Abstract

Obesity is often misunderstood as a simple matter of overeating or moving too little. In reality, it’s a deeply rooted physiological condition caused by the breakdown of several key systems in the body. This paper examines the development of obesity through five closely interconnected biological mechanisms: fat storage (adiposity), insulin resistance, energy balance, hunger signaling via leptin, and chronic low-grade inflammation. These systems work together to regulate how we store energy, control appetite, burn calories, and respond to stress. When one system begins to fail, like when fat cells grow too large or the brain stops responding to fullness signals, the others often follow, creating a cycle that makes weight gain easier and weight loss harder. The paper also highlights how prevention needs to go far beyond willpower or dieting. Real solutions come from supporting the body’s natural systems through better sleep, balanced eating, physical activity, stress management, and more. Understanding the biology behind obesity helps us replace blame with empathy and find smarter, more lasting ways to support health.

Key terms

Introduction

Obesity is not just a personal struggle; it is a public health crisis that affects over 650 million adults and 124 million children worldwide. Traditional narratives have oversimplified its causes, framing obesity as a result of poor choices, lack of exercise, or overeating. However, such views ignore decades of research that reveal a much deeper truth: obesity is a chronic physiological disorder involving multiple, interdependent systems that govern metabolism, hormonal signaling, energy storage, and immune response.

Rather than a purely behavioral issue, obesity reflects a breakdown in metabolic homeostasis, the body’s ability to maintain internal balance in response to changing environments. At its core, obesity is the result of a persistent imbalance between energy intake and expenditure, complicated by the dysregulation of hormones such as insulin and leptin, altered fat cell function, and chronic low-grade inflammation.

This paper explores the physiological mechanisms that cause obesity and the interventions that can help prevent or reverse it. We focus on five interconnected biological systems:

• Adiposity (fat accumulation and behavior of fat tissue)
• Insulin resistance (metabolic inefficiency and hormonal disruption)
• Energy balance (caloric intake vs. expenditure dynamics)
• Leptin resistance (dysfunctional satiety signaling)
• Inflammation (chronic immune activation affecting metabolism)

By understanding how these systems interact, we can move toward more effective, biologically grounded strategies to prevent obesity not only at the individual level, but across public health, clinical, and policy landscapes.

1. Adiposity: The Biology of Fat Storage

Adiposity is the quantity and distribution of fat, and that fat, as active tissue, is capable of storing excess energy in the form of triglycerides and communicating with the brain and immune system through hormones and messengers such as leptin, adiponectin, and resistin, assists in thermoregulation, and contributes to the body’s response to infections. (Neufingerl and Eilander 2021)

It comes in two primary forms: white adipose tissue (WAT), the primary storage type that also secretes hormones to regulate appetite and guide energy balance, and brown adipose tissue (BAT), rich in mitochondria that burns calories to produce heat through thermogenesis. It is more abundant in infants, and in adults is found in small quantities, which can be activated with safe cold exposure or during some physical activity. Immune cells, such as macrophages, release the inflammatory factors TNF-α and IL-6 while protective adiponectin falls below a certain threshold. This is known as the ‘adipose tissue dysfunction’. This phenomenon lowers the insulin signal and increases the risk for metabolic disease. From a pathobiology perspective, the location of fat tissue is important because subcutaneous fat located just under the skin is usually neutral, sometimes even protective, and visceral fat that envelops the liver, pancreas, and intestines is pathologically active and produces and excretes inflammatory factors and free fatty acids bound for the liver via the portal vein. This visceral fat is associated with type 2 diabetes, heart disease, hypertension, and non-alcoholic fatty liver disease. These behavioral patterns begin at a young age. For example, by performing daily exercise, teens can decrease their fat stores, which improves the functions of the fat cells. These exercise habits, coupled with the intake of healthy unsaturated fatty acids found 5 in nuts, olive oil, and fatty fish, the avoidance of ultra-processed foods, proper hydration that facilitates the lipolytic response, and the application of safe cooling in daily life to invigorate brown fat, shift the ratio of subcutaneous to visceral fat in the desired direction while maintaining the long-term functionality of the adipose tissue. (Guarino et al. 2023)

2. Insulin Resistance: When Cells Stop Listening

Insulin, which is produced in the pancreas, is a hormone that functions as a ‘key’ that enables the cells in the body to absorb blood sugar. Blood sugar (or glucose) comes from the food we eat, and in particular carbohydrates, which serve as energy for anything from the movement of the muscles to activities done in the brain. When blood glucose is well managed in the body, these cells extract the glucose from the blood and either use it for immediate energy or store it for later use. Save this process, other functioning organs in the body would not get energy, and along with that, blood sugar levels would go uncontrolled.

Insulin is like a key that lets sugar from your food into your cells so they can make energy. With insulin resistance, the locks on the cells get sticky. The key still fits, but the door is hard to open. More sugar stays in your blood, so your pancreas sends out extra insulin to try to force it in. Constantly high insulin, called hyperinsulinemia, makes your body store more fat, especially in your belly, and increases the chance of developing type 2 diabetes over time.

When your body stops responding well to insulin, the effects show up everywhere, because your muscles do not pull in sugar for energy and you feel tired or weak after carb-heavy meals, your liver keeps making sugar even when you do not need it and your blood sugar rises, your fat cells get told by high insulin to store more and belly fat often increases, and your brain’s dopamine system can be thrown off so cravings for sweet or fatty foods get stronger and overeating becomes easier. Early signs include feeling wiped out after eating, 6 getting powerful and frequent cravings for sugary or starchy foods, noticing belly fat that does not budge with normal efforts, and sometimes seeing dark, velvety skin patches on the neck or underarms called acanthosis nigricans.

What drives this problem are habits like eating lots of added sugar and refined grains that spike blood sugar and insulin, long periods of sitting that make muscles worse at using sugar, and ongoing stress that raises cortisol and pushes blood sugar up. What helps most are steady changes such as moving every day with walking, biking, swimming, or strength training so muscles listen to insulin better, cutting back on added sugars and refined carbs while eating more fiber from whole grains, vegetables, beans, and lentils to smooth blood sugar, using a consistent daytime eating window of about ten hours if it suits you so insulin can drop between meals, practicing mindfulness, deep breathing, or yoga to lower stress, and protecting sleep so hormones stay in rhythm. The big idea is simple: insulin resistance is usually a response to a long-term mismatch in food, movement, stress, and sleep, so spotting it early in your teens or early twenties and making steady changes can lower your risk of type 2 diabetes later.

Improved lifestyle habits determine levels of insulin resistance. Diets high in added sugars and refined grains cause blood glucose and insulin levels to spike intermittently, leaving your body with no option other than to “tune out” insulin over time. Prolonged periods of physical inactivity result in the muscular system losing the ability to absorb glucose as blood levels of the sugar increase. Chronic stress also adds insult to injury because of the stress hormone, which elevates blood sugar levels and promotes insulin resistance. The positive news here is that gradual changes work. Exercise most days of the week, including low-impact activities: walking, biking, swimming, and weight lifting, to strengthen the ability of muscle tissues to respond to insulin. Avoid added refined sugars and carbs and consume more whole, plant sources of fiber, including whole grains, vegetables, and legumes, to stabilize blood sugar levels. Time-restricted feeding, or an eating schedule with a shorter time of eating around ten 7 hours, works well for some because it promotes a more sustained drop in insulin between meals. Stress is more effectively managed using mindfulness, breathing exercises, and yoga, and sleep quality must be prioritized in order to regulate hormone levels.

By understanding insulin resistance not as a random malfunction but as the body’s response to a sustained imbalance in diet, activity, and stress, we can take proactive steps to restore metabolic health. Early intervention during adolescence or young adulthood can prevent years of progression toward type 2 diabetes and related conditions, making it a vital focus in obesity prevention efforts. (McGlynn et al. 2022)

Figure 1: Insulin resistance is a type of reaction in a person’s body, especially muscle cells, that makes it less responsive to insulin. By having less reactive insulin within the body, normally it would facilitate the amount of glucose consumed to either store it as an energy source, but since it is getting resisted, the cells do not respond correctly to the insulin signal. This leads to a reduced glucose intake and an increased spike in glucose levels.

3. Energy Balance: The Calorie Equation and Beyond

Energy balance is the match between the energy you take in from food and drinks and the energy your body uses for living, moving, and digesting. While it looks like simple math (eat more than you burn to gain, burn more than you eat to lose), your body constantly adapts, so the balance shifts. (Pardo et al. 2021)

Most daily burn comes from basal metabolic rate (BMR), roughly 60–70%, which powers your heart, lungs, brain, and cells even at rest. Physical activity adds a variable share that includes workouts, sports, walking, chores, and small movements like standing and fidgeting (NEAT). Digestion also costs energy via the thermic effect of food (TEF), with protein costing more than carbs or fat. Brown fat can add a small cold-activated boost by turning stored energy into heat. Harsh calorie cuts trigger metabolic adaptation (adaptive thermogenesis) that lowers BMR and, with hormone shifts that raise hunger and reduce fullness, slows loss and promotes regain. Energy imbalance comes in three forms: positive (intake > burn, weight rises), negative (intake < burn, weight falls, but too-large deficits can cause muscle loss, nutrient gaps, and slower metabolism), and neutral (intake ≈ burn, weight holds), and small changes can tip you between them. Long-term balance works best when you support the system rather than obsess over every calorie by building and keeping muscle with resistance training to raise BMR, eating enough protein to protect muscle, increase fullness, and boost TEF, avoiding crash diets that cause large slowdowns, and keeping consistent routines for meals, sleep, and movement. For teens and young adults, habits formed now tend to stick, so favor nutrient-dense foods, daily activity you enjoy, and sustainable patterns, and treat energy balance as a lifelong rhythm rather than a short-term fix to give yourself the best chance at a healthy weight and steady energy. (Kalaitzopoulou et al. 2023)

Figure 2: Energy balance is the amount of calories consumed through food and drink that is equivalent to the amount of calories the body has burned down to equal it out. There are three types of energy balance. A positive energy balance is a state where a person consumes an excessive amount of calories that the body cannot expend. This results in increased adiposity (Obesity) and weight gain. A negative energy balance is the result of taking way too less calories compared to what the body is burning. This will result in weight loss. Lastly, neutral energy balance is the type where the body is equally regulating the amount of calories intake, while the calories are equally burned down. This will lead to weight maintenance.

4. Leptin: The Hunger-Regulating Hormone

Think of leptin as your body’s built-in fuel gauge. It’s a hormone made mostly by your fat cells, and its job is to keep your brain updated on how much energy you have stored. When your body has plenty of fuel, leptin travels through your blood to the hypothalamus, the brain’s control center for hunger, energy, and weight, and delivers a simple message: “We’re good. You can slow down on eating and speed up on burning energy.”

When this system is working as it should, you naturally feel satisfied after eating, your metabolism hums along, and you have the energy and motivation to be active. After a meal, leptin levels rise, telling the brain that your energy needs are met. The brain responds by easing hunger signals and nudging your body to burn a little more. Maybe through movement, maybe through heat production, in a neat feedback loop that helps keep your weight steady without you having to think about it.

When the leptin system breaks, it is called leptin resistance. Leptin levels are high, sometimes very high, but the brain does not “hear” the message. The hunger off-switch feels stuck. Even with plenty of stored energy, the brain acts like fuel is low, so hunger goes up and calorie burn slows down. You can feel hungry soon after eating, and your body holds on to fat. More body fat makes more leptin, which makes the resistance worse, so the cycle repeats. Several forces can throw this system off. Inflammation in the brain, especially in the hypothalamus, can block leptin’s signal. Diets heavy in sugary, ultra-processed, or greasy foods raise oxidative stress, which damages the brain’s appetite pathways. Poor sleep makes it harder too; even one short night can lower leptin, raise ghrelin, and push stronger cravings the next day. Frequent overeating can also numb leptin receptors, the way loud noise can numb hearing.

Leptin affects more than hunger. It interacts with dopamine and serotonin, which shape mood, motivation, and pleasure, so weak leptin signaling can make you feel less driven to move and more likely to eat for comfort. It also affects fertility. If the brain thinks energy is low, it may slow or pause reproductive functions, even when the body has enough fuel. Leptin also links to the thyroid, which sets metabolic speed, so leptin problems often come with a slower metabolism.

The upside is that leptin sensitivity can improve. Getting a solid 8–9 hours of sleep each night helps keep hormone rhythms steady. Regular movement, especially strength training and cardio, reduces brain inflammation and helps leptin signals get through. Omega-3 fats from foods like salmon, walnuts, and flaxseed can also help calm brain inflammation. And avoiding constant snacking, particularly on processed foods, lets leptin rise and fall naturally so your brain has a chance to “hear” it again. (Besci et al. 2023)

Figure 3: Leptin is a peptide hormone made mainly by fat cells, and its blood level reflects total fat stores. Its primary role is to signal the hypothalamus that energy is sufficient, which reduces appetite, adjusts energy expenditure and sympathetic tone, and helps coordinate reproductive, thyroid, and immune functions. In common obesity, leptin levels are high but signaling is blunted (“leptin resistance”), so added leptin seldom causes weight loss, whereas replacement helps in true deficiency and some lipodystrophies. (Kamal-Rahmouni et al. 2002)

5. Inflammation: The Immune System’s Double-Edged Sword

Inflammation is the body’s built-in alarm system. It’s there to protect us when something goes wrong, like when you cut your finger, catch a cold, or sprain your ankle. In those moments, your immune system sends in its “first responders.” The area becomes red, warm, and swollen because immune cells are flooding in to fight off germs, clear away damage, and start the healing process. Once the job is done, the alarm switches off and your body goes back to normal. That’s acute inflammation, and it’s a good thing.

However, sometimes the body’s alarm does not shut off; it stays low and constant for weeks or years, which is called chronic low-grade inflammation, and it quietly damages tissues over time. In obesity, it often starts in fat tissue, where overgrown fat cells get stressed and send out distress signals that call in immune cells called macrophages; these cells release inflammatory chemicals such as TNF-alpha and IL-6 that make cells ignore insulin and handle sugar poorly, and blood tests often show higher C-reactive protein (CRP), a sign that inflammation is active across the body. This slow fire spreads: in the gut it can weaken the lining and let harmful bacteria slip into the bloodstream (leaky gut), in the brain it can disturb the hypothalamus so hunger and fullness signals break down and leptin resistance develops, in the liver it pushes fat buildup that can lead to non-alcoholic fatty liver disease (NAFLD), and in blood vessels it speeds plaque growth, which raises the risk of heart attack and stroke.

What you eat, how much you move, and how you handle stress can all influence inflammation. Diets full of sugary drinks, processed meats, fried foods, and packaged snacks make it worse by increasing oxidative stress, a kind of cellular “rusting” that triggers inflammation. Not moving enough is another problem, because muscles release special anti-inflammatory chemicals when you exercise. High stress levels keep the hormone cortisol elevated, which in turn can push inflammation higher. And when you don’t sleep well, your immune system loses its rhythm, tipping the balance toward more inflammation. (Nagorcka-Smith et al. 2022)

The good news is that you can turn the alarm back down. Eating more anti-inflammatory foods, like berries, leafy greens, olive oil, and fatty fish, gives your body nutrients that help calm the immune system. Fermented foods like yogurt, kefir, or kimchi can feed healthy gut bacteria, which in turn protect against inflammation. Moving your body regularly, even just a brisk 20-minute walk, helps your muscles release anti-inflammatory signals. Learning to manage stress through things like meditation, deep breathing, or simply taking time to relax can lower cortisol levels. And making sleep a priority, aiming for 8 to 9 hours most nights, gives your immune system the time it needs to reset. (Nikooyeh and Neyestani et al. 2021)

Figure 4: In nutrition, inflammation is the body’s immune signaling state as affected by diet and body fat. Acute inflammation helps repair, but chronic low-grade inflammation arises with energy excess and poor food quality, raising markers like hs-CRP, IL-6, and TNF-α and promoting insulin resistance, cardiovascular disease, and fatty liver, while ultra-processed foods, refined carbs, trans fats, and heavy alcohol push inflammation up and whole-food patterns rich in vegetables, fruits, legumes, whole grains, nuts, olive oil, omega-3 fish, and fiber that feeds the gut microbiome tend to bring it down, with weight control, regular activity, sleep, and stress management strengthening the effect.

The Cycle: How All Five Systems Work Together

Obesity isn’t caused by one thing; it’s caused by many things going wrong at once:

These problems feed into each other, making it harder to break the cycle. But the good news is: small changes can help reset the system.

Prevention

You don’t need to be perfect. But supporting your body’s natural systems goes a long way in keeping obesity away.

To support metabolic flexibility, try intermittent fasting to improve insulin and leptin and vary your calorie intake across days through caloric cycling, and if you are under 18 or have a medical condition consult a clinician before fasting; eat anti-inflammatory foods by prioritizing whole, unprocessed meals, colorful fruits and vegetables, and healthy fats such as nuts, seeds, olive oil, and fatty fish instead of fried foods; manage stress with short daily meditation, breathing exercises, or yoga and by journaling or talking with a friend, since chronic stress raises cortisol and can promote belly fat; and align with your body’s clock by eating during daylight hours, sleeping at night, and keeping a consistent bedtime because your hormones follow a daily rhythm that works best on a regular schedule.

Conclusion

Obesity is not a simple choice. It’s not a result of laziness or weakness. It’s a physiological condition caused by complex changes in the body’s systems, especially the way fat is stored, sugar is used, hormones are regulated, and the immune system responds to stress. But that also means obesity can be prevented. Not just with willpower, but with knowledge, consistency, and self-care. When we understand how the body works, we can give it what it needs to function better. Instead of focusing only on weight, we should focus on balance between eating and moving, between sleeping and waking, between stress and rest. That’s the key to helping your body feel strong, energized, and healthy.

References

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The author utilized an artificial intelligence tool, Google Gemini, and Perplexity to enhance the clarity and readability of the writing. All final content, critical interpretation, and responsibility for accuracy remain solely with the author.

About the author

Ryan Jung

Ryan is currently a junior attending school in Suffield, Connecticut.

The post Hack Your Hunger: How to Reset Your Body’s Fuel Gauge appeared first on Exploratio Journal.

Postpartum care in Pakistan is shaped not only by the availability of medical services but by the family power structures that determine whether women are able to use them. Understanding how patriarchal norms and household authority influence access, autonomy, and recovery is essential for addressing persistent gaps between clinical recommendations and women’s lived experiences of postpartum health.

This study asks: How do family dynamics and patriarchal norms in Pakistan shape women’s postpartum care, decision-making power, and recovery experiences? To answer this question, I conducted in-person surveys with 102 postpartum and first-time pregnant women at the Civil Hospital Gynecology Clinic in Sialkot. The survey combined quantitative measures of access, support, and trust with open-ended qualitative responses that captured personal narratives. This mixed-methods design allowed both identification of broad patterns and deeper insight into how women navigate care within their families.

Findings show that education and geography were strong predictors of postpartum autonomy, with women who had higher levels of schooling or who lived in urban or nuclear households reporting more shared decision-making and comfort expressing health needs. Family influence functioned as both support and restriction. Many husbands encouraged clinic visits and helped with household responsibilities, while mothers-in-law in joint families often upheld traditional expectations that delayed or limited care. Although most women trusted medical professionals, many still waited for family approval before acting on advice.

These results suggest that maternal health interventions in Pakistan should involve entire families, especially husbands and elderly women, in order to improve postpartum care and support women’s recovery.

Introduction

Maternal health after childbirth is a critical yet often overlooked aspect of women’s well-being in Pakistan. Postpartum care, which refers to the medical treatment, emotional support, and social conditions that shape a woman’s recovery in the weeks and months after giving birth, goes beyond access to clinics. It is shaped by family power dynamics and cultural norms that determine who controls a woman’s body and recovery. In many households, mothers-in-law or husbands make key decisions about medical treatment, nutrition, and rest, leaving new mothers with limited autonomy. This family-centered control reflects patriarchal norms, meaning the beliefs and expectations that grant men and elder family members authority over women’s bodies, choices, and mobility. These systems of authority influence women’s physical recovery and emotional health in ways that are often invisible in clinical discussions. Understanding postpartum care provides insight into how social structures in Pakistan can both support and restrict a woman’s path to healing. Building on this context, this study is guided by the question: How do family dynamics and patriarchal norms in Pakistan shape women’ s postpartum care, support, and recovery experiences, including access to medical care, emotional support, and decision-making power? This paper first reviews existing research on postpartum care and inequality, then presents survey findings from Sialkot, and concludes with an analysis of how family dynamics shape women’s recovery experiences.

Postpartum health has lasting effects on maternal well-being and child development, which makes this question especially important to investigate. In many parts of Pakistan, women’s health choices are filtered through family authority and cultural traditions, and this can either support or delay recovery. Studying these dynamics allows us to understand why some women are able to access professional medical support while others rely primarily on family guidance or cultural practices. It also highlights the importance of trust, authority, and gender relations in shaping health outcomes.

To address this question, I relied on original survey data that I collected at the Civil Hospital in Sialkot, Pakistan. I selected the Civil Hospital Gynecology Clinic as my primary research site because it allowed me to reach women from diverse social and economic backgrounds living in both urban and rural areas. Through my survey, I gathered information on access to care, the involvement of family members, and the kinds of support women received. Since I administered the survey in person, I was also able to include open-ended questions that encouraged respondents to share their personal stories. Their responses offered valuable insight into how women experienced cultural expectations and family authority in their daily lives. By combining quantitative and qualitative methods, I was able to identify overall trends while also preserving the individual voices of women whose recovery was shaped by their families and communities.

From the data collected, findings reveal a complex picture of postpartum care in Pakistan. Many women described receiving strong support from family members, particularly from husbands who encouraged medical visits, accompanied them to clinics, and sometimes shared childcare or household tasks. This stands in contrast to other accounts in the literature that emphasize restrictive family control, showing that women’s experiences vary widely. The most important contribution here is that support within families can act as a turning point, allowing women to act on medical advice rather than being blocked by household hierarchies. At the same time, women living in conjoint or extended households also reported tension with mothers-in-law, whose hesitation about biomedical care created delays or doubts. Taken together, these findings suggest that postpartum care is shaped less by the availability of services alone and more by how Mother in Laws and paternal family members negotiate authority, trust, and responsibility in everyday life.

These findings point to the need for maternal health programs in Pakistan that address both medical and social factors. Policies that focus only on clinical services risk overlooking the influence of family authority and cultural norms on women’s ability to access care. Interventions that involve husbands, mothers-in-law, and other key family members may be more effective in improving outcomes because they address the reality that health decisions are often made collectively. At the same time, strengthening women’s education and building trust in healthcare providers can help shift reliance away from restrictive practices toward evidence-based care.

More broadly, discussions of maternal health in Pakistan are often shaped by stereotypes that portray women as powerless victims of tradition. While patriarchy and inequality remain pressing barriers, the findings here show that women’s experiences are more complex, shaped by both restriction and support. This variation is not random, it tends to follow predictable special patterns shaped by class and household structure. For instance women in urban and nuclear often exercise more autonomy than women who live in either rural and conjoint family systems. Recognizing this nuance matters because it opens space for imagining new forms of intervention that are grounded in women’s actual realities rather than external assumptions. There is also a clear need for further research that captures these diverse experiences, especially studies that center women’s own voices and explore how family dynamics are changing across different communities. By situating postpartum health within both medical and cultural contexts, this study highlights how improving maternal well-being in Pakistan requires not only better services but also new ways of thinking about women in these settings.

Literature Review

Information Pathways and Trust in Pregnancy Guidance

Understanding how Pakistani women receive and interpret information about pregnancy and postpartum care is central to examining how family dynamics and patriarchal structures shape their health decisions. Habib et al. (2017) found that while nearly 90% of women were aware of at least one contraceptive method, only one-third had ever used them, with unintended pregnancies reported in over one-third of antenatal patients. Health care providers were cited most frequently as the primary source of family planning information, yet the gap between knowledge and practice reflected deeper barriers, including illiteracy, rural residence, and short birth intervals. These structural and educational constraints indicate that medical advice alone does not guarantee adoption of practices, especially when women lack the autonomy or support to act upon it.

Similar evidence from Thatta underscores how trust mediates whether medical guidance is even considered credible. Asim et al. (2021) showed that mistrust of public facilities and fear of biomedical interventions, such as iron/folate tablets or tetanus vaccination, pushed families toward traditional healers, home remedies, or spiritual leaders. Even when women expressed interest in facility births, decisions were often overridden by family members who favored cheaper home-based care. In my survey, 91% of respondents said family members were their main source of pregnancy information, while 78% cited medical professionals, showing that family remains the most influential actor even when clinical advice is available. However there is one limitation in the sample collected, which is the number of women who decided to opt for home care over medical facilities. Omer et al. (2021) also described delays in hospital care due to reliance on spiritual advice, with fatal consequences in some cases. These findings highlight that information is filtered not just through women’s individual understanding but through the social and cultural expectations imposed by family and community.

Past literature shows that women often view family members such as husbands, mothers-in-law, or elders as more credible than doctors. My survey aligns with this pattern: 36% of women reported that their in-laws were “very important” in decision-making, and over 43% of women who sought spiritual advice did so at the request of family members, not by personal choice. At the same time, some studies suggest that increased exposure to clinics or health workers may encourage women to place greater value on medical advice. In my data, 77% of women reported fully trusting medical professionals, showing that trust in doctors is rising but is still expressed within a family-influenced environment. These possibilities create an important motivation to examine how women balance family authority with professional guidance during the postpartum period.

According to Atif et al. (2023), partner support plays a critical role in whether women are able to follow medical advice and access maternal health services. Using national data from the Pakistan Maternal Mortality Survey, the authors found that women whose husbands provided emotional and financial support, helped with pregnancy-related decisions, or accompanied them to health facilities experienced safer childbirth and better maternal outcomes. Their findings show that supportive husbands can help women overcome restrictive family norms and strengthen trust in medical care, illustrating how family roles shape not only who shares health information but also who acts on it. In my survey, 60% of husbands helped with daily household responsibilities, and 40% of couples discussed pregnancy decisions often, suggesting that support from husbands can soften the effects of restrictive household norms. In many households, doubts raised by mothers-in-law could be set aside if husbands pushed for medical treatment. This shows that families with more flexible or shared decision-making are more likely to act on medical guidance, creating pathways that allow women to get care. It also shows that families are not all the same; some continue strict traditions while others move away from them.

In the end, asking who in the family makes the final decision is not just about telling stories. It matters because it shows that trust and care-seeking depend on specific family relationships, not only on general views of medicine. This means that interventions need to look beyond women alone and instead reach the household as a whole. Working with husbands, addressing mothers-in-law, and understanding how authority shifts within families can turn social influence into a tool for improving access to care.

Interpersonal Relationships and Support Systems

Postpartum care in Pakistan is inseparable from household and community relationships, where family structures both provide support and reinforce restriction. In a study of low-income Karachi settlements, Fikree et al. (2004) found that although more than half of women delivered in facilities, postpartum follow-up remained minimal, only one-quarter of those counseled for check-ups actually attended. Symptoms such as high fever (21.1%) and heavy bleeding (13.9%) were common, yet initial responses involved home remedies or traditional healers before seeking professional help. These patterns reflect how postpartum care is first negotiated within the family, often delaying engagement with formal health systems. Family hierarchies exert strong control over such decisions.

Omer et al. (2021) also observed that these delays, rooted in family authority, contributed directly to maternal deaths. Such examples illustrate how family support systems can function as mechanisms of control when patriarchal expectations prioritize household finances, family reputation, or cultural norms over women’s health. Interpersonal dynamics also intersect with violence and neglect. Fikree and Bhatti (1999) found that 34% of women reported physical abuse, with 15% experiencing violence during pregnancy. Abuse was strongly linked to anxiety and depression, underscoring how harmful relationships compromise not only mental health but also women’s willingness and ability to seek care. Mumtaz et al. (2011) expanded this understanding by showing how gender and caste intersect: in the case studies of Shida and Zainab, domestic violence, indebtedness, and social devaluation prevented access to life-saving care, even when facilities were physically available.

Together, these findings emphasize that interpersonal relationships are double-edged Supportive husbands or peers may encourage health-seeking and family planning, as noted by Habib et al. (2017), but patriarchal family structures often silence women’s preferences, limit mobility, and normalize neglect. For this reason, examining postpartum health in Pakistan requires not only mapping medical access but also analyzing how power circulates within the family system, where decisions about women’s care are often made by others, not the women themselves.

Not all family structures operate in ways that restrict women’s health. Atif et al. (2023) found that when husbands provided consistent emotional and financial support during and after pregnancy, women experienced safer childbirth and improved maternal outcomes. These findings suggest that interpersonal networks are not fixed. When families prioritize women’s health, relationships can shift from acting as barriers to enabling access to care. This matters because it shows that interventions should not only treat families as obstacles but also as potential partners in change. By strengthening supportive roles within households, especially those of husbands, health systems can use existing family structures as entry points for improving maternal and postpartum care.

Patriarchal Norms, Family Power Dynamics, and Women’s Health Decision-Making

Patriarchal authority in Pakistan is a defining factor in women’s ability to access postpartum health care. Studies consistently show that men dominate decision-making in reproductive matters, with women’s voices either sidelined or entirely excluded. Ghani and Hassan (2023) found that in households practicing polygyny, women’s autonomy was particularly constrained, with husbands retaining primary control over maternal health decisions. By contrast, nuclear families were more likely to allow women some say in health matters, suggesting that family form plays a role in shaping the balance of authority. Similarly, Rahman (2025) examined joint-family systems in northern Pakistan and reported that while extended families offered social and financial security, they also entrenched patriarchal hierarchies. In these settings, elder males and mothers-in-law dictated women’s health-related movements, reinforcing women’s dependency and limiting their direct decision-making power.

This concentration of authority is not just cultural but institutionalized in Pakistan’s gender system. Ali (2011) argues that gender roles in Pakistan are reinforced through educational, legal, and policy frameworks that privilege male control. The paper emphasizes that discriminatory practices are embedded in social institutions, making autonomy not just a household issue but a national structural one. At the same time, it also highlights women’s education as a key factor that can disrupt patriarchal expectations, opening limited but meaningful pathways for change.

Patriarchal authority in Pakistan shapes women’s health care choices not only through explicit rules but also through everyday expectations about obedience, modesty, and family honor. These unwritten norms create an environment where women learn early that their well-being is often secondary to household reputation or financial priorities. Even when health services are nearby, many women hesitate to seek them if it means challenging the authority of a husband, elder male, or mother-in-law. In rigid households, decisions about rest, travel to a clinic, or the use of contraception are less about medical need and more about maintaining control. Yet in families where authority is more flexible, these same structures can be reinterpreted: a husband who insists on supporting his wife’s care, or an elder who views postpartum recovery as protecting family strength, can transform patriarchal authority into permission rather than denial.

Socioeconomic Inequalities and Access to Care

Economic and social inequalities are equally powerful in shaping postpartum health outcomes. Aftab et al. (2025) conducted a systematic review of maternal health across South Asia and found that economic status, education, women’s occupation, and autonomy were the strongest determinants of access to maternal health services. In Pakistan specifically, women from poorer households and those without formal education were far less likely to receive skilled postnatal care, showing how inequality translates directly into health gaps. Afridi et al. (2025) further demonstrated this by applying an inequality of opportunity framework to Pakistani DHS data, finding that circumstances beyond women’s control, such as family wealth, parental education, and place of birth, accounted for much of the disparity in maternal health use.

Recent national-level data highlight the persistence of these divides. A study by Maleki et al. (2024) found that illiteracy, unemployment, and rural residence were consistently associated with lower postnatal care use, even when services were theoretically available. They argue that trust in healthcare facilities erodes further among poorer women, who often experience low-quality treatment or unaffordable fees. Similarly, Misu et al. (2023) compared Pakistan with Bangladesh and found that Pakistan’s PNC coverage had the widest inequality gaps by education and wealth. In particular, the richest, most educated women were many times more likely to access postnatal care than the poorest, least educated, suggesting that class-based disparities are entrenched within Pakistan’s health system.

Economic inequality does not only determine whether services are available, but also how women experience them. For many, the decision to seek care is filtered through the reality of daily survival. A woman from a low-income household may know that postnatal check-ups are important, yet the cost of transport, the need to return quickly to wage labor, or the fear of being treated poorly in a public facility can make professional care feel out of reach. By contrast, women in wealthier families often have both the means and the social confidence to demand better treatment, which widens the divide further. These patterns show that access is not just about the existence of clinics but about whether women can realistically use them with dignity and trust. Without addressing these underlying inequalities, expanding services risks reinforcing the very divides it is meant to reduce.

The literature reviewed above highlights major structural inequalities in postpartum care, but it also reveals a gap that my research is designed to address. While existing studies document which groups of women face the greatest barriers, far fewer examine how women themselves interpret postpartum advice, negotiate family expectations, or build trust in medical care after giving birth. Much of the current evidence comes from national surveys or quantitative analyses, which identify patterns but cannot fully capture women’s lived experiences of navigating these inequalities. My study addresses this gap by focusing on women’s postpartum decision making and their perceptions of care quality in everyday life. Based on the literature, I expect to find that socioeconomic constraints interact with family dynamics, cultural norms, and experiences inside healthcare facilities to shape whether women feel able and willing to seek postnatal care. This approach allows my study to contribute a more detailed and grounded understanding of how inequality affects postpartum health access in daily life.

Data and Methods

I chose this research site and population because the Civil Hospital serves a wide range of women from diverse socioeconomic backgrounds, making it an ideal setting for examining how income, education, family roles, and trust in medical care shape postpartum decisions. Surveying 102 women at this location allowed me to reach participants from both urban and peri-urban areas who rely on affordable public healthcare rather than private clinics, which typically serve higher-income families. This site also provided access to both postpartum mothers and first-time pregnant women, making it possible to understand not only women’s reflections after childbirth but also the expectations and concerns that shape care-seeking earlier in pregnancy. Focusing on this diverse population helps address the gap in the literature by providing detailed insight into how women navigate postpartum care in everyday life. Participants ranged in age from late teens to early forties, reflecting the wide reproductive age span served by the clinic. Most respondents were married and living in extended family systems, where mothers-in-law and husbands often influenced decisions about medical treatment and rest. Educational backgrounds varied: while some women had completed secondary or higher education, others had limited formal schooling, particularly those from rural villages surrounding Sialkot. This variation in age, education, and living arrangements made it possible to observe how family authority and socioeconomic conditions differently shaped women’s postpartum experiences and access to care.

The survey instrument was designed to capture both quantitative and qualitative data. Closed-ended questions measured factors such as frequency of clinic visits, type of medical care accessed, involvement of husbands and mothers-in-law in health decisions, and sources of postpartum support. These items provided a systematic picture of women’s access to care and the distribution of decision-making authority within households. To complement this, the survey also included some open-ended questions that encouraged women to share their personal experiences in their own words. These narratives revealed the cultural meanings and emotional aspects of postpartum recovery that numbers alone cannot capture.

Data collection took place through in-person administration to over 100 postpartum and first time pregnant women attending the clinic. In-person surveys reduced literacy barriers and made it possible to build trust with respondents. When appropriate, questions were translated into local dialects to ensure clarity and accessibility. Respondents were assured of confidentiality, and participation was voluntary.

Results

When the data are examined across education, location, trust, and family structure, clear relationships emerge in how social and structural factors shape women’s postpartum experiences. Education level appears to be one of the most influential variables. Among respondents, 18 % had no formal education, another 18 % had completed only primary school, and 35 % had finished secondary school, while 25 % held a college or university degree and 4% had graduate or professional qualifications. Women with higher education were more likely to describe shared or cooperative decision making with their husbands and greater comfort expressing their health needs. For example, many of the women who rated themselves as very comfortable talking to their husbands when they felt unwell were also those with secondary or higher education, contributing to the 70 % who chose the highest comfort rating. Their responses suggested that education provides both knowledge and confidence, allowing them to navigate healthcare systems and negotiate with family authority. In contrast, women with limited or no schooling often relied more heavily on in-laws and deferred to others in medical and household decisions. A 24 year old participant with limited schooling explained, “I wanted to tell the doctor about my pain, but I felt shy. My mother-in-law spoke instead, and she said everything was fine.” This pattern indicates that education not only expands access to information but also influences power dynamics within families, shaping whether a woman’s voice is heard in her recovery process.

Economic inequality also emerged as an underlying factor, reflected indirectly through patterns of residence. None of the 102 respondents lived in major cities such as Karachi or Lahore. Instead, 59 women, or about 58 %, lived in small cities or towns such as Sialkot, and 43 women, about 42 %, lived in rural villages. These distributions suggest that most of the surveyed women live in lower to middle income settings with limited healthcare infrastructure. Regional location also shaped access to education and services. Women in rural or semi rural households often described financial barriers such as the cost of transportation, clinic fees, or medication, which discouraged them from seeking professional care. A 32 year old mother from a rural village said, “The clinic is far and we cannot pay for a rickshaw every time. Sometimes I just stay home and take the advice of my sister-in-law.” In contrast, women from more urbanized or economically stable families, often those with higher education levels, reported greater mobility, better nutrition, and more frequent engagement with healthcare providers. This indicates that geography in Pakistan not only represents physical distance from hospitals but also mirrors economic divisions that influence health outcomes. Economic constraints therefore reinforce social hierarchies, limiting autonomy for poorer women while amplifying dependence on family authority to make healthcare decisions.

Patterns of information sources also reflect underlying social divides. Overall, 91 % of respondents identified family members as a main source of information about pregnancy, while 78 % cited medical professionals. Only small minorities reported relying on social media, 8 %, or journalists, 2 %. Women in rural or small town households, who are more likely to experience economic hardship, appear to depend primarily on informal, family based knowledge networks rather than institutional or technological ones. In contrast, participants with higher education levels and more urban residence more frequently mentioned doctors or online platforms, indicating greater exposure to formal healthcare systems. Despite these differences, trust levels revealed a striking contradiction. Although medical professionals were widely trusted, with 77 % of respondents giving doctors the highest trust rating, many women still deferred to family approval before acting on medical advice. A 29 year old woman living in a joint family shared, “I trust the doctor, but if my husband’s mother says wait, then we wait. It is not my decision alone.” This pattern suggests that economic and cultural hierarchies intersect, where lower income families place collective authority above individual medical autonomy. Women from wealthier or more educated households, by contrast, demonstrated greater confidence in navigating between traditional and professional advice. These findings illustrate how economic inequality influences not only access to information but also the ability to act on trusted knowledge, reinforcing the idea that empowerment depends as much on social permission as it does on awareness.

The survey also highlights how husbands and in-laws shape everyday postpartum support. Most respondents lived with their husbands, 89 %, and a majority also lived with their children, 80 %. Just over half, 51 %, lived with their husband’s parents or other in-laws, reflecting the prevalence of joint or extended household arrangements. During pregnancy and the postpartum period, 60 % of women reported that their husbands helped with household responsibilities daily, while another 25 % received help a few times a week or occasionally. At the same time, 46 % of respondents described their in-laws as “very important” in pregnancy related decisions, and another 18 % said they were “somewhat important,” meaning almost two thirds saw in-laws as significant decision makers. Many women also reported having to compromise their own preferences, with about 67 % agreeing or strongly agreeing that they had to set aside their own wants and feelings to please a husband or another family member. These numbers show that even in households where husbands are supportive, authority is often shared or negotiated with elders.

Satisfaction levels further support these relationships. Nearly three quarters of respondents, 74.5 % , described themselves as very satisfied with their most recent pregnancy experience, and another 16.7% were somewhat satisfied. Many of the women who expressed high satisfaction also reported active spousal involvement and shared household responsibilities. One 26 year old first time mother reflected, “I felt happiest when my husband helped. Even small things made a big difference. When he listened, I felt safe.” This connection suggests that emotional support and cooperative family dynamics can have as much impact on well being as medical treatment itself. On the other hand, women who faced stronger in-law authority or limited say in their own care tended to describe neutral or lower satisfaction levels, indicating that social restrictions can directly affect perceptions of recovery. An older mother of three from a small town commented, “We trust the doctors, but still ask elders before doing anything. It feels wrong to go against them.” Her statement reflects the emotional weight of respect and obedience in shaping decisions.

Spiritual and religious guidance also played a role in women’s experiences. Thirty eight % of respondents reported visiting a religious leader during their most recent pregnancy. Among those who did, 43 % said they went because it provided personal comfort, and another 43 % said they went because in-laws expected or required it. Some also described visits as a result of pressure from husbands or other family members. These patterns show that religious consultations are not only a matter of individual belief but are intertwined with family expectations and authority. For some women, religious leaders provided reassurance alongside medical care. For others, spiritual advice contributed to delays or doubts about biomedical treatment, especially when elders prioritized ritual or tradition over clinical recommendations.

In addition to survey responses, interviews with several women provided deeper insight into how these dynamics unfold in daily life. A 27 year old mother from rural Sialkot explained, “The doctor told me to rest after my delivery, but my mother-in-law said too much lying down makes a woman weak. So, I got up to cook again after two days.” Her statement reflects the tension between professional medical guidance and traditional family expectations. Another participant, a university educated woman living in an urban neighborhood, described a contrasting experience: “My husband and I decide things together. If the doctor says I need medicine, we buy it the same day. He even comes with me to appointments.” These accounts illustrate how education and family structure intersect to shape women’s autonomy.

Taken together, these patterns reveal that postpartum health in Pakistan is shaped by overlapping systems of influence, including education, geography, trust, religion, and family structure, that together determine whether women experience empowerment or constraint. Families remain central to recovery, but their influence can either reinforce patriarchal control or evolve into a source of shared support. As women gain education or move closer to urban environments, they are increasingly able to advocate for themselves, transforming traditional hierarchies from within. These findings highlight that improving maternal well being requires not only access to healthcare but also the reshaping of the social and cultural environments that define how women heal.

Discussion/Conclusion

The results of this study show that postpartum care in Pakistan is shaped not only by access to healthcare but by the social relationships that determine who supports or restricts a woman after childbirth. Education, geography, and trust emerged as the strongest predictors of autonomy and satisfaction. Women with higher education and those living in urban settings described greater independence, stronger partnerships with husbands, and more comfort communicating their needs. In contrast, rural and less-educated women were more likely to depend on in-laws and family approval before acting on medical advice. Yet across these differences, a common thread appeared: families remain the center of care. When relationships were cooperative and emotionally supportive, women were more likely to trust doctors, attend clinics, and report high satisfaction with their recovery. This demonstrates that postpartum health is both a medical and relational outcome, built through dialogue, understanding, and shared responsibility within households.

These findings help answer the core research question by revealing how patriarchal norms and family dynamics interact to shape postpartum recovery. The study challenges the idea that patriarchal families are entirely restrictive and instead shows that change is emerging from within them. Education, communication, and exposure to urban environments are gradually transforming rigid hierarchies into systems of shared authority. This perspective fills a major gap in current literature, which often depicts Pakistani women as passive or powerless. Instead, this research shows that women are active participants who use negotiation, trust, and relational understanding to advocate for their health. The implications are clear: improving maternal well-being requires engaging with the family structure itself, transforming it from a site of control into a network of care.

Theoretically, this study reframes how gender and authority are understood in patriarchal societies. It supports the idea that patriarchy is not a fixed system but a social process that can evolve through education and everyday interaction. Women’s agency operates within these systems, not outside them. By voicing needs, seeking medical help, or involving husbands in decision-making, women subtly reshape cultural norms that once silenced them. This research therefore deepens our understanding of family systems theory and feminist health perspectives by showing that social change often begins at the household level, where shared understanding replaces hierarchy.

From a policy perspective, the results suggest that health interventions should not isolate women from their families but include those families as allies. Programs that encourage spousal communication, provide couple-based counseling, and train community health workers to engage in-laws can bridge the gap between trust in medicine and the freedom to act on it. Expanding education for both men and women remains essential, as knowledge empowers families to move away from harmful customs toward evidence-based care. By focusing on collective education and trust, policymakers can promote care environments that support rather than limit women’s recovery.

Culturally, the findings highlight an ongoing transformation in how families perceive care and authority. Younger, more educated couples often practice forms of partnership that were rare in earlier generations. These evolving relationships reveal that traditional values and modern health practices do not have to conflict; they can coexist when grounded in empathy and communication. This gradual shift from control to cooperation represents a quiet cultural revolution within Pakistani households, one that holds the potential to improve maternal outcomes across communities.

At the emotional and familial level, the research reveals that support functions as a form of healing. When husbands share household work, when mothers-in-law encourage rest rather than judgment, and when women feel safe expressing discomfort, recovery becomes both physical and emotional. Better support creates better pregnancies, not only because it improves access to care but because it restores dignity and peace of mind. Families that nurture women during the postpartum period create cycles of trust that benefit future generations.

Although this study offers important insight into how family structures influence. Because the research was conducted exclusively at the Civil Hospital Gynecology Clinic in Sialkot, the findings likely reflect the experiences of women who have at least some level of access to biomedical care. This means the results may be skewed toward women who are more open to seeking medical help, more trusting of healthcare providers, or more financially and socially able to visit a public hospital. Women who cannot reach facilities at all, or who rely on home births, traditional healers, or private clinics, may face different barriers that are not captured in this sample. If the study had taken place in a rural village, the results might have shown stronger effects of geographic isolation, poverty, or elder family control on postpartum care-seeking. Similarly, a study in a private hospital might have highlighted how wealth shapes access to higher quality services and stronger trust in providers. Using a different research design, such as in-depth interviews or home observations, might also have revealed more detailed information about women who avoid or delay postpartum care entirely. These possibilities show that the sample likely leans toward women who are able to access public healthcare, and future work in alternative settings would provide a fuller picture of postpartum experiences across Pakistan. Additionally, while in-person oral surveys minimized literacy barriers and allowed clarification of questions, they sometimes limited depth, as responses were brief and constrained by time and setting. The modest sample size further restricts generalization to the national level.

Nonetheless, these constraints do not diminish the study’s significance. By centering women’s firsthand narratives within existing family power hierarchies, this research highlights how maternal recovery is shaped less by medical access alone and more by cultural authority within households. Even within a localized setting, these findings illuminate broader social patterns, offering a foundation for future studies and policy efforts aimed at balancing familial influence with maternal autonomy in postpartum care.

In conclusion, this study shows that family authority in Pakistan can either suppress or sustain maternal health, depending on how it is practiced. Education, trust, and shared responsibility act as turning points that redefine what care looks like within patriarchal systems. The research reminds us that true progress in maternal health will not come only from new hospitals or doctors but from reshaping the relationships at home. When families become partners in healing, postpartum care transforms from a private struggle into a collective act of compassion and empowerment.

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About the author

Eshal Afzal

Eshal Afzal is a senior at West Windsor–Plainsboro High School South whose academic work focuses on maternal health, gender equity, and the sociocultural dynamics of postpartum care. She conducted survey-based field research with postpartum women at the Civil Hospital Gynecology Clinic in Sialkot, Pakistan, under the guidance of Dr. Bart Bonikowski.

She is also the founder of Nisa Maternal Care, an initiative providing postpartum health kits and educational support to underserved women. Her broader interests include medical anthropology, global health, and women’s health in low-resource settings.

The post Beyond Access: How Family Power Dynamics Shape Postpartum Care in Pakistan appeared first on Exploratio Journal.

Abstract:

Numerous studies have been conducted regarding the outcomes of COVID-19 on the world healthcare system, the global economy, and on mental health, as well as what epidemiological factors contributed to the spread of the virus. However, little research has been completed to analyze other factors that helped the disease thrive, beyond the characteristics of the virus itself, and where society stands today as it prepares for a possible future epidemic.  

The objective of this paper is to critically analyze the primary body that was tasked with controlling a pandemic – the World Health Organization (WHO) – and the measures they put in place – The International Health Regulations (IHR) – to manage the risk of an event like COVID-19. More specifically, through case studies and examples drawn from the pandemic response efforts, along with directional input from a former staff member of the WHO, the research will dig into what non-biological aspects contributed to the spread of the virus, what steps have been taken by the WHO since, and what potential gaps still exist today.

By advocating for improved international public health collaboration and concerted efforts to enhance pandemic preparedness, this research contributes to the intellectual discourse on mechanisms to help ensure a more-resilient response to future global health threats in an increasingly interconnected world.

Keywords: COVID-19, WHO, IHR, IHR 2005, PHEIC

I. Introduction

Founded in 1948, the World Health Organization (WHO) is a United Nations agency of 194 member states that is tasked with promoting health on a global scale. Because a key element of its charter is to help prevent the spread of serious public health threats beyond a country’s borders, the WHO later established the International Health Regulations (IHR) to more effectively control specific highly contagious diseases. These regulations have been updated multiple times since their adoption in 1969, including important changes contained in a revision called IHR 2005, to deliver even better protection worldwide.

Despite the WHO’s efforts to put a foundation in place for effectively addressing a pandemic (with the IHR and its amendments), COVID-19 exposed serious gaps in global preparedness. A lack of transparency and sharing of information across countries underscored the need for quicker identification and collaboration worldwide. Clear differences in how member states reacted once a pandemic was declared highlighted the need for more consistent reporting and response. And considerable differences in the containment strategies used by these countries to slow the spread of the disease, both inside and outside their borders, shined a light on the inadequacies of the existing regulations.

In the years following the deadly outbreak, countries have banded together to revise and update the IHR even more. In June 2024, additional amendments were announced, which included a clearer definition of a pandemic emergency and a more-effective way to declare one. Member states also made a recommitment to solidarity and equity, and they agreed to better share resources in the future to prevent (and collectively respond to) similar outbreaks.

This paper aims to better understand the shortfalls of IHR 2005 – the version of the regulations in place at the time of the COVID-19 outbreak – that led to less-than-ideal responses. It will also evaluate the potential effectiveness of the most recent 2024 amendments and identify possible roadblocks to success in addressing a future public health threat of a similar magnitude, as well as offer suggestions for better future pandemic management.

II. Overview of COVID-19 and the Role of IHR

A. Background on COVID-19

COVID-19, was caused by the SARS-CoV-2 virus, a novel coronavirus that is part of a family of viruses that includes those responsible for the common cold, as well as more severe illnesses like SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). Coronaviruses are characterized by crown-like spikes on their surface, which helps them attach to host cells. Genomic sequencing of SARS-CoV-2 revealed it to be closely related to coronaviruses found in bats. It also shares similarities with the virus responsible for SARS, suggesting (although disputed) that it may have originated in bats and then jumped to humans, possibly through an intermediary host, which is a phenomenon known as zoonotic spillover. (Lora, 2021). 

COVID-19 reportedly first emerged in December 2019 in Wuhan, Hubei Province, China. The initial cases were linked to a seafood market in Wuhan, which also sold live wild animals. By January 2020, COVID-19 cases were spreading rapidly in Wuhan, leading to the imposition of localized lockdowns and travel restrictions. (History, 2023). Due to its many transmission methods the disease was already in a position to spread across borders as worldwide travel generally continued. 

On March 11, 2020, the WHO declared COVID-19 a global pandemic. The decision was based on its rapid and widespread transmission, the likes of which the world had not seen for more than a century with the Spanish Flu in 1918. The virus soon spread to other countries, primarily through international travel, and it reached 200 countries in just months – quickly reaching Europe, North America, and around the globe. This outbreak led to widespread health crises, economic disruptions, and societal changes. (WHO, 2024). 

B. Background on the WHO and its Relationship with IHR

Headquartered in Geneva, Switzerland, the WHO is a specialized agency of the United Nations, which was established on April 7, 1948. This date, now celebrated annually as World Health Day, marks the beginning of a global effort to improve health standards and manage health crises on an international scale. (WHO, 2021). WHO’s core mission is to promote health, keep the world safe, and serve the vulnerable, encompassing a broad array of activities aimed at enhancing global health standards and coordinating international health efforts. (WHO, 2024).

The WHO operates through a structured governance system. The World Health Assembly (WHA), its decision-making body, comprises representatives from all member states and convenes annually to set policies, approve budgets, and make critical decisions on health issues. (WHO, 2021). The Executive Board, composed of 34 members elected for two-year terms, implements WHA decisions and provides guidance on health policies and programs. The WHO Secretariat, led by the Director-General, manages the organization’s daily operations.

Among its many functions, the WHO is known for developing international health standards, providing technical assistance to countries, and monitoring global health trends. It also plays a crucial role in disease prevention, strengthening health systems, and helping coordinate emergency response. Notable achievements include the eradication of smallpox and ongoing efforts to control polio, which underscore the WHO’s significant impact on global health. (WHO, 2021).

The IHR is an international legal agreement first adopted in 1969 by all 194 WHO member states with the goal of managing specific diseases such as cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. (WHO, 2021). However, as global health threats evolved, so too did the IHR with several changes adopted over the next 35 years. 

In the early 2000s, the IHR was revised once more to address an even broader spectrum of public health emergencies, reflecting the changing nature of worldwide health risks and the impact of globalization. This latest set of amendments, called IHR 2005, were introduced to prevent, protect against, control, and provide a public health response to the international spread of diseases while minimizing unnecessary interference with international travel and trade. It was the version of the IHR in place when COVID-19 first emerged. 

In more recent years, the IHR was updated once again, covering all public health emergencies – not just those related to specific diseases – and emphasizes a comprehensive approach to health security. This includes requirements for countries to develop and maintain core capacities to detect, assess, notify, and respond to public health threats. (Taylor, 2020).

III. Shortcomings of IHR 2005 Exposed by COVID-19:

Even though the WHO worked hard to prepare for a pandemic, including the approval of IHR 2005, it was not fully prepared for a disease that spread with the speed and ease of COVID-19. In retrospect, there were critical gaps in its regulations – and in how each member state interpreted and executed them – that led to delayed and inconsistent compliance. Ultimately, these problems had national and global repercussions, including the death of millions of people, the investment of trillions of dollars in relief, and a significant impact on people’s mobility, work, and even mental health. These are some of the key shortcomings that were exposed:

A. Slowness of Declaration of a PHEIC

One clear gap in IHR 2005 was how and when a Public Health Emergency of International Concern, or PHEIC, is declared. A PHEIC is defined by the IHR as “an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response.” The purpose of declaring a PHEIC is to prompt global cooperation and mobilize resources for a coordinated response to manage and contain health emergencies. (Stuckleberger, 2020). This designation facilitates the implementation of measures and strategies to prevent the spread of the disease and reduce its impact on global health.

Despite early indications of a novel respiratory illness in China in late 2019, a PHEIC was not declared until January 30, 2020. (History, 2020). This delay was in part caused by China placing considerable effort into suppressing information and attempting to prevent critical test results from leaving China’s borders, but it was also caused by an apparent lack of clarity on the wording of what constitutes an extraordinary event. 

The results of a delayed PHEIC were significant on a global scale, with clear implications to global response timing, coordination, and resource allocation. For instance, WHO noted that a late start dampened efforts to mobilize resources, coordinate surveillance, and deploy critical medical supplies and personnel to affected regions. (WHO, 2024). In order to prevent similar results in the future, new language and alignment on the definition of a PHEIC would be needed, and the WHO would need to provide greater assurances to individual countries that sensitive information would be protected in order to encourage them to willingly share information. 

B. Delayed Reporting and Fragmented Response Mechanisms

Effective pandemic response hinges on the prompt and transparent reporting of outbreaks by member states. As mentioned, the initial reaction to COVID-19 was compromised by local Chinese authorities hiding information and downplaying the severity of the situation. However, other countries around the world also established barriers in reporting cases and sharing crucial information about the virus. This inability, or unwillingness, to comply with reporting obligations specifically called out by IHR 2005 led to critical global delays in assessing the gravity of the problem and the timing of a coordinated counterattack.

A second component of response that broke down during the pandemic was the consistency in which corrective efforts – called the “response mechanism” – were carried out worldwide. Many countries, particularly low and middle-income nations, struggled to allocate adequate funds for surveillance, laboratory capacity, and public health infrastructure. (Jones, 2021). They simply had too many domestic needs competing for limited resources, and thus reacted with varying degrees of effectiveness. Compounding the problem, the WHO’s ability to support these countries of lower socioeconomic status with technical assistance and financial support was hindered by funding shortages and competing global health priorities. This divide highlighted the urgent need for sustainable financing alternatives to bolster global health security and enhance pandemic preparedness, as well as more-effective prioritization amongst states themselves, to deliver a more-complete response mechanism worldwide.

The combination of delayed reporting and a fragmented response mechanism delivered a perfect environment for a pandemic to thrive. Inconsistencies in how countries communicated about the health risk highlighted vulnerabilities in the enforcement of the IHR 2005. (Stuckleberg, 2020). Added to this, a significant variance in the protections put in place by individual member states to control the spread of the disease resulted in cracks that led to a faster spread. Together, these challenges put the WHO in a position where it was not able to effectively execute on its mission. 

C. Inconsistent Compliance with WHO Recommendations on Travel Restrictions and Quarantines Across Member States

A third and critical deficiency of IHR 2005 was also uncovered by the pandemic: containment. The IHR recommends travel restrictions and quarantine to curb the spread of disease, while minimizing disruptions to international travel and trade. These guidelines are based on scientific evidence and aim to protect global health by advising member states on proportionate measures. (UN, 2020). 

 At the onset of the pandemic, countries implemented travel restrictions at different times based on their assessment of the threat and local public health capabilities. Some nations, such as New Zealand and Australia, quickly imposed strict travel bans and border controls. In contrast, other countries were slower to act, or they implemented partial measures at first – allowing the virus to spread more widely before restrictions were enforced. (Illmer, 2021). 

Quarantines were also not consistent in terms of scope. For instance, some states imposed comprehensive bans on non-citizens and non-residents, while others were less stringent, particularly within their region. Some countries also enforced strict protocols for travelers arriving from high-risk areas, including mandatory health screening and isolation in designated facilities for multiple days. Other countries allowed self-isolation at home or imposed less-rigorous monitoring and enforcement, leading to varying levels of effectiveness in preventing virus transmission. (Illmer, 2021). 

Finally, the extent and frequency of testing for travelers varied widely from one member state to another. Some required multiple tests and proof of negative results, which might have included a mix of tests taken before departure, upon arrival, during a stay, and before return. Other countries required less-frequent testing – sometimes just at arrival or departure, if at all. (Illmer, 2021). 

These differences in approach prevented authorities from detecting and isolating cases quickly. Importantly, the inability to contain the virus also led to more, and faster, mutations – making it even more difficult to diagnose and treat the symptoms, as well as to build an effective vaccine for prevention and elimination. To limit the scale of future pandemics and drive more consistency in the implementation of containment techniques, the WHO would need to better manage numerous factors, including clearer rules, consistent health infrastructure, social factors, and even communication barriers. 

IV. Recent Responses to Address Shortcomings: Amendments to IHR 

While IHR 2005 represented a considerable step forward from its predecessors in terms of preparing the world for a global pandemic, COVID-19 exposed a number of inadequacies in it as well – particularly in the areas of declaration, response, and containment. One of the best ways to address these deficiencies on a global scale was to adjust the IHR even further, which was completed by the WHO in 2024 with a new set of amendments. Below are some of the most important changes that were included.

A. PHEIC and Pandemic Emergency Declaration

Article 54 of the 2024 IHR amendments represents a critical element in the revision process aimed at improving the management and response to PHEIC. This article specifically sets out to address the conditions under which a PHEIC is declared and managed, as well as streamline the PHEIC process, enhance the effectiveness of global responses, and ensure that future emergencies are managed more efficiently. (WHO, 2021).

Specifically, the language now includes better guidance on how to assess the severity of the health threat, its potential for international spread, and the impact on public health systems. (WHO, 2024). It also requires the WHO to assess potential emergencies more promptly, with predefined timelines for decision making and communication. And in addition to addressing past delays in emergency identification, these changes also seek to reduce the risk of premature or inappropriate declarations that may distract important resources during an emergency, by ensuring that only events meeting these stringent criteria are classified as PHEICs.

Once a PHEIC has been named, there is also a need for ongoing assessment of them. Article 54 introduces the concept of mandatory periodic reviews. The WHO Emergency Committee is now tasked with evaluating the status of each in-process PHEIC at regular intervals. (WHO, 2024). These reviews assess whether the conditions warrant the continuation of the PHEIC status, or determine if the status should be downgraded or lifted. This action, which includes evaluating ongoing risks and the effectiveness of response measures, ensures that the PHEIC designation remains relevant and appropriate based on the evolving situation. (Farge, 2023).

B. Reporting and Response in the Context of IHR Amendments

IHR 2005 introduced significant enhancements to promote transparency in information sharing among member states and with the WHO. These amendments were integrated into multiple sections of the IHR, notably Article 10 which focuses on the dissemination of information, and Article 11 which addresses confidentiality and publication of information (Searchinger, 2024).

During the COVID-19 pandemic, the challenges of transparency under the IHR 2005 were highly visible. Timely and complete sharing of information between Chinese health authorities and the WHO would have been essential in understanding the nature and severity of the emerging threat. These initial delays, and inconsistencies in reporting and information sharing, greatly impacted early international awareness and response efforts. (WHO, 2024).

Under the latest 2024 amendments, there is a clear emphasis on comprehensive information exchange during public health emergencies. Member states are now further obligated to share timely and accurate data related to disease outbreaks, public health risks, and planned response measures with the WHO and other relevant stakeholders. (Farge, 2023). This includes epidemiological data, laboratory findings, surveillance reports, and best practices in outbreak response.

The amendments also clarify the confidentiality provisions outlined in Article 11, ensuring that sensitive information is appropriately protected while facilitating the dissemination of critical health information. (IHR, 2024). The combination is intended to promote openness and collaboration among member states, aiming to foster a unified global approach to managing health crises.

C. Coordinating Financial Mechanism

Another key revision now included in the IHR is the Coordinating Financial Mechanism, which aims to break down financial constraints and improve the allocation of resources during health emergencies. The introduction of this mechanism reflects the lessons learned from past crises, including the 2014 Ebola outbreak and the COVID-19 pandemic, which highlighted the need for more-robust financial coordination and support. (WHO, 2021).

The primary goal of the Coordinating Financial Mechanism is to ensure that sufficient funds are available for effective response to public health emergencies. This includes covering the costs associated with emergency interventions, such as medical supplies, vaccines, and treatments. By securing a reliable funding source, it intends to eliminate financial barriers that may hinder timely and effective responses to health crises. (Stucklerberger, 2020).

The newly defined mechanism also seeks to improve coordination among various funding sources, including governments, international organizations, and private sector entities. This involves streamlining financial contributions and ensuring that resources are allocated efficiently and transparently. The enhanced coordination helps avoid duplication of efforts and ensures that financial resources are directed to where they are most needed, thereby improving the overall effectiveness of the response. (Stucklerberger, 2020).

Lastly, in order to create and build capacity, this mechanism focuses on expanding resources, particularly in second and third-world countries. This includes funding to strengthen health infrastructures, improve surveillance systems, and train healthcare workers. By addressing capacity gaps, it aims to improve the preparedness and response capabilities of countries with limited resources, ensuring a more equitable and effective global response. (Miller, 2024).

V. Looking Ahead: Geopolitical Challenges to Global Health Cooperation

The 2024 amendments to IHR 2005 represent meaningful progress in the preparation for the world’s next great pandemic. However, there is still work to be done. Additional obstacles, which previously stood in the way of a unified, global response during COVID-19, will likely remain in place even after the latest changes are implemented. Largely geopolitical in nature and driven by individual countries’ own unique political, economic, and social priorities, these ongoing challenges may require additional clarification, diplomatic efforts, or new amendments to ensure consistent execution against the obligations set out in IHR. 

A. Vaccine Nationalism

Vaccine nationalism emerged prominently during the COVID-19 pandemic, where wealthier nations prioritized securing vaccine doses for their populations through bilateral agreements and domestic production. This approach resulted in disparities in global vaccine distribution, with low-income countries facing delays in accessing vaccines through multilateral initiatives like COVAX (Miller, 2024). 

For instance, countries like the United States and numerous European nations signed early procurement deals with vaccine manufacturers, ensuring rapid vaccination of their populations. In contrast, many third-world countries struggled to secure sufficient vaccine supplies, prolonging the pandemic’s impact on their vulnerable populations. Agreements on vaccine equity and balanced distribution will be necessary to prevent a similar situation in the future. 

B. Political Tensions and Information Sharing

Long-standing tensions among certain member states likely contributed to delays in information sharing and cooperation during the initial stages of COVID-19. China is a known political rival of the United States and other Western countries, which gave them an incentive to withhold critical epidemiological data coming out of Wuhan from the rest of the world in the early days of the pandemic. This, of course, disrupted early global awareness and response efforts, allowing the virus to spread beyond China’s borders before global countermeasures were fully in place. 

China was highly criticized about its lack of information transparency and timely notification to international health authorities. (Miller, 2024). However, past criticism largely from existing rivals may not be enough to change this behavior in the future – particularly when officials may see sharing sensitive information as a sign of geopolitical weakness or as a national security threat. The confidentiality provisions outlined in Article 11 are designed to help prevent these practices, but nationalistic tendencies are more likely to win out during a crisis. Additional international relations efforts by individual states to solidify alignment on global health priorities will be necessary, as will unified global pressure to adhere to the amended principles of IHR.

C. Trade and Export Restrictions

One of the most essential worldwide needs during the pandemic was for healthcare items like respirators, which were critical for some of the hardest-hit COVID patients to breathe. Expecting a high demand domestically for these medical supplies and related personal protective equipment (PPE), numerous countries implemented international trade restrictions and export bans on them. Such protectionist measures disrupted global supply chains and exacerbated shortages of essential medical supplies in regions heavily impacted by COVID-19 (Miller, 2024). 

Similar to what led to vaccine nationalism, country leaders will be tempted in future healthcare crisis situations to protect their citizens first. A commitment to preventing these practices – via additional clarifications to the IHR, or even new amendments – will be needed to avoid putting overseas frontline workers and vulnerable populations at greater risk. Additional diplomatic efforts will also be necessary to ensure open, international cooperation in pandemic response.

VI. Conclusion

COVID-19 highlighted a critical need for transparent communication, enforceable mechanisms, and equitable distribution of resources to ensure effective preparedness and response. IHR 2005 provided a solid starting point to accomplish these core objectives, but a number of deficiencies were exposed during the height of the pandemic that led to unnecessary worldwide disruptions, spending, and suffering. 

The latest round of amendments, which were adopted in June 2024, address some of the most important gaps in IHR 2005 including those related to declaration, response, and containment. They represent the coordinated effort of the WHO and its member states, and they are likely to further enhance global resilience against future health threats and foster international solidarity in health crises. 

However, there are still obstacles to be overcome – most notably geopolitical factors such as vaccine nationalism, political tensions affecting information sharing, and trade barriers – which can lead to disparities in vaccine distribution, delayed international cooperation, and strained global health governance processes. As we reflect on the lessons learned from COVID-19, it becomes evident that investing in global health security frameworks is not only a moral imperative but also a strategic necessity that will require ongoing clarifications, amendments, and diplomatic ingenuity.  

VII. Acknowledgments

The author of this paper would like to acknowledge Dr. Allyn Taylor – for her support throughout the writing process.

VIII. References

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About the author

Sydney Garber

Sydney Garber is a senior at Capital High School in Boise Idaho. She is a top ten student in her class and is actively involved in student government and mock trial, as well as an all-state softball pitcher.

Sydney intends to study international relations in college, with a long-term goal of becoming a foreign diplomat or working at the United Nations. To that end, she is the campus captain of a statewide program to drive voter registrations and has interned at the DACOR-Bacon House in Washington DC – an organization dedicated to leaders in international relations and foreign policy.

In addition to pursuing her career aspirations, Sydney is also an active volunteer. She is Founder and President of The Iron Butterfly Initiative – an organization dedicated to advancing mental health in women’s sports – which has been covered by the Associated Press and more than 250 media outlets worldwide. She is also a founding member of the Idaho branch of the National Charity League, where she served as Vice President of Philanthropy and Vice President of Programming.

The post The Short- and Long-Term Shortcomings of the International Health Regulations (IHR) Exposed by COVID-19 appeared first on Exploratio Journal.

Abstract

This review examines three key factors that impacted vaccine hesitancy among the elderly during China’s COVID-19 pandemic in 2020-2022. The elderly are a high-risk group for a poor outcome from COVID-19 due to preexisting factors such as comorbidities. Even once a vaccine was available for them in China, there was great reluctance for the elderly to get fully immunized. This reluctance to vaccination provides an essential and helpful example for future generations so we can learn from the past to implement safety measures and prevent deaths. This review offers the additional benefit of making this example better known to a broader audience on a global scale.

The three factors contributing to vaccine hesitancy among the elderly that are examined in this paper are the role of vaccination policy, health literacy, and coping skills. China’s initial exclusion of the elderly from the vaccination guidance, coupled with strict eligibility requirements, led many to perceive the vaccines as dangerous. Low health literacy causes the elderly to rely on unverified social media sources, spreading misinformation. Lastly, factors such as stress and isolation drove vaccination avoidance behaviors, hindering access to medical care and information. This review offers valuable insights into the complex drivers of vaccine hesitancy in China’s elderly population, informing future public health strategies.

Introduction

As a novel airborne viral infection, SARS-Cov-2 (commonly known as COVID-19) spread globally soon after its discovery in Wuhan, China, in 2019. The pandemic eventually resulted in 7 million deaths and three-quarters of a billion cases of infection through 2022(World Health Organization, 2024). Globally, the elderly and immune-compromised comprised the majority of deaths during the first two years of the pandemic. China, in particular, was hit hard because it has 200 million elderly, defined as individuals aged 65 and above. While China had ranked among the top countries for life expectancy pre-pandemic, it was estimated that the elderly comprised 76.51% of deaths during the first year of the pandemic (China CDC Weekly, 2023).

Despite being the most vulnerable demographic, the elderly demonstrated the most vaccine hesitancy in China. Vaccination hesitancy refers to the delay in acceptance or refusal of safe vaccines despite the availability of vaccination services (World Health Organization, 2015). According to the World Health Organization, vaccine hesitancy is influenced by confidence, misinformation, complacency, and convenience. Now that nearly two years have passed since the COVID-19 health crisis, more evaluation can be done on the factors contributing to vaccine hesitancy. This paper thus seeks to examine the three most prominent factors of the government’s initial vaccine policy, health literacy, and the efficacy of the elderly’s coping strategies that contributed to high vaccine hesitancy to determine the most culpable factor.

Vaccination Policy

In China, vaccination hesitancy in the elderly population appears to have been influenced by the delay in their eligibility for the vaccine, as determined by China’s policies at the beginning of 2021. China was able to develop a vaccination against COVID-19 at record speed, which became available by January 2021, and was cautious in its implementation (Wang et al., 2023). According to an article by Wang et al. in the magazine Nature Medicine, the Chinese “government excluded older populations (those aged 60 or older) from its early vaccination guidance” for COVID-19, fearing the comorbidities and potential for harmful side effects that the elderly populations may be susceptible to (Wang et al., 2023). In setting this policy, China considered its rapidly aging population, with the population shrinking in the magnitude of hundreds of millions, and recognized the need to prevent as many deaths as possible, even from deaths resulting from vaccination side effects. This same reasoning underlined its Zero-COVID Policy that strove to reduce COVID-19 infections in China. The dynamic zero-COVID policy sought to identify the early onset of cases through frequent screening and isolate the infected individual to pre-empt any chance of widespread cases (Ba et al., 2023). Even before the onset of the COVID-19 pandemic, the Chinese policy of non-pharmaceutical interventions, or NPI policy, already reflected the government’s concern about deaths caused by the side effects of medicine (Mohamadi et al., 2021). In the same spirit, the Chinese government introduced a policy that excluded the use of vaccination to protect the elderly in the first two months of vaccination use. During those two months, the greater general population could observe the efficacy and any potential unknown harmful side effects from vaccination. The necessary delay and initial exclusion of the elderly from COVID-19 vaccination may help to explain the death toll in the first half of 2021.

Understanding that the 200 million elderly in the country were more vulnerable since many had existing and chronic conditions, the government also deferred to the elderly to be vaccinated at their own pace instead of encouraging them to be vaccinated earlier like some of the younger groups (Peng, 2023). Unfortunately, vaccine hesitancy among the elderly became a persistent problem after the vaccinations were deemed safe for use. Part of this may have been due to continuing restrictions. As of April 2021, requirements for the elderly population to be eligible to receive vaccination shots remained higher than other demographic groups. All elderly were required to have blood pressure within a specific range, and many were disqualified because their pressure was too high (Wang et al., 2023). In addition, anyone with a preexisting chronic condition, such as diabetes or kidney disease, was disqualified on the grounds of “contraindication.” Regrettably, many elderly who were otherwise eligible interpreted the strict requirements for vaccination as indicative of the vaccine’s potential danger to their age population.

In late 2021, a new strain of the virus known as Omicron – not as lethal as previous strains but spreading much more quickly – also led many to believe that the existing vaccinations were mistakenly ineffective. Between those who were not eligible and those who were fearful, millions of elderly were not vaccinated (Zhao et al., 2022). This fear would persist until 29 November 2022, when the government policy emphasized that all elderly should be vaccinated. Thus, it can be seen that in the intervening time – almost two years – a large proportion of the elderly population in China, for one reason or another, were not vaccinated. The extensive infarction rate and high mortality figures amongst the elderly can be attributed to this vaccination hesitancy.

Health Literacy

Despite the elderly Chinese people over the age of 65 having a literacy rate of 85%, which is a high number compared to the world average, health literacy among them is much lower (Trading Economics, 2024). Health literacy is defined as “the degree to which individuals have the ability to find, understand, and use information and services to find health-related decisions and actions for themselves and others” (CDC, 2023). One of the factors contributing to relatively low health literacy rates is how information is disseminated in China, especially in rural areas. Instead of looking for trustworthy articles published by reliable universities and studies online and even reliable news channels, many tended to rely on word-of-mouth and information that originated from unverified sources on the internet. As a result, hearsay and social platforms like WeChat proved much more potent than state media, especially without internet research-based culture (Zhu et al., 2022). Therefore, a closer examination of how the Chinese elderly population engages with information on vaccinations sheds light on why so many were misinformed and held negative views of the vaccinations.

One aspect of the misinformation was the sheer amount of contradicting information floating around either on WeChat or among rumors circulating in rural areas through word-of-mouth. According to a study by Xudong Gao, Feng Ding, et al., “72.3% of elderly participants reported COVID-19 information avoidance”, citing “information overload.” The high number indicated that many elderly found too much contradictory information on COVID-19, and it was difficult to ascertain the truth from fear-mongering articles (Gao et al., 2022). As such, many chose to avoid reading COVID-related articles altogether, instead remaining ignorant. This study concluded that the Chinese health authorities could have done a better job communicating the importance of vaccination and proper ways to protect themselves. Another article written by Pan Li, Zhong Jiaming, et al. corroborates the findings by Gao and Ding, which state that health information literacy in China is relatively low. Almost 85% of all participants scored less than 60 points on a 100-point system, indicating that the elders’ understanding of other vaccines and how COVID might impact them was very low (Li et al., 2022). This low health information literacy could be attributed to the education level and the absence of information tailored toward the elderly, who might not have been as well-educated as their young counterparts.

The difficulty controlling the spread of misinformation regarding the harmful side effects of vaccination on social messaging platforms like WeChat further exacerbated the collective reluctance of the elderly in China to want to be vaccinated (Zhu et al., 2022). Since there is no vetting process on WeChat, conspiracy theories and misinformation regarding COVID are spread quickly. Anyone can post videos regarding COVID-19, irrespective of background. Furthermore, the ease of sharing the links in family groups aided in the spread of misinformation regarding COVID-19, in particular, fear-mongering regarding the danger of vaccinations (Gao et al., 2022). Furthermore, the researchers found that because respect for the elderly is so entrenched in Chinese culture when the elderly generation shared a conspiracy theory or misinformation regarding COVID-19 on WeChat, the younger generation was reluctant to challenge or debunk them. This reluctance helps to explain why the conspiracy rate amongst the elderly was high and their health literacy was low (Zhu et al., 2022).

In a study conducted on COVID-19, information on WeChat was found to influence health behavior based on criteria considered by the Health Belief Model (HBM). HBM predicts health behavior based on one’s perception of disease. Therefore, This model is the most prevalent model used to study behavior-related changes related to vaccinations. (Wu et al., 2023). The study found that 89% of all the papers published on WeChat were not associated with any academic institution (Wu et al., 2023). Thus, the truthfulness of its findings could not be verified or further evaluated for credibility. The most popular articles viewed by users during this period were vaccination effectiveness and disease protection. The paper suggested that the WeChat platform significantly altered the public perception of vaccination efficacy and its side effects, contributing significantly to vaccination hesitancy (Wu et al., 2023). Hence, by analyzing the health literacy rate in the elderly Chinese population and the widespread use of media platforms such as WeChat, it is clear that health literacy was a major factor in creating hesitancy against vaccination, likely contributing to the higher infection and mortality rate amongst the elderly. Coping Strategies and Other Health-Related Behaviors

Another essential factor to consider in relation to vaccine hesitancy during the COVID-19 pandemic among China’s elderly is coping skills or coping strategies, which are based on existing medical knowledge and the ability to access necessary medical care. Coping is defined more broadly as “the thoughts and behaviors mobilized to manage internal and external stressful situations… aim(ed) to reduce or tolerate stress” (Algorani et al., 2023). During the COVID-19 pandemic, coping was needed by the elderly population in China to alleviate stress, fear, and depression. Coping skills or strategies also include health-related behaviors such as frequent use of hand sanitizer, scheduled hospital visits, and tests to prevent the infection of COVID-19. Despite the recognized benefits of staying in touch with social groups, many elderly people in China displayed avoidance behaviors during the pandemic that went beyond physical contact, resulting in a reduction of information-communication technology such as face calls (Tang et al., 2023)—cumulatively, two and half years of isolation caused much psychological distress to many due to loneliness. Another independent study done by a Japanese team also confirms the direct link between psychological distress and the perceived feelings of loneliness engendered by isolation (Konno et al., 2021). There were also some spatial differences in coping skills displayed during the pandemic, as identified in a survey conducted by Wu, Zhang, and others(2022). In this survey, participants in Northeast China, which is less economically developed, tended to score higher on fear as a factor compared to the generally better-educated Southwest provinces, which had access to better news. This suggests that coping skills also depend on correctly interpreting news, staying informed, and managing one’s fear of COVID-19.

A specific factor that hinders coping skills and other health-related behaviors is stress. Research has shown that stress during the pandemic was induced by worries over being infected, excessive protective behavior, and frequency of access to COVID-19 news, and contributed to an increased proportion of elderly with anxiety disorders (Wu et al., 2022). The study also found that patients’ resilience directly correlates with how much an individual fears COVID-19 and how often they engage in physical exercise to keep their minds and bodies healthy (Wu et al., 2022). Those who were more afraid scored higher on the stress scale and, on the whole, struggled to find effective coping mechanisms such as exercise and maintaining key social contact. In other words, the elderly who were more afraid tended to self-isolate more (not go out, socialize through phone or social media) or exercise. This fear would drastically impact their stress level compared to those who engage in some form of socializing. Only 34% of the 800 elderly studied during the pandemic said they used social media actively to engage with their families and friends, which explains why the level of education played a role. The subjects with additional years of schooling tended to adopt better-coping mechanisms such as exercising, educating themselves, and maintaining social contact through modern technology. The less educated elderly subjects were less proficient with technology. Granted, under strict lockdown, many could not physically see their friends and family, and the parks were also shut down. In such circumstances, those with access to technology had greater coping skills. Economically, those who owned a garden or more private space also tended to do better for their mental and physical health (Kastner et al., 2023). Another study also supports that offering and receiving social interactions helped the elderly with their mental well-being and, by extension, their coping strategies, such as seeking help and advice from friends and loved ones (Tang et al., 2023). Furthermore, the elderly, like individuals of other ages who trusted the government’s policies and were confident in their community and medical professionals, also became less stressed, wore masks, and got vaccinated (Tang et al., 2023). They were also better able to adopt better health-related behaviors such as going for a walk, eating more protein, and proactively getting tested routinely. The study concluded that those who could maintain a positive mindset of trust and settle into a routine could better manage their fear and health situation. The proper mindset and support system proved the critical difference to more resilient and healthier individuals within the elderly group.

Discussion

The government policy regarding vaccinations, where the elderly were asked not to be vaccinated for the first two months after the inception of the vaccination and had further restrictions once eligible, unfortunately, contributed to vaccine hesitancy among this population. Social media platforms in China, most notably WeChat, picked on this information and amplified it. Consequently, the elderly population who were vulnerable to misformation became more afraid of the vaccination due to conspiracy theories and distortion of facts they saw on WeChat. In hindsight, additional efforts to educate the elderly on health literacy might have increased the vaccine uptake among the elderly and improved their ability to cope during the pandemic. The studies covered in this research paper all point to the fact that vaccination hesitancy as a result of misinformation and low health literacy adversely impacted the elderly’s capacity to cope with the pandemic.

The lack of health literacy played a unique and vital role in fueling vaccination hesitancy and reduced coping skills among the elderly during the COVID-19 pandemic. Although the initial vaccine policy precluded the elderly from receiving vaccinations in China, the government soon made it abundantly clear that vaccination would effectively mitigate the spread of COVID-19 and reduce the severity of the symptoms in this age group. The misinformation regarding vaccination had already spread, however, especially among the elderly, who tended to access information regarding the disease through social media sites and conversations with their peer instead of official medical sources. This played a greater role in the educated and more rural regions of the Northeast instead of the country’s more urban, better-educated Southeast region. Differences in health literacy also affected coping mechanisms and physical/mental health regulation. The less someone receives updated and official data, the more likely the person is to be vaccinated due to unfounded fear.

Conclusion

The large and growing number of elderly in China posed a unique challenge during the COVID-19 pandemic. This was partly due to the difficulty of protecting them from a virus they were especially vulnerable to, given their comorbidities and weakened immune systems. Vaccine hesitancy exacerbated the situation in China due to the elderly population’s comparatively low health literacy and the vaccine rollout for this age group. This paper highlights a valuable lesson on the interplay of factors impacting vaccine hesitancy. Improving health literacy among the elderly may improve how this population responds to future challenges.

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About the author

Jamie Diao

Jamie is a current 11th-grade student at HKIS. Some of his interests include subjects such as Biology and Chemistry, and he enjoys playing football in his free time.

The post Factors Impacting Vaccine Hesitancy Among the Elderly During the COVID-19 Pandemic in China: A Review appeared first on Exploratio Journal.

Highlights

• Early stages of Alzheimer’s are critical for identifying and stopping the disease’s progression, offering a window for potential intervention.
• Environmental factors such as pollutants and chemical waste have been found to significantly contribute to the risk of developing Alzheimer’s
• Advanced medical imaging techniques play a pivotal role in detecting Alzheimer’s biomarkers facilitating early diagnosis.
• AI’s emergence in diagnostic processes and the push towards personalized medicine may represent the frontier in combating Azlheimer’s promising more targeted and effective therapies.

Abstract

In navigating the complexities of Alzheimer’s Disease (AD), this review emphasizes the critical role of early detection in altering the course of this prevalent neurodegenerative disorder. With dementia affecting approximately 50 million individuals globally and AD being the predominant form, the urgency of diagnosing AD in its early stages—Subjective Cognitive Decline (SCD) and Mild Cognitive Impairment (MCI)—cannot be overstated. Identifying AD early opens the door to diagnostic and therapeutic strategies that can substantially slow or even halt the progression of the disease.

This review begins with a introduction to Alzheimer’s Disease, giving a picture of its clinical and pathological landscape. The discussion then moves to the crucial early stages of AD, Subjective Cognitive Decline and Mild Cognitive Impairment, highlighting how these early warning signs connect to the more severe stages of the disease. The review offers a dive into the causes of AD, particularly focusing on the build-up of chemical waste in the brain. It also explores the genomic landscape of AD with a special focus on the Apolipoprotein E (APOE) gene, a key indicator for the progression from early cognitive changes to more advanced stages of Azlheimer’s disease. Additionally, the paper evaluates the power of cutting-edge diagnostic tools, namely Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI). These non-invasive techniques are crucial for spotting the early pathological signs of AD well before clinical symptoms appear, offering a window for timely intervention.

Key Term Table

• Alzheimer’s disease (AD): A degenerative brain disease that falls under the category of dementia, caused by complex brain changes following cell damage
• Amyloid beta: A large membrane protein that plays an essential role in neural growth and repair. However, when it malfunctions it can lead to Alzheimer’s disease.
• Apoptosis: A form of programmed cell death
• Atrophy: Decreasing in size of body tissue
• Blood Brain Barrier (BBB):A network of blood vessels and tissue that helps keep harmful substances from reaching the brain
• Cerebrospinal fluid: A clear fluid found within the tissue surrounding all vertebrates’ brains and spinal cords. It helps cushion and provide nutrients.
• Dementia: A general term for several diseases affecting memory, thinking, and the ability to perform daily activities.
• Endothelial cells: A thin layer of cells that line the interior surface of blood vessels, forming a barrier between the bloodstream and the body’s tissues. 
• Mild cognitive impairment (MCI): A condition in which people experience a slight but noticeable decline in memory or thinking skills, more than expected with normal aging.
• SCD: When a person feels they have a decline in memory or cognition, but it’s not detectable on standard memory tests.
• Tau: Tau is a naturally occurring protein that helps stabilize the internal skeleton of nerve cells (neurons) in the brain. When it malfunctions, it can lead to Alzheimer’s disease. 

1. Introduction:

1.1 What is Dementia and Alzheimer’s disease?

Dementia encompasses a range of symptoms associated with a decline in memory, thinking, and decision-making abilities, significantly impacting daily life activities. According to the World Health Organization, around 50 million people worldwide have dementia, and there are nearly 10 million new cases every year (Dementia, n.d.).  It is not a single disease but rather a broad term that covers various underlying conditions, with Alzheimer’s disease being the most prevalent, accounting for 60 to 80 percent of all dementia cases (What Are Alzheimer’s Plaques and Tangles? | BrightFocus Foundation, n.d.).

Alzheimer’s is a degenerative brain disease that is caused by complex brain changes following cell damage. The symptoms of Alzheimer’s can vary from one person to another and gradually worsen over time. Some symptoms in its earliest stages include losing things, and forgetting dates. Symptoms in its most severe stages include inability to communicate, no awareness of recent experiences, and seizures (What Are the Signs of Alzheimer’s Disease?, n.d.). Research indicates that these brain alterations begin well before noticeable memory loss occurs, often a decade or more, during a phase when individuals appear symptom-free. “During this preclinical stage of Alzheimer’s disease, people seem to be symptom-free, but toxic changes are taking place in the brain,” according to the National Institute on Aging. This preclinical stage involves malfunctioning two naturally occurring proteins: beta-amyloid and tau (Alzheimer’s Disease: The Basics – , n.d.).

Abnormal levels of beta-amyloid build up in the brain and form plaques between nerve cells. While inside the nerve cells tau creates neurofibrillary tangles, or twisted fibers. It is thought that the beta-amyloid plaque buildup outside the neuron initiates pathways inside the neuron that, in consequence, cause these neurofibrillary tangles. These toxic protein build ups prevent the nerve cells, or neurons, from transmitting information as they otherwise would. They lose connections with other nerve cells and die over time due to apoptosis (Amyloid and Tau: The Proteins Involved in Dementia — DPUK, n.d.).

Alzheimer’s disease initially affects the hippocampus, the brain region essential for memory formation. As the disease progresses, other brain areas are also affected and shrink (Alzheimer’s Disease: Causes, Stages, Symptoms & Prevention, n.d.).

1.2 What is Subjective Cognitive Decline?

Subjective Cognitive Decline (SCD) refers to individuals’ self-reported experiences of deteriorating memory or increased confusion. It is one of the initial signs of Alzheimer’s disease and related dementias that a person might notice. Some cognitive decline can occur as adults age, but frequently forgetting how to perform routine tasks is not a normal part of aging and can affect a person’s ability to live and function independently, which is SCD. However, SCD doesn’t equate to a clinical diagnosis of cognitive decline confirmed by a healthcare provider (life.1, n.d.)

Around 11.1% of adults in the US, or approximately 1 in 9, report experiencing SCD. SCD is less understood compared to Mild Cognitive Impairment (MCI) and Alzheimer’s disease (life.1, n.d.). Its clinical significance is often debated due to challenges in defining and diagnosing SCD in patients. 

1.3 What is Mild cognitive impairment?

Mild cognitive impairment (MCI) is when people have more memory or thinking problems than other people their age. The symptoms of MCI are not as severe as those of Alzheimer’s disease or related dementia but are considered to be more severe than SCD. In contrast with SCD, MCI is regarded as a clinical diagnosis and involves noticeable cognitive decline that is detectable through clinical evaluation and cognitive testing. Signs of MCI include losing things, forgetting to go to important events or appointments, and having more trouble coming up with words than other people of the same age. People with MCI can usually take care of themselves and carry out their normal daily activities, but it’s prevalent for family and friends to notice these changes. MCI is very common among the elderly; roughly 10% to 20% of people over age 65 have MCI, with the risk increasing as someone gets older (What Is Mild Cognitive Impairment?, n.d.).

2. Causes of Alzheimer’s disease:

Although the exact causes of Alzheimer’s Disease remain unknown, increasing evidence suggests that environmental and lifestyle factors, including exposure to pollutants and chemical waste, may play a significant role. Research, including systematic reviews and meta-analyses, consistently points to a link between exposure to pesticides and a heightened risk of developing AD. For example, a study in 2019 found that individuals exposed to pesticides had at least a 50% higher risk of AD than those not (Elonheimo et al., 2021). 

In addition to pesticides, exposure to certain heavy metals, namely arsenic, mercury, and cadmium, has also been linked to an increased risk of AD. A study in 2018 demonstrated that AD patients had significantly higher levels of mercury and cadmium in their systems than healthy controls, indicating that these toxic metals might contribute to AD’s progression (Elonheimo et al., 2021). 

2.3 Connections of SCD and MCI with Dementia and Importance of Early Detection:

The early identification of Subjective Cognitive Decline (SCD) and Mild Cognitive Impairment (MCI) plays a critical role in the clinical research, prevention, and management of Alzheimer’s disease. The progression typically begins with SCD, advances to MCI, and eventually leads to dementia. 

SCD is recognized as a significant risk factor for dementia, manifesting approximately 15 years before the onset of MCI (Shim et al., 2022). A study done by Dementia and Neuropsychologia showed that subjects with SCD exhibited a significantly elevated risk for the development of cognitive impairments when compared to their counterparts without SCD. Their data showed there was a 7.23% cumulative risk of transition from SCD to dementia across an average monitoring duration of 5.27 years (Parfenov et al., 2020). Individuals diagnosed with MCI face an increased likelihood of developing Alzheimer’s disease or related dementias. Estimates suggest that approximately 10% to 20% of individuals aged 65 or older with MCI may develop dementia within a year (What Is Mild Cognitive Impairment?, n.d.). 

The emergence of disease-modifying drugs aimed at slowing the onset and progression of AD dementia has been met with challenges, primarily due to the timing of treatment initiation. Most treatments have been initiated too late after significant brain tissue injury has already occurred in AD. This observation underlines the critical need for initiating AD-related clinical studies and interventions during the preclinical stages. In this way, SCD and MCI are critical windows for potentially more effective intervention (Shim et al., 2022).

2.4 Genomic Predictors of Alzheimer’s Disease Progression

A metadata study by Sonia Moreno Grau and Agustin Ruiz highlights the crucial role of specific proteins and genomic markers in predicting the transition from  SCD and MCI to Alzheimer’s disease, offering insights into potential avenues for early detection.

The risk of AD dementia is influenced by a broader genomic landscape, with research to identify 28 genes associated with the onset of Alzheimer’s Disease (LOAD). Among these, APOE stands out as a confirmed indicating factor in the transition from MCI to AD. Conversely, the relevance of APOE diminishes in the context of SCD progressing to Alzheimer’s disease. This observation aligns with the understanding that SCD represents an earlier stage of cognitive decline preceding MCI. Therefore, the APOE protein may not be as prevalent or influential during this initial phase (Genome Research in Pre-Dementia Stages of Alzheimer’s Disease – , n.d.).

3. The Role of Diagnostic Imaging in the Early Detection of AD

Numerous studies have highlighted that a significant portion of older adults with Subjective Cognitive Decline (SCD) exhibit biomarker abnormalities that align with those found in Alzheimer’s disease (AD). This has spurred interest in identifying reliable biomarkers for early detection. Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI) are two diagnostic tools proven to effectively identify these AD-related biomarkers in individuals with SCD. Specifically, these biomarkers include increased amyloid uptake observed in PET scans, and medial temporal atrophy detected through MRI (Shim et al., 2022). 

3.1 MRI scans of MCI and  Alzheimer’s Disease

3.2 PET Scans of Alzheimer’s Disease

3.3 Comparative Analysis of Alzheimer’s Disease Detection Methods: PET, MRI, EEG, and Lumbar Puncture

PET scans stand out in detecting Alzheimer’s disease because they can visualize amyloid plaques using amyloid imaging agents. This capability stems from PET’s molecular imaging approach, which highlights the presence of amyloid plaques and provides functional information about the brain’s metabolic activity done at low reactivity. In Alzheimer’s disease, specific brain regions exhibit reduced metabolism early, which PET scans can effectively detect. Despite its high diagnostic value, one of the main limitations of PET scanning is its cost, which is much higher compared to other diagnostic methods (Zhang et al., 2016).

On the other hand, MRI is highly valued for its ability to produce high-resolution images of the brain’s structure, making it a viable option for detecting Alzheimer’s disease. The technique is beneficial for observing the brain’s hippocampus region, which typically undergoes atrophy in Alzheimer’s disease. MRI’s strength lies in its capacity to detect changes in brain volume and structure as the disease progresses. However, these structural changes usually manifest later in the disease course, which might make MRI less effective for early diagnosis (Zhang et al., 2016). 

PET and MRI are both modern imaging techniques that are both in vivo and non-invasive. Lumbar puncture is a traditional method for detecting Alzheimer’s disease. This procedure is more invasive, involving the collection of cerebrospinal fluid (CSF) from the lower part of the spinal canal to analyze for Alzheimer’s biomarkers, such as abnormal levels of beta-amyloid or tau proteins. Although effective in identifying these biomarkers, the procedure can be uncomfortable for the patient and carries potential risks, including headache, infection, bleeding, or, in some cases, spinal cord damage (The Use of Lumbar Puncture and Safety Recommendations in Alzheimer’s Disease: A Plain Language Summary – , n.d.).

4. Discussion and Conclusion

The early detection and management of Alzheimer’s disease (AD) presents a complex challenge to the medical and scientific community, underscored by the multifaceted nature of the disease. Alzheimer’s disease, often considered to have various underlying conditions rather than a single entity, embodies a spectrum of neurodegenerative processes that contribute to its heterogeneity. This complexity reflects the diverse clinical manifestations and trajectories observed among patients and highlights the intricate interplay of genomic, molecular, and environmental factors that drive the disease’s progression.

The variability in the progression and onset of Alzheimer’s underscores the necessity for robust diagnostic tools capable of identifying the disease in its earliest stages. Non-invasive in vivo medical imaging techniques such as Positron Emission Tomography (PET) and Magnetic Resonance Imaging (MRI) have shown considerable promise, offering a window into the brain’s functional and structural changes long before clinical symptoms become apparent. The ability of PET scans to detect amyloid plaques and tau pathology, alongside MRI’s capacity to visualize structural brain alterations such as hippocampal atrophy, represents a pivotal advance in our approach to Alzheimer’s diagnosis and monitoring.

However, the challenge extends beyond the mere detection of AD biomarkers. The goal is to integrate these findings into a coherent framework that allows for the early identification of individuals at risk and the implementation of preventive or mitigating strategies. In this context, the advent of artificial intelligence (AI) in the analysis of PET and MRI could be a new era in Alzheimer’s research. AI algorithms, with their ability to discern patterns and anomalies based on vast datasets, offer the potential to enhance the diagnostic accuracy of imaging studies. By facilitating the early detection of AD-related changes and predicting disease progression, AI-driven tools can enable more timely and targeted interventions, potentially altering the disease’s trajectory.

Another promising approach is the area of personalized medicine, due to the variability and complexity of Alzheimer’s disease in each of its patients. Personalized medicine is rooted in the belief that since individuals have unique characteristics at the molecular, physiological, environmental exposure and behavioral levels, they need to have interventions provided to them for diseases they possess that are fit to these unique characteristics. This method allows the ability to predict which medical treatments will be safe and effective for each patient, and which ones will not be ​​(Goetz & Schork, 2018). 

Additionally, classifying Alzheimer’s disease into subtypes, including amyloid pathology, tauopathy, inflammatory, and cerebrovascular subtypes, represents a promising advancement towards addressing its complexity. This classification facilitates a deeper understanding of the disease and opens pathways to more specific and effective treatment approaches for each subtype, highlighting the crucial role of personalized interventions in the future of Alzheimer’s management

Works Cited

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About the author

Sofia Sattler

Sofia is currently a high school student interested in medicine, particularly neurodegenerative diseases. She has previously published research on Parkinson’s disease. In her free time, Sofia volunteers at dog shelters and enjoys playing tennis.

The post Early Detection, Early Hope: A Review of Emerging Strategies in the Early Detection and Intervention of Alzheimer’s Disease appeared first on Exploratio Journal.

Abstract

Heart disease, also known as cardiovascular disease, encompasses a range of conditions affecting the heart or blood vessels. It is a significant health concern that cuts across race, gender and nationality. Various types of heart disease exist, including coronary artery disease, heart failure, arrhythmias, and valvular heart disease, each with its own set of symptoms and risk factors such as diet and genetics. Similarly, neurodegenerative diseases like Alzheimer’s, Parkinson’s, and Huntington’s disease pose challenges to cognitive and motor function, with Alzheimer’s being the most common form of dementia. These diseases affect individuals of different ethnic backgrounds and genders, with African Americans having a higher prevalence of Alzheimer’s.

The connection between heart disease and neurodegenerative diseases is substantial, with inflammation, oxidative stress, vascular dysfunction, hypertension, and dyslipidemia playing significant roles in both disease groups. Lifestyle factors such as diet and physical activity contribute to the development of these diseases. The heart-brain axis underscores the interplay between cardiovascular and brain health, with cardiovascular diseases influencing brain function and vice versa. Sleep apnea, often associated with heart failure, can exacerbate cognitive impairments due to its impact on oxygen flow to the brain.

Understanding the complex relationship between heart disease and neurodegenerative diseases is crucial for developing effective prevention and treatment strategies. Addressing common risk factors and promoting a healthy lifestyle may mitigate the burden of these diseases on individuals and healthcare systems. Further research into the mechanisms underlying their connection is warranted to advance clinical management and improve patient outcomes.

Keywords: cardiovascular, coronary, neurodegenerative, heart-brain, Alzheimer, Parkinsons

Introduction

Background Information

Heart disease, also known as cardiovascular disease, refers to a class of diseases that involve the heart or blood vessels. It is a broad term that encompasses various conditions, each affecting different parts of the cardiovascular system. In regard to ethnicity, the majority of people who die due to heart disease are African American. Asian people take up 18.6%, black people take up 22.6%, white people take up 8%, and hispanic people take up 11.6%. (1) In regard to sex, there are more male cases of heart disease compared to women. According to the american heart association, 52.9% were men and 47.1% were women in 2016 and this trend continues strongly and has been seen even in the many years after that. (2)

Types of heart disease

There are many different types of heart diseases. A few examples include coronary artery disease, heart failure, arrhythmias, and valvular heart disease. Coronary artery disease is the most common type and occurs when the blood vessels supplying the heart muscle become narrowed or blocked. (5) It can lead to chest pain, also known as angina, or a heart attack. It is generally due to the buildup of plaque which blocks the body’s blood supply and increases the strain on the heart.

Plaque buildup causes the arteries to narrow over time which is a process known as atherosclerosis. The most common cause of coronary artery disease is heart failure due to the weakening of the heart over time. Heart Failure occurs when the heart can’t pump blood effectively, leading to insufficient blood flow to meet the body’s needs. This can happen if the heart can’t fill up with enough blood or when the heart is too weak to pump blood properly. As the heart loses the ability to pump blood, blood backs up into other parts of the body; for example, it can back up into the lungs and cause shortness of breath.

Arrhythmias are irregular heartbeats. They can either be too fast, a condition known as tachycardia, too slow (bradycardia) or irregular. Arrhythmias can affect the heart’s ability to pump blood effectively when the electrical signals that tell the heart to beat don’t work properly. Valvular Heart Disease involves damage to or defects in the heart valves, impairing the flow of blood through the heart. The heart can’t pump blood effectively and has to work harder to pump, while the blood can be leaking back into the chamber or a narrow opening. This can also lead to heart failure since the heart can’t pump a sufficient amount of blood for the whole body. (6) There are many causes for heart disease, one leading factor being diet. Sodium intake plays a major role. The average American consumes about 3,400 mg of sodium each day, which is well over the recommended 2,300 mg. Eating too much sodium can lead to high blood pressure. Having a high blood pressure damages the lining of the arteries making them more susceptible to the buildup of plaque and narrowing of the arteries. (7) Congenital heart disease is a heart problem a baby has at birth. In most cases, congenital heart disease has no known reason, but it can be due to family history and chromosomal abnormalities (both genetic factors), or due to maternal factors (including medications or substances the mother comes in contact with while pregnant). (8)

Neurodegenerative diseases

Neurodegenerative diseases are a group of disorders characterized by the progressive degeneration of the structure and function of the nervous system. These conditions primarily affect neurons, the building blocks of the nervous system, leading to a decline in cognitive function and, in some cases, motor function. These diseases are generally characterized by neuron loss. A few examples of these kinds of diseases are Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, and multiple sclerosis. (9) Going more in depth, Alzheimer’s Disease affects memory, thinking, and behavior. It is the most common cause of dementia. The brain itself shrinks causing brain cell connections and the cells themselves degenerate and die, causing the loss of memory. This disease mainly involves the parts of the brain that controls thought, memory, and language. (10) Parkinson’s Disease involves the degeneration of dopamine-producing neurons, leading to tremors, stiffness, and difficulty with balance and coordination. Nerve cell damage in the brain can cause the dopamine levels to drop. It affects the nervous system and parts of the body controlled by nerves. (11) Huntington’s Disease causes the progressive breakdown of nerve cells in the brain which can lead to the development of many different neurodegenerative diseases like Parkinson’s. A genetic mutation in the HTT gene causes Huntington’s disease. The HTT gene makes a protein known as huntingtin. This protein helps the neurons function. If the body is unable to make this protein, it can cause the development of this disease. (12) Amyotrophic Lateral Sclerosis affects motor neurons, leading to muscle weakness and atrophy. It is the progressive degeneration of nerve cells in the spinal cord and brain. As the motor neurons, which are the neurons that control the voluntary muscles decline, it stops being able to send signals to the muscles. There are 2 types of motor neurons: upper motor neurons and lower motor neurons. The upper controls the brain and spinal cord and its role is to control the lower motor neurons. The lower consists of cells in the brian stem which is the lower part of the brain. They first receive instructions from the upper neurons then send messages that tell the muscles in the body to move. Multiple Sclerosis is due to nerve damage disrupting the communication between the brain and the body. The immune system attacks the protective sheet, myelin, that protects and covers nerve fibers which cause communication problems between the brain and the rest of the body. The disease can cause permanent damage and deterioration to the nerve fibers.

For Alzheimer’s disease, African Americans still have the highest percentage of cases, which is 13.8%. Hispanic people have 12.2%, white people have 10.3%, and American Indian and Alaska Native individuals have 9.1% of the cases. (3) In this case, women are more likely to develop a neurodegenerative disease compared to men (3:1 ratio). (4)

Cerebral ischemia and ischemic strokes

A failing heart cannot pump a sufficient amount of blood to the body when it’s at rest or during physical activity. This can lead to a risk of the brain not getting enough blood, a condition known as cerebral ischemia. Atherosclerosis can lead to both cerebral ischemia and an ischemic stroke, the most common type of stroke. (13) An ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced. Plaque buildup can reduce the blood flow to one part of the brain but it can also lead to blood clots which can completely block the flow. When a plaque formation becomes inflamed, it can rupture, causing the formation of a blood clot. This can prevent the brain cells from getting nutrients and oxygen it needs, causing them to die very quickly. (14) Once neurons start dying at a fast rate, people can start developing many different neurodegenerative diseases such as Alzheimers and Parkinsons. During the development of Alzheimer’s disease the brain starts shrinking and since neurons are dying, many connections in the brain are also lost. In the case of Parkinson’s disease, dopamine producing neurons start to degenerate. These neurons are only in specific parts of the brain, such as the prefrontal cortex, so blockages in the arteries near these parts of the brain can lead to the development of Parkinson’s.

Body

Mutual Influence of heart disease and neurodegenerative diseases:

Links between heart disease and neurodegenerative diseases

It is undeniable that there are some links that can affect both heart disease and neurodegenerative disease. Some autopsy studies show that as many as 80% of individuals with Alzheimer’s disease also have cardiovascular disease. This is very important because it shows a major correlation between the two seemingly distinct diseases. They can be linked together through a variety of ways that will further be looked into. (15) One main link is inflammation. In heart disease, inflammation contributes to the development and progression of atherosclerosis by promoting the accumulation of inflammatory cells in arterial walls, leading to plaque formation and increasing the risk of cardiovascular diseases.

In neurodegenerative diseases, inflammation contributes to neuronal damage; activated immune cells release pro-inflammatory molecules, starting the degeneration of neurons and contributing to the progression of conditions like Alzheimer’s, Parkinson’s, and Amyotrophic Lateral Sclerosis (ALS). Another link is oxidative stress. In heart disease, oxidative stress plays a role in the progression of atherosclerosis and cardiovascular events by causing damage to lipids, proteins, and DNA, contributing to inflammation. In neurodegenerative diseases, oxidative stress is implicated in the pathogenesis (development/ progress) as it leads to the accumulation of cellular damage in neurons, exacerbating inflammation, and contributing to the degeneration of nerve cells in conditions like Alzheimer’s, Parkinson’s, and ALS.

Vascular dysfunction also has a link between both diseases. In heart disease, vascular dysfunction impairs blood vessel function, leading to reduced blood flow, compromised oxygen delivery, and an increased risk of conditions like atherosclerosis. In neurodegenerative diseases, vascular dysfunction can contribute to reduced cerebral blood flow, impacting nutrient delivery to the brain and potentially showing cognitive decline in conditions like Alzheimer’s.

In heart disease, hypertension strains the heart and arteries, promoting vascular dysfunction and increasing the risk of coronary artery disease, heart failure, and stroke. In Neurodegenerative Disease, hypertension is a risk factor for small vessel disease and may contribute to cognitive impairment and an increased risk of neurodegenerative conditions. (16)

In Heart Diseases, dyslipidemia (elevated cholesterol levels), contributes to atherosclerosis, leading to vascular dysfunction and an increased risk of heart attacks and strokes. In Neurodegenerative Diseases, dyslipidemia may contribute to the development of vascular-related neurodegenerative disorders by affecting blood flow to the brain and promoting inflammation.

And of course, lifestyle is a key factor to living a good and healthy life. An unhealthy lifestyle, with factors such as poor diet and physical inactivity, contribute to vascular dysfunction, fostering conditions conducive to the development of heart disease and neurodegenerative diseases. (17)

Heart brain axis

It is believed that cardiovascular diseases can affect brain function and many brain diseases are associated with heart dysfunction which is the heart-brain axis. The brain is the one in charge of regulating the function of the heart and impaired brain function can lead to the development of cardiovascular diseases. Similarly, cardiovascular diseases can reduce the amount of blood flow sent to the brain which can lead to the development of various brain diseases. (18) Firstly, how do brain diseases contribute to the development of cardiovascular diseases? Cardiac rhythm changes, also known as arrhythmia, can reflect abnormal brain function and be biomarkers for different brain diseases. The autonomic nervous system (ANS) is in control of the body’s involuntary muscles such as the heart and lungs. The brain is in control of the ANS. When the body has a seizure, the brain’s electrical activity is disturbed and those changes can lead to a disruption in the ANS, also leading to arrhythmias.

Next, how do cardiovascular diseases contribute to brain diseases? Diseases such as heart failure and atrial fibrillation are risk factors to many different brain diseases such as dementia or Alzheimer’s disease. Cardiac rhythms and electroencephalograms are also found to be highly synchronized, which is another link between the brain and heart. Electroencephalography is the measurement of electric activity in different parts of the brain. This means the electrical rhythms of the heart and brain are very synchronized further confirming the idea of the heart-brain axis.

Sleep apnea

Heart failure can influence sleep apnea. One way in which this works is through the accumulation of fluids. Heart failure often leads to fluid buildup in the lungs and other tissues, which can block the airways. This makes it more challenging for the air to flow easily during breathing. The heightened resistance contributes to obstructive sleep apnea. Sleep apnea has a lot of effects. The first one being memory loss. Due to the lack of sleep, people can start to develop short term or long term memory loss. Another effect is brain damage due to the lack of oxygen going to the brain. By starving the brain of oxygen, the development of cerebral hypoxia can occur. Since brain cells are very sensitive to lack of oxygen, they can start dying rapidly especially as more and more oxygen is getting cut off.

Preventative measures for developing heart or neurodegenerative diseases

There isn’t a specific way to cure heart or neurodegenerative diseases so the important thing in these cases is prevention, with lifestyle and environmental factors being key. It’s important to focus on getting enough rest at night and staying regular with working out. Eating a healthy diet and cutting back on foods that have high sodium, cause high blood pressure and cholesterol is extremely important. The best thing you can do for your body and health is eat healthy, exercise regularly, and get enough sleep. Learning new things everyday can create new connections in the brain which delay the onset of diseases like Alzheimer’s or makes it less damaging for the brain. It’s simple to do this, start by learning a new language or picking up a new hobby. These small changes in your life can create a significant difference in the outcome of your health. That being said, since there’s no cure for Alzheimer’s, protecting your heart’s health can be key to delaying the onset of or reducing the effects of these neurodegenerative diseases.

Summary

Our research explores the relationship between heart disease and neurodegenerative disorders, emphasizing the impact of cardiovascular health on brain function. Our research has highlighted the significance of a healthy lifestyle in mitigating the risk of diseases like Alzheimer’s and Parkinson’s. We believe our findings can contribute to the field of cardiovascular and neurodegenerative diseases, offering fresh insights into prevention and treatment strategies. We thus conclude that understanding the interplay between heart and brain conditions is crucial for patient care and hope that our research could prompt further study and innovation in this area.

References

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3. Aaron, L. C. (2024, March 5). Quantification of race/ethnicity representation in Alzheimer’s disease neuroimaging research in the USA: a systematic review. https://www.nature.com/articles/s43856-023-00333-6
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About the author

Veena Mahalingam

Veena is currently an 11th grader at the American International School in Chennai. She is passionate about medicine and her favorite subject is biology — she expands her knowledge on this by interning at cancer research labs. In her free time, Veena enjoys swimming, reading, and playing the guitar.

The post Interplay Between Heart Disease & Neurodegenerative Diseases: Implications for Clinical Management appeared first on Exploratio Journal.

Abstract

Diabetes is a disease characterized by increased insulin resistance and decreased insulin secretion in response to glucose stimulants. It is an epidemic rising in prevalence worldwide, with many contributing factors, including Body Mass Index, lifestyle, family history, ethnicity, etc. Diabetes must be constantly monitored and effectively subdued with proper medication and by adapting to a healthy lifestyle. And this becomes possible through the comfortable, convenient, and serene access to a health care centre. The main aim of this study is to examine sex-wise and age-wise travel patterns of the patient’s access, from nine taluks to a private Diabetic Centre, located in Tiruchirappalli city, Tamil Nadu, India. The data are collected using a Multivariate Random sampling method, from 225 patients, during 2019, 2020, and 2021, for nine taluks in Tiruchirappalli district. The Statistical techniques used in the present study is the Proximity Analysis using Multiple ring buffer method. The Overlay analysis is done using Arc GIS. The study describes patients’ travel patterns with respect to their age and sex, in accessing a Diabetic Centre located in Tiruchirappalli City.

I. Introduction

Diabetes is one of the public health priorities in the world due to its chronicity and premature mortality associated with the disease [1]. Globally, 463 million people in the age group of 20–79 and one in five older adults (>65 years) has diabetes [2]. Diabetes is a disease that must be constantly monitored and effectively subdued with proper medication and healthy lifestyle and this becomes possible through the comfortable, convenient, and serene access to a health care centre. Easy access to a health care facility is essential in diabetes it requires the management process to be life-long and the patient’s continuous engagement with the health system [3]. One of the unexplored aspects of diabetes in India is the health care accessibility or distance travelled by the patients to seek their care [4]. There are evidences that distance is a barrier to health care utilization and frequency of visits [5] [6]. The main aim of this study is to examine sex-wise and age-wise travel patterns of the diabetic patients, from nine taluks accessing a private Diabetic Centre, located in Tiruchirappalli city, Tamil Nadu, India.

II. Objectives, Data, Methodology

The objective of the study is to analyse the travel pattern of patients from their residence to a Diabetic Centre located in the study area, with respect to patterns like age and sex. The data are collected using a Multivariate Random sampling method, from 225 patients, during 2019, 2020, and 2021, for nine taluks in Tiruchirappalli district. The Statistical techniques used in the present study is Proximity Analysis using Multiple ring buffer method. The Overlay analysis is done using Arc GIS.

III. Study Area

Tiruchirappalli district is situated in Tamil Nadu on coordinates of 10°10⁰’N to 11° 30⁰’N latitude and 78°0⁰’E to 79°0⁰’E longitude, covering an area of 4,404 sqkm, with a population of 1,182,000, as per 2011 census. It has nine taluks, 14 blocks and 404 village panchayats [Fig 1]. The study site is Diabetic Centre (H), located in Thillai Nagar, Tiruchirappalli city. Thillai Nagar is the poshest commercial and elite residential locality with a daily floating population of 5 lakhs. It is the hub for hospitals, clinics and nursing homes that are better equipped to offer personalized care with an excellent doctor-to-patient ratio. 

IV. Result and Discussion

1. Sex Wise Travel Pattern: Using Buffer and Overlay Analysis

The data for the sex wise travel pattern of the patients, for male and female, accessing a Diabetic Centre is collected, calculated and is shown in Table 1. It represents the data collected from total number of Male (X), Female (X) patients and the calculation of mean (x̅). The Figures 2 and 3 shows the Buffer analysis of Sex wise travel pattern of Male & Female respectively. Three buffer zones (5km,8km,12km) are created to represents the sex wise travel pattern to the diabetic centre in the study area. Each lines denotes 5 persons from a particular taluk. The average number of male patients is 15.55 and the female patients is 9.44. In Tiruchirappalli, Musiri, Lalgudi, and Manachanallur, the male and female travel pattern is noticed to be higher than other taluks. The results show that the male patients travel longer distance than the female patients. The Figure 4 shows the Buffer and Overlay analysis of Sex wise travel pattern of Male & Female. From the figure, it could be observed that the patients access the Diabetic centre almost from all cardinal directions. The travel pattern of female patients is minimal, when compared with male patients. Beyond 12km buffer line, the travel pattern of male and female are noticed to be less.

2. Age Wise Travel Pattern: Using Buffer and Overlay Analysis

Age structure is one of the prominent factors in health care and health analysis. The data for the age wise travel pattern of the patients, male and female, accessing a Diabetic Centre is collected, calculated and is shown in Table 2. It represents the data collected from total number of the patients, male and female (X) and the calculation of mean (x̅), for age groups- <15, 16-40, 41-60 and >60. Among the total respondents, the age groups belonging to 41-60 constitute the highest number of the patients, followed by the age groups >60 (62 patients), 16-40 (55 patients). The age group <15 has the lowest number of patients (9 in number).

The Figure 5 shows the Buffer and Overlay analysis of Sex wise travel pattern of Male & Female patients. Three buffer zones, for 5km, 8km and 12 km are drawn to assess the age wise travel pattern of the patients. The results prove that the age group (41-60) travel a longer distance compared with other age groups.

IV. Conclusion 

The travel pattern of the diabetes patients to access a Diabetic Centre in Tiruchirappalli city is analysed in the present study. The sex wise and age wise travel pattern is calculated and mapped, using buffer and overlay analysis. The analysis of the sex wise travel pattern of the patients proves that the female patients prefer a shorter travel distance than men patients. The age wise travel pattern proves that the patients in the age group of 41-60 travel longer distance than other age groups. The results of the present study reveal that distance play a vital role for the patients to access the health services. 

V. Acknowledgment

The authors of this paper would like to acknowledge the Dr. Balaji, for his support in data analysis and mapping.

VI. References

[1] World Health Organization, n d. Diabetes [WWW Document]. World Heal. Organ. URL https://www.who. int/news-room/fact-sheets/detail/diabetes (accessed 28 .10. 20).

[2] The International Diabetes Federation, n d. International Diabetes Federation – Diabetes in SEA [WWW Document]. URL https://idf.org/our-network/regionsmembers/south-east-asia/diabetes-in-sea.html (accessed 28. 10. 20).

[3] Olickal, J., Devasia, J. T., Thekkur, P., Chinnakali, P., Suryanarayana, B. S., Kumar Saya, G., … & Subrahmanyam, D. K. S. (2021). How far persons with diabetes travel for care? Spatial analysis from a tertiary care facility in Southern India. Annals of GIS, 27(4), 341-349.

[4] Rekha, R. S., S. Wajid, N. Radhakrishnan, and S. Mathew. 2017. “Accessibility Analysis of Health Care Facility Using Geospatial Techniques.” Transp. Res. Procedia 27: 1163–1170. doi:10.1016/j.trpro.2017.12.078

[5] Bronstein, J. M., and M. A. Morrisey. 1990. “Determinants of Rural Travel Distance for Obstetrics Care.” Med. Care 28 (9): 853–865. doi:10.1097/00005650-199009000-00013

[6] Nemet, G. F., and A. J. Bailey. 2000. “Distance and Health Care Utilization among the Rural Elderly.” Soc. Sci. Med 50 (9): 1197–1208. doi:10.1016/S0277-9536(99)00365-2

About the author

Harnishya Palanichamy

Harnishya is currently in Grade 11 and is passionate about computer science and Artificial Intelligence. Playing football, piano, debate, hiking, reading and 3D printing are some of her pastimes.

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Abstract

A body of research demonstrates how contemporary Western approaches to healthcare can lead to ineffective care. This is especially prevalent with respect to groups of recent immigrants whose cultural beliefs impact their view of illness and treatment, deviating from the “standard of care” that Western practitioners are accustomed to. For example, some Hmong people choose to preserve their cultural traditions, and avoid doctors, presuming their beliefs will be ignored and belittled by Western medical practitioners. This research builds on the efforts of anthropologist Arthur Kleinman and other social scientists to investigate how to more effectively provide care for recent immigrants through cultural brokerage. Studies show cultural brokerage is critical for creating effective doctor-patient interactions, and neglecting it compromises care. Drawing from case studies that examine medical experiences from the perspectives of three distinct groups: (1) Hmong immigrants; (2) South American immigrants; and (3) American clinicians, this study investigates the benefits and challenges of implementing cultural brokerage in medical care. By addressing the issue from the viewpoint of the patient and provider, this research aims to promote the implementation of these practices in hospitals and clinics worldwide, making cultural understanding and openness to holistic approaches to illnesses a more common practice amongst practitioners.

Introduction

The term “melting pot” came into usage in 1908 to describe the fusion of cultures that had made up the United States (Crossman 2011). There is no singular culture or set of beliefs that guides the country of the U.S., (Crossman 2011). In fact, cultural norms are quite varied across the United States and can cause division (Thomspon 2010). This is the case partly due to the United States being the home of culture wars: debates over issues of public policy. The origin of the “culture wars” dates to the 1960s, when a counterculture emerged and traditional values were challenged (Thompson 2010). According to Thompson, American public opinion is “considerably more ambivalent and internally inconsistent than the image of a culture war implies” (Thompson 2010).

Recently, the immigrant population in the U.S. has been growing. According to the U.S. Census Bureau, the number of current residents born outside of the U.S. climbed by nearly a million last year, rising 14% since 2017, reaching a record high of just over 46 million immigrants with varied statuses, from naturalized citizenship to green card holders, to undocumented (Rose 2023). More specifically, in August 2021, the U.S. Census indicated there has been a radical change in the racial demographics of the U.S. in the last decade, from 2010 to 2020. While the U.S. Hispanic population was 16.4% in 2010, it reached 18.7% in 2020. Similarly, the Asian-American population increased by 35% from 2010 to 2020, which is the fastest-growing ethnic segment of the US population (US Census 2021). This study focuses on the medical treatment and cultural brokerage of two distinct groups categorized under two immigrant populations: Mexican-Americans, who generally identify as Hispanic or Latino Americans, and Hmong Americans, who identify as Asian Americans.

A central dimension of culture is communication and language. With the rise in immigration in the US, cross-cultural communication increasingly occurs in medical environments. However, cultural competency training has remained stagnant, which leads to an increase in miscommunication and misunderstandings between medical practices and coworkers, and medical practitioners and patients as colloquial language, body language intentions, and physical gestures are not standard across different cultural groups (Kastanakis and Voyer et al. 2013).

In an article, “Intercultural Misunderstandings: Causes and Solutions,” Michael B. Hinner states that “Intercultural misunderstandings involve a number of complex causes which can easily escalate into conflicts.” Denotative meaning usually signifies the objective meaning of a word or signal within a culture, but when communicating interculturally, the same word may not carry the same denotative meaning across cultures (Hinner 2017). One example of a simple misunderstanding related to language from Hinner comes from the use of the phrase “faculty.” The German word “Fakultät” refers to an “organizational unit at a German university,” while American English assigns the word department that meaning. Yet, an American university department has faculty members; for example, the department’s teaching staff.

Cultural misunderstandings are especially detrimental in contemporary U.S. healthcare settings. A true example of the struggles immigrants face in Western healthcare is depicted in The Spirit Catches You and You Fall Down book, by Anne Fadiman, an essayist and reporter. This book, an award-winning thorough investigation of the medical troubles of a young girl named Lia Lee, highlights the importance of cultural competency in healthcare. In the beginning of the book, Lia, a young Hmong child who experienced a seizure. By the time she got to the hospital her seizures stopped and the doctors prescribed her antibiotics for a cough she had because her sisters could not communicate to the doctors that she previously had a seizure. The hospital’s lack of interpreters and translators played a large role in this miscommunication. There was one cleaning staff who spoke Lao, which isn’t even Hmong, and even he wasn’t on staff at the time (Fadiman 1997). The book explores how the doctor-patient dynamic is influenced by aspects of culture, such as language, religion, traditions and ways of life (rituals and customs). There is a wide variation within a larger cultural grouping, regional or otherwise, that set of beliefs about health and disease, treatment and “cure.” Our belief systems can even influence how we experience illness. In the case of Lia, the cultural difference transcended just language. In Western medicine, epilepsy is considered an abnormal condition with negative health effects that should be treated, the Hmong view it as a gift. There exists a common Hmong belief that those who are epileptic are gifted with the ability to enter the spirit realm (Fadiman 1997). This story highlights how cultural beliefs may require medical practitioners to alter their “standard” approach and individualize the care they provide.

Knowing these cross-cultural miscommunications are becoming more prevalent in the medical field, this study investigates what factors of U.S. approaches to healthcare, which often do not account for patients’ unique cultural backgrounds, influence recent immigrants’ care and disease management and what effect they have on that care.

Background and Literature

To meet this study’s objective of examining cultural brokerage in healthcare through an analysis of peer-reviewed empirical research, a review of scholarship and analysis of recent research on cultural brokerage was conducted.

To research the importance of cultural brokerage in healthcare, I searched “Google Scholar” and “JSTOR.” Moreover, information was drawn from Anne Fadiman’s 1997 book The Spirit Catches You And You Fall Down. All articles and casework, as well as the book, were chosen carefully in order to optimize credibility by narrowing the year each source was written, the quantity of citations each source has received, and the named authors of each piece.

Once legacy data was collected and analyzed from a sufficient quantity of articles, I aimed to bridge the gap between the perceptions and experiences of medical practitioners in the healthcare industry and those of distinct immigrant groups: (1) Hmong people; and (2) Mexican-Americans. Data was then categorized into four groups: (1) information surrounding cultural brokerage in the modern Western medical system; (2) the background and experiences of the Hmong people; (3) the background and experiences of Mexican-Americans in healthcare; and (4) the viewpoints of physicians in the U.S. The objective of culminating unique research groups is to provide an optimally well-rounded comprehension of cultural competence in medicine.

Defining Cultural Brokerage and its Relevance to Health

Cultural Brokerage is defined as the bridging of the gap between the lifeworld and medicine in cross-cultural perspectives in healthcare, like having a cultural translator. The “lifeworld” is denoted as the “immediate, everyday, concrete whole of the subjectively experienced world” (Dodd 2015). In other words, it is the ground of all knowledge in one’s lived experiences. In cases in which patients come from a more marginalized class, educational, or ethnic background, the lifeworld-medicine gap may be further widened and complicated; thus additional cultural brokerage work is needed. Given the widely documented gaps between the cultures of Western medicine and the lifeworld of Hmong and Mexican-American patients, one can argue that cultural brokering is required, potentially, in any doctor-patient interaction, and not just in cross-cultural settings. Researcher Ming-Cheng Miriam Lo emphasizes the importance of patient-centeredness in her article on cultural brokerage: culturally competent healthcare and having compassion for the needs of individual patients (Lo 1997). Lo proposed a five-dimensional frame-work for conceptualizing patient-centeredness: (1) biopsychological perspective; (2) patient-as-person; (3) sharing power and responsibility; (4) therapeutic alliance; and (5) doctor-as-person (Lo 1997). While the voice of medicine is technology-centered, the patient’s lifeworld voice is largely fragmented due to their experience being multifaceted and complex. The suppression of the lifeworld voice by the institution of Western American medicine is considered highly problematic, as it makes distorted communication, erratic diagnoses or inappropriate treatment plans more likely (Lo 1997). It is vital to find ways to elicit the lifeworld voice of patients; focusing on patient centeredness is one way to do so.

Lo conducted a research study utilizing 24 open-ended, in-depth interviews with primary care physicians who self-identified as having worked intensively with limited English proficiency patients (LEP) and who expressed interest in promoting culturally competent healthcare (Lo 1997). It was concluded that the doctors’ cultural brokerage often required expensive resources that could nurture deeper clinical interaction and continuity of care (Lo 1997). Given the current political economy of the U.S. healthcare system, there were few resources available to fund longer consultations, promote continuity of care, or encourage regular doctor visits to the home, especially at low-income clinics frequented by immigrant and minority patients. There is insufficient time for doctors to see patients, causing providers to rush through the appointment, causing patients to feel uncared for and unheard (Lo 1997). However, the healthcare system is largely constrained by finances, which dictate the quality of care patients receive (Lo 1997). Moreover, the implementation of patient centeredness is limited by a lack of medical resources within the healthcare system, making it difficult to employ cultural brokerage (Lo 1997).

Kleiman draws upon multiple case studies to emphasize the distinction of “illness” versus “disease” (Kleinman 1978). The American model of care is often overly focused on treating the condition of patients. On one hand, patients identify illness problems as “the difficulties in living resulting from sickness.” Conversely, doctors often disregard illness problems because “they look upon the disease as the disorder.” Both views are, however, insufficient, according to Kleinman (Kleinman 1978). The functions of “curing and healing” are likely more productive when done together (Kleinman 1978). It is crucial to break out of the modern “mediocentric orientation” of Western medicine to optimize clinical practice (Kleinman 1978). Clinicians might be blinded by the importance of social and cultural factors’ influence on disease despite the fact that medicine is less relevant in the treatment of patients without biological diseases. One background study revealed nearly 50% of patients listed the reason for seeking care in the U.S. and Taiwan as the treatment of illness problems (Kleinman 1978). In one case study, a 33-year-old Chinese man came to the doctor with symptoms of what the doctor concluded was a mental disorder (Kleinman 1978). However, the patient “denied feeling depressed.” In fact, he attributed his symptoms of dizziness and weakness to not getting enough blood. He began treating himself with “traditional Chinese herbs and diet therapy” while receiving psychiatric care in which he spoke to psychiatrists of his problems in detail. The patient “responded to a course of antidepressant medication with complete remission of all symptoms,” but denied that he was suffering from a mental illness due to his belief that he was actually suffering from a “wind” disorder, otherwise a lack of blood to his body. This case shows how “culture shapes the biomedical view of clinical reality;” while American doctors did not believe the Chinese patient, they learned to treat him while understanding his beliefs and perception of the illness in order to treat him (Kleinman 1978).

The case of the Hmong

History

The identity of the Hmong people is shaped by their historical independence and isolation, living in mountainous regions in northern China approximately 4,000 years ago (Fadiman 1997). Their geographical isolation “heightened their linguistic and cultural distinctiveness.” In the early 19th century, the Chinese government persecuted the Hmong people due to their refusal to “integrate into Chinese society.” Since 1975, more than 200,000 Hmong have fled Laos as refugees. During the 1955-1975 Vietnam war, a portion of the Hmong in Laos were recruited by the U.S. CIA to fight against Communist forces in Laos (Yau). Two years later, the U.S. gave up its involvement in the Vietnam war in 1973, and the North Vietnamese and Pathet Lao Communists took Laos over. A segment of the Hmong were suspected of being U.S. spies and fled Laos to escape persecution (Vang and Flores, 1999). As a result, Hmong people began settling in different countries, including Thailand, Vietnam, and northern Laos. Today, “the Hmong people have spread out all over the world; China, Vietnam, Laos, Thailand, Burma, Australia, Canada, France, Germany and the United States are among the countries to which they have migrated” (Vang and Flores). However, the Hmong retained their cultural practices worldwide. A study in the Catesol journal states, “the ability of the Hmong people to preserve their traditional beliefs and practices has been one of the trademarks of their culture” (Biliterate Voices of Hmong Generation 1.5 College Women: Suspended between Languages in the US Educational Experience). Approximately 90 percent of Hmong refugees have been resettled to the United States. The first flow to the United States included approximately 3,500 Hmong by December 1975. The 2000 Census counted 102,773 foreign born who self-identified as Hmong in the U.S. Yet many Hmong chose to stay in refugee camps in Thailand, waiting to return to Laos (Yau). Moreover, the Hmong have largely been displaced, and the U.S. was central to their upheaval and instability by contributing to the multitude of challenges faced by the Hmong American community.

Perception

Hmong people interpret seizures to be a spiritual issue, not a medical disease. As such, traditional Hmong beliefs are at odds with modern medical intervention. In Fadiman’s book, it is evident Lia’s parents value a holistic treatment to illness as more effective than treatment with medicine. In fact, Lia’s parents believed Lia’s seizures were not the main concern. They believed her seizures occurred when her soul left her body, oftentimes as a result of a loud sound. Additionally, by the time Lia was four and a half, “Lia’s parents had been told to give her at various times, Tylenol, ampicillin, amoxicillin, Dialitin, phenobarbital, erythromycin, Ceclor, Tegretol, Benadryl, Pediazole, Vi-Daylin Multivitamins with Iron, Alupent, Depakine, and Valium.” These medications were prescribed in varying combinations, and no doctors hesitated to question whether Lia’s parents were capable of giving her the prescribed doses. When Lia returned to the hospital with indicative low levels of medication in her body, doctors called Child Protective Services who moved Lia to a different household for 6 months. Despite receiving the proper dosage of medications, Lia’s seizure frequency worsened until she returned to her family. Although Lia’s family attempted to comply with the orders of the doctors, they believed Txiv neebs could optimally treat Lia. Txiv neebs are Hmong shamans who negotiate with spirits to ensure the health of their patients, and most American doctors disregarded the Hmong family’s perceived importance of these shamans to attempt to treat Lia (Fadiman, 1997).

Cultural Policies and Practices

Furthermore, the Hmong have many distinct practices which underscore their uniqueness as a cultural group. In Fadiman’s book, The Spirit Catches You And You Fall Down,” Fadiman describes the common practice of most Hmong women to bury their placentas after giving birth. As such, it was sensible for Foua, Lia’s mother, to desire the doctor to give her Lia’s placenta to take home and bury. However after giving birth to Lia in the Merced Community Medical Center on July 19, 1982, the doctors incinerated Lia’s placenta. This was done because doctors generally feared that allowing the Hmong to take the placenta home may result in its consumption by mothers or the possible spread of hepatitis B (Fadiman, 1997). Moreover, childbirth in Hmong culture “is closely associated with supernatural powers.” Researcher Pranee Liamputtong Rice conducted a study to examine the beliefs and practices of Hmong women in Australia. Analyzing 27 Hmong women, three shamans, and two medicine women, it was found that in the Hmong tradition, the “first 30 days after birth is seen as the most dangerous period for a new mother.”

Importantly, the 27 Hmong women who were analyzed came from Laos where they lived in high mountainous regions. Their environments changed drastically, from living in pure isolation to living in a diverse community. Regardless of the change to a new social environment, the majority of Hmong seem to retain their traditional cultural practices, especially those surrounding childbirth. The Hmong “believe in reincarnation,” and they are “patrilineal and patrilocal.” Family names follow a clan system, and there are “ten clans in Melbourne.” The average Hmong family is large, which is attributed to the central role of family to the Hmong people. In this study, most Hmong women are described to have “four to six children, and it is likely they will continue to have more.” Traditionally, the “Hmong put a high value on having many children,” specifically boys because they can help in farming and continue traditional practices such as worshiping ancestral spirits, caring for their parents in old age, and carrying on the clan name. Such traditional customs are still practiced. Moreover, traditional customs in the 30 days after childbirth are crucial for a mother, as this is the period of time in which women are most vulnerable to “illnesses and misfortune,” according to the 27 Hmong women.

They practice 30 days of confinement post-birth, and list several restrictions. For one, it is widely believed a Hmong woman’s first meal post birth should be a poached egg with white pepper because “this will give a woman strength which is lost during the act of giving birth,” one Hmong test subject stated. Another Hmong woman said, “The truth is that the pepper is the most important. The pepper will help to wash your body so that it won’t give you afterbirth pain.” The elderly emphasize the consumption of hot food after birth so that the “blood will run properly.” If you eat cold food, “your blood will clog after birth.” Hmong women refer to food that is “poisonous” as “jab,” which “can be fatal because it is wrong to the body.” This prohibited food includes “banana and bamboo shoots,” describes a Hmong woman. Another woman said “if you eat ice it can kill you” because of its cold properties. Similarly, green vegetables and fresh fruits are seen as “cold” and are believed to “cause asthma, coughing and swelling in old age.” After childbirth, a new mother is prohibited from entering another clan’s homes. It is believed that “because she is still bleeding her `polluted’ body may weaken the clan spirit (dab qhuas) and bring into that household bad health, illness and perhaps even death.” One Hmong woman stated, “If you forget and you go into their house then you have to go and have ua neeb (shamanic ritual) to heal the house and to clean out your uncleanness, your 28 Midwifery blood, so that the spirit txhiaj meej will come back to live in their house.” Herbs are crucial in maintaining the health of a new mother. Chicken herbal medicine, otherwise called tshuaj quib by the Hmong, is prevalent in confinement. Many new mothers use these herbs to relieve pains after birth, replacing strength lost during birth, providing a good appetite, and improving weight loss during birth. The ten practices above are unique to the Hmong cultural group and have been proven difficult to maintain living in a country surrounded by people of different backgrounds. For one, one Hmong woman stated “in this country (Australia) there is no open fire but there is a heater so we use it.” In fact, the majority of the 27 Hmong women in this study exclaimed their frustrations with attempting to continue their practices in a new country. Some “women do not strictly observe all of the Hmong traditions. This has caused ill health in these women,” one Hmong mother stated. She talked about her daughter who “experienced poor health.” She went to the hospital for about two weeks, and despite the doctors performing various examinations and X-rays, she did not get better until her aunt performed a shamanic ritual (called ua neeb by the Hmong). She received Hmong medicines and her aunt covered her legs with a blanket. Her mother recalled, ‘This made her legs have warmth again, and she got better.” Overall, the Hmong women state to have difficulties abiding by the restrictions of their 30 day confinement period after giving birth in Australian hospitals. While in Australian hospitals “women are encouraged to take active care of their new babies,” the new Hmong mothers view this as problematic because it prevents many of them from resting after birth. The study’s results suggest “Western health professionals must remain aware and respect the indigenous beliefs and practices linking the events of reproduction and the health status of women” (Rice).

In addition to the unique cultural practices of Hmong after child birth, the Hmong retain traditional customs throughout their lifetime. In a study on “Hmong American Adolescents’ Perception of Ethnic Socialization Practices,” researchers MyLou Y. Moua and Susie D. Lamborn interviewed 23 14- and 18-year-old Hmong-American adolescents. A content analysis was conducted of the responses from the interview, and the analysis resulted in “10 categories of ethnic socialization.” These practices included (a) participating in cultural events, (b) sharing history, (c) preparing traditional food, (d) language use, (e) wearing traditional clothes, (f) strengthening family ties, (g) preparation for marriage, (h) participation in religion, (i) encouraging ethnic pride, and (j) expressing high expectations.

The results revealed that 65.2% of the adolescent respondents participate in the annual New Years celebration, funeral rituals, wedding ceremonies, or traditional dances. One 15-year-old boy reported that “his mother encouraged him to observe cultural rituals at funerals, such as listening to the songs performed by Hmong elders using the queej, a flute-like instrument made from bamboo.” 56.5% of the participants mentioned that mothers talked about Hmong history or their specific family history. One 15-year-old girl said, “She [mother] shares stories about the Hmong and how they moved down from China to Laos and Thailand and how they are scattered everywhere.” Additionally, a total of 52.2% of the participants said that their mothers encouraged them to wear traditional clothing. “The cultural experience can include wearing the clothes, helping to make it, and learning to wear it. The adolescents also learn traditional quilting and embroidery skills that are used to decorate the clothes and other items.” Ethnic socialization related to cooking and food was mentioned by 52.2% of the participants. “Some adolescents mentioned that they helped their parents with picking the vegetables and selling them at the local farmers’ markets,” and the use of the Hmong language was mentioned by 52.2% of the participants as an important aspect of ethnic socialization. One 15-year old girl indicated that her mother encourages her to learn the Hmong language: “She really wants us to speak Hmong fluently. At least know how to read and write in Hmong because it will help her out a lot, you know.” Also, religion as a form of ethnic socialization was mentioned by 39.1% of the participants. Shaman is the traditional Hmong religion; “the Shaman religion includes ancestral worship and maintaining spiritual connections with deceased family members.” Most Shaman Hmong believe that when a person loses one of his or her souls, the person will eventually become sick and may die. One 15-year-old girl stated, “My dad’s cousin is one of the shamans. She [mother] really believes in it. [So, can you explain something, like what Shaman represents?] It’s sort of like calling the spirit. If you lost your soul, you have to call a shaman to come in and go find your soul.” On the other hand, a few of the Hmong American participants were Christian and many view the church as a way to remain connected with other Hmong people and to the Hmong culture. The results of this study underscore the significance of traditional practices to the Hmong people outside of those surrounding childbirth. Participants in this study described their mothers as those who encourage them to participate in cultural events, teach them about history, and help them learn food preparation, understand the language, and wear traditional clothes (Moua and Lamborn).

Cultural Barriers in the Medical World

Many Hmong Americans have trouble communicating their beliefs due to language and communication barriers. A research study labeled “Technical Meets Traditional: Language, Culture, and the Challenges Faced by Hmong Medical Interpreters” reveals the communication barriers that exist in the modern medical world. Despite the existence of translators, this study found various factors that affect the ability of interpreters to make accurate medical interpretation for Hmong-speaking patients. In the United States today, approximately “67 million people (23% of the total population) are of a non-White ethnicity, and 61.6 million individuals speak a language other than English at home.” As such, the need for intercultural communication, which denotes a type of social interaction between people of different cultures, between patients and healthcare providers is greater than ever in the modern day. Interpretation is defined as “the processes of encoding and decoding messages, negotiation, and compromise to accommodate differing cultural frameworks of reference and identification.” Medical interpreters are critical for “ensuring effective communication between Limited English Proficiency (LEP) patients and healthcare providers.” Yet even with the best technical translation, “intercultural miscommunication can contribute to health disparities.” Previous studies of Spanish, Hmong, and Japanese interpreters found that “omissions and editorializations (for instance, when interpreters provide their own views on the interpretation of a word or phrase spoken by the patients and providers) were the most common sources of inaccuracies.” Of the 327,000 individuals in the Hmong population in the United States, “37% have LEP. Hmong patients have reported that “low-quality interpretation contributes to poor interpersonal relationships with their providers, emotional distress, and an inability to follow medical treatment plans.” In interviews, 13 Hmong interpreters were asked about their experiences interpreting for Hmong patients. Then, the audio recorded interviews were analyzed by two Hmong nursing students. Three common factors that lead to inaccurate medical interpretation were found: (a) there is a mismatch between the interpreter’s and patient’s gender, (b) discussion involves culturally taboo topics about reproductive body parts and sexual health or activity, and (c) differences exist in culture and generational language between the Hmong interpreters and patients. Specifically, a large part of the inaccuracy of Hmong medical interpreting stems from the challenges of finding words and phrases that are sufficiently equivalent in Hmong and English during medical interpretation. “This gap affects intercultural communication.”

The three factors are listed as such:

1. “Most of the female interpreters expressed having more difficulty interpreting for male patients, particularly older male patients who hold traditional beliefs,” than male interpreters with female patients. Interpreter #1007 stated “I had a much older Hmong male patient, and he did not like the fact that I was a woman… He didn’t really say anything, and he just rolled his eyes at me… “
2. All interpreters in this study agreed that patients are more comfortable discussing issues surrounding reproductive and sexual health with same-gender interpreters. Interpreter #1003 stated, “It gets uncomfortable when I’m interpreting for a male, and he’s going in for concerns about prostate issues or erectile dysfunction. I feel uncomfortable because I feel like I shouldn’t be talking about this.”
3. Differences in culture, generation, and birth/raised location of Hmong translators and patients “were reflected in significant language differences.” For instance, “all the interpreters mentioned that accurate communication with Hmong patients was hindered when the patient was older and foreign-born.”

Moreover, the Hmong language is evolving in its American usage. “Hmong patients, especially older adults and those who are foreign-born, often use borrowed Lao or Thai terms in their speech; since the interpreters do not have exposure to these formerly important contact languages, they perceive the words as a hindrance to accurate communication.” There are a multitude of cultural barriers that hinder the doctor-patient relationship for Hmong Americans in the medical world. However, recognizing these barriers is an important step towards mitigating the barriers (Lor et al.).

Beyond the medical world, cultural inequalities exist in the education system. Hmong people in school experience school life in unique ways due to their family’s experiences. In a study published in the Catesol journal which analyzes the stories told by Hmong people in the educational system, one Hmong girl’s parents didn’t attend any after school events or award ceremonies because they were working. It was hard for her to watch all the other children run to their parents after events, while she had to call her parents to pick her up and wait 30 minutes for them to come. Furthermore, similar to the lack of translators in the hospital in Fadiman’s book, the stories of Hmong people’s experiences before college “showed that the ESL intervention that was supposed to help their language progression was often actually more of a hindrance than a help. The fact that they were labeled ESL and stigmatized by being pulled out of their regular classrooms likely contributed to their experiences of feeling marginalized” (Biliterate Voices of Hmong Generation 1.5 College Women: Suspended between Languages in the US Educational Experience).

Healthcare Inequalities

At the end of Fadiman’s book, The Spirit Catches You And You Fall Down, Lia was in an unresponsive state due to a seizure which lasted too long. She spent four days at the Merced Community Medical Center in this state before returning home to die. However, discouraged by the doctors who Lia’s parents believed were telling them Lia should die rather than could die in the next few days, they set to work preparing natural Hmong healing remedies, boiling herbs and washing her body with the mixture. To the American doctors’ surprise, Lia doesn’t pass away. In fact, two years after Lia entered an unresponsive state, she remained alive. Despite her complete paralysis, her parents diligently care for her, frequently hosting txiv neebs and practicing Hmong animal sacrifices in the name of calling her soul back to her body (Fadiman, 1997).

Similarly, many Hmong aren’t treated substantially due to the doctors’ treatment of disease rather than illness; many Hmong feel under-treated and not cared for. An article on “Hmong Americans and Healthcare Inequalities and Solutions” indicates that “There are many reasons for disparities in the US healthcare system. One is that medical research tends to lump different Asian groups together, so that health risks that affect one group, such as ─ Hmong Americans ─ are averaged out with other groups with very different risks.” The objective of this research paper is to find solutions to the problems to help Hmong Americans get better access to healthcare and maximize its benefit. Previous studies found there are several reasons for the reluctance of the Hmong Americans to access Western healthcare services. These are: (a) the language barrier, (b) errors inputting Hmong American data in computer databases, (3) the cultural aspects of the Hmong Americans such as traditional beliefs, (4) and the cultural insensitivities on the part of healthcare providers. Fadiman’s book legitimizes these beliefs of many Hmong Americans, as oftentimes they experience second-class care. Cultural differences make it hard for the older patients to ask questions to the doctor regarding their diagnosis or prescription. Also, if there is an interpreter available, “there is no guarantee that the interpreter is fully effective because the interpreter may lack the knowledge regarding the Hmong American patients’ background.” As a result of the budget cuts in 1984, the California state government terminated the Hmong interpretation services at various medical center and welfare services office. “The interpreter services are available on a seasonal basis and on casual occasions only. The Hmong’s only choice is to use their children as interpreters, who are not as accurate in translations as are professional Hmong translators” (Berger and Lee, 2011).

Hmong Americans also have trouble accessing the healthcare system. “Since they do not make enough money and work menial jobs, healthcare insurance is hard for them to obtain; thus, access to see medical specialists is sometimes impossible” (Berger and Lee). This makes it hard for them to notice and respond promptly to cancer when it appears. Lack of knowledge of the health field itself is another issue. “Since they are poor, they do not get the proper education to understand more about the advantages of the Western healthcare instead of traditional beliefs in healing the illness.” The Hmong traditional belief of healing is limited to shamanic rituals, herb usage, and massages. Yet many find comfort in these traditional forms of treatment and are less familiarized with the modern Western approach to healthcare, and the inequalities in healthcare underscore their hesitation towards Western medicine. (Berger and Lee).

The case of Mexican-Americans

Like the Hmong people, millions of Latin Americans have recently immigrated to the United States. Latin America became the top origin region for U.S. immigrants in 1990, and by 2019 migrants from Latin America comprised 6.5%of the US population. More specifically, Mexico is the largest source of Latin American migrants to the United States (“Latin American Immigration to the United States,” 2023). Mexicans account for 60 percent of all Hispanics in the U.S. (Haner and Lopez, 2023).

Cultural Policies and Practices

Similar to Hmong cultural practices, Mexican culture commonly promotes alternative health and illness remedies with origins in ancient Mestizo/Indian folktale which view the causes of illness to include social, physical, and spiritual forces. Researcher Lopez’s “Use of Alternative Folk Medicine by Mexican American Women” research showed that “even among highly assimilated Mexican-American women, there persist traditional, indigenous beliefs, and practices” (2005). Indigenous Mexican health care beliefs contrast with Western European systems in notable ways. “‘The curanderismo that many Mexican American families practice today perceives illness both as a biological event (Western European perspective) and as a “social-interpersonal matrix” of causes and cures.”’ In Indigenous Mexico, physical health was viewed to be dependent on a proper balance of the body’s four humors: the hot fluids of blood and yellow bile, and the cold fluids of phlegm and black bile. The body’s symmetry is thought to be restored through ingesting foods and herbs with opposing qualities, sometimes with the guidance of persons with particular knowledge of herbal and food properties. Many Mexican American families practice their own traditions of folk medicine within their home and extended family networks. Candle-lit religious altars may be established in the home for commemorative, religious, and healing purposes. The use of home-made poultices, herbal treatments, and religious amulets are practices transferred from generation to generation which form a group of remedios caseros (home remedies). The article reveals Curanderismo persists for practical reasons which confront many impoverished Mexican Americans for whom U.S. health care systems have failed. Lack of medical insurance (33), language barriers, lack of knowledge of and accessibility to mainstream medical services have also served to sustain an informal system of health care providers and home remedies (19, 34, 35). Equally important may be the lack of culturally sensitive providers available to this growing population (8, 36). One of the primary reasons that Mexican folk traditions may persist is that some of the folk illnesses defy ontological explanations or descriptions that can be readily understood by mainstream doctors (5). The mother who seeks medical care for her child who is believed to be suffering from caida de mollera (fallen fontanel) may often be confronted by a medical staff who view the child’s dehydration and fever to be the result of “parental ignorance, superstition, or simply as abuse and/or neglect.” In contrast, a curandero may offer understanding and relief for the parent. The researcher administered a questionnaire to Latina students, 619 graduate students and 123 undergraduate students. The questionnaire provides evidence to support the “persistence of indigenous health care beliefs and practices among urban, assimilated Mexican American women.” Pearson’s r analysis revealed a significant relationship between age and whether the Mexican Americans had heard of folk healers, with an r of 0.286 and a p of 0.016. The more religious subjects were noted to be, the greater use of folk practitioners (p= 0.001). As indicated, “older respondents were more likely to answer in the affirmative.” Importantly, an r of -0.248 and a p of 0.039 revealed a correlation between the increased use of Mexican medicines and fewer doctor’s visits in the U.S. Although the health status of this study sample was mostly healthy, a significant majority of participants expressed “their comfort levels and communication levels with U.S. doctors as not entirely positive experiences.” On the contrary, a majority of the participants heard of folk healers and many knew of people who had used them. Approximately 26% of the sample had been treated by a curandero, but a greater percentage of individuals used the services of a sobador (Lopez, 2005).

Cultural Barriers in the Medical World

A systematic review of literature by researcher Caraway L. Timmins, “The impact of language barriers on the health care of Latinos in the United States,” underscores the cultural inequalities and barriers of the healthcare system. In the year 2000, 11% of adults in the U.S. labeled Spanish as their “primary language.” However, the U.S. health system is largely geared towards serving English speakers. This study examined language barriers for Latino populations in healthcare from 1990 to 2000. Two of the three studies examining health status or outcomes found “language to be a risk factor for adverse outcomes.” Moreover, six of the seven studies (86%) evaluating quality of care found a significant detrimental effect of language barriers. In fact, non-English speaking status was a marker of a population “at risk for decreased access” to healthcare. Researchers recommend that healthcare practitioners “devise effective strategies to bridge language barriers” (Timmins, 2002).

Practitioners

Many medical practitioners in the U.S. recognize the necessity of bridging the cultural divide to treat patients. The beliefs of contemporary medical western physicians on biomedical care in the U.S. are summarized in Fadiman’s book, The Spirit That Catches You And You Fall Down. On one hand, it is evident there is no sustained doctor-patient relationship with one doctor to develop better understanding of minority patients. Doctors likely don’t attempt to form close bonds with patients of unique cultural backgrounds because they believe they are not competent in understanding them. Lack of knowledge surrounding the histories and perspectives of unique cultural groups can often lead to misunderstandings in the healthcare system. For example, one doctor describes the frequent tension between doctors and patients.Doctors can become frustrated with the viewpoints of these patients and many times give them “suboptimal care” (page 75). Additionally, many nurses considered Lia a “burden and a pest” (page 113). It is evident their lack of understanding contributes to their frustrations. Furthermore, cultural diversity was often an obstacle to doctors. The objectives of doctors in Fadiman’s book do not seem to align with Kleinman’s definition of brokerage- “a concern for the psychosocial and cultural facets that give illness context and meaning.” In the book, according to Lia’s primary doctors, Neil and his Peggy, “cultural diversity [often] ceased being a delicious spice and became a disagreeable obstacle” (page 265). Bruce Thowpaou Bliatout, a Hmong medical administrator who wrote about mental health problems as traditional ailments of the liver, provided suggestions to mitigate doctor-patient relations (page 265).

Conclusion

Overall, this research on healthcare reveals gaps between the cultures of Western American medicine and the experiences of immigrant groups. Moreover, it indicates the importance of cultural brokerage in order to optimally treat patients in the United States. This field of study is highly relevant, as the “U.S. population is becoming increasingly diverse.” By the year 2020, the U.S. Census Bureau projects a 77% increase in the number of Hispanics, a 32% increase in AfricanAmericans, a 69% increase in Asians, a 26% increase in Native Americans, and less than a one percentage point increase in the White population (Kelly, 2005). To remain a country which was “founded on principles of equality and justice for all,” learning to treat all U.S. residents competently in the healthcare industry is vital (“The ERA: A New Foundation for Equality in the United States,” 2023).

Furthermore, the results exhibit the unique perceptions of distinct cultural groups surrounding healthcare, and their preference of traditional practices and customs, such as the use of folk healers. For instance, Hmong Americans use herbs to treat diseases and believe a new mother should partake in a 30 day confinement period after giving birth. Similarly, Mexican Americans utilize folk healers to heal illness. Both groups are evidently reluctant to go to the doctor to be treated, as a majority feel disadvantaged by the healthcare system. Also, many American healthcare practitioners lack the cultural competence to treat patients of diverse cultural backgrounds. The differences between the Western approach to medicine and that of the Hmong and Mexican groups are highlighted by the modern American practitioners’ treatment of disease, rather than illness, as well as their lack of accountancy of the lifeworld into treating patients. Studies indicate that if practitioners are more knowledgeable on the distinct cultural backgrounds of their patients and learn to be more receptive towards their patients’ perceptions of a given illness, doctor-patient relationships will be amended and cultural inequalities in the healthcare system can be mitigated.

This analysis has important implications for the advancement of cultural competence in medicine. The paper explains a framework for properly addressing the treatment of diverse groups by medical practitioners.

Importantly, it is not possible, let alone feasible, to have a translator for every spoken language in the world. As a result, the most effective solution might be increasing the quantity of translators for the five most prominent spoken languages in each state, despite the immense limitations of this mitigation. Furthermore, not speaking a language does not signify a lack of cultural competence or “cultural brokerage.” Cultural competency includes a deeper understanding and acknowledgment of diverse cultural backgrounds and unique perceptions of medical care in relation to illness as a whole.

On the other hand, it is crucial to indicate the limitations of this research paper, as it draws from accounts of people, which serves as data. People’s accounts are subjective and biased. Thus, it is not valid to assume the results are of definite true nature. Additionally, the validity of using research analysis to complete this study is limited in that any limitations or errors made in previous research is carried into this paper.

Considerations

In terms of what should be done next and the future directions of the field, it would be beneficial to conduct future research on different cultural groups in the U.S. The three largest minority groups in the U.S. are Africans, Asians, and Latinos. Given that this study analyzed distinct Asian and Latino groups, it would be important to look at the cultural inequalities of African Americans in the U.S.

In regards to future research, it would also be helpful to widen the scope of this study beyond cultural groups within the U.S., examining groups in South America, Australia, and etc. Although Hmong women in Australia were mentioned in this study, “historically, Latino communities have been part of the fabric of Australia,” revealing the possible benefits of analyzing the cultural competence of practitioners in Australia in regards to the Latino community. One study on “Latinos in Australia” reveals the struggles of the Latino community to assimilate into Australian society. The first wave of Latino migrants to Australia occurred in the mid-1990’s, and the second wave began in 1998. Obstacles Latino migrants encountered when first settling in Australia include the need for “social support networks that help to ease their political, economic, and social integration into Australia” (Río). There is a gap in understanding whether there exists cultural competence in healthcare systems in Australia for minority groups such as Latinos.

Works Cited

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Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Burnaby, B.C., Simon Fraser University Library, 1997.

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About the author

Ariella Rukhlin

Ariella is currently a senior at the Oceanside High School. She is an avid conversationalist and host of her podcast, “Chit-Chatting and Questioning the World.” While working on the podcast, she found a need for equality in education after realizing how many young people lack access to scientific information. Inspired and passionate about educational equity, she wrote and self-published a book, “A Curious Book On Curious Minds,” and donated the proceeds to the Save the Children Foundation, which helped fund a mobile Library in Ethiopia through the Camel Library initiative. Ariella is also a member of the Bridges Program — this roundtable discussion group tackles critical social issues to expose students to different ideas, cultures, and lived experiences with the hope of addressing the growing racial, religious, and ethnic divide on Long Island.

An avid learner in the school classroom and beyond, Ariella believes people should utilize everything they can to research every facet of the world around them because it enriches life and makes it so much more interesting.

The post Cultural Competence in Medicine: Western Approaches to Healthcare and their Implications on Immigrants’ Care and Disease Management appeared first on Exploratio Journal.

Abstract

Osteoporotic vertebral fractures represent a significant sociomedical problem that impairs the quality of life of the elderly population. Clinical examination, additional diagnostic methods (X-ray, CT, DXA, LVA) and fracture risk assessment (Frax) are key for effective assessment of the severity of the fracture, timely decision on the method of treatment, as well as initiation rehabilitation. Of great practical importance is the effect of antiresorptive therapy on formation callus. In patients suffering from osteoporosis, who despite treatment have a fracture, it is recommended not to interrupt bisphosphonate therapy, which was started several months before diagnosed fracture. Bisphosphonates should be introduced into the treatment in a period of 2-4 months from occurrence of the fracture, depending on the location of the fracture, i.e. the time required for callus formation. Recombinant parathyroid hormone is an effective anabolic therapy accelerates bone regeneration during fractures, increases callus volume and faster recovery bone strength. Osteoporosis therapy should not be started without checking the total and ionized Ca, P, 25(OH)D, PTH as well as general biochemical analyses, and then introduce antiresorptive or anabolic therapy. Rehabilitation treatment is designed individually and includes exercises balance, strength, range of motion and postural training lead to improvement spinal mobility, muscle strength and overall functionality. The aim of this review is to emphasize timely diagnosis, evaluation, and treatment of osteoporotic fractures vertebrae.

Keywords: Osteoporotic Vertebral Fractures, DXA, FRAX. Therapy, Rehabilitation

1 Introduction

Osteoporotic vertebral fractures affect approximately 1 in 3 women and 1 in 5 men over the age of 50 (1,2) leaving significant physical, psychological, and social consequences for patients, leading to reduced mobility, functional limitations, and decreased quality of life (3,4). Rehabilitation interventions have been shown to improve pain, functional outcomes, and overall well-being in patients with osteoporotic vertebral fractures (5-7). Pathophysiology and clinical presentation have shown that osteoporotic vertebral fractures result from a combination of reduced bone mineral density and changes in bone microarchitecture (7,8). Studies have demonstrated that the trabecular bone, particularly in the vertebral bodies, is most susceptible to osteoporotic fractures due to its high metabolic activity and abundant remodeling (9-11). Clinically, patients with osteoporotic vertebral fractures may experience acute or chronic back pain, which can be worsened by movement, prolonged sitting, or activities involving spinal loading (12). Height loss and kyphotic deformity are also common clinical features, contributing to postural changes and functional limitations. Potential hip fractures present great potential risk that cannot be overlooked (13- 15).

2 Radiological Examination 

Imaging techniques such as X-rays, CT scans, and MRI are used to diagnose and assess the severity of osteoporotic vertebral fractures (7). DXA is the the absolute gold standard (13) for bone mineral density measurements and a widely used technology for assessing bone health and measuring bone mineral density (BMD) (14-16). DXA may offer precise and accurate measurements of BMD at various skeletal sites, including the spine, hip, and forearm. It utilizes low-dose X-ray beams that pass through the bone, allowing for the calculation of BMD based on the differential absorption of these beams by bone and surrounding tissues. The BMD results obtained are compared to reference values, typically provided by age-matched and gender-matched populations, to determine if an individual’s bone density is within the normal range or if osteoporosis or osteopenia is present. In addition, It provides information about body composition. It can determine the percentage of lean mass, fat mass, and total body fat, allowing for the evaluation of body composition changes over time (14-17). This feature is particularly useful in monitoring the effects of interventions, such as exercise and nutrition, on body composition and overall health. Moreover, DXA can estimate the risk of fractures by utilizing algorithms that combine BMD measurements with clinical risk factors. These algorithms, such as the Fracture Risk Assessment Tool (FRAX), provide a comprehensive assessment of an individual’s fracture risk over a specified time period, aiding in treatment decisions and preventive strategies (18). Lateral Vertebral Assessment (LVA) is a radiographic method that provides quantitative measurements of vertebral heights and allows for the identification of vertebral fractures. It offers advantages such as low radiation exposure and quick assessment, making it a valuable tool for screening and monitoring osteoporosis-related fractures. LVA complements DXA by providing additional information about vertebral fractures and aiding in fracture risk assessment (19,20).

3 Fracture risk assessment and risk factors

Factors that increase the risk of developing osteoporosis encompass being 50 years of age or older, being of the female gender, belonging to the Caucasian ethnicity (particularly of northern European or Asian descent), having a genetic predisposition, having a petite and slender physique, experiencing undernourishment, leading a sedentary lifestyle, having a history of amenorrhea, late menarche, or early menopause, suffering from deficiencies in estrogen and androgen hormones, engaging in alcohol consumption or cigarette smoking, maintaining a diet low in calcium, and using certain medications (such as steroids, insulin, anticonvulsants, chemotherapeutics, or heparin) (21-23) The FRAX index combines DXA measurements and clinical risk factors to estimate the probability of future fractures. FRAX integrates clinical risk factors and bone mineral density (BMD) measurements to estimate the 10-year probability of specifically both major osteoporotic fracture (hip, clinical spine, forearm, or shoulder) and hip fracture. The clinical risk factors taken into account by FRAX include age, sex, previous fracture history, parental history of hip fracture, smoking status, alcohol consumption, glucocorticoid use, rheumatoid arthritis, and secondary causes of osteoporosis. By considering these risk factors along with BMD measurements, FRAX provides a comprehensive assessment of an individual’s fracture risk. FRAX calculations are based on large population-based cohorts and validated in numerous studies. It helps identify individuals at high risk of fracture who may benefit from early interventions, such as pharmacological treatments, lifestyle modifications, and fall prevention strategies. FRAX does not consider all possible risk factors, such as vitamin D deficiency or secondary causes of osteoporosis (14-18,24,25).

4 Conservative Management

Conservative management strategies for osteoporotic vertebral fractures aim to alleviate pain, improve function, and promote healing without surgical intervention. Various classes of medications are commonly used for treating osteoporotic fractures. Bisphosphonates, like alendronate and risedronate, inhibit bone resorption (26). Selective Estrogen Receptor Modulators (SERMs), such as raloxifene, mimic estrogen’s effects on bone (27). Teriparatide stimulates bone formation and is administered via injections (28). Denosumab, a monoclonal antibody, targets bone resorption (29). Calcitonin helps regulate calcium levels but has modest fracture risk reduction (29). Due to wide range of pharmacological options today, the complete assessment of the patient overall condition must be made before choosing the appropriate treatment (26-30). When we discuss the efficient medications, we cannot skip to mention that anabolic agents, like romosozumab, promote bone formation by inhibiting sclerostin and are highly effective, especially in postmenopausal women with severe osteoporosis. The effect of antiresorptive therapy on callus formation is important. Bisphosphonates should be introduced into the treatment within a callus formation period which is 2-4 months from the fracture occurrence. Patients who suffer from osteoporosis and despite treatment have a fracture, it is recommended to continue therapy which has started months before the diagnosed fracture.

Recombinant parathyroid hormone is an effective anabolic therapy which accelerates bone regeneration during fractures, increases callus volume and faster the bone strengthening (28,30).

5 Biomarkers

Biochemical markers in bone metabolism, including serum cross-linked C-telopeptide of type I collagen (CTX), N-terminal telopeptide (NTx) ,tartrate-resistant acid phosphatase 5b (TRACP 5b) , and bone-specific alkaline phosphatase (BALP) provide crucial insights into bone health. Elevated CTX and NTX levels indicate increased bone resorption, while higher BALP levels suggest enhanced bone turnover. These markers help assess the effectiveness of treatments like anti-resorptive medications. Additional markers like osteocalcin (OC), serum procollagen type I N-propeptide (PINP), and dihydropyrimidine dehydrogenase (DPD) aid in early bone loss detection and treatment guidance, enhancing patient care when combined with clinical assessments and imaging techniques. Total and ionized calcium Ca, P, 25(OH)D, PTH and general biochemical analyses have to take place before introducing antiresorptive or anabolic therapy (31-33).

6 Rehabilitation of Patients with Osteoporotic Vertebral Fractures 

Mechanical stimulation affects bones in two distinct ways. Firstly, repetitive strain can have a negative impact, resulting in minor damage to bone structure. Conversely, strains surpassing a certain threshold stimulate new bone production and enhance bone resilience under greater loads. The interconnectedness of these effects is commonly referred to as the mechanistic theory, which plays a pivotal role in preventing osteoporotic fractures. It revolves around the concept of minimal effective strain (MES), crucial for safeguarding bone density. To maintain bone structure, strain within the physiological range (800-1,500 μstrain) is essential. Deviations from this range yield varying outcomes, including increased bone resorption at less than 800 μstrain, strengthened bones at 1,500–3,000 μstrain, or even pathological fractures at 15,000 μstrain. Hence, rehabilitation programs aimed at preventing bone loss should incorporate kinesitherapy alongside conventional pharmacological treatments (30,33,34). The management of vertebral fractures can be categorized Into three phases: the acute phase, post-acute phase, and the rehabilitation phase. In the acute and post-acute stages, the primary objectives include effective pain management and ensuring the stability of the fracture (35). Conservative treatment involves the use of an orthosis, designed to provide spinal stabilization. Orthoses are typically employed for a duration of 8 to 12 weeks to aid in the healing of fractures. During the initial 8 weeks following a vertebral fracture, patients are advised to refrain from engaging in resistive strength training. However, relaxation exercises, breathing routines, and range of motion exercises can be introduced to counteract joint rigidity (36-40). Still, it is crucial to minimize prolonged bed rest during these phases and instead encourage mobility in patients. Prolonged bed rest has the potential to lead to undesired consequences such as muscle atrophy, weakness, joint stiffness, pressure sores, deep vein thrombosis, respiratory issues, disorientation, and even depression (38,39). Before initiating the rehabilitation phase, radiological assessment of progress in fracture healing is pivotal. In the early stages, it is advisable to introduce neuromuscular stabilization exercises targeting the thoracolumbar region, which help immobilize this area. Within the rehabilitation program, exercises to strengthen the dorsal extensor muscles, aimed at reducing kyphosis, are recommended. Moreover, postural retraining, balance enhancement, and proprioceptive exercises are crucial for minimizing the risk of falls and secondary fractures (39-43). Rehabilitation phase has to be individually tailored, still it must be underlined that the resistance training, balance exercises and postural training lead to improvements in spinal mobility, muscle strength and overall functionality of the patients.

7 Physical Modalities

Physical modalities used to improve bone repair include various therapeutic techniques and treatments aimed at enhancing bone healing and bone health. Some of these modalities include Low-Intensity Pulsed Ultrasound (LIPUS) (44), Electrical Stimulation (45), Functional Electrical Stimulation (FES) (46), Magnetic Field Therapy (47), and Vibration Therapy (48). LIPUS therapy involves the use of low-intensity ultrasound waves to stimulate bone healing. I’’s often used to accelerate fracture healing and can promote the formation of new bone (44). Electrical stimulation methods such as direct current, inductive coupling, and capacitive coupling have been employed to promote bone repair. These modalities can enhance the production of bone cells and help in the healing process (445). FES involves the use of electrical currents to stimulate muscle contractions. I’’s used to counteract muscle atrophy and promote bone health in individuals with limited mobility, such as those with spinal cord injuries (46). Pulsed electromagnetic field (PEMF) therapy uses electromagnetic fields to stimulate bone repair. I’’s often utilized in the treatment of non-union fractures and other bone-related conditions (47). Whole-body vibration therapy and localized vibration therapy are techniques that involve the application of mechanical vibrations to stimulate bone formation and improve bone density (48). It’s important to note that the choice of physical modality depends on the specific condition, the stage of bone healing, and the recommendations of healthcare professionals. Individualized treatment plans are typically created to address the unique needs of each patient.

8 Nutrition in Supporting Bone Healing

Nutritional therapy plays a significant role in supporting the healing process and overall bone health following an osteoporotic vertebral fracture. Calcium is essential for bone health. Ensuring the patient is getting an adequate amount of calcium through dietary sources such as dairy products (low-fat or non-fat milk, yogurt, cheese), fortified plant-based milk alternatives, leafy greens (kale, collard greens), and fortified cereals. Aim should be around 1,000 to 1,200 milligrams of calcium daily, but individual requirements may vary (49). Vitamin D is crucial for calcium absorption and bone health. Spending time in the sun (with sunscreen) to allow body to produce vitamin D naturally. Additionally, including foods rich in vitamin D in diet, such as fatty fish (salmon, mackerel), egg yolks, and fortified foods like orange juice and cereals. Magnesium contributes to bone health by helping to convert vitamin D (50,51) into its active form. Good sources of magnesium include nuts, seeds, whole grains, and green leafy vegetables. Usage of vitamin D supplement if levels are low is mandatory step. Furthermore, Vitamin K is necessary for bone mineralization (52). You can find it in foods like leafy greens (kale, spinach, collard greens), broccoli, Brussels sprouts, and certain vegetable oils. Protein intake is essential for the repair and maintenance of bones and muscles (53). Lean protein sources like poultry, fish, lean meats, beans, lentils, and tofu are preferable. High sodium intake can lead to calcium loss in the urine (54). Maintaining a balanced intake of phosphorus is one of the challenges. While it is important for bone health, an excessive intake can interfere with calcium absorption. Phosphorus is naturally present in many foods, including dairy products, meats, and nuts (55).

9 Conclusion

The comprehensive management of patients with osteoporotic vertebral fractures involves a multidisciplinary approach, combining rehabilitation interventions, radiological examinations, biochemical markers, conservative management strategies, and prevention of complications. By addressing these aspects, healthcare professionals can optimize patient outcomes, alleviate pain, improve functional abilities, and enhance the overall well-being of individuals affected by osteoporotic vertebral fractures.

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About the author

Milutin Todorovic

Milutin is a junior at Glenbrook South High School, located near Chicago. He is particularly interested in the intersection between econometrics and medical sciences. Outside of school, Milutin is involved in the Varsity Debate Team, Model United Nations, and being an Oralist for the Math Team; he enjoys playing Tennis in his free time, writing Columns for his school’s Newspaper (the Oracle), and being a club leader for the German National Honor Society.

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