Interrelationships of Epistemologies of the South and cross-cultural care in health and Nursing practices

Abstract

Objective

to reflect on the interrelationships of transcultural care and the Epistemologies of the South of health and Nursing practices.

Method

this is a reflective study, based on a narrative review of the literature, highlighting the concepts of abyssal line, ecology of knowledge, and decolonization of knowledge from the framework of the Epistemologies of the South.

Results

after the reflective analysis of the material, three reflexive axes emerged, namely: Populations south of the abyssal line; Ecology of knowledge and interculturality; and Decolonization of knowledge in health and nursing practices: culturally congruent care.

Final considerations and implications for practice

the appreciation of the self-care culture of vulnerable population groups south of the abyssal line is essential to create opportunities for visibility and voice removed by the colonization process in the health field, as a result of the overvaluation of biomedical knowledge. There is a need for dialogue between knowledge to build an environment of mutual learning, characterized as the ecology of knowledge. For this, the decolonization process is needed from the perspective of post-abyssal thinking, with the appreciation of popular knowledge, in favor of culturally congruent care. Finally, in nursing, the framework of the Theory of Universality and Diversity of Cultural Care equips nurses to plan and implement sensitive transcultural care.

Keywords:
Delivery of Health Care; Knowledge; Cultural Diversity; Transcultural Nursing; Vulnerable Populations

Resumo

Objetivo

refletir sobre as interrelações do cuidado transcultural e as Epistemologias do Sul nas práticas em saúde e Enfermagem.

Método

trata-se um de estudo reflexivo, com base em uma revisão narrativa da literatura, destacando os conceitos da linha abissal, ecologia dos saberes e descolonização do saber do referencial das Epistemologias do Sul.

Resultados

após a análise reflexiva do material emergiram três eixos reflexivos, a saber: Populações ao Sul da linha abissal; Ecologia dos saberes e a interculturalidade; e Descolonização do saber nas práticas em saúde e Enfermagem: cuidado culturalmente congruente.

Considerações finais e implicações para a prática

a valorização da cultura de autocuidado de grupos populacionais vulneráveis ao sul da linha abissal é fundamental para oportunizar a visibilidade e a voz, retirados pelo processo de colonização no campo da saúde, fruto da supervalorização do saber biomédico. Observa-se a necessidade do diálogo entre os conhecimentos para a construção de um ambiente de aprendizagem mútua, caracterizado como ecologia dos saberes. Para isso, é preciso o processo de descolonização na perspectiva do pensamento pós-abissal, com a valorização do saber popular, em prol de um cuidado culturalmente congruente. Por fim, na Enfermagem, o referencial da Teoria da Universalidade e Diversidade do Cuidado Cultural instrumentaliza o enfermeiro para planejar e implementar o cuidado transcultural sensível.

Palavras-chave:
Assistência à Saúde; Conhecimento; Diversidade Cultural; Enfermagem Transcultural; Populações Vulneráveis

Resumen

Objetivo

reflexionar sobre las interrelaciones del cuidado transcultural y las Epistemologías del Sur en las prácticas de salud y Enfermería.

Método

se trata de un estudio reflexivo, a partir de una revisión narrativa de la literatura, destacando los conceptos de la línea abisal, ecología del saber y descolonización del saber en el marco de las Epistemologías del Sur.

Resultados

luego del análisis reflexivo del material surgieron tres ejes reflexivos, a saber: Poblaciones al sur de la línea abisal; Ecología del conocimiento e interculturalidad; y Descolonización del saber en salud y prácticas de Enfermería: cuidado culturalmente congruente.

Consideraciones finales e implicaciones para la práctica

la valorización de la cultura del autocuidado de los grupos poblacionales vulnerables al sur de la línea abisal es fundamental para generar espacios de visibilidad y voz sustraídos por el proceso de colonización en el campo de la salud, producto de la sobrevaloración de la biomedicina conocimiento. Hay una necesidad de diálogo entre saberes para construir un ambiente de aprendizaje mutuo, caracterizado como la ecología del saber. Para ello, se necesita el proceso de descolonización desde la perspectiva del pensamiento postabismal, con la valorización del saber popular, en pro del cuidado culturalmente congruente. Finalmente, en Enfermería, el marco de la Teoría de la Universalidad y Diversidad del Cuidado Cultural equipa a los enfermeros para planificar e implementar un cuidado transcultural sensible.

Palabras clave:
Atención a la Salud; Conocimiento; Diversidad Cultural; Enfermería Transcultural; Poblaciones Vulnerables

INTRODUCTION

Culture is understood as a composition of elements that characterize non-biological activities, and involves symbols, values, practices, traditions, and customs, shared by different social group members, as a collective product of human life. Through it, characteristics of the reality of human groups, such as health, are expressed. Thus, the term culture of care is related to the attributes of caring for oneself and others in a given group.¹

It is understood that self-care describes and explains the practice of care performed by the person in relation to a need to maintain health and well-being. Thus, everyone performs self-care, which is directly influenced by the conceptions, values, and individual and collective perceptions of each person and/or group.²

Added to this context is the cultural diversity evidenced by the plurality of knowledge and social and health practices. It is believed that the expression of cultural diversity, today, comprises the overcoming of the denial of differences.³ However, these differences are still interpreted as negative, with questions related to the valorization of knowledge (hegemonic) in detriment to other (non-hegemonic).

This thought emphasizes the need for a harmonious dialogue between cultures, not to homogenize them, but rather the possibility of living together based on respect and negotiation. In the current context of globalization with high cultural interaction, in addition to the presence of phenomena such as immigration movements, the presence of refugees in several countries, and health inequities to vulnerable groups such as indigenous, rural, and riverine populations, which have their own self-care culture and need culturally congruent health care.

However, in health care, the lack of knowledge of the historical and socialcultural context of the groups assisted is still predominant, as well as the devaluation of cultural self-care practices in territories where non-hegemonic cultures predominate. These practices coexist with the biomedical model, still hegemonic and overvalued.⁴ Therefore, the discussion about how health and nursing practices can be developed and experienced in this cross-cultural context is believed to be pertinent.

With that said, this study aims to reflect on the interrelationships of cross-cultural care and the Southern Epistemologies in health and nursing practices.

The theoretical framework of Epistemologies of the South

Boaventura de Souza Santos is a recognized thinker, awarded in many parts of the world. In one of his works, the book “Epistemologies of the South”, he offers reflections about epistemologies. Epistemology is any notion or idea, thoughtful or not, of the conditions of what counts as valid knowledge. It is through valid knowledge that a given social experience becomes intentional and intelligible. There is, therefore, no such thing as practical knowledge and social actors.⁵

The Epistemologies of the South arise from the view that the world is varied and diverse about cultures and knowledge, but that throughout the history of modernity, a form of knowledge based on the epistemological model of modern science has been superimposed, disregarding other knowledge.⁵

Thus, it can be said that the Epistemologies of the South are procedures that aim to validate the knowledge born in the struggle against capitalism, colonialism, and patriarchy, that is, knowledge born from social struggles. In this way, the Epistemology of the South represents the epistemological diversity of the world and the South represents it metaphorically as a field that aims to overcome the consequences of colonialism under countries in the geographic southern region.⁵

From this perspective, among the concepts of the referential in question, those that will support this study are the abyssal line, ecology of knowledge, and decolonization of knowledge (Figure 1).

Figure 1
Concepts from Epistemologies of the South.

Thus, the proposal to reflect on the interfaces of health practices and transcultural Nursing from the perspective of Epistemologies of the South is based on Boaventura's approach to supporting Nursing practices with a holistic vision, free from pre-judgment, without imposing knowledge. In such a way that the referential is based on diversity, plurality, and respect for individuality.

METHOD

This is a reflective study that aims to answer the following question, “How does the theoretical perspective of Epistemologies of the South relate to health and Nursing practices in the context of cross-cultural care?”

The study was developed during the first semester of 2021 as a product of the course “Advanced Topics in Education, Health, and Citizenship” of the Ph.D. program in Nursing at the Federal University of Rio Grande do Norte.

To operationalize the reflection, a narrative literature review was conducted from September to November 2021 by searching for books, articles, and documents on the topic in question in order to discuss it from a theoretical/contextual point of view.⁶ The Virtual Health Library (VHL) was searched using the terms Epistemologies of the South and transcultural care.

To structure the theoretical framework and deepen the thematic-conceptual understanding, the book “Epistemology of the South” was read, as well as scientific articles that enabled the formation of bridges between the referential in question and the development of health care and Nursing practices in the cross-cultural context. Documents considered important about cross-cultural care were used as reference.

For the treatment of the information, it was used the elaboration of annotations with reflective points allowed a panoramic view of the documents and the construction of this study.

RESULTS AND DISCUSSION

From the reflective analysis of the material and the group discussion among the authors on the theme, three reflective axes emerged, namely: Populations South of the abyssal line; Ecology of knowledge and interculturality; and Decolonization of knowledge in health and Nursing practices: culturally congruent care.

Populations south of the abyssal line

Through the thought conceived by Boaventura, it is understood that the invisible abyssal line that separates the world of knowledge and experiences characterizes a visible dichotomy between the legal and the illegal, the latter being in the south.⁵ In the south is the invisibility of non-hegemonic forms of knowledge, popular, lay, peasant, indigenous knowledge, or knowledge that is not compatible with the knowledge of the north.

This knowledge is constructed by social actors, culturally defined population groups, who have their worldviews and relate to each other and other social groups in their ways. These different relationships give rise to different epistemologies, which end up being oppressed and minimized by the epistemology north of the abyssal line.

Being south of the abyssal line refers to the set of countries in the world that were subjected to European colonialism, and that have not reached economic development similar to that of the global north. Thus, it denotes a counter-hegemonic position and illustrates the presence of a set of subjugated knowledge and practices, considered inferior. This inferior position is linked to the knowledge of these populations, silenced every day with the advance of globalization and capitalism.

Through reflection, it can be inferred that immigrants, refugees, indigenous people, gypsies, and people from the countryside, forests, and waters, are some of these people who suffer from the minimization of their knowledge in health. This repression has repercussions in their space in society, as well as in their power of voice and representativeness, which contributes to the process of acculturation, an increase of social differences, and erasing of their identities in today's world.

Ecology of knowledge and interculturality

From the perspective of the Epistemologies of the South, the Ecology of Knowledge is a set of epistemologies that are based on the possibility of counter-hegemonic diversity and globalization and aim to contribute to giving them credibility and strengthening them. It is based on two assumptions: there is no neutral epistemology and those that claim to be are the least neutral; epistemological reflection should not focus on abstract knowledge but on knowledge practices and their impacts on other social practices. When we talk about the ecology of knowledge, we mean the ecology of knowledge practices.⁵

That said, the ecology of knowledge is a concept that aims to promote dialogue between the various pieces of knowledge and may help to understand the context, history, tensions, and challenges experienced by interculturality in the context of health care for vulnerable populations south of the abyssal line. Thus, it enhances the possibility of approaching the reality of these populations, as well as their daily lives in living, having, and achieving health.

In relation to the health and Nursing fields, the ecology of knowledge has a positive impact by providing professional practice with the responsibility to accept the diversity and contexts of users and the recognition of a plurality of forms of knowledge that must be taken into account beyond scientific knowledge.

The nurse in this scenario has the responsibility to accept the diversity of users' styles, in order to offer care that respects each individual as well as dignified and intercultural care. It is proposed, then, to guide practices, considering the diversity of worldviews, individual and group characteristics, along with the epistemological pluralism that recognizes the existence of multiple views.

Decolonizing knowledge in health and Nursing practices: culturally congruent care

When considering the decolonization of knowledge, it is required to understand what colonization is. Colonialism was also an epistemological domination, based on an unequal relationship of knowledge-power that led to the suppression of many forms of knowledge belonging to the colonized peoples and nations, relegating many other forms of knowledge to a space of subordination. Therefore, the colonization of knowledge denotatively means a model of radical exclusion and exploitation that, in the epistemological field, subjugates and minimizes the knowledge and practices south of the abyssal line.

Therefore, healthcare practices can be understood as the set of knowledge used to recognize or identify a problem related to the physical and/or mental balance of a person, and, consequently, to plan actions aimed at recovering this balance. It is noteworthy that healthcare practices are strongly influenced by cultural, historical, social, political, and economic processes. Besides such factors, there are others, of a more subjective nature, which also influence healthcare practices, such as beliefs and religion.⁷

Currently, the hegemonic care model overvalues biomedical knowledge, rejecting any other type of knowledge that does not come from academia, based in some way on theories or experiments. However, for health care, the valuing of culture and care practices is increasingly necessary, in order to make the cared-for person the main protagonist of this process. Therefore, this understanding is what establishes a watershed between considering the culture of the other as the possibility of a power-generating encounter or, differently, the culture of the other as an obstacle to be overcome.⁸

Nursing as a profession, field, and science, presents components sensitive to cultural issues concerning health care. Its theoretical basis is the Theory of Universality and Diversity of Cultural Care (TUDCC). This theory was proposed by Madeleine M. Leininger, and considers that the worldview of individuals and their social and cultural structures influence their state of health, well-being, or disease.⁹

It is possible to understand that such influence occurs because social and cultural factors structure and influence the understanding of what health and disease are, as well as shape the actions of care and self-care of individuals or population groups for health maintenance. This perception can enable health professionals to broaden their vision and sensitivity when assisting social minorities or marginalized populations.

According to Leininger, human caring is universal, thanks to this human beings have survived over time because they are able to care for themselves and each other in varied ways and in different environments. Thus, they are universally caring beings who survive in a diversity of cultures by their ability to provide the universality of care in various ways according to different cultures, needs, and lived situations.⁹

In the meantime, Nursing covers itself with the cloak of caring, by paying attention to human responses and care needs of the individual, family, and community in a professional and scientific manner, while at the same time paying attention to the humanistic and social facets of this care. Therefore, by understanding this context, TDUCC is concerned with providing nursing care that is congruent with the culture of each person/group by approaching the aspects of the human being's life, in its complexity, considering people as beings of relationships in the community, with their own self-care culture.¹⁰

Therefore, the existence of differences between professional health systems (scientific knowledge) and popular health systems (culture of care and self-care) is affirmed, which can create conflicts if they are not worked on from the perspective of the ecology of knowledge. The nurse in this scenario acts as a link that brings these systems together by seeking congruence between the practices of these two care systems.

The TDUCC illustrates this relationship and action of the nurse using a theoretical-conceptual model called the Sunrise model (Figure 2) to describe this interaction.¹¹ It is a model, seen as a cognitive map that has the objectives of discovering, explaining, interpreting, and predicting knowledge of care, as well as developing culturally congruent Nursing care. It consists of four levels and goes from level I - more abstract - to level IV - less abstract. The first three levels provide subsidies for care planning and execution, since they involve the development of knowledge related to the care culture of the person to be cared for, although this terminology is not used by the author.¹²

Figure 2
Sunrise conceptual-theoretical model.

The nurse, when using the TDUCC, works in mutual knowledge and respect, in order to produce a health practice based on popular and professional systems in the sense of decolonization of knowledge, thus, valuing the knowledge that is south of the abyssal line, fruit of post-abyssal thinking. By knowing, recognizing, and valuing the way of life of individuals and groups, and inserting the culture of self-care in the care plan, the nurse enables the technical-scientific support of nursing care, as well as the autonomy of the individual, family, and community, characterizing a true ecosystem of knowledge in practice.

CLOSING REMARKS AND IMPLICATIONS FOR PRACTICE

Through this reflexive study, it was possible to observe points of intersection between the Epistemologies of the South and health and Nursing practices in the cross-cultural context. The valorization of the culture of care and self-care of population groups south of the abyssal line is fundamental in the current social context, with the perspective of providing visibility and voice removed by the colonization process experienced in the health field over the centuries with the overvaluation of biomedical knowledge.

In contrast, it is observed the need for dialogue between knowledge (professional and popular) for the construction of an environment of mutual learning, characterized as the ecology of knowledge. For this, the decolonization process is placed in the perspective of post-abyssal thinking, with the appreciation of the southern populations' knowledge for the structuring of culturally congruent health care and Nursing.

As implications for practice, it is considered that Nursing has the referential of the Theory of Universality and Diversity of Cultural Care, which has excellent potential to align the care process to the intercultural perspective, valuing the characteristics of the worldview and cultural structure of the individual, family, and collectivity, positioning the nurse in the important role of interlocutor between health systems, professionals, and the population, to promote approximation between these social actors, the recognition of knowledge, and reflective care in a transcultural mutuality regime.

Finally, the development of other studies that articulate modern theoretical thoughts/references with theories of specific sciences, such as Nursing, is considered important in order to transpose concepts and theoretical relations, considering that science cannot be hermetic in spite of the increasingly challenging social demands.

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Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

• Publication in this collection
  31 July 2023
• Date of issue
  2023

History

• Received
  12 Dec 2022
• Accepted
  24 May 2023