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  The Client Study
  The client was assigned a pseudonym - John in order to maintain the confidentiality during this study. John is a 78 year old white English male, who was born in the spring of 1933 in the east London. Both of John"s parents were English, his father was a professional builder at the time, and his mother worked at the factory. John also had sister, who was 4 years older. Their family lived in London until the 1940, when in the early spring, in order to avoid the upcoming German air raids, John with his sister and mother was evacuated to the Blackpool. Five years later John"s father joined the family in Blackpool, and after a few months moved them to Bolton, were he found a job.
   John recalled being an active child while growing up in Bolton, he liked sports: the football and wrestling to be specific. Although, according to John the wrestling was rather needed due to Bolton being a fairly violent place at the time. After leaving school in 1949, John worked with his father, until he was called in to National Service from 1950 until 1952. During the time in Army John met his future wife and went on to marrying her in 1954. Following his discharge from army, John found himself a job at the paper mill, were he worked on the line for few years. Until in 1958, when John"s right hand got accidently trapped in the equipment and was damaged.
  This injury took him long time to recover, and because he was valued as a good worker, he was offered a job at the paper mills office in the role of the workers representative in the work study. Over the course of next ten years John has received the extensive on job training and moved on from works representative to the manager in charge of work study provision. John"s next career move happened in 1970s, when he took a job in one of the Cornwall councils. Initially working in the same role, John later transferred over in to the health and safety management and eventually retired from it in the late 1980s.
  John is still married to his first wife, they have two sons, one daughter, five grandchildren and two great grandchild. He and his wife, who is also retired, are house owners and living independently from their children in Cornwall. John"s passion is in gardening and driving. Although John does say, that he used to enjoy the game of pool when he lived in Bolton, but it is not as easy to play now, since there are no similar, social clubs in Cornwall.
  The reason, for John to be interviewed in this case study, lays in the contrast of two facts. John"s ethnicity puts him in to the UK"s cultural majority, and as some research suggests (Back and Solomos, 2000) it is an advantage for health outcomes, but at the same time John comes from the social conditions and background, that suggest the poor health outcomes from "risk-orientated life-styles" (Costello and Haggart,2003). This possible equilibrium creates an opportunity to investigate the extent of the cultural influence on the John"s health and illness experience.
  During the time of this interview John was an inpatient on the surgical ward, awaiting the removal of the Melanoma from his forehead. John has the Lentigo type the malignant Melanoma; it is the cancerous type of tumour of the pigmented skin cells, which is usually contributed to prolonged exposure to the sunlight and currently is on the rise in UK (Bower and Waxman, 2010). John acknowledges the fact that he never wore a hat and has worked outside for the large proportion of his life; he also thinks that the appearance of tumour was aggravated by his hobby of gardening.
  At this stage, it is necessary to take a look at the meaning of the culture itself, in order to fully develop the understanding of the culturally defined health issues facing John. While there are a number of theories attempting to define the concept of culture; some of them being very abstract and others are very specific, only two definitions are going to be used in this work.
  The first one is the sociological definition of the culture, which was initially suggested in the late 1950s by Richard Hoggart, E.P. Thomson and later finalised by Raymond Williams (Ritzer and Smart, 2001). It defines culture as the "signifying system" - a communicating median of the social order, which not only allows it to be explored, reproduced and experienced by the society, but converges it with the ideal or religious social processes in to the "whole way of life" (Ritzer and Smart, 2001, p. 395; Williams, 1981, pp. 10-13). The definition by Williams (1981) also incorporated the more specific meaning of the term culture as the "artistic and intellectual activities" (Williams, 1981, p. 13), simultaneously including the wider range of such activities. Therefore Williams (1981) implies that culture is a self regulating social construct which is both the by-product of the historically accumulated social processes of whole human society, and the large constituting part of social order which in turn regulates this society.
  In contrast the psychologist Dev Cohen (2001) suggests that culture is the natural adaptive response of the individual human being to its biological environment. It happens in the form of prolonged in time translation of the individual human behaviour patterns, in to norms of larger social groups (Cohen, 2001). This view is supported by the Norenzayan and Heine (2005) who clarify it by highlighting the social nature of human being and showing how dependent are the individuals decisions on the peer pressure. Both Cohen (2001) and Norenzayan and Heine (2005) name the conflict of the individual interests with the social group interest as a source for the development and diversity of the world culture.
  The main difference between these definitions lays in the elements of the society that the authors are focusing on, the Williams (1981) is concentrating on the large social constructs and their interaction with the culture, where as the Cohen (2001) is searching for the source of the culture on the individual level, rooted in the biology. The similarities that can be seen in both, Cohen (2001) and Williams (1981) definitions are the mutual self-propelling interdependence of the development of an individual and culture; and the core role it plays in the behaviour of a human.
  This direct effect of the behaviour on health and the health related decisions (Ogden, 2007; Kronenfeld, 2010), combined with the evidence (Loustaunau and Sobo, 1997) which shows that even the meaning of health and illness may vary from one culture to another, make these specific definitions and the whole concept of culture relevant to nursing.
  The established complicacy of the concept of culture may raise the concern about the influence of interviewer and the environment on the validity of the collected evidence. To avoid this, the interview was conducted in the dedicated interview room, increasing privacy and confidentiality. Also all of the attempts were made to establish and maintain the good rapport between the interviewer and the patient, the thorough explanation and consent of the patient was gained, and the Giger and Davidhizar Transcultural Assessment Model (2008) was used in the process of interview.
  This model was chosen because of its ease of application to the practice, and the availability of well established guideline, which includes the interview questions and the observations of the patient. It is based on the idea of same driving forces behind the different cultures, allocating the six cultural phenomena, which are applicable in individual"s assessment and increase the assessor"s cultural competency, in order to allow the delivery of the culturally acceptable care (Giger and Davidhizar, 2008). Giger and Davidhizar (2008) define such unique cultural phenomena as: communication, space, social organization, time, environmental control, and biological variations.
  Communication in any form is considered (Giger and Davidhizar, 2008) to be the single, strongest factor that can influence the understanding between individuals. The reason for that lays in the basal nature of any form of communication, verbal or nonverbal, in all of human interactions (Giger and Davidhizar, 2008). Therefore the verbal or nonverbal communication is the instrument of preservation and expression of the individuals" culture and it carries such cultural indicators as: primary language, volume of speech and its style, use of silence, touch and body language (Giger and Davidhizar, 2008). These indicators, and the knowledge of culture of the interviewed, allow the interviewer to draw a part of the conclusion of whether there is an issue, arising from the cultural incompatibility of the patient, and the care setting or health expectations (Giger and Davidhizar, 2008). In case of John, he is the English speaking male with a strong voice, although he does have a minor Lancashire accent but it does not affect the clarity of his speech. John has an infrequent use of silence in his speech and an open body language, with no offensive gestures. In the beginning of the interview John accepted a handshake without difficulty, indicating no touch related cultural issues.
  When Giger and Davidhizar (2008) talk about space they imply the distance between the communicating individuals. The emphasis to distance is given because of the acknowledged (Hall, 1966) presence of four zones of interpersonal space: intimate, personal, social and consultative, and public. The Model of assessment (Giger and Davidhizar, 2008) highlights that these zones are often culturally defined and that it is important is to establish the patient"s personal space; because if it"s breached the likelihood of patient not complying with care is greatly increasing. The Johns interview was conducted in what could be considered as a social interpersonal space: with him and interviewer facing each other, while sitting on two chairs and no table between them. John exhibited no discomfort or concern about the setting.
  Social organization according to Giger and Davidhizar (2008) is the process of self-identification of the individual with specific cultural groups, which are usually congregated by ethnicity, religion, beliefs or the concept of the social class. This self identification is an important indicator of possible behaviours towards health and health decisions (Costello and Haggart, 2003; Larkin, 2011; Suls et al, 2010). The social organization indicator could also provide an insight in to the type of social network that the interviewed is participating in and the extent of social support, available to the individual from their family (Costello and Haggart, 2003). John is married and has large extended family that, although not living with him, is ready to provide support. He considers himself Christian, but does not indicate the religion as the very important part of his life. It is also important to mention that John is not only the head of the house; he is the primary carer for his wife, who appears to have poor health. John is clearly expressing, throughout the interview, the strong notion towards the independence and stoic tendencies in character (Suls et al, 2010).
  Time in the context of this Assessment Model (Giger and Davidhizar, 2008) is an interesting cultural phenomenon that operates on the idea of different time orientation of individuals, resulting from the time orientation of the culture they grew up. The importance of this aspect lays in the effect it will have on the treatment compliance and future planning of individual"s health care (Giger and Davidhizar, 2008). Meaning that if the interviewed individual is orientated towards past or present it needs to be taken in to consideration when organising the follow up of treatments or explaining the new medications (Giger and Davidhizar, 2008). From the interview it is evident that John is oriented towards the present and future, with former being prevalent. He does not wear a watch, although when asked if he knows what time it is, John is trying to approximately guess what it is in "clock" format (Giger and Davidhizar, 2008).
  The Environmental control is an ability of the individual to plan and affect the surrounding nature and environmental factors (Giger and Davidhizar, 2008). This cultural phenomenon appears to have a very significant effect on the individual"s perception of health and illness and on the how an individual will use the health care and seek support (Costello and Haggart, 2003; Larkin, 2011, Suls et al, 2010). John states in the interview that whenever he felt ill he was using the GP service rather than trying to self medicate. It indicates that John"s locus of control (Giger and Davidhizar, 2008) is internal, but there is a possibility of the shift towards the external type, it is indicated through the emotions that John exhibited, when asked about his concerns related to melanoma. Up until that point John was very responsive in the interview, but then he became quite emotional and the interview had to be stopped. It appears he is very worried about being unable to care for his wife and participate in his usual activities.
  The final cultural phenomenon listed by the Giger and Davidhizar (2008) is the Biological differences. The aim of this aspect is to identify any possible genetic predispositions, of an interviewed individual, to illness; as well as to attempt to establish their general physical baseline and its correlation with culture (Giger and Davidhizar, 2008). Upon the observation, during John"s interview, with exception of newly developed Melanoma, he appears to be in average shape with no history of cancer or cardiovascular or cardiocerebral complications. He is not exhibiting any symptoms of respiratory deficits, according to John he quit smoking over fifty years ago, when he worked at the paper mill. John does have the minor sight and hearing deficits that are compensated with the hearing aid and spectacles.
  Summarising this interview it is possible to establish the John"s perspective of the culturally important issues. The first of John"s culturally defined issues, is the fear of possible loss of his independence and the loss of role in the family, which can result from the societies, families and cultural expectations of him taking on the sick-elderly role (Nettleton and Watson, 1998; Field and Taylor, 2007). It can be seen in how even though John is ready to follow the medical treatments and accept the help from the outside, at the same time he is adamant to accept the help from his children, who are happy to offer it.
  The second issue is the experience of living with and after the cancer, and the fear of having it again. John clearly shows the common cognitive and emotional response to cancer, in the form of anxieties, triggered by his own understanding of causes of cancer and cancer effects and the expectations of his own health (Ogden, 2007; Field and Taylor, 2007). These anxieties, combined with the aforementioned, society imposed sick role (Nettleton and Watson, 1998; Field and Taylor, 2007), have a potential to cause the direct effect on John"s abilities, confidence and quality of life.
  The final, clearly traceable issue is the John"s body image that is going to be altered by the surgical scaring on his forehead (Ogden, 2007). Although it is yet unclear if this is going to be a serious issue, since John has had the experience of body image altering trauma to his hand, during his work years.
  After the John"s culturally important issues have been established, it is possible to analyse if there is the conflict or the cooperation between these issues and the cultural viewpoint of his care setting. The overlook of the public health policies of UK government shows that the direction, which the political powers take in this aspect, is to put the individual and family in charge of their own health care, in the community settings (Costello and Haggart, 2003; Larkin, 2011). It is achieved primarily through the health related advice and increase in the education about the illness generating risk-behaviours (Costello and Haggart, 2003; Larkin, 2011). This tendency in the context of John"s cultural issues can either create the conflict or provide support for his independence; it is unclear at the moment how effective for elderly is the provision of these policies, by health and social services (Field and Taylor, 2007).
   In the actual NHS Hospital based care environment, due to the complex systems of illness reduction control, the care culture will have both: the intention to empower the patients in their own care, and the time and money saving drive, to take over the patients" abilities (Larkin, 2011). The extension of the roles of the nurse in the medical and administrative duties, and the reduction of the time spend with patient, also cause the hospitals" culture, of patients" non-participation in their own health care (Field and Taylor, 2007). Finally the emphasis on the aforementioned (Larkin, 2011) reduction of illness strategy that exists in the hospitals is quite different from the government policies of prevention of illness and promotion of health (Costello and Haggart, 2003; Field and Taylor, 2007). Due to the John"s strive to independence and health expectations there is a potential cultural shock, with the care setting culture of these aspects.
  The potential culture viewpoint conflicts between the patient and care setting, suggest that there is a deficit in health care provision. The Costello and Haggart (2003) describe how the care provision is planed based on the results obtained from the measurement of the large social groups, rather than individuals, therefore the outcomes for the individual"s, cultural and social needs satisfaction is very inefficient. Although it is necessary to mention that the government in response to societal pressures is introducing privatization and there is a constant drive towards client satisfaction and the individualization of healthcare provision (Field and Taylor, 2007). Consequently, in order to improve the care provision, every single one healthcare professional involved in the direct care delivery, must account for the individual cultural variations (Costello and Haggart, 2003).
  References
  Back, L. Solomos, J. (2000) Theories of Race and Racism. New York: Routledge. Socindex [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Bower, M. Waxman, J. (2010) Oncology. 2 edn. Chichester: Wiley-Blackwell . MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 12 May 2012)
  Cohen D. (2001) Cultural variation: Considerations and implications. Psychological Bulletin 127(4):451-471 PsycARTICLES. [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Costello, J. Haggart, M. (2003) Public health and society. Basingstoke: Palgrave Macmillan. .MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 11 May 2012)
  Giger, J.N. Davidhizar, R.E. (2008) Transcultural nursing :assessment & intervention. 5th ed.. St. Louis: Mosby.
  Hall, E.T. (1966) The silent language. Westport: Greenwood
  Field,D. Taylor,S. (2007) Sociology of health and health care 4th ed. Oxford: Blackwell Publishing
  Kronenfeld, J.J. (2010) The impact of demographics on health and healthcare. Bingley: Emerald. MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Loustaunau, M. O. Sobo, E. J. (1997). The cultural context of health, illness, and medicine. Westport, CT: Bergin & Garvey.
  Larkin, M. (2011) Social aspects of health, illness and healthcare. Maidenhead: McGraw Hill/Open University Press. MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 12 May 2012)
  Nettleton, S. Watson, J. (1998). The body in everyday life. London; New York: Routledge. Socindex [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Norenzayan, A. Heine, J. S. (2005) Psychological Universals: What Are They and How Can We Know? [Online]. Available at: http://artsci.wustl.edu/~pboyer/CEwebsite/Archive/Norenzayan&Heine.pdf (Accessed: 11 May 2012)
  Ogden, J. (2007) Health psychology. 4th edn. Maidenhead: Open University Press McGraw-Hill Education MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Ritzer, G. Smart, B. (2003). Handbook of social theory. London: Sage. MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012)
  Suls, J.M. Davdson, K.W. Kaplan, R.M. and, (2010) Handbook of health psychology and behavioral medicine. New York; London: Guilford Press. MyiLibrary [Online]. Available at: http://library.city.ac.uk/search (Accessed: 10 May 2012) Williams, R. (1981) The sociology of culture 2nd ed. Chicago: University of Chicago press.
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