How can societal culture and values influence health and rehabilitation outcomes?

KEYWORDS:

• Evidence based medicine
• health care
• culture
• values
• social responsibility
• socio-cultural

1. Introduction

Discussion of the influence of culture and values in health care and rehabilitation can be controversial. Ironically, this controversy is culturally produced. In many countries, reliance on the objectivity of science to drive equity and rigor in health care has led to a situation of decreased explicit consideration of how socio-cultural dynamics contribute to what is considered good practice and appropriate systems [1]. In this climate, the assertion that values and culture may affect outcomes can appear incongruous and uncomfortable. However, arguably culture has produced our well-developed scientific mind-set, and values have driven the primacy of scientific evidence in clinical decision-making. We can think of culture as relating to social behavior within a particular people or society that is a manifestation of shared ideas and customs. Values are the principles or standards that convey what people consider to be important in life. COVID-era politics have made both culture and values more visible than they have often been, but science-driven health care still seems to stand apart as objective and ‘neutral’ compared to the value-laden decisions we see reported in the media. This ‘neutrality’ is a culture in its own way. Scientific evidence has not always been the key driver for medical decision-making [2], neither is it universally considered the most important factor by all stakeholders in health care [3]. Whatever culture dominates our health care systems and whatever values structure our hierarchies of importance, we need to critically examine their effects in relation to what health care and rehabilitation exist to achieve. The purpose of this editorial is to highlight specific areas of research that make culture and values within health care and rehabilitation visible, enabling a discussion of their effects. Given the brevity of the article, the focus is on three key aspects of health and rehabilitation systems where researchers have clearly demonstrated the influence of societal culture and/or values on outcomes. They are: what health services are available in a given society; the existence of unconscious bias in health care; and the influence of societal values on health and rehabilitation goals. These aspects manifest at the system level, the level of interpersonal interactions, and how dominant assumptions shape what is considered appropriate, legitimate, and successful.

2. System level: what is (and is not) available and accessible within our health-care systems

What health services are available is strongly influenced by societal culture and values. For example, drawing from the above example from westernized health systems, what is valued within the paradigm of evidence-based medicine (EBM) is influential in determining what health services are available and funded. EBM, in turn, is reflective of values that sit within these societies: prominently, the objectivity of positivist science. Objectivity is interpreted as trustworthiness, and this is evident in the well-known EBM hierarchy of evidence. For the most part, EBM continues to rely heavily on randomized controlled trials (RCTs), which test the efficacy of interventions for a defined population.

This brings us to the question of how the culture and system of values that EBM exists within affects what is made possible for the consumers and recipients of health care A key argument in favor of EBM is for equal access to high-quality care. However, it is not this simple. In one specific illustration of (probably unintended) effects, the need for RCTs to demonstrate efficacy in terms of generalizability of the intervention being tested across a population inherently marginalizes treatment systems in which it is expected that a treatment or medicine will interact with individual people in different ways, as is common in traditional medical systems [4]. The more recent precision medicine, being grounded in the same scientific culture, has been viewed as either a development of or a competitor to traditional EBM. This is vastly different from the position of traditional medical systems which focus on healing as an art of attunement as opposed to the science of precision. The dominance of EBM as a decision-making tool in health-care provision privileges health care that fits the EBM paradigm, affecting availability and access to traditional medical treatments and systems, with a very real influence on the health and wellbeing of some parts of our communities. Significantly, this includes Indigenous peoples [5], who already experience substantial health disparities relative to non-Indigenous counterparts worldwide [6]. As an example, Māori in Aotearoa New Zealand have seen the individualized nature of Western treatment systems creating access barriers and poorer outcomes when compared to treatment that encompasses vital cultural concepts such as whānau (family systems) and wairua (spirit) [7].

3. Interpersonal level: effects of bias and discrimination

In a famous critique of Western medical culture first published in 1982, Eric Cassell demonstrated a paradox. The goal of medicine is expressly to relieve suffering through the treatment of disease, but because the focus of scientific medicine is treating bodies (where disease is located) it often fails to attend to the complexities of people (who experience suffering), so suffering can actually arise as an outcome of treatment [8]. This can happen in many different ways. Mark Tonelli, in a critique of EBM from 2006 [9], highlighted that because medical treatment and care deals with individual patients (not populations, as in the research that it draws from), competent medical practice requires far more than the ability to critically appraise research evidence as a basis for decision-making. Even at the level of prescribing relatively well-studied treatments, the prudence and judgment required to decide how alike the ‘patient sitting in front of me’ is to a studied population relies on well-developed skills in considering various personal and contextual factors. As such, it is a necessary complexity that judgment is also needed at the level of the individual health professional when responding to the particular patient. Often unconsciously, societal values come into play here too. Implicit bias in health-care professionals has been found to mirror the biases of wider society – in other words, discrimination according to race, sex, gender identity, functional ability, sexual orientation, or whatever marginalized human categories exist in wider society will be replicated in health-care environments, contributing to poorer outcomes for groups who already experience discrimination [10]. This is layered on top of institutional discrimination, which already affects education and employment opportunities and therefore financial and social security [11]. This alienation can be hard to imagine for those who have always felt ‘at home’ in the health system (notably health professionals). People who have health care experiences during travel to other countries often talk about experiences of cultural misfit and the vulnerability that creates. In situations of institutional discrimination and implicit bias, this misfit and vulnerability essentially occurs for people in their home environment.

4. Dominant assumptions: The influence of societal values on health and rehabilitation goals

In addition to producing implicit bias that contributes to discrimination, societal values influence the explicit and implicit goals of health care and rehabilitation. As well as providing the foundation for what counts as a legitimate intervention, these goals determine what constitutes ‘success’ and what is ‘failure,’ and experiences of succeeding or failing can profoundly affect health and wellbeing. It is well reported in the field of psychology that feelings of shame, deriving from subjective experiences of not living up to family or societal expectations, are associated with a variety of poor health outcomes [12]. It is less well reported how we can unintentionally create these conditions in health and rehabilitation settings. A good discussion exists in the literature that critically explores the effects of rehabilitation practices for people who experience long-term disability. The tension here occurs around the value placed on being, becoming, or at least approximating ‘normal.’ In rehabilitation, the focus is to assist people to return to ‘normal’ activities and ways of doing things (such as paid employment or walking to mobilize) or to approximate normal functioning as closely as possible. Studies drawing on theory within disability studies have examined the effects of the implicit normative judgment that one ought to strive to function normally. They highlight that people who are unable to function in ways that are considered normal – especially those who go through extensive rehabilitation and ‘fail’ to achieve this – internalize this judgment [13]. In this way, the judgments about what is important in life that reflect the values of the society also contribute to very personal experiences (achievement, gratification, failure, shame) when people strive to achieve the goals that are central to health care and rehabilitation [14]. Those experiences inevitably affect outcomes, not only or necessarily in relation to the service the experiences occur within, but more generally in health and wellbeing – including outcomes that the patients themselves give specific importance to [12,13].

5. Discussion

The approach taken in this editorial has been to highlight some of the ways in which societal culture and values can contribute to poorer outcomes for some people in health care and rehabilitation. This is because it shows a contrast between the caring intent of our systems and the lived realities of some people. Of course, the same influences with regard to culture and values create many outcomes we would judge as positive and desirable. In the spirit of the late philosopher Michel Foucault, the point is not to say that things are all bad, but that it is dangerous not to observe, examine, and consider what is actually occurring; who benefits and who is harmed because of what is normal, what we value, and the way that we do things. Utilitarian ethics would argue that some harm may be acceptable as long as we judge that we are doing the greatest good for the greatest number. However, it is problematic that there is a pattern to who is harmed, and there are many important critiques of utilitarianism [15]. Again, COVID-era politics clearly show that this is in no way a simple issue.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewers disclosure

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Acknowledgments

Thank you to Gareth Terry and Rean Fadyl for helpful comments on an earlier version of this manuscript.

Additional information

Funding

This paper was not funded.