Section 3.14: Understanding the role of Culture in Health

What is Culture?

When you think of the word culture, what words come to mind? Do you think of any personal experiences, like your own family traditions or practices from places you have traveled to that were new to you?

When you think of culture, do you think of food?

Music?

Family?

Holidays?

Traditions?

Art?

Ways to heal if you are sick?

Can you define culture by any one thing? 

Most people find it hard to define culture in one word, concept or experience. Culture encompasses many things and influences our choices as individuals, households and populations in many ways. 

Culture can be defined as the set of distinctive spiritual, material, intellectual and emotional features of society or a social group … that encompasses, in addition to art and literature, lifestyles, ways of living together, value systems, traditions and beliefs.

(UNESCO, 2009)

As the graphic below illustrates, culture is a multifaceted, intersectional concept that each of us will understand, define and experience differently. 

Let’s explore the role of Culture in health!

In 2014 the Lancet Commission on Culture and Health, argued that “the systematic neglect of culture in health and health care is the single biggest barrier to the advancement of the highest standard of health worldwide.”

Can you think of a way that culture plays a role in your health, including the ways you define and seek out healing and healthcare?

For example, imagine you wake up with a cold — what do you do? Do you eat certain foods? Do you prepare a special drink? Is the drink hot or cold? Do you avoid specific foods or activities? Maybe you make a doctor’s appointment right away, or maybe you call your acupuncturist, chiropractor — or a family member for advice. 

Where did you learn these healing practices? From your family? From your ‘culture’? Or have you learned or borrowed any practices from other cultural traditions or belief systems?

Now let’s think about health providers — sure, we can assume that health providers like doctors, nurses and other medical professionals are trained with much of the same medical knowledge. But aren’t doctors and nurses people with a particular culture too? How might the culture of different providers affect the care they give generally — or to specific people?

Understanding how culture influences and informs individuals’ perceptions of health, their health behaviors, their health needs and health outcomes is an essential part of being a public and global health actor. 

Cultural beliefs, traditions and practices can affect individuals’ and populations’ health behaviors. If health systems or providers do not integrate a meaningful understanding of culture into their practice and delivery of health services, some individuals or populations might choose to delay care seeking. Or, some might not seek care at all. These delays – or avoiding – care seeking can have serious negative consequences on health outcomes.

Watch the following video to explore some more of the practical applications of Cultural considerations within a health context — and the potential consequences of not considering Culture in medicine, Public and Global Health.

Patterns of Resort

When a family member is sick, why do some people choose to visit a traditional healer before a doctor trained in western biomedicine? Why do others trust practitioners trained in traditional practices to treat a headache but not diseases like cancer?

Patterns of resort refers to the steps individuals or families take to address ill health, including the types of practitioners they use and the timing of their care seeking

(Skolnik, 2019)

Patterns of resort is often used today to mean that people try the most familiar, simplest or cheapest treatments [for illness] first and seek more expensive, complex or unfamiliar treatments later.

(Barnard Health Care, 2020)

A number of individual and social determinants influence individuals’ choices to seek health care from different types of practitioners. These determinants can include, but are not limited to:

The following videos offer examples of how different traditional medicine practices are used by populations around the world to maintain good health and combat illness and disease — including in high income countries. We suggest you choose at least one to watch, though all are interesting!

Note how traditional medicine is used around the world either on its own as preventive or curative health care or in parallel with western biomedical diagnoses and treatments.

Where traditional medicine is widely practiced, traditional medicine may cost less money than biomedical services. A family with limited financial resources might take a sick child to a traditional healer first and only go to a western biomedical provider if the child does not get well. Or, as integrated members of the community, traditional healers may accept payment in installments or forms of payment other than cash such as food, animals or barter services. Sometimes traditional healers are the only healers physically accessible to populations if biomedical health services are located very far away and transportation is not available or is too expensive

In countries like the United States, however, medical practices such as acupuncture which are not covered by most health insurance providers might actually be more expensive than visiting a western biomedical doctor and could be considered a ‘luxury’ medical treatment.

These hypothetical examples all illustrate different factors in different contexts which affect patterns of resort in healthcare seeking.

While you watch these videos, reflect on the reasons people give for using traditional medicine or western medicine (in Nigeria and other former British colonies referred to sometimes as ‘English medicine’)? 

How do these different factors affect peoples’ patterns of resort in healthcare seeking?

Working Across Cultures

One of the most intriguing and exciting aspects of work in global health can be the opportunity to engage with and learn about cultural contexts and practices which are very different from your own. This ‘culture contact’ can happen even when working in your own country or own community.

To ground our discussion about working across cultures in Public and Global Health, watch this short video about a Nigerian bonesetter, who practices traditional medicine. Pay close attention to your initial reactions to the information shared in this video.

What did you think about the traditional bone setter from Nigeria who uses herbs to heal fractured bones? 

Were these practices familiar or different from your own perceptions of ‘medical care’? Did you find yourself judging them? If you broke a bone, would you go to a bonesetter? Can singing, prayers and animal sacrifices treat illness or disease?

Is a health treatment ‘wrong’ just because it is not familiar to us? To protect the safety and well-being of all individuals, what policies need to be in place within countries to regulate the practice of western biomedical and traditional medicines?

What ‘lens’ do you use when you consider cultural practices, beliefs and norms very different from those you know? How do your own beliefs, practices, norms and experiences inform how you understand others’ How do we apply these lenses in our work as global health actors?

Much of our work in public and global health involves encouraging individuals and populations to adopt healthy behaviors. That sometimes means suggesting that people adapt or stop previous behaviors for new behaviors. 

But, before we can discuss behavior change in ways that are respectful, informed and inviting it is essential that we understand why people do what they do within the context of their own culture. We also need to reflect on our own identities which shape our beliefs and assumptions related to health and health care seeking — and also our perceptions of others’ beliefs and assumptions which may influence our thoughts on others’ behaviors and beliefs which are different from our own.

Each of us occupies a unique positionality which is formed at the intersection of our many identities, relative positions of power and privilege and life experiences.

When you think of your identity, what comes to mind? 

Is our identity defined by one thing? Or, like the concept of culture, are we defined by a variety of factors? Our identity — or identities — are multifaceted, a combination of who we as well as the life experiences we have had. Our identities shape the ways in which we perceive, understand, judge and value the world around us — and any ‘new’ worlds we encounter. 

Look at the graphic below — where do the pieces of your identity intersect to form the ‘lens’ through which you perceive, understand, judge and engage with the world?

• Gender
• Age
• Race
• Ethnicity
• Class
• Nationality
• Ability
• Language
• Sexuality
• Mental health
• Education
• Body size
• …and many more.

As you think about your positionality, or where you are ‘located’ on the graphic below, also reflect on where and how your identity might offer you privilege and create power dynamics in certain spaces.

How do you think understanding and reflecting on our positionality — or the intersection of our identities and life experiences — is relevant to ethical global health work?

For example, in Public and Global Health research, researchers often need to consider their privilege when conducting their work. Do power imbalances exist between researchers and the participants in their research? How might this affect research participants’ willingness to be open and honest with researchers?

You can also think back to the film Stop Filming Us. Compare the positionality of, for example, the European film maker with the Congolese film makers. Or the positionalities of the Congolese photographer and the refugee communities she photographed? What were the different intersections of identities — and therefore different positionalities — of each of those individuals? How did that affect their ability and power to ‘tell the story’ of Congo?

In the fields of Public and Global Health, understanding our own positionality includes reflecting on why we perceive certain practices or beliefs as ‘different’, ‘right’, ‘wrong’ or ‘strange’? It also involves seeing practices and beliefs from the perspective and positionality of the person who engages in those practices and finds them ‘normal.’ Recognizing, addressing and breaking down these positions of power and power dynamics are all part of our work to decolonize Public and Global Health and ensure our work moves us closer to health equity and justice.

Ethnocentrism and cultural relativism are two perspectives which may help us in processing and understanding of our own positionality, especially as it relates to Public and Global health.

Cultural relativism is the idea that because cultures are unique, they can be evaluated only according to their own standards and values.

(Haviland, 1990)

There are two different categories of cultural relativism.

Absolute cultural relativism considers everything that happens within a culture must and should not be questioned by outsiders. 

Critical cultural relativism creates questions about cultural practices in terms of who is accepting them and why. Critical cultural relativism also recognizes power relationships.

(https://en.wikibooks.org/wiki/Cultural_Anthropology/Introduction, n.d.)

Ethnocentrism is a viewpoint in which which people studying cultures often viewed them from the point of view of their own culture and will judge what they saw to be lacking.

(Skolnik, 2021:168)

Note that a key aspect of ethnocentrism is engaging in value judgments of one culture over another. From an ethnocentric perspective, the culture or practices you perceive as ‘normal’ (because they are what you know best) are considered ‘correct.’ Any other cultural belief or practice that does not line up with your norm will be judged for how it is different in comparison.

How might each of these two perspectives play out in public and global health practice? What might the practical implications be on health outcomes if one perspective informs policy formation over another?

To think these questions through with a practical example, consider the case study below on placenta burial and the reflection questions that follow the case study.

Now that you have read about some traditions around placenta burial, imagine you are a health care provider in a place like the United States. For most of the American population placenta burial is not a deep-seeded cultural tradition.

What if you are confronted with a patient from one of the cultural backgrounds described in the case study above?

Is placenta burial wrong if it is not a practice recognized by western biomedicine practiced in the United States?

Do individuals giving birth have the right to dispose of their placenta as they choose?

How do you think an individual might be affected if their health care provider states that placenta burial is not important, not medically proven to have benefits or not possible? Do you think the individual seeking medical care will be more or less trusting of that provider? Will the individual feel safe as a patient? What if individuals avoid health care because they do not feel their important cultural practices are recognized, valued and respected?

As the case study demonstrates, the ability to see outside of one’s own perspective is an important skill with practical implications for public and global health actors.

Cultural humility is this process of self-reflection and recognition that our perception of what is ‘normal’, ‘acceptable’ or ‘right’ is just one way of engaging in the world. 

Cultural humility is defined as a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities.

Sufrin, 2019

Engaging in the process of cultural humility is the ethical responsibility of medical providers as well as Public and Global Health actors.

What is Cultural Diversity?

UNESCO (2001) described cultural diversity as a source of exchange, innovation and creativity, embodied in the uniqueness and plurality of the identities of the groups and societies making up humankind.  Cultural diversity, according to UNESCO, isas necessary for humankind as biodiversity is for nature (2001).

Cultural diversity widens the range of options open to everyone; it is one of the roots of development, understood not simply in terms of economic growth, but also as a means to achieve a more satisfactory intellectual, emotional, moral and spiritual existence.

(UNESCO, 2001)

What is Diversity in healthcare?

Diversity in any workplace means having a workforce comprised of different identities, experiences and perspectives. Healthcare diversity can refer to a number of qualities, including but not limited to the following characteristics: race, ethnicity, gender, age, sexual orientation, religion, political beliefs, education, physical abilities and disabilities, socioeconomic background, language, culture. Even military service is considered a unique background and experience that should be included in diversity.In other words, it refers to when the medical and administrative staff of a healthcare facility represents a wide range of experiences and background.

The following video discusses cultural diversity in healthcare, specifically in clinical medicine and patient care.

The graphic below demonstrates the current representation gaps in U.S. healthcare staff.

Why is Healthcare Diversity so important?

Benefits of diversity in the healthcare workplace

Increased provider comfort levels  Studies show that students who have trained at diverse schools are more comfortable treating patients from ethnic backgrounds other than their own.

Boosted creativity and innovation A wide range of perspectives can lead to better solutions.11

Enhanced understanding of value sets A more diverse group of healthcare professionals will have a better understanding of colleagues’ and patients’ different belief systems.12

Improved communication Not only may some patients be able to more effectively communicate with providers who speak their language, but they might also receive better care. Patients with limited English proficiency [in English-dominant settings] experience higher rates of medical errors and worse clinical outcomes.

Increased patient trust Patients of color may be more likely to seek out care. A Stanford University study found that Black male patients who were treated by Black doctors were more likely to seek preventative services than those who were treated by non-Black doctors.

Reduced health disparities Improved cultural competence and ethnic and racial diversity can help to alleviate healthcare disparities and improve healthcare outcomes in diverse patient populations.13

Improved employee engagement and retention People take pride in working for companies that are making a positive impact in society.

Read the short case study below for an example of the importance and practical applications of integrating cultural diversity into healthcare.

What is Cultural Competency?

Reflecting on our own positionality including our potential biases and positions of privilege, engaging in cultural humility and espousing diversity in healthcare can lead to cultural competency.

Cultural competency in healthcare is the ability of healthcare providers to offer services that meet the unique social, cultural, and linguistic needs of their patients. In short, the better a patient is represented and understood, the better they can be treated.

(Jordan, 2020)

According to Napier et al (2014) “Competence is highly anthropological, embracing culture less as static and stereotypical than as something always in the making. At its best, cultural competence, then, bridges the cultural distance between providers and consumers of health care through an emphasis on physicians’ knowledge, attitudes, and emerging skills. Competence is about creation and growth of meaningful relationships.”

In terms of cultural competency in health, “competence is the nurturing of communication between caregivers and patients to remove barriers to care.  Therefore, cultural competence can no longer be considered only “a set of skills necessary for physicians to care for immigrants, foreigners, and others from ‘exotic’ cultures”.  Moreover, cultural competence should not concern itself exclusively with perceived differences. Culture is less successful when it functions as a medium through which medicine translates clinical realities to uninformed others than when it produces new social circumstances that successfully contextualize clinical knowledge.

Addressing structural determinants of health: making healthcare Culturally Safe

Structural determinants of health we have discussed — such as colonial legacies of oppression and systemic racism — can cause trauma within communities for generations. This trauma can be intimately tied to past and recent interactions with government systems and agents like the health system and health providers. If individuals do not feel they will receive unbiased, safe care from health providers will they choose to use services at all?

Making health services, research and Public and Global Health work culturally safe is another framework through which health systems, medical and Public and Global Health professionals can work towards justice and equity in health care and health outcomes.

Cultural safety is a focus on improving the delivery of quality healthcare through changes in thinking about power relationships and patients’ rights.

(Papps and Ramsden, 1996)

The following video gives a concise but excellent explanation of cultural safety in healthcare settings.

If you did not watch the video below on making health care culturally safe for Aboriginal people during Prelim Engagement, we recommend you watch it now. If you already watched it, you might find it interesting to watch again now that you have read more about culture and health.

As you watch (or re-watch) this clip, keep the concepts of cultural diversity, cultural humility, cultural safety and patterns of resort in mind. Reflect on the tangible actions this health system has taken to combat negative historical and structural determinants of health against Aboriginal people.

Can you think of where they might go even further in tackling negative historical and structural determinants of health?

The bigger picture: Culture, Health and a Culture of Health

In 1988 Masi discussed multiculturalism in healthcare stating that: “Culturally sensitive health care is not a matter of simple formulas or prescriptions that provide a single definitive answer: rather, it requires understanding of the principles on which health care is based and the manner in which culture may influence those principles” and stressed “the importance of understanding community needs, cultures and beliefs; the active interest and participation of the patient in his or her own health care; the importance of a good physician-patient relationship; and the benefit of an open minded approach by physicians and other health-care workers to the delivery of health-care services.” (Masi, 1988).

Later, in 1996, on the occasion of the Year of Culture and Health, Dr. Hiroshi Nakajima, Director General of WHO, and Mr Federico Mayor, Director General of UNESCO, published an editorial stating:

How are the concepts of Culture and Health framed within policy and practice?

Napier et al (2017) stated that a culturally grounded approach is required to enrich health policies with special attention to be paid to incorporating cultural awareness into policy-making. The aim is to develop “adaptive, equitable and sustainable healthcare systems, and to making general improvements in many areas of population health and well-being”(Napier et al, 2017:vi).

The authors detailed the following reasons for understanding the importance of understanding and integrating cultural contexts to health and well-being policy development. Reflect on how Napier and colleagues’ argument for the integration of culture into healthcare and Public and Global Health contexts references a number of concepts we have discussed in this section so far.

The PEN-3 cultural model

Over the past decade, available evidence focusing on the impact of culture on health has increased dramatically (Airhihenbuwa 2007a; Dutta 2007; Airhihenbuwa and Liburd 2006; Shaw et al. 2009). This indicates not only a widespread and growing interest in the influence of culture but also the realization of its importance in eliminating health disparities, addressing health literacy, and designing and implementing effective public health interventions (Airhihenbuwa and Liburd 2006; Shaw et al. 2009; Airhihenbuwa and Webster 2004). This increasing focus, however, requires a clear understanding of the impact of culture on health.

Culture in this context refers to shared values, norms, and codes that collectively shape a group’s beliefs, attitudes, and behavior through their interaction in and with their environments (Airhihenbuwa 1999). To explore the influence of culture on individual health is ‘to recognize that the forest is more important than the individual tree’ (Airhihenbuwa 1999). Also, exploring the cultural context of the forest allows one to understand and appreciate the ways in which the individual trees are shaped as well as explore the roles, connections, and relationships (whether positive or negative) that exist between the trees (Singhal 2003). These cultural dynamics are essential for public health interventions to be effective and sustainable. Iwelunmor et al (2014) worked on framing the impact of culture on health and, to that end, they developed a cultural model (PEN-3) and applied in public health research and interventions.

What is a Culture of Health?

A culture of health is broadly defined as one in which good health and well-being flourish across geographic, demographic, and social sectors; fostering healthy equitable communities guides public and private decision making; and everyone has the opportunity to make choices that lead to healthy lifestyles

(Evidence for Action, n.d.)

A culture of health requires respecting the many cultural traditions … and a discourse that honors our differences as it advances our common interests. 

Plough, 2020

How can we build a Culture of Health?

Chandra et al (2017) provided the background on the development of an action framework placing “well-being at the center of every aspect of life, with the goal of enabling everyone in our diverse society to lead healthier lives, now and for generations to come” (p.1). Considering that “health is a function of more than medical care, the authors argue that solutions to U.S. [and other countries’] health problems must encompass more than reforms to health care systems. …. The Culture of Health action framework is designed around four action areas and one outcome area. Action areas are the core areas in which investment and activity are needed:

(1) making health a shared value;

(2) fostering cross-sector collaboration to improve well-being;

(3) creating healthier, more equitable communities; and

(4) strengthening integration of health services and systems.

Summary

We know there was a lot of information to absorb in this section of reading. The main ideas to take away are that culture and health are inherently interconnected for each of us. Cultural beliefs, practices  and norms influence not only health behaviors and health care seeking, but also the perspectives and work of health providers and Public and Global Health actors. Considering the influences of our culture and positionality, as well as the cultures and positionalities of individuals and populations we work closely with as Public and Global Health actors, are essential, ethical reflections necessary to move us closer to health equity and justice around the world.

Supplementary Resources

Building a Culture of Health: What Does it Take? https://youtu.be/__lq-znG–w

Chandra, A., Acosta, J., Carman, K. G., Dubowitz, T., Leviton, L., Martin, L. T., Miller, C., Nelson, C., Orleans, T., Tait, M., Trujillo, M., Towe, V., Yeung, D., & Plough, A. L. (2017). Building a National Culture of Health: Background, Action Framework, Measures, and Next Steps. Rand health quarterly, 6(2), pp 1-11.

Napier AD, Ancarno C, Butler B, Calabrese J, Chater A, Chatterjee H et al. Culture and health. Lancet. 2014; 384: pp 1612-1617.  

Napier AD, Ancarno C, Butler B, Calabrese J, Chater A, Chatterjee H et al. Culture and health. Lancet. 2014; 384: pp 1618-1629.  

Hofstede’s 6-D Model of National Cutlure: https://www.youtube.com/watch?app=desktop&v=TF47NnxACdg&feature=youtu.be

Iwelunmor, J., Newsome, V., & Airhihenbuwa, C. O. (2014). Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethnicity & health, 19(1), 20-46, pp  1-2 & 11.

Reimagined in America Webinar: Taking a well-being approach: https://youtu.be/IufDVQqGBZE 

Reimagined in America Webinar: Building Inclusive Healthy Places: https://youtu.be/W9Dlde_19EU

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References

References Section 3.11 Understanding the role of Culture in Health?

1. American Association of Diabetes Educators. (2015). Cultural considerations in diabetes education. AADE Practice Synopsis. Chicago, IL: American Association of Diabetes Educators. Available at: https://www.diabeteseducator.org/docs/default-source/default-document-library/cultural-considerations-in-diabetes-management.pdf?sfvrsn=0
2. Airhihenbuwa, Collins & Iwelunmor, Juliet & Munodawafa, Davison & Ford, C.L. & Oni, T. & Charles, Agyemang & Mota, C. & Ikuomola, O.B. & Simbayi, Leickness & Fallah, M.P. & Qian, Z. & Makinwa, B. & Niang, Cheikh & Okosun, Ike. (2020). Culture Matters in Communicating the Global Response to COVID-19. Preventing Chronic Disease. 17. 10.5888/pcd17.200245.
3. Barnard Health Care. (2020). Health Seeking and Patterns of Resort. https://www.barnardhealth.us/medical-anthropology/healthseeking-and-patterns-of-resort.html
4. Centers for Disease Control and Prevention. (2021, June 9). Social determinants of health, health equity, and vision loss. https://www.cdc.gov/visionhealth/determinants/index.html
5. Chandra, A., Acosta, J., Carman, K. G., Dubowitz, T., Leviton, L., Martin, L. T., Miller, C., Nelson, C., Orleans, T., Tait, M., Trujillo, M., Towe, V., Yeung, D., & Plough, A. L. (2017). Building a National Culture of Health: Background, Action Framework, Measures, and Next Steps. Rand health quarterly, 6(2), 3.
6. Cultural Anthropology. (N.d.) https://courses.lumenlearning.com/culturalanthropology/
7. Evidence for Action. (n.d.) What is a Culture of health? https://www.evidenceforaction.org/about-us/what-culture-health).
8. Haviland, W.A. (1990). The nature of culture. In Cultural Anthropology (6th ed). Fort Worth, TX: Holt, Rinehart & Winston, Inc.
9. Hiratsuka, V. Y., Trinidad, S. B., Avey, J. P., & Robinson, R. F. (2016). Application of the PEN-3 model to tobacco initiation, use, and cessation among American Indian and Alaska Native adults. Health promotion practice, 17(4), 471-481.
10. Iwelunmor, J., Newsome, V., & Airhihenbuwa, C. O. (2014). Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions. Ethnicity & health, 19(1), 20–46. https://doi.org/10.1080/13557858.2013.857768
11. Jordan, A. (2020). The Importance of Divesrity in Healthcare & How to Promote it. Provo College. https://www.provocollege.edu/blog/the-importance-of-diversity-in-healthcare-how-to-promote-it/
12. Masi, R. (1988). Multiculturalism, medicine and health Part I: Multicultural health care. Canadian Family Physician, 34, 2173.
13. Matsuura, K. (2005). Appendix I UNESCO Universal Declaration on Cultural Diversity UNESCO Universal Declaration on Cultural Diversity. Diogenes, 52(1), 141-145.
14. Napier, A. (2014). David et al. “Culture and health”. The Lancet, 384(9954), p1607-1639. Available at: https://www.thelancet.com/commissions/neglect-of-culture-in-health  
15. Napier A. D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., … & Woolf, K. (2014). Culture and health. The Lancet, 384(9954), 1607-1639. pp 1632)
16. Napier, D., Depledge, M. H., Knipper, M., Lovell, R., Ponarin, E., Sanabria, E., & Thomas, F. (2017). Culture matters: using a cultural contexts of health approach to enhance policy-making. World Health Organization Regional Office for Europe. 
17. Plough, A. L. (2020). Culture of Health in Practice: Innovations in Research, Community Engagement, and Action. Oxford University Press.
18. Skolnik, R. (2021). Global Health 101 (4th ed). Burlington, MA. Jones and Bartlett Learning.
19. Sufrin, J. (2019). Three things to know: Cultural Humility. Hogg Foundation for Mental Health. https://hogg.utexas.edu/3-things-to-know-cultural-humility
20. University of British Columbia. (n.d.) Positionality & Intersectionality. https://indigenousinitiatives.ctlt.ubc.ca/classroom-climate/positionality-and-intersectionality/ Accessed May 19 2021.
21. UNESCO. (2010). 2009 UNESCO Framework for Cultural Statistics. Institute for Statistics of the United Nations Educational, Scientific and Cultural Organization. https://unstats.un.org/unsd/statcom/doc10/BG-FCS-E.pdf
22. UNESCO Universal Declaration on Cultural Diversity. (2001). Available at: http://portal.unesco.org/en/ev.php-URL_ID=13179&URL_DO=DO_TOPIC&URL_SECTION=201.html 
23. Ward, Branch and Fridkin. (2016). What is Indigenous Cultural Safety – and why should I care about it? Here to Help. https://www.heretohelp.bc.ca/visions/indigenous-people-vol11/what-indigenous-cultural-safety-and-why-should-i-care-about-it
24. WHO (‎1996)‎. Culture and health. 49(‎2)‎ : 3-31. https://apps.who.int/iris/handle/10665/50204
25. WHO. (2019). WHO Global Report on Traditional and Complementary Medicine 2019. https://apps.who.int/iris/bitstream/handle/10665/312342/9789241515436-eng.pdf?sequence=1&isAllowed=y