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1: introduction Unit 1: introduction - cultural construction of bodies learning outcome linking physical, mental and social well being with culturally competent patient care introduction viewing the body as...

1: introduction Unit 1: introduction - cultural construction of bodies learning outcome linking physical, mental and social well being with culturally competent patient care introduction viewing the body as a site of biological & social intervention culture — ways of life, mores/norms and how we make sense of the world the body — constructions as much as biological/material reality malay society — cultural construction rooted in history and politics cultural constructions of the body according to marcel mauss’ ‘body techniques’ — how we use our bodies (e.g. to eat, walk, sit) is learned and normalised bodies in science and medicine are also described using culturally-informed images and assumptions in western societies, masculinity and femininity are seen as opposed and hierarchical in western science, male gametes are productive (generative), dynamic; while female gametes are entropic (degenerative) but, in malay society, gender relations are bilateral, complimentary, but these are significantly augmented by patriarchal islamic frameworks of gender malay society a cultural, dynamic, political hybrid category of people across the malay world (e.g. singapore, malaysia, indonesia, thailand, brunei and philippines) demographically diverse — shaped significantly by colonial constructs, socioeconomic transformations, state policies and islamic revivalism 1: introduction 1  in singapore, 13.5% of the population have an ancestry from regions such as java, sumatra, sulawesi and riau islands historically, under the colonial regime, were skeptical of western medicine, healthcare and hospitals stereotyped as superstitious, idle, culturally backward and ignorant malay cosmology & bodily equilibrium semangat — spirit of life, permeates the universe, dwelling in humankind, beast, plant and rock angin — determines individual personality, drives and talents are already present at birth, palpable during trance malay conceptualisation of health and bodily equilibrium is influenced by various pre- islamic, cross-cultural humoral theories about the body (e.g. the balance of heat and cold) malay cosmology of being + modern healthcare cultural competence in healthcare is vital: we must understand that sickness and death are comprehensible and manageable because of our beliefs, values and worldviews culture shapes our emotional responses to health issues and crises culture informs our social networks on best practices for support culturally competent care learning outcomes Describe and explain the determinants of health Describe and explain factors influencing health behaviours: Social Ecological Model Describe and explain how culture influences health and health behaviours Describe and explain Culturally Competent Patient Care. Apply the cultural competence framework, social ecological model and 7C’s principles of health communication to promote health 1: introduction 2  what is health? public health and medicine aim to promote and preserve health health is a basic human right concepts of health physical, mental and social well-being, not merely absence of diseases of infirmity ability to perform personally valued family work and community roles ability to deal with physical, biologic and social stress ability to adapt and self-manage despite physical, social and emotional challenges concept of health is holistic — we need to consider the patient’s perspective e.g. people with disabilities perceive themselves to have good health because they accept their physical deficits and adapt to the environment around them health from the patient’s perspective positive health (wellness) feeling of true well-being 1: introduction 3  fitness refers to strength, suppleness, stamina and having mindfulness and life skills healthy lifestyles does not only prevent diseases, but also improves wellness determinants of health age, gender, ethnicity and economic status factors influencing people’s health behaviours 1: introduction 4  how does culture influence health and health behaviour? what is culturally competence in patient care? the ability (skills) of a healthcare provider or individual to: understand and respect values, attitudes, beliefs, moral norms, customs and behaviours that differ across cultures of patients and communities (i.e. health and illness from the patient’s and society’s perspective) consider and respond appropriately to above differences in planning, implementing and evaluating patient care and health promotion programmes 1: introduction 5  cultural competence in patient care will maximise health outcomes for individual patients and their families health is as much about caring as curing integrating cultural competence into public health social-ecological model to change behaviours to promote health 1. changing people’s behaviour at multiple levels 2. practise cultural competence 1: introduction 6  3. design effective culturally-responsive messages be sensitive and responsive to the malay community’s health beliefs and practices explore their beliefs and practices — can ask them what they think caused their illness and what they fear most about their illness etc. acknowledge them evaluate them: harmless — leave alone beneficial — encourage uncertain — consult experts on malay cultural beliefs harmful — change through health education and involve them in the local community and religious leaders ensure interventions are compatible with their beliefs to promote well-being be creative in managing patient’s cultural beliefs and practices harmless cultural practice — leave alone e.g. midwife recites an incantation to release mother and infant during postnatal period beneficial cultural practice — encourage e.g. replacing salt with herbs and spices, traditional postnatal message to increase blood flow uncertain cultural health practices do further study refer to credible/reliable sources for evidence-based information e.g. complementary and alternative medicine (CAM) harmful practices 1: introduction 7  e.g. traditional practitioners massaging enlarged lymph node in armpit caused by spread of breast cancer e.g. combining chemotherapy with traditional medicine case study — culturally responsive intervention on nutrition longhouse community in long jegan, sarawak malnutrition among berawan children because bananas are not consumed due to cooling beliefs they steam bananas because it is a culturally acceptable food that will drive away cold elements communication process model (SMCR) 7Cs of effective communication 1: introduction 8  1. command attention by stating a threat threat = seriousness and susceptibility e.g. 1 in 3 singaporeans die of cancer by showing cultural relevance use appropriate language and pictures incorporate islamic teachings into messages on screening and treatment 2. clarify and simplify message limit number of messages — maximum 7, optimal 3-5 words 1: introduction 9  organise ideas in message in a logical way that the audience will use them limit the use of jargon, technical or scientific language 3. communicate a benefit besides long-term health benefits that are not tangible presently, talk about the immediate benefits that the person values 4. be consistent 1: introduction 10  5. create trust use credible spokespersons (e.g. scientist and expert) use testimonials from laypersons to make it more relatable 6. cater to the heart and head use emotional appeal and positive appeals to complement the facts facts — reasons and rationale given to the audience to get them to adopt a recommended health behaviour emotional appeal — emotional appeal is more persuasive than just rational facts positive appeal — e.g. replace salt with herbs and spices for food to taste good 7. call for action 1: introduction 11  communicational channels summary 1: introduction 12 1: introduction 13  2: feminist-postcolonial critiques of science and wellness Unit 2: feminist-postcolonial critiques of science and wellness the wellness industry — what do we know about wellness? emotional, social, environmental, social, spiritual, physical and mental wellness when we think about wellness — images of meditation and yoga come to our minds the point of yoga is for inner peace, but most of the spiritual elements of it has been taken out has inner peace or wellness become industrialised? notions of only being a productive member of society only if one has achieved inner peace the wellness industry — when and why? ‘wellness’ was popularised post WW2, and goes beyond ‘the absence of disease’ — but, there is still individual responsibility to maintain health in response to the four main pressures of modernity — interconnectedness of communication technologies, population boom, ageing society and the increased tempo of everyday life wellness as an industry (i.e. workplace wellness) involves maximising potential of individuals to be better employees to achieve cost-saving on insurance approach to health is now optimising and pushing the limits to achieve the best health possible feminist-postcolonial approaches to science and wellness medicine, science and technology — not neutral, are historically informed by colonial, eurocentric, ableist and masculinist ideologies scientific knowledge has been used as justifications for the inferiority of some ethnic groups — justifies ‘civilising’ missions and social hierarchies 2: feminist-postcolonial critiques of science and wellness 1  today, we find that science continues to perpetuate many biases through the lack of interest and/or funding on women’s health (e.g. endomentriosis — female sexual dysfunction) are certain people getting more opportunities and chances to thrive compared to others? women are overwhelmingly the consumers of wellness products (e.g. alternative remedies, yoga, fitness classes, diet plans and weight-loss groups) the hallmarks of achieved wellness is thought of to be slenderness, flexibility, relaxation, control and a delicate appetite — these are the visage of elite female beauty in our society neoliberalism, gender and wellness neoliberalism — the idea that the market should be free from regulations and interventions because it will distort the economy the economy will restore itself wellness as a movement is deeply rooted in capitalist systems and is inseparable from the multi-trillion dollar wellness industry (pilzer, 2002; rubinstein, 2020) the industry consists of businesses marketing diets, vitamin supplements, exercise programs, spa treatments, tourism, and other related ventures (starr, go & pak, 2021) the idea of ‘empowering’ individuals to make the right choices and lead communities suggests that it is upon the sufficiently empowered individual that health responsibility lies if they choose not to empower themselves, they will face condescending judgements choices are individualised, even though health outcomes can be outside of one’s control — failure is also individualised (i.e. they have all their resources needed to make the right choices, if they make the wrong choice, its on them) attention is taken away from toxic workplace cultures, state austerity, poor infrastructure and inequalities making it difficult to bring workplace bullies to justice problems with neoliberal models of wellness 2: feminist-postcolonial critiques of science and wellness 2  1. promote a conservative, individualistic health ideology, thereby undercutting communal, structural, redistributive and sympathetic approaches to health 2. promote workplace discrimination 3. promote homogeneity and prescribe one specific way of life for everyone challenges to wellness nowadays 1. wellness is understood as a holistic approach to optimising one’s health outcomes in a range of aspects (e.g. emotional and spiritual) 2. we find that in the workplace, wellness is often reduced to measurable outcomes like BMI, blood pressure and cholesterol levels etc. 3. good mental health is rarely measured in checkups to indicate soundness of wellbeing (as a worker) — physical health can be easier to measure, but mental health and well-being is not as straightforward neoliberal approaches to health in the singaporean context according to dutta (2021), singapore’s neoliberalism amidst the covid outbreak was extreme — migrant workers were not given the same healthcare treatment as singaporeans according to starr, go & pak (2021), crisis commodification was a mode of public health management — was it effective? ‘the myth of the lazy native’ by syed farid alatas talks about colonial stereotypes by the british of malays (mainly men) as idle and reluctant to corporate with the demands of colonial masters, have left a long-lasting impact on cultural image of malay communities these stereotypes necessitated the immigration of impoverished labourers from china and india to perform extractive work for imperial enrichments the image of malays as ‘lazy’, along with superstitious and fatalistic spread cross other discourses; medicalisation in singapore created the malay muslim body as a ‘source of trouble’ for colonial and contemporary health administration 2: feminist-postcolonial critiques of science and wellness 3  historically, in singapore and malaya, malays were suspicious of doctors and reluctant to seek medical assistance in colonial hospitals it was difficult to get malays to receive modern healthcare (e.g. hospitals, birthing, nurses) because they have been stereotyped by the british — they don’t want to give in to the colonial power ‘problematic’ malay mothers the socio-political policing of malay women in the late colonial (early 20th century) and post-independence periods (1950s-1960s) was based on portrayals of ‘native’ women as incompetent mothers medical research in singapore racialises a medical issue (e.g. being malay is a ‘risk factor’ for abortion (lim et al., 2012) poorer malay women are also targets of ‘family planning’ policies (i.e. sterilisation programmes) conclusion the self-monitoring of wellbeing is consistent with the withdrawing of the state from offering free, affordable, and sustainable access to collective wellbeing examine what we mean by ‘bad choices’ — do they actually bring us joy and pleasure — and is it really a ‘bad’ thing? 2: feminist-postcolonial critiques of science and wellness 4  3: religion, gender, and cancer Unit 3: religion gender and cancer breast cancer in singapore — analysis of the health problem it is the most common cancer among women (29.7%) it is the leading cause of cancer deaths among women (17.2%) initiatives to fight high breast cancer burden: breast cancer screening programmes outreach mammogram facilities subsidies for mammography malay women — breast cancer mortality and screening malay women experience the highest mortality: 5-years overall survival rate = 59% 3: religion, gender, and cancer 1  76% for chinese, 68% for indian women the high mortality rate is due to: late presentation and a higher proportion of malignant tumours low breast cancer screening rate at 21% (malays) vs 40% (chinese and indans) it has been the same trend for the past 2 decades structural influences on breast cancer screening such as access to service did not differ by ethnicity, and attending breast cancer or colon cancer screening was not associated with income or educational level the lower breast cancer screening rate in malay muslim women is consistent with findings in other muslim malays worldwide proven method to screen for breast cancer — mammogram in mammography, each breast is compressed horizontally, then obliquely and an x-ray is taken of each position community needs assessment — mixed methods study qualitative study: in-depth interviews, 2017-2018 explore individual-level, interpersonal-level, socio-cultural, religious and environmental factors influencing breast cancer screening behaviour among malay women aged 40-69 years in singapore quantitative study: community survey, 2018-2020 determine prevalance (%) of above factors (e.g. knowledge, perceptions, socio-cultural and religious beliefs) on breast cancer and screening determine factors associated with breast cancer screening individual-level influences — reasons for not screening 3: religion, gender, and cancer 2  religious beliefs — religious teachings encouraged not to do so a test from allah getting breast cancer is a trial from god to test one’s faith, hence, it should be viewed as a challenge to overcome personal responsibility to take care of one’s health allah wants us to take car of our own health, thus, it is my personal responsibility to get screened interpersonal-level influences on screening why husbands do not encourage wives to get screened breast cancer is not talked about openly in the malay community why husbands encourage wives to get screened awareness of curability of breast cancer if detected early had seen pamphlets on screening at polyclinics had known close relative with cancer and seen how they suffered community-level influences on screening traditional healers and masseuses’ beliefs 3: religion, gender, and cancer 3  harmful beliefs hindering clients from screening breast lump is caused by blockage of blood flow and water retention — massages will encourage good blood flow mammogram harms the body because of radiation mammogram triggers cancer cells to grow beneficial beliefs encouraging clients to get scanned if i feel a lump, i’ll ask my client to go to the clinic religious leaders’ teachings summary of findings from qualitative study 3: religion, gender, and cancer 4  survey — national representative sample of HDB flats in singapore 271 malay-muslim women aged 50-69 years prevalence of mamography — 58.2% attended mammography at least once, 31.0% attended mammography regularly once every 2 years statistically significant factors that were positively associated with mammography increasing age perceived benefit of saving lives from early detection perceived importance of the value of mammography perceived susceptibility to breast cancer cues from healthcare providers (i.e. doctors and nurses) statistically significant factors that were negatively associated with mammography modesty concerns (83%) appraisal of difficulties in life as a punishment from allah (66%) perceptions of “i must have symptoms to go for screening” (33%) perceived structural barriers: high cost (79%) no time (40%) 3: religion, gender, and cancer 5  inconvenience (45%) planning community mosque-based intervention based on findings from the needs assessment study — design intervention to increase breast cancer screening among malay women aged 50-69 years in singapore intervention was implemented in mosques — why mosques? the studies conducted found breast cancer screening to be associated with religious beliefs religious teachers in mosques are a credible source of religous teachings majority (>70%) of malay women 50-69 years (eligibility age for screening) attend mosques for religious classes supporting evidence — worldwide studies found interventions in mosques increased mammogram uptake the intervention — promote screening behaviour target group — malay women 50-69 years who attend mosques for religious classes implementation team — religious teachers, healthcare providers, breast cancer survivors and screeners how to change people’s behaviour — integrated strategies to adopt screening behaviour 3: religion, gender, and cancer 6  designing effective and culturally responsive messages — 7Cs of effective communication fear appeal — how to use it more effectively? focus on immediate consequences of risk behaviour in a personalised way (personal susceptibility) e.g. you are at higher risk if you are 50 years and above, and if you have family history of breast cancer induce a moderate and manageable level of fear 3: religion, gender, and cancer 7  e.g. if the lump is small, it can be removed without cutting the entire breast induce a higher level of self-efficacy than the fear level (i.e. show specific, easy ways on how to get screened) e.g. it is easy to make an appointment, we’ll show you how show the effectiveness of the new behaviour in reducing the threat (response efficacy) e.g. screening early will save your life, early stage is treatable intervention strategies and activities 1. health talk by religious teachers (ustazahs) incorporated into religious classes in mosques conveyed islamic teachings about health e.g. for those who believe that illness like breast cancer is punishment and there’s nothing they can do except be patient and seek forgiveness for the sins they have committed (myth) → they will be replied with sayings of the prophet muhammad, as allah sends down both disease and the cure, urging them to treat themselves medically 2. video viewing in mosques screener shares tips on how to reduce pain from mammogram cancer survivors talks about her experience of undergoing chemotherapy for breast cancer and how she prays to allah for help 3. question and answer session by healthcare professionals 4. mammobus is sited at mosques to increase access, cultural acceptance, convenience and saves time effect of intervention on mammogram uptake evaluated using cluster randomised controlled trial of mosques 3: religion, gender, and cancer 8  feedback on the intervention conclusion 3: religion, gender, and cancer 9  public health recommendations 3: religion, gender, and cancer 10  4: colonialism and imperial legacies of mental health Unit 4: colonialism and imperial legacy of racial wellness psychiatry and empire-building according to frantz fanon (1925-1961), the experience of colonial rule was the experience of a kind of madeness: he describes arab as living in a state of depersonalisation, and algeria as having systematic dehumanisation as the field of psychiatry was becoming more advanced in the 19th century, it was practiced very differently in europe and in the colonised world psychiatry was used to undermine the full subjectivity of non-western individuals although the influence of western psychiatrists who worked in colonised societies was not always so direct, they nonetheless contributed to the operations of colonialism in a few ways: demonstrated that ‘normal’ behaviour of colonised people were actually abnormal — they cannot adapt to modernity their minds and brains were not developed for self-governance questions we can raise about (colonial) history of mental illness how universal were/are the categories of mental illness? how did different cultural traditions deal with these problems? was/is it possible to argue for cultural difference, without being read as arguing for racial difference? latah — culture and colonial legacies mild episodes of latah — involuntary utterances of incomprehensible (to whom?), meaningless (to whom?), or obscene words or actions for a few seconds or minutes 4: colonialism and imperial legacies of mental health 1  mimicking words and actions of others, claims of temporary ‘amnesia’, and no memory of the episode occuring affects all groups across malay-indonesian worlds, primarily post-menopausal women western biomedical models typically medicalise aberrations and poorly-understood, ‘bizarre’ behaviours in non-western societies latah has been observed by western chroniclers since 19th century clinical categories have been imposed on the latah as an ‘involuntary syndrome’, displays of echolalia, echopraxis, and startle reflex — even as a potentially dangerous mental disorder by colonial observers timeline of observations regarding latah 1922: dj galloway argues that the primitive malay mind spent too much time daydreaming, and that this unconscious state fostered a reflex or instinctive reaction, due to the lack of formal schooling 1952: pow meng yap found that latah is attributed to low level cultural development and that subjects often possessed below-normal intelligence 1972: p manson and manson-bahr found that “all of the malay races are very high strung and nervous… and there appears to be a hereditary tendency to the latah state in every malay.” why do the colonial/medical/anthropological observers see the latah through such a lens? among malays, latah is understood to be a momentary lapse in semangat attributed to surprise, shock, or stress latah is seen to transgress moral codes, while at the same time maintaining normative boundaries; as performing or acting, nothing deviant or abnormal, only humourous and harmless decolonising mental health decolonising means decentering western/eurocentric models of knowledge and experiences, re-centering non-western/former colonised/marginalised ways of understanding the world 4: colonialism and imperial legacies of mental health 2  histories of colonialism and racism that inform mental health practices that perpetuate the under-serving of discriminated communities and minorities need to be unpacked and challenged several approaches in doing so: 1. listen — the first step to rights-based approach to mental health 2. open the closed circle of therapists — important to recognise the unique contribution of traditional healers and spiritual guides as community counsellors and therapists 3. adapt training for therapists — to promote trust and cultural sensitivity in speech, silence and non-verbal communication 4. adapt therapies to cultural contexts — re-writing ‘rules’ of treatment so that they are more meaningful and provide sustained relief 5. honouring ancestral wisdom — recognising spiritual healing 6. challenge psychiatric ‘expertise’ — recognise that western biomedical knowledge pathologise cultural practices that were poorly understood 7. recognise cultural context and complexity — apply cultural humility 8. confront the mental health industrial complex — recognise the lack of affordability and accessibility conclusion The language of the psyche was and is a powerful one, whether it is wielded by professional psychiatrists… … or by local communities defining who is, and who is not, behaving according to accepted norms. It is also a language which can be used for a range of political purposes. The latah idiom allows people of a diverse spectrum of ethnic groups within the Malayo-Indonesian populations to express themselves in myriad ways… … -joking, satire, entertainment, protest, habit, femininity, and masculinity-and to respond to a multitude of personal crises typically associated with human fragility The meanings of latah may continue to evolve… 4: colonialism and imperial legacies of mental health 3 4: colonialism and imperial legacies of mental health 4