
 We are all born cultureless- and have to be taught our culture by
various individuals, such as our parents
 This process is called socialisation
 All new parents are actively involved in socialisation when they teach
their children to talk, walk and behave

10. Culture
 Culture must not be confused with society. They are not the same
thing
 Culture is an element of society- the most extensive element
 It can be described as society’s ‘personality’ and comprises the
following aspects of social life: behaviors, norms, values, beliefs and
the physical artefacts, i.e. all the objects made by the members of a
society.
 The latter, tangible products of human society are what we call
material culture e.g. cars, televisions, beds, homes, churches,
technology, paintings, etc.
 Intangible creations or objects of human society (non-material
culture), includes knowledge, beliefs, norms, values, symbols and
language.

11. Components of Culture
1) Knowledge and beliefs- the
Cognitive Component
2) Value and Norms- the Normative
Component
3) Symbols and Language- the
Symbolic Component

12. Components of Culture
The Cognitive Component: Knowledge &
Beliefs
 Knowledge forms the foundation for social behaviour
 Knowledge is a collection of relatively objective ideas and
facts about our physical and social worlds
 Beliefs are ideas that are relatively subjective, unreliable
or not linked to evidence
 We acquire our beliefs through the process of
socialisation; they help shape how we perceive our
surroundings and our personality development

13. Components of Culture
The Normative Component: Values, Norms
and sanctions
 Comprises elements necessary for the maintenance of integration and
conformity in society
 This component specifies the correct ways of thinking and behaving
and of defining morality
 Values are defined as socially shared ideas or standards about what is
good, desirable or important
 They represent general criteria for evaluating our own views and
actions or those of others
 The social rules that determine how we ought to behave arise from
the values
 Thus, laws against murder clearly reflect the value we place on
human life.

14. Components of Culture
The Normative Component: Value, Norms and
Sanctions (continued)
 Sometimes the values within a
society conflict
 Most human populations, no matter
how diverse, share at least some
consensus over values such as what
is good or bad, appropriate or
inappropriate
 The consensus is often not perfect,
but without some degree of value
consensus, societies will be
characterized by conflict and
tension. Some general values
respected by most globally:
 Achievement
 Activism
 Freedom
 Progress
 Materialism
 Efficiency

15. Components of Culture
The Normative Component: Value, Norms and
Sanctions (continued)
 Norms are the social rules that specify how people should
behave
 They serve to guide people’s actions in particular
situations and within particular roles, groups,
organizations and institutions
 Eg tell us how to act in elevators, how to address our
parents, teachers and how to greet people
 Norms can be prescriptive: defining how one ought to
behave in given situations OR
 Norms can be proscriptive: defining how one ought not to
behave.

16. Norms serve to guide people’s actions
(E.g. hand shaking)
 Although the form of a
hand shake may differ,
the response is the
same
 Norms make
interactions
predictable
 Norms vary in their
degree of importance

17. Components of Culture
The Normative Component: Value, Norms and
Sanctions (continued)
 Folkways are norms that designate a society’s
customs for routine and casual interaction and for
distinguishing between right and rude.
 They are weak norms that specify expectations
about proper behaviour
 Violating folkways are not considered serious-
may be considered impolite and inappropriate
 Will not be arrested for it

18. Components of Culture
The Normative Component: Value, Norms and
Sanctions (continued)
 Mores (pronounced mo-rays)
 Refers to strongly held norms that specify normal behavior and constitute
demands, not just expectations
 Violation of mores involves a strong negative societal reaction
 In many societies, some such norms are considered so important that they are
called laws
 Some categories of people are put in charge of enforcing such laws and
specific punishment is imposed on violators
 E.g. committing murder- brought to justice by laws and police, severely
punished by a judge

19. Components of Culture
The Normative Component: Value, Norms and
Sanctions (continued)
 Norms guide behavior
 How does society force people to obey the norms of a society?
 Via Sanctions:
 Can be positive (reward) or negative (punishment)
 Can be informal (enacted by friends/family) or formal (enacted by formal
institution)
 The process by which are used to make people conform is called social control
 Socialization causes us to internalize cultural norms and impose constraints on
our own behavior
 When we disregard an internalized norm, it results in our experiencing guilt
and shame

20. Components of Culture
The Symbolic Component: Symbols and
Language
 A symbol is used to represent or stand for something. Can take various forms
 Key example: Language. It differs across different cultures. It does more than
enable us to communicate. It can determine or influence how we think and it
can be a source of thought.
 It can be a physical object such as a wedding ring standing for a promise
between two people
 It can also be a characteristic of an object, like the Aids- awareness ribbon
 Or a gesture: a fist raised in the air

21. Activity on page 38!!!!

22. Analyzing Culture
 Due to different theories on the social phenomena,
culture is also being seen through different lenses
 The theories help us to understand
 Assists us to view our own culture more
objectively/scientifically
 Malinowski (anthropologist in branch of functionalism): he
maintains that cultural phenomena do not develop
because people accidently or unintentionally invent them
or simply borrow them from others. Rather, they are
determined by basic needs and the possibilities of
satisfying these. 3 kinds of needs:

23. Analyzing Culture
Structural Functionalism
 Biological needs: food, shelter, reproduction
 Instrumental needs: social control, education, political
organization, economics
 Integrative/symbolic needs: knowledge, religion, art
 Stable orderly system with interrelated parts that serve
functions
 Core values
 Cultural universals: values found in every culture in the world

24. Analyzing Culture
Structural Functionalism
(continued)
 Culture functions: to meet the needs of individuals rather than society
as a whole
 When the needs of individuals- who comprise society are met, the
needs of society are also met
 The way in which individuals’ needs are served, is that society
provides institutions, customary practices and beliefs
 Eg for the need of production- the institution of marriage and family
has been provided
 Eg to ensure order and stability- society has developed laws
 Eg as means of intellectual, emotional and pragmatic control of
destiny and chance- society has developed magic and religion

25. Analyzing Culture
Structural Functionalism
(continued)
 Dysfunctions of culture: if a society has multiple subcultures, it leads to a
lack of consensus about core values
 It is resolved by educating the members of a society on cultural diversity
 This is the responsibility of institutions of education and the family
 Strengths of the functionalist approach: that it can help explain puzzling
cultural practices like magic rituals that are ridiculed as being both
ignorant and irrational
 Malinowski’s viewpoint: rituals are highly sensible and effective
 (study on Trobraid Islanders)
 Superstitiousness ….Scientific grounds
 Major weakness of the functionalist approach: it overemphasises harmony
and cooperation, resulting in cultural conflict being underestimated and
the extend of cultural change in society being downplayed

26. Analyzing Culture
The Conflict perspective
 Based on the assumption that social life is about competition and struggle
 With members of powerful groups seeking to control scarce resources
 Acc to this perspective of culture, values and norms help sustain the privileged position of the powerful
 Culture thus reflects the interest of the rich and powerful in this perspective
 Certain values- such as competitiveness- benefit the powerful like stimulating worker productivity,
enabling obtaining larger profits
 By believing in competition, the powerless will feel that the powerful are entitled to their riches and
privileges
 This illustrates the way in which certain ideas are cultural creations are used
 A system of ideas that guides the way in which people think and act accordingly, is called ideology
(capitalism, communism and apartheid)
 A strength of the conflict theory is that it stresses how cultural values and norms may perpetuate social
inequalities.
 A limitation of the perspective is that it underestimates the extent of integration in society in that it
focuses on societal discord and the divisiveness of culture

27. Analyzing Culture
Symbolic Interaction
 Describes people as active in that they create, maintain and
modify culture during their numerous daily symbolic interactions
 This means that one’s culture does not determine one’s behavior;
neither are the norms and values static-but dynamic in that we are
constantly interpreting and re- them, thus changing them
 The strength of the Symbolic Interaction is that it reminds us that
despite its structural elements, society consists of people
interacting with one another. Alters us to the fact that people who
maintain and change culture by means of interaction with others
 The aspect is also a point of criticism, because it fails to take into
account the larger, macro-level social structures, such as social
class- aspects considered by the structural-functionalist and
conflict perspective

28. Concepts related to Culture
Cultural Universals &
Cultural Diversity
 Cultural Universals – the
commonalities that cultures
share. Language, marriages,
health systems, religion,
economic system, recreation
 Cultural Diversity- the
differences that cultures
share. different ways of
looking at things, different
ways of dressing, different
ways of expressing
personality/goodness
Cultural Relativity &
Ethnocentrism
 Culture: language, values, beliefs, rules,
behaviors, artefacts and other
characteristics common to or shared by the
members of a particular group.
 Race: biological term(genetic- hair, etc)
 ethnicity: non-biological characteristics
that provide members of a group with a
sense of common identity such as ancestry,
culture, history etc
 Ethnocentrism: the practice of judging
another culture by the standards of one’s
own culture and regarding one’s own as
superior.
 Cultural relativism: the practice of judging
another culture by its own standards

29. Subcultures
 Groups within a group
 They develop their own unique symbols, norms and values.
 Can be formed around many aspects such as age, occupation, ethnic
group and sport interests
 A person can belong to various subcultures simultaneously
 Have unique traits
 Do not oppose the dominate culture of a society (opposite of
counterculture)
 Members of counterculture are likely to question the morality of the
majority group and engage in some or other form of protest activities

30. Activity on subculture!
Page 44

31. Cultural Change
 Culture is not static, but changes over time
 Something considered unacceptable
behavior years ago, may be acceptable now
 Change is inevitable, people resist change
often

32. Cultural Change
3 main sources of influence responsible for change,
but also for resistance to change:
 1) Forces within a society:
 Invention: a key process of cultural change e.g. cellphones,
electronic money
 Culture loss
 2) Habit
 3) Contact between societies:
 When societies come into contact with one another; it leads
to change
 Diffusion- the movement of cultural aspects from one
culture to another
 Acculturation- when traits replace traditional cultural
patterns

33. Cultural contact & culture and health
 Cultural Contact : occurs between cultural groups in the society
 Culture and health:
 - influences of culture on health and rehabilitation is important
 - a good healthcare provider( able to recognize, learn about cultures of
his/her patients. Be aware of the fact that people define themselves
culturally)
 - what should health providers do with such knowledge?

34. Cultural competence

35. Cultural competence concepts
 Cultural Awareness: involves the understanding of the
importance of cultural differences. Also entails being conscious
of one’s personal reactions to people who are different
 Cultural Sensitivity: which goes beyond awareness and
comprises an appropriate attitude towards cultural differences
 Cultural Competence: involves having the capabilities of
dealing with differences effectively
 Cultural Responsiveness: which falls between sensitivity and
competence, is the ability to respond to a patient's care needs
in a way that matches the patient’s expectations

36.  Cultural Competence is used to encompass all the
aspects contained in aspects mentioned
 Cultural competence is an important set of skills
for all
 Vital skill for health care workers
 Have to be culturally competent to understand
priorities, communicate empathy and acceptance,
be responsive to individual and community needs,
and work effectively with cultural groups to
develop culturally relevant interventions
 Must recognize and show tolerance towards
pluralistic approach to health

37. Race & Ethnicity:
The social significance of race
 Race: A category composed of men and women who share
biologically transmitted traits that members of a society
deem socially significant.
 Sociologists regard race as a social construction in the
sense that biological traits are endowed with social
meaning.
 A race is a group of people who have been singled out on
the basis of real or alleged physical characteristics.
 There are no biologically pure races.
 Race is a significant concept only because most people
consider it to be.

38. Race & Ethnicity:
The social significance of race
 From the definitions it is clear that:
 1) Race implies some or other categorisation based on a physical trait;
and
 2) people decide what that specific trait is and its importance.
 It is thus a socially constructed concept.
 In most cases it is skin colour; in others, it may be height, facial
features, hair texture or eye colour.
 i.o.w. theses are social decisions- determined by people and not by
biology.
 Unfortunately history teaches us that racial classification has largely
been made in order to give one group an advantage over another and
that is used to rank people in a system of classification that regards
one type of group as superior.

39. Race & Ethnicity:
The social significance of race
 Ethnicity: A shared cultural heritage.
 This concept refers to people who have common
cultural characteristics and an ethnic identity.
 Races may also be analyzed as ethnic categories
in many cases.
 Because they share a common culture and a
common identity, members of an ethnic group are
drawn toward one another and feel a sense of
"oneness," unity, and shared fate.

40. Video:
Demographic structure of race
and ethnicity

41. Problems in race relations, page 50
 1) Prejudice and discrimination
 2) Racism of nurses towards patients
 3) Strategies for working with diverse clients
 4) Racism between colleagues
 5) Patients acting in a racist manner towards
nurses

42. Problems in race relations
1) Prejudice and discrimination
 Prejudice has to do with the inflexible and
irrational attitudes and opinions held by members
of one group about another.
 Prejudice: For example, a person may hold
prejudiced views towards a certain race or gender
etc. (e.g. sexist).
 Being prejudiced usually means having
preconceived beliefs about groups of people or
cultural practices.

43. Problems in race relations
1) Prejudice and discrimination
 Discrimination refers to negative behaviors
directed against another group, especially on the
basis of sex/race/social class, etc.
 Eg. World War II - In Germany and German-
controlled lands, Jewish people had to wear
yellow stars to identify themselves as Jews. Later,
the Jews were placed in concentration camps by
the Nazis.

44. Problems in race relations
1) Prejudice and discrimination
 Racial discrimination in South Africa. Apartheid (literally
"separateness") was a system of racial segregation that was
enforced in South Africa from 1948 to 1994. Non-white people
where prevented from voting and lived in separate
communities.
 Age discrimination is discrimination against a person or group
on the grounds of age.
 Gender Discrimination: In Western societies while women are
often discriminated against in the workplace, men are often
discriminated against in the home and family environments.
For instance after a divorce women receive primary custody of
the children far more often than men. Women on average earn
less pay than men for doing the same job

45. Problems in race relations
1) Prejudice and discrimination
 Prejudice take the form of a stereotype when an
exaggerated description is applied to every person in
some category.
 Statements such as ‘all whites are….’ or ‘all coloured
people……’ are typical of stereotypical thinking.
 Prejudice contain an element of judgement.
 Stereotyping is an oversimplified image or idea held
by a person or group of another.
 Discrimination involves an act of unfair or unequal
treatment that cannot be hidden.

47. Problems in race relations
2) Racism of nurses towards patients
 Racism has been reported in health care in the
way that nurses treat their patients.
 With regard to patients, race can influence health
status when people. This is as a result of
inequalities experienced in daily life.
 Fear of discrimination may even prevent people
from seeking help.

48. Problems in race relations
2) Racism of nurses towards patients
 Although the nursing profession is reluctant to admit
it, studies have shown that nurses are guilty of racist
treatment towards their patients.
 It manifests in small ways such as in harmless jokes
and gestures (e.g. raised eyebrows).
 Kirkham research: established that nurses who
manifest resistant care usually relied on stereotypical
things when approaching clients and resented the fact
that they had to nurse someone from a different
race. They believed it caused additional work.

49. Problems in race relations
2) Racism of nurses towards patients
 The nurse who offered generalised care, was
conscious of the patient’s cultural or racial
diversity, but regarded it as a non-issue. Their
view was that basic human respect would cover
all patients.
 Impassioned nurses regarded caring for diverse
patients as a positive challenge that they
enjoyed. The desire was to learn from their
patients. They were eager to learn and
accommodate and understand them.

50. Problems in race relations
2) Racism of nurses towards patients
 Not all nurses are impassioned nurses.
 Resistance nursing is unacceptable.
 Leads to misconduct.
Resistant care Generalist care Impassioned care

51. Problems in race relations
3) Strategies for working with diverse clients
 On an individual level:
 Connect with others.
 Deal with the family of the patient.
 Try to accommodate cultural practices as far as
humanly possible.
 Balance your own expectations.

52. Problems in race relations
3) Strategies for working with diverse clients
 Interpersonal and institutional level:
 The healthcare setting.
 The role of colleagues.
 The commitment of the institution.
 Education.

53. Problems in race relations
4) Racism between colleagues
 Step 1
 Document any and all incidents of racism that happen to you in the workplace
or that you witness. Write down names, dates, times and detailed
descriptions of what occurred. If you have physical evidence, hold on to it in
a secure place, such as a locked fireproof box.
 Step 2
 Report each racist incident that occurs to your supervisor, union steward, or
both. Talk about the incidents with anyone you trust, particularly if they have
gone through something similar -- this can help you through an otherwise
difficult emotional process.
 Step 3
 File formal complaints through whatever system is available in your
workplace or union. If necessary, hire a lawyer who specializes in
discrimination cases and file a lawsuit. Present the lawyer with all your
documentation and evidence of the racist incidents that have occurred.

54. Problems in race relations
5) Patients acting in a racist manner towards
nurses
 Nurses are often confronted with this.
 Such attitudes can affect nurses’ morale and self-
confidence.
 It may even offend them to a point where they do
not want to care for the patient.
 Read case on page 54.

55. Problems in race relations
5) Patients acting in a racist manner towards
nurses
 Actions like this leave nurses feeling hurt and
confused about how to act.
 They may even lose their temper.
 In some cases the nurse would try to avoid the
patient or else someone else to take over.
 Another response is to isolate racist patients as to not
upset the other patients and provide them with a
carer of the same ethnic background.
 This approach has dangers as it creates a precedent
in that patients can demand to be treated by
someone of the same background.

56. Problems in race relations
5) Patients acting in a racist manner towards
nurses
 Capozzi & Rhodes provide the following advice:
 - seek help, advice and support.
 - set limits with patients- remind them that such
comments are inappropriate in the health care
setting.
 - obtain backup from management. Team
approach.
 - deal with the problems of racist and abusive
behaviour at institutional level. Guidelines.

57. Race & Health
 Erosive health: when race impacts on health
when those discriminated against suffer on
multiple fronts.
 ‘ A state of consistent and deliberate decline in
the elements that produce well-being. These
elements are spiritual, emotional, physical and
environmental.
 The result of erosive health is due to lack of real
tangible involvement and economic political
power’.

58. Reference list
 Pretorius, E. Matebesi, Z and Ackermann, L. (2013). Juta’s Sociology for
healthcare professionals. Lansdowne, Cape Town, South Africa. Page 9- 24.
 http://smallbusiness.chron.com/deal-racism-work-18745.html. Retrieved on
12 July 2015.