What is the process of giving up cultural traditions and adopting the social customs of the dominant culture of a place?

Understanding Culture in the Context of Healthcare

Cultural orientation is just one of many different perspectives that individuals draw on as they make health and healthcare decisions. Individual psychology, past experiences, religious and spiritual views, social position, socioeconomic status, and family norms all can contribute to a person's health beliefs and practices. These beliefs and practices can also change over time and may be expressed differently in different situations and circumstances. Because of the significant variability in health beliefs and behaviors seen among members of the same cultural group, an approach to cultural competency that emphasizes a knowledge set of specific cultural health practices in different cultural groups could lead to false assumptions and stereotyping. Knowledge is important, but it only goes so far. Instead, an approach that focuses on the healthcare provider acquiring skills and attitudes relating to open and effective communication styles is a preferable approach to culturally effective and informed care. Such an approach does not rely on rote knowledge of facts that may change depending on time, place, and individuals. Instead, it provides a skills toolbox that can be used in all circumstances. The following skills can lead to a culturally informed approach to care:

Don't assume. Presupposing that a particular patient may have certain beliefs, or may act in a particular way based on their cultural group affiliation, could lead to incorrect assumptions. Sources of intracultural diversity are varied.

Practice humility. Cultural humility has been described byHook et al. (2013) as “the ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity.” Cultural humility goes beyond cultural competency in that it requires the clinician to self-reflect and acknowledge that one'sown cultural orientation enters into any transaction with a patient (seeChapter 2.1).

Cultural humility aims to fix power imbalances between the dominant (hospital-medical) culture and the patient. It recognizes the value of the patient's culture and incorporates the patient's life experiences and understanding outside the scope of the provider; it creates a collaboration and a partnership.

Cultural competency is an approach that typically focuses on the patient's culture, whereas cultural humility acknowledges that both physicians and patients have cultural orientations, and that a successful relationship requires give and take among those differing perspectives. It also includes an understanding that differences in social power, which are inherent in the physician–patient relationship, need to be understood and addressed so that open communication can occur.

Understand privilege. Members of the majority culture have certain privileges and benefits that are often unrecognized and unacknowledged. For example, they can have high expectations that they will be positively represented in media such as movies and television. Compared with minority groups, those in the majority culture have less chance of being followed by security guards at stores, or having their bags checked. They have a greater chance of having a positive reception in a new neighborhood, or of finding food in the supermarket that is consistent with one's heritage. These privileges typically go unnoticed by members of the majority culture, but their absence is painfully recognized by members of nonmajority cultural groups. The culturally informed physician should try to be mindful of these privileges, and how they may influence the interaction between physicians and patients.

Be inquisitive. Because of the significant amount of intracultural diversity of beliefs and practices, the only way to know a particular patient's approach to issues concerning health and illness is through direct and effective communication. Asking about the patient's/family's perspective in an inquisitive and respectful manner will usually be met with open and honest responses, as long as the patient does not feel looked down on and the questions are asked in genuine interest. Obtaining ahealth beliefs history is an effective way of understanding clinical issues from the patient's and family's perspective (Table 11.2). The health beliefs history gathers information on the patient's views on the identification of health problems, causes, susceptibility, signs and symptoms, concerns, treatment, and expectations. Responses gathered from the health beliefs history can be helpful in guiding care plans and health education interventions.

Be flexible. As members of the culture of medicine, clinicians have been educated and acculturated to the biomedical model as the optimal approach to health and illness. Patients and families may have health beliefs and practices that do not fully fit the biomedical model. Traditional beliefs and practices may be used in tandem with biomedical approaches. An individual's approach to health rarely is exclusively biomedical or traditional, and often a combination of multiple approaches. The health beliefs history provides clinicians with information regarding the nonbiomedical beliefs and practices that may be held by the patient. Culturally informed physicians should be flexible and find ways of integrating nonharmful traditional beliefs and practices into the medical care plan to make that plan fit the patient's needs and worldview. This will likely result in better adherence to treatment and prevention.

The listener

We must now turn to the audience and examine the receptive aspects of musical language. It is easy to be too solemn in discussing the role of the listener in a musical event; music is written and played for people to hear, enjoy and hopefully understand. Before examining the listener's part we will look briefly at the problems of musical semantics, development of musical appreciation and other factors involved in audience response.

We have noticed that words are necessary to describe music or to talk about it; these words can be employed objectively or subjectively. Words are used objectively in analysis of a piece, and persons of comparable musical education can be expected to produce similar, if not identical, verbal analyses of the same work under test conditions. Words are used subjectively to describe affective or emotional responses, and here we are on far less certain ground, as a study of different interpretative commentaries on many major works will show; Sessions (1971c) quoted the different descriptions of Beethoven's Seventh Symphony by Berlioz and Wagner as an example of the difficulty of defining the emotions aroused by a specific composition. Imberty (1970) examined the problem experimentally by recording individual subjective verbal responses to Debussy's Preludes for Piano; responses were different and even contradictory for the same musical extract. Imberty concluded that music is semantically ambiguous. These observations support the view that musical experience, that is, reception, perception and interpretation, is a matter for the individual listener. Persons of similar musical education and verbal capacity cannot be expected to have identical experiences, or if they do they are unlikely to formulate these experiences in the same terms, though we may all be socially guilty of using descriptive terms deriving from what we have read or learned about a composition.

French psychologists in particular have investigated musical perception over the last twenty years, for example, Francés (1958). Imberty (1968, 1969) and Zenatti (1969, 1970) studied the development of musical perception in children and university students. They found that melody is the most important factor for children; appreciation of tonal structure is progressively acquired with increasing age. The question whether consonance is socially or biologically determined was examined by Imberty (1970). He concluded that evolution of the sensation of consonance and development of musical language run along parallel paths. The acceptance of chords as consonant is not simply a matter of hearing, education and familiarity are influential in persons of all ages. Adults accept certain chords as consonant, in contrast to children, because they recognise them as a functional element in a language in addition to simple auditory acceptance. Consonance is an individual attainment influenced by biological and “acculturation” factors. This interesting work shows how the receptive aspects of musical language are enlarged over the years.

Any concert or radio audience consists of a heterogeneous group of people with differing standards of musical knowledge, variously developed musical vocabulary or language, and differing capacities for discussing what they have heard. They come in different states of preparedness, some are well informed about the programme and have studied the works to be played or sung, while others have come unprepared except for the intention of enjoying the music. However, virtually all are conditioned towards what they are about to hear because they know the names of the composers and the works to be played. The composer's name raises mental pictures of the person and his style, and these notions, whether true or false, modify expectation; knowledge of the programme raises memories of previously heard performances and of things read or otherwise learned about the compositions included there. Anticipation also stems from knowing the names of the performers, especially if the conductor, soloist and orchestra or choir are familiar.

There are also non-musical factors which influence or modify a musical occasion, and some of these have been mentioned in Chapter 1. The environment is important, the concert hall or opera house may appear beautiful or ugly and the acoustics good or poor, or it may be unacceptably hot or cold; listening may take place at home against a benign, familiar background. Pre-performance expectation can be heightened by knowing one will meet friends beforehand. The audience may prove acceptable or unacceptable; their dress and manners may be alien or they may applaud too long and too loudly. There are sensitive individuals who only fully enjoy music heard alone or in the presence of carefully chosen companions. Some listeners who are themselves performers are not fully satisfied musically unless they are actively engaged in performance.

Apart from all these musical and non-musical influences which modify audience response there are other individual factors to be considered. The listener can attend different events in different frames of mind. He may go in an analytical mood and listen carefully to the structure of the items performed, or he may decide quite voluntarily that he will listen in a relaxed way and simply enjoy himself; ideally he will combine these types of approach. His mental state will also affect perceptual experience so that the fatigue, anxiety or depression of daily life can alter his responses. Modification of responses in persons with emotional disorder can be extreme; a highly competent amateur brass player noticed no tendency to sadness on hearing or playing pieces in a minor key until he suffered a depressive illness following a head injury; thereafter he wept unrestrainedly whenever he heard music in the minor. The effects of organic brain disease on the listener's emotional responses cannot be discussed here, but the selective results of thalamic damage have been mentioned in Chapter 1 and may be usefully recalled at this point.

What is the listener's role in a musical event? He is an essential member of the group for he has the privilege of ultimate interpretation whether he comes in knowledge or ignorance, enthusiasm or boredom. The one element in the event which is permanent and unchanging is the score, for although the performance can be expected to accord generally with the composer's ideas this cannot be guaranteed, and executants may hold genuinely different opinions on the manner of performance. Each listener is free to reach his own conclusions, both on the music and the composer's intentions, but these individual notions about meaning all derive from the musical structure embodied in the score, with the reservation that early scores are generally in a rather fluid state, for example the figured bass.

We have argued that intellect and temperament or emotional state are indivisibly linked in musical invention. This idea is also true of performance, at least in general terms. Similarly, the listener's responses are both intellectual, that is to say cognitive and objective, and emotional or affective, though the proportions vary from one person to the next. If a composition is technically faultless or approximately so and the listener is sufficiently educated to understand the ways in which the composer is using musical language, that is to say his style, then hearing and comprehension may go hand in hand. However, this intellectual approach is clearly insufficient, for emotion can never be excluded from artistic experience, even a didactic work like The Art of Fugue brings a sense of satisfaction and completeness as Bach proceeds to solve the problems in counterpoint he has set himself. Admittedly the work of some composers speaks more to the intellect and that of others predominantly to the emotions, but the man who appeals equally and unitedly to the twin horsemen of mind and affect gains the wider response. It has been implied that a proportion of any audience is insufficiently educated musically to appreciate the composer's skills and subtleties to the full; insofar as such persons enjoy the performance they will do so in more subjective than objective ways, but their experience is not necessarily less valid or perceptively acute than that of the more informed.

In contrast to the score a musical performance is a transient evanescent thing; it can never be exactly repeated, there are too many variables involved in the environment, performers, and audience, but the effects of a performance can be long lasting granted good musical memory and auditory imagination; admittedly as time passes certain passages or aspects tend to stand out in memory so that the long term picture is to some extent a caricature of the original.

Listening to music is not always planned in the ways we have been discussing, unexpected or accidental exposure is a common experience which deserves attention. Events of this sort may enlarge or enhance the whole perceptual experience because of the unusual or pleasing surroundings in which the music is heard; personal examples include a Bach violin partita floating across an English meadow from one cottage to another, and perhaps more predictably a Buxtehude organ fugue suddenly sounding through the cloisters at Heiligenkreuz Abbey near Vienna.

The B.B.C. have recently broadcast a few musical programmes without giving the composers’ names and it would be interesting to know the audience's responses. One celebrated example of the consequences of concealing the composer's name concerns Ravel's Valses Nobles et Sentimentales. These “were first performed to the accompaniment of hoots and catcalls at the Société Musicale Indepéndente, where the music was all anonymous. The audience voted for the authorship of each piece. By a minute majority the paternity of the Valses was ascribed to me” (Ravel, 1972b). “So many votes wandered in unexpected directions: Zoltan Kodály and Erik Satie for instance … such howlers are surprising” (Roland-Manuel, 1972). To the prepared or unprepared listener the music is the important element in any musical occasion, nevertheless the experience is incomplete for some people unless they know at least who wrote the music and preferably details of the work.

3.3.1 Measurement issues

Acculturation scales were used for measuring acculturation levels among ASIR in only eight studies (7 in North America and 1 in Europe) (Aljaroudi et al., 2019; Brittin & Obeidat, 2011; Eldoumi & Gates, 2017; Jaber et al., 2003; Jadalla et al., 2015; Kahan, 2011; Méjean et al., 2009; Tami et al., 2012). These ASIR-nutrition studies used adapted versions of acculturation rating scales that were originally developed for other immigrant subgroups (e.g. Latino), without considering the development and validation of context-specific acculturation scales that are culturally sensitive to ASIR. For example, two American studies utilized a modified version of the Acculturation Rating Scale for Mexican Americans, ignoring the need to construct an ethnic-specific scale (Jaber et al., 2003; Jadalla et al., 2015). Furthermore, a study of ASIR women in Canada used an adapted version of the Male Arab-American Acculturation Scale, ignoring the cultural differences between Canada and the US and dietary variation among men and women (Aljaroudi et al., 2019; Lopez-Gonzalez, Aravena, & Hummer, 2005).

The eight studies used general proxy items to examine acculturation levels, including mainstream language proficiency, length of residency and nativity. None of these studies considered a multi-dimensional approach and the complexity of the acculturation process, with no assessment of contextual details such as neighbourhood resources, community and family cohesion, presence of social/cultural pressures and ASIR's socioeconomic status. These studies also did not examine the political and socioeconomic contexts of ASIR's countries of origin or migration trajectories, which would lend context to the reasons for and experiences of migration that can affect the process of acculturation and dietary change. The studies also overlooked the measurement of religious influences that also can affect ASIR's dietary acculturation process. For example, Muslims' religious dietary proscriptions (e.g. prohibited alcohol and pork products) may mediate acculturation into mainstream Western lifestyles (Garduno, 2015).

4.13 Acculturation

About acculturation, here are two systematic reviews included in this article. One reported indirect association between acculturation and perinatal depression among Latina women (Lara-Cinisomo et al., 2018). The indirect association was illustrated between Marianismo (the traditional female role of virtue, passivity, and priority of others over oneself) and PPD. The other review has been mentioned in the immigration above, and acculturation is now going to be talked about in details (Chen et al., 2018). One of the included studies used four-dimensional scores (duration of living in Taiwan, local language ability, social assimilation and social attitude) to asses acculturation, and found local language ability and social attitude were negatively related with PPD. Another “doing-the-month postpartum practices” presenting acculturation showed a negatively relationship either. The number of studies on acculturation included is scarce, and most of them have geographical limitations, so more definitive conclusions cannot be draw.

3.2.1 Acculturation

Acculturation is defined as the “process that individuals undergo in response to a changing cultural context” [25: 349]. Problems with the acculturation process were cited as reasons for gambling among migrants. A German study found that experience of acculturative stress was a significant predictor for both severity of gambling problems and motivation, and craving to gamble among migrants (Jacoby⁎ et al., 2013). Other studies supported this explanation, citing that feeling lonely and/or isolated (Chui⁎, 2008; Hum⁎ and Carr, 2018; Sobrun-Maharaj⁎ et al., 2013), communication problems, relationship problems, boredom, frustration, under- or un-employment, gambling to relieve stress associated with moving (Tse⁎ et al., 2012) and experiencing difficulties of fitting into the host society were reasons for migrant gambling (Sobrun-Maharaj⁎ et al., 2013). Feeling pressure to send money home was also mentioned (Sobrun-Maharaj⁎ et al., 2013) as was men potentially feeling a loss of status which may lead them to gamble in order to try to ‘save face’ (Sobrun-Maharaj⁎ et al., 2013). Gambling was also viewed by some as an activity in which migrants could engage with relatively few barriers to access. For example, migrants reported they did not need to be proficient at speaking the home country's language in order to participate in certain gambling activities (Chui⁎, 2008; Tse⁎ et al., 2012). Lack of suitable or appropriate leisure activities was mentioned as sometimes leading individuals to visit gambling environments (Tse⁎ et al., 2012).

One study emphasised how migrants' prior experiences in their home country and feelings associated with relocation could also influence gambling participation as gambling may be used as a form of coping strategy if, for example, migrants are moving from a country where they experienced trauma (Hing⁎ et al., 2015).

Acquiring a new found sense of freedom or independence in the new country may also have implications for migrants' gambling participation (Crentsil⁎, 2015; Feldman⁎ et al., 2014). For example, new migrants may experience fewer cultural restrictions in the new country or reduced family oversight (Feldman⁎ et al., 2014). African migrant women gamblers in Finland reported participating in gambling in an attempt to feel independent and enjoyed having the freedom to gamble (Crentsil⁎, 2014; Crentsil⁎, 2015; Crentsil⁎, 2017).

2.1.5 Acculturation (via language proficiency and preferences)

Language use accounts for much of the variance in some measures of acculturation, so it is used as a proxy indicator for a participant’s level of acculturation—that is, the extent to which an individual from one cultural group adapts and borrows traits and values from another culture. (At the same time, this language based approach is not without its limitations, and for that reason, as previously noted, the more comprehensive measure of acculturation, the Vancouver Index of Acculturation, was also included in the protocol.) However, the need also for a language based, short measure amenable for administration to 9–10 year olds and the more general project preference for the use of standardized measures led us to utilization of the PhexX items which would assess this content. The Acculturation Questionnaire is a subset of questions from the PhenX Acculturation protocol. The PhenX items come from questions used by the National Latino and Asian American Study (NLAAS) (Alegria et al., 2004), which were originally derived from the “Short Acculturation Scale for Hispanics” (Marin et al., 1987). These items ask about proficiency and preference for speaking a given language in different settings. The questionnaire consists of five items administered independently to both parent and child. The first item requires participants to rate how well they speak English (i.e., poor, fair, good, excellent). This is followed by a question asking how well they speak or understand another language or dialect besides English. If no other language is spoken or understood, the questionnaire is considered complete. Otherwise, participants who endorse speaking another language are asked to identify the other language and then asked two additional questions. The first asks which language is spoken most with friends and the second asks which language is spoken most with family. Participants rate each of these items on a 5-point scale ranging from “other language all of the time” to “English all of the time.” Participants are provided with an option to answer “don’t know” or “refused.” These items will allow us to track changes in the parent and child over the course of the ABCD study.

Data are currently available on 4096 parents and 4092 youth. Of those, about 95% of parents and 98% of youth endorsed “good” or “excellent” for their proficiency in speaking English. Youth (39%) were more likely than parents (32%) to endorse speaking or understanding another language. We speculate that the higher percentage of youth speaking languages other than English may reflect the popularity of dual-language programs in many school districts. This has prompted us to include an additional item on the measure that inquires about participation in such programs. Spanish was by far the most common other language endorsed by parents (50%) and youth (53%) Among parents endorsing knowledge of another language, average scores for the items querying language spoken to friends suggested that English was spoken most of the time (M = 4.04, SD = 1.18, n = 1324), as was the case when speaking with family members (M = 3.76, SD = 1.36, n = 1325). A similar pattern was observed for youth (friends: M = 4.52, SD = 0.76; family M = 3.86, SD = 1.34). In both cases, the means reflect a tendency for the “other” language to be spoken more often with family than friends. None of these differentiations in language preference choice when speaking with friends or with family, for both youth and parents, significantly differentiated high risk from low risk families.

Finally, it is important to keep in mind that the ABCD protocol is only available in English for youth and English or Spanish for parents. Data are currently only available on 220 parents that have completed the protocol in Spanish. This number will undoubtedly continue to grow as the sample accumulates and in the final sample a different pattern of responses on this instrument may be present.

Patient Attitudes and Additional Factors

Additional cultural factors influencing the acceptability of ACP that were investigated on a lesser scale/by fewer studies than those discussed previously were caregivers' acculturation level44; patients' attitude to acknowledging a terminal diagnosis52; collective (family-centered) versus autonomous (patient-centered) approaches to decision-making in American veterans42 and New Zealanders19; and patient preference for who to involve in EOL conversations and decision-making in Japan45 and Hawaii.49 Two studies suggested how clinicians discuss EOL care might differ depending on patient ethnicity: Sharma et al.58 found black race was associated with higher odds of hospice discussion, whereas Mack et al.53 found EOL discussions resulted in increased awareness of illness being terminal among white patients, but not black patients. Further research into these factors is required before solid conclusions can be drawn about their respective influence on the uptake of ACP.

4 Acculturation and ethnic identity development

Acculturation can be likened to a meteor hitting the earth. To what degree does the meteor retain its character once it hits the earth's surface, and to what degree does it disintegrate (becoming neither meteor nor earth), combine with the earth, or lose its nature and become more earth than meteor? These four possible outcomes correspond to Berry's outcomes of separation, marginalization, integration and assimilation, respectively.

Adopting aspects of the (now) host culture and retaining aspects of one's native culture leads to integration, which is the healthiest outcome. Retaining native values and customs and not adopting the host culture's value system is characteristic of separation. Ethnic enclaves in the United States in which Indians predominantly live among and interact with other Indians are outgrowths of this strategy. Assimilation involves shedding one's original ethnic identity as one would shed a coat, and taking on values, customs, behaviors of the host country. Marginalization is shedding one's own ethnic identity while not adopting the identity of the locals, essentially not belonging to either group. This strategy is associated with the most psychopathology, possibly due to social support being likely limited (e.g. Berry, 1991; Hodges, 2003).

First-generation Indian-Americans experience loss (stemming from being separated from friends and family from the home country), homesickness, and migration stress, initially feeling like strangers in a strange land. Much of Indian-American fiction (such as the short stories penned by authors like Jhumpa Lahiri) focuses on the struggles of these new immigrants, especially the women who had a strong support network of other women in India but now find themselves relatively isolated in America. If first-generation Indian-Americans who migrate as young adults to the United States do not establish a strong support system (consisting of either friends or family) and yet have children when they are in the United States, they are possibly at risk of becoming highly interdependent or intertwined with their children (Baptiste, 1993). The process of acculturation looks different for other Indian-Americans who are either born in the United States, or migrate earlier (in childhood or adolescence) or later (when already elderly) in their lifetimes. In addition, this acculturative process also differs as a function of gender, given the strong sex-based cultural customs and expectations in Asian Indians.

3.1 Socio-demographic characteristics

In one study, socio-demographic variables and family disharmony contributed to prenatal anxiety (N = 467) (Kane et al., 2016). Lower levels of acculturation were associated with prenatal anxiety in a sample of Puerto Rican women (N = 1412) (Barcelona de Mendoza, Harville, Theall, Buekens, & Chasan-Taber, 2016). In this sample, bicultural psychological acculturation (as measured by the Psychological Acculturation Scale) was associated with lower trait anxiety in early pregnancy while English–language preference and higher generation in the US were associated with higher trait anxiety in early pregnancy. Similarly, in a study from Montreal, those who did not speak French as their primary language, suggesting less acculturation, and those who had lower income had greater prenatal anxiety (Dunkel-Schetter, Niles, Guardino, Khaled, & Kramer, 2016).