- the representation of illness and its causes influence the therapeutic pathway. Illnesses (convulsions, delirium, madness) attributed to supernatural factors, to the transgression of a taboo or to an evil spell (sterility, abortion, breast cancer) will be treated by traditional medicine. Thus, in Haiti, it is the Houngan, the traditional healer, who determines if the patient's illness is due to natural or spiritual causes. It is he who will direct a patient towards one care system or another. Teams working there have appreciated that the Houngan figures as an unavoidable intermediary for them.

- lay  knowledge about health and traditional medical practices feed a singular medical imaginary and can impede the effectiveness of care. So in a programme in Latin America, the antibiotics prescribed were rarely taken because, for the local people, these unknown medicines, which work by killing the microbe, enclose the spirit of the illness within the body. Knowledge of how the illness was viewed, therefore, enabled carers to adapt their explanations when the prescription was made out so that taking the antibiotics would become acceptable. In the same way, the opinion that is still widespread in the West, according to which a plump baby is a healthy baby shows in equal measure that certain beliefs must be overcome.

- the society, the group, and the family environment around the patient often play a key role in decisions concerning the therapeutic pathway above and beyond the individual motivations and resistances of the patient: young mothers will not change their child's food if this implies going against the principles put forward by their mother or mother-in-law. And when the power of the elders is not in opposition to certain new ideas, there remains the fear of being marginalised as a result of following the course of action proposed (for example : "what will my mother think if I take the contraceptive that I have been given free of charge?").

Here it is essential to remember that in society, some illnesses are tackled by the patient alone (as in the case of STDs) and others require the bonds of community solidarity like problems with fertility. Some illnesses only require one treatment; others which have more of a stigma attached, bring the identity of the patient into play.

 Examples of sociocultural determinants

- religious principles (forbidden foods, imposed sexual behaviour...) have a powerful impact on the outcome of prevention campaigns; certain messages about mother and child health run counter to taboos on food, like the example of certain West African countries that consider that a pregnant woman must not eat red meat in order to avoid haemorrhaging at the moment of delivery, nor bananas to avoid having "a soft child"…

- language and jargon: the words used when talking about illness, the understanding of messages, the introduction of new words without any chance of their being translated show us that language is also a cultural determinant of the first order in accessing health care. How many dialects are capable of providing a translation for "asepsis"?

- usage of a common language does not indicate that "the same language is being spoken" either ; Even in situations where a common language or a translation is available, how can a carer interpret, even when a translation is available,"It hurts on the outside but not on the inside"?

- the qualities of the relationship between carer and cared-for - in other words, communication, listening, welcome - are fundamentals in the caring process, and are determinants of the trust and feeling of effectiveness afforded or not to the carer.

- other sociocultural determinants such as competition in the provision of health care (medical pluralism) or  new social, political, and  economic issues arising from projects also have to be taken into account as unavoidable elements when we define our approach.

décembre 2011