How do rodrigues and harding define culture

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Wolf, Charles Jr. Questioning Cultural Diplomacy. Metaphors for diplomats. Conflict Resolution and Peace Building. Kultur als Faktor in der internationalen Politik. Cultural diplomacy of Slavic European Union member states : a cross-country analysis. India's cultural diplomacy : present dynamics, challenges and future prospects.

International journal of arts, humanities and management studies; 1 , 9, S. A new era in cultural diplomacy : promoting the image of China's "Belt and road" initiative in Asia. EU cultural diplomacy : challenges and opportunities. Promotion of Ukraine's cultural diplomacy in the EU. Cultural diplomacy and cooperation in the Mediterranean : a constant investment.

The new nature of cultural diplomacy in the age of online communication. International E-learning as an emerging cultural diplomacy practice. The usage of new media in cultural diplomacy : a case of Turkey.

Philippine cultural diplomacy : unraveling its full potential. Archives of key journals were searched, in order to find relevant articles that had been missed in the initial database search. Journals were selected for hand searches if they contained a high frequency of relevant articles, identified in the electronic, hand and cited references searches see Table 2.

For Spain, the full medical anthropology bibliography [20] , and medical anthropology conferences were also hand-searched. Grey literature —documents that are disseminated outside standard publication channels such as scientific journals but which have a definite influence on scientific output for example policy reports or conference proceedings — was obtained from experts identified from the expert network on culture and EoL care that was created concurrently to the scoping as part of the PRISMA project.

All documents were considered for relevance based on titles and abstracts. When the information was not sufficient to decide on inclusion or exclusion, the full text was evaluated. Because of the dearth of evidence in this area and the exploratory nature of the scoping of this literature, the team first became familiar with the literature from each country and then discussed inclusion and exclusion criteria in a team meeting.

This was then used as a guide for deciding about their relevance to the review question. We included reviews and original research studies that informed about socio-cultural issues in EoL care.

We excluded studies on clinical tools, pain and symptom management, pharmaceuticals, donation and transplants, neonatal EoL issues, legal issues and psychology. However if any of these studies contained relevant elements they were read fully and included. The electronic searches were restricted to the English language.

Handsearches in the national languages were conducted for Spain, Portugal, Italy, Germany, Belgium and the Netherlands. To optimise comparability between countries we restricted the review to papers that were produced after the arrival of the ideas of the palliative care movement.

Data extraction was conducted for all studies, which inventorised study details, participants, methodology, and main findings. The initial stage was mainly oriented towards examining the extent, range and nature of research activity, although this already implies interpretation and formed a part of the synthesis of the findings.

A mapping of reported practices and concepts was carried out regarding cultural issues in EoL care for each country through techniques of identification, listing, tabulating and counting individual studies. The overviews and opinion pieces were from this point not systematically analysed, although they were read as background literature and informed the further stages of synthesis. Themes across multiple studies were developed inductively through constant comparison of findings.

Each team member developed a country-specific narrative synthesis. Second, the country-specific syntheses were exchanged among the members of the team and read. Each developed a framework of themes that was capable of integrating all the themes used in the syntheses of the other countries, retaining the capacity to still compare findings across countries in a meaningful way.

These frameworks were then discussed in team meetings and a common framework was agreed upon, consisting of five themes: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The narrative syntheses for each country were then rewritten according to these cross-cutting themes. This assisted the comparison of practices, and ideas related to developments in EoL care across the countries and the identification of similarities or differences in approaches.

A third step focused on the body of literature itself, as a source of information on how the evidence approaches and thereby constructs the issues it addresses. Then, by examining the number and type of studies, insight was gained into the evidence itself, and how cultural knowledge featured among other types of knowledge generated in research on EoL care for example relating to clinical practice or service development.

This showed the areas of expertise in different countries and revealed gaps in knowledge. Identified papers were well distributed between and Articles published before were in Dutch and beyond the scope of this review. These were, however, well cited in the papers appearing in international journals.

This already points towards the contested history of palliative care in the Netherlands: it is either seen as an underdeveloped area of expertise, when one considers its start with the establishment of hospices in the early s [21] , or as a field which already started to develop through work in nursing homes back in the s [22]. The literature on the Netherlands provided information about a variety of settings in which EoL care is provided and the experience and role of health professionals involved [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30].

Some studies described how the differences in EoL care settings affected the type of care provided [27] , [29]. Despite the key role played by informal carers in home care, only two studies focused on their experiences [31] , [32]. Euthanasia and physician assisted suicide PAS were the most common topics of research in this area.

A recent comparative study of the Netherlands and Belgium on the first five years of euthanasia legislation showed that there are differences in how the legislation is applied in each country [33]. Other MELDs such as non-treatment decisions [34] and palliative sedation [35] , [36] were also explored. Considerable attention was devoted to the definitions, differences between, and incidences of, MELDS [37] , [38] , [39] , [40]. A culture of tolerance towards euthanasia and PAS was described which had been embedded in Dutch society for over years [41] , [42].

Other articles explored the importance of self-governance for terminally ill people in a Dutch context [32]. One study focused on the role of the euthanasia consultant who evaluates the criteria for careful practice and advises about palliative care [46].

An ethnography showed that a request for euthanasia often served a symbolic purpose and enabled open discussion about taboo subjects of death and suffering [47].

Similar findings came from subsequent studies [32] , [48]. Issues relating to communication revolved mainly around advance directives ADs [41] , [50] , [51] , [52] , [53] , disclosure and information giving [26] , [54] , [55] , [56] , [57] , [58] , [59]. The issues relating to ADs were determined by the euthanasia situation. Public knowledge about ADs was found to be high. These are documents in which one can state the wish for euthanasia in certain cicumstances.

Only three studies addressed EoL care relating to ethnic minority groups in the Netherlands. One study found that euthanasia was not less common, while symptom alleviation occurred less among this group [61]. Another study examined Dutch professional home care and the barriers to the use of this care for terminally ill Turks and Morrocans and their families [62]. The majority of articles were published between and The first publications appeared when the euthanasia debate had just started, resulting in the enactment of the euthanasia law in Unlike in the Netherlands, this debate was brief and palliative care played an important role in it.

Although palliative care had only started five years before, it was very successful. The two movements developed in parallel. This model is inclusive of euthanasia, and as such it responds to the pluralist make up of Belgian society. Against this background, research aimed at developing an understanding of place of care and death. Studies provided insight into different settings where people die in Belgium [65] , [66] , [67] , [68] , [69] , the determinants of place of death [66] , [69] , [70] , [71] , [72] , [73] , [74] , [75] , and how place of death compared internationally [70] , [74] , [76].

One study focused on transitions between settings [77]. One key aspect of the health system in Belgium was that GPs tended to work alone and often had a long-standing and trustful relationship with patients. MELDs was the most researched topic in the Belgian literature, mainly focusing on definition of concepts [79] , [80] , [81] , [82] , incidence of MELDs [69] , [80] , [83] , [84] , decision making [85] , [86] , including communication [87] , key actors [88] , [89] , [90] , and the role of health professionals [91] , [92] , [93] , [94] , [95] , [96] , [97] , [98] , [99] , [] , [].

These studies present evidence for or against the legal developments in Belgium. The studies that assessed MELDs in practice showed that the slippery slope effect had not materialized [65]. Also, with the availability of palliative care, euthanasia requests were less likely [] , [] , [] , [] , [].

These requests were however not preventable in all cases. A study comparing practices of euthanasia and assisted suicide with the Netherlands, showed that there were significantly fewer cases in Belgium than in the Netherlands , mostly in patients suffering from diseases of the nervous system, and in hospital [33].

Other topics related to MELDs included application of laws and other regulations, institutional written ethics policies, and opinions and attitudes [65] , [83] , [86] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , [] , []. The articles on communication examined disclosure [] , [] , [] , [] , [] , [] , [] communication with different actors [98] , [] , [] , barriers to communication [] , [] , [] , [] and ADs [96] , [] , [] , [] , [] , [] , [].

One paper looked at the approach to EoL care by different ethnic groups in Belgium and called attention to non-Western perspectives []. The majority of articles were published within the last decade, with the remaining studies having been published between and The growing importance of nursing homes as a place of care and death, and the need to incorporate palliative care into these institutions, was highlighted [] , [].

ADs was a well-covered theme. Studies explored awareness of ADs, use and compliance [] , [] , [] , [] , [] , [] , [] , [] , [] , [] and desired level of bindingness [] , [] , [] , []. Medical end of life decisions was also a major theme in the literature.

Active euthanasia is illegal in Germany and the National Board of Physicians rejects any liberalisation concerning active euthanasia []. PAS is not illegal in Germany. However, physicians have the responsibility to attempt to apply all medical measures to prevent death, making PAS unfeasible in practice []. Cross-country comparisons found that Germans had relatively low acceptance of euthanasia given the secular and individualistic characteristics of the society [].

Its association with Nazi medicine has been avoided by using different terminology. The German literature on EoL care reflects a lack of social consensus on all topics and by all stakeholders. One study was published in the early s, ten were published in the s and the vast majority 34 were published between — A topic frequently touched upon within the original studies was the proportion of deaths in institutional settings in Norway. Norway has the highest percentage of beds in nursing home facilities per capita in Europe, more than twice that of most European countries and the highest number of deaths in nursing homes and hospitals [] , [].

Therefore the importance of palliative care provision within the nursing home setting was emphasised [] , []. Several studies also focused on different aspects of home care [] , [] , [] , [] , [] , [] , []. Studies of carers examined their characteristics [] , concerns [] , activities [] , effects of caring [] , [] , [] , [] , [] , and setting where the care was provided [] , [].

One of the sub-themes relating to communication was the uncertainties experienced by doctors and nurses regarding disclosure [] , []. A general reluctance to talk about death was found [] , [] , and a 20 year study in one hospital showed that open discussion of death with patients had not increased over time [].

This was ascribed to the Norwegian respect for privacy [] , although it could also be attributed to a strong death taboo. Another communication issue concerns the stakeholders included in decision-making. Its incidence was studied with two studies on patients [] , [] and two on health professionals [] , [].

Treatment limitation was the most frequently studied topic amongst the original studies, including its incidence [] , [] , [] , [] , criteria for limiting life [] , [] , [] , [] , and ethical dilemmas surrounding decisions [] , [] , [] , [] , [] , [] , []. The role of nurses and physicians was examined and the effect of EoL decisions [] , [] , [] , [].

Norwegian physicians have more conservative attitudes than other Scandinavian and western countries in regard to treatment limitation, euthanasia and PAS [] , [] , [].

In Norway palliative sedation and euthanasia were said to have only recently been differentiated, and guidelines for practice provided. Frequent topics in the Norwegian literature were healthcare spending and accounting. Only six of the studies for Spain were conducted before and since then research on EoL care has increased.

The main palliative care resource was home care teams, the second, in-patient units [14]. Percentages of healthy people who would like to die at home were generally higher than those who actually die at home [] , [] , [] , [] , [] , [] nevertheless a recent survey showed that half of the population has preferences for specific care settings or hospitals for terminal patients []. There was greater consensus among healthcare professionals than among the general public that the home is the ideal place of death [] , [] , [] , [].

A majority of the caregivers were found to be overloaded [] , [] and did not have any economic help or enough information of the resources available [] , [] , []. Disclosure of information regarding diagnosis, prognosis and treatments was found to be the most frequently discussed in the literature and this was also the topic of the identified review []. International comparisons described southern European countries as partial and non-disclosure countries [] , [] , [] and Spanish awareness studies suggested that this trend persisted over time [] , [] , [] , [] , [] , [] , [].

On the other hand, studies with healthy populations show that preferences are evolving towards open disclosure [] , [] , [] , [] , [] , []. Intermediate positions were also found; the majority of doctors stated that they would inform the patient only in certain circumstances or if requested by the patient [] , [] , [] , [] , [] , [] , [] , [] , [].

In Spain, the legal and administrative development of ADs is one of the most advanced in Europe []. Most doctors found the policies relating to their implementation a positive development [] , []. In an international study Spain was shown to occupy an intermediate position in Europe regarding the acceptance of euthanasia among the general public [] , and the acceptance had risen since among the general public.

In international comparisons, Spain was among the countries with the lowest prevalence of Do Not Resuscitate DNR orders, and among those where these were discussed less with the patient. There were low rates of treatment withdrawal [] , [] , [] , [] , [].

In Spain the rates of all three practices were higher than in Portugal, Italy, Greece, and in the case of withdrawal of dialysis Spain was above Germany. However, terminal sedation is still controversial in Spain. Part of the controversy concerns its use to manage existential and family distress, more common in Spain than in other countries []. Regarding feelings towards death and dying amongst both health professionals and the general public in Spain, fears related to pain were found to be the most important [] , [] , [] , [] , [].

However morphine consumption per capita was below the European and global average []. Fears about death were found to be a major barrier to good EoL care []. Four research studies examined EoL experiences of migrants from Morocco [] , [] , Latinamerica [] and UK [] in Spain, and four overviews were found that covered EoL issues for migrants [] , [] , [] , []. In Italy, there has been a steadily growing number of research studies since EoL care is delivered mainly by home care teams [] and the number of hospices rose from four in [] to 90 in [14] mainly due to new palliative care policies since [].

Nevertheless they were frequently characterised in a negative way as barriers to full disclosure and limitation of non-useful treatment [] , [] , [].

Also as in Spain, most studies from Italy focused on disclosure of information, with a review from on this topic []. Awareness studies published between and showed that a trend of partial and non disclosure persisted [] , [] , [] , [] , [] , [] , [] , [].

Other sources however suggest that physicians preferences are moving towards full disclosure [] , [] , [] , []. ADs are not legally recognised. Europe-wide surveys of the general public found that Italy was among the countries with the lowest acceptance of euthanasia [] , but the differences between Catholic believers and non-believers were higher than in other European countries.

Death was less likely to be preceeded by a MELD than in other European countries [] whereas terminal sedation was more frequent. A recent paper showed that there is still low and often incorrect awareness of palliative care among the general public []. Many of the studies focused on pain management and showed low opioid consumption [] and a significant proportion of patients not receiving appropriate treatment [] , [] , [] , [] , [] , [].

However knowledge about pain and analgesics was found to have improved [] , [] , []. Four articles focused on Italians as minorities in other countries [] , [] , [] , []. Only one original study gave specific information on immigrants [] and one overview presented the islamic perspective in pediatric biomedical ethics including EoL []. More than half of the articles were published in the last five years 11 , with the remaining studies having been published between and The development of services and research started relatively late in Portugal where the first palliative care unit only opened at the end of [].

There were country-wide statistical data on place of death: with almost one-third of all deaths occurring at home []. As in Spain and Italy, caregivers needs included information, time to relax and economical support and care []. Following again the southern Europe trend, disclosure was one of the main themes explored in original studies. Portugal, like Italy, is among the countries with the lowest public acceptance of euthanasia [].

The use of terminal sedation was lower than in other countries. Delirium was the most common grounds for initiating sedation while pain was an uncommon reason []. A recent publication calls for attention to informal caregiving for older people [].

There is still little agreement about what constitutes EoL care in Europe. Researchers, practitioners and policy makers have different understandings of its scope, definitions, goals and approaches [] , [] and there are limited resources for its development. Identifying and analysing diversity in understandings and practices in EoL care in the different countries is essential for reaching consensus on EoL care, and for achieving workable standards.

In this scoping exercise we found a diverse body of evidence on socio-cultural issues in EoL care with differences in meanings and priorities in each of the countries see Table 3 and Table S1. This reflects a situation where EoL care has developed in different directions since the unique ideas of the hospice movement found resonance in Europe.

The initial concept of palliative care has changed through its increasing contact with mainstream medicine in the different countries [] and with the cultural traditions relating to health, illness, death, dying, bereavement, and ideas about care, the family, and the duties of medicine and society. This scoping exercise revealed practices in EoL care that attest to cultural differences in ideas of best practices in EoL care.

Disclosure practices in Mediterranean countries contradict the obligation to open information about diagnosis and are influenced by the continuous presence of the family in EoL care [].

Also, the focus on cultural identity may be due to self-reflection as a consequence of the process in which palliative care is incorporated into national health systems. In other instances its strong moral values have come into contact with alternative conceptions of good care, which were based on professional experience of care for the dying developed over long periods of time.

Here we think of the Dutch situation where euthanasia has developed as acceptable as a last resort and has long since been a topic that can be discussed openly []. The research generated in these seven countries on cultural issues at the EoL is directed towards the countries autochthonous cultural traditions and practices. However, for the scoping of this field we think this approach was justified.

First, the scoping exercise was exploratory; no previous work has attempted to map cultural issues in EoL care across different European countries. Second, because we understand culture as an abstract notion, rather than a concrete set of values, beliefs, attitudes, opinions or other ethnic features we did not determine a priori any factors that could constitute culture.

Third, regarding the topic of EoL care, we could follow national boundaries as there are distinct approaches between countries which are the result of different institutional forms of health care and a variety of ways of organising the professions that are in charge of care provision at the EoL. The reviews confirm that there are clearly distinguishable national cultures of EoL care. This shows with the exception of the Netherlands, which already had a research tradition in EoL care the first studies appearing not much later than the establishment of services on the European continent, with a growing production towards more recent times.

The findings from this review on culture and EoL care from the seven European countries contrast with the UK research activity in this area, where EoL care has developed considerable expertise on ethnic minority groups.

Thirteen reviews were identified in this area of which four reviews were commissioned to directly influence policy and this already shows the recent interest in these issues in the UK [18]. In contrast, very little attention has been paid to cultural issues of ethnic minorities in EoL care in the European countries included in this review. In the Netherlands we found that some pioneering work had started in this area, and in the other countries there were a few scattered exceptions.

This scoping of the literature informs about the gaps in the evidence on culture and EoL care and this points to future needs for research for the further development of the evidence-base. In the UK, apart from the research on ethnic minority groups, a vast literature exists on EoL care and this has not yet been reviewed with attention to socio-cultural issues.

This was also not possible in this project due to time and resource constraints. Such a study could shed light on the culture-specific pre-occupations with EoL care in the UK.

It could show the dominant concerns towards care at the end of life and the configurations of positions towards these concerns in a diversity of contexts and settings. It is important to attend to culture and its uses in a broad sense so that it includes the majority culture as this will reveal that particular well-established practices are in fact culturally and historically situated.

When these practices are then compared with those of other countries as we did in this scoping exercise it can show why certain practices become normalised while others remain unrecognised or become contested.

Insights such as these lead to awareness of cultural differences and can enhance international collaborations. The insights from this scoping exercise contribute to the debate about the quality and nature of research in palliative care.

As a consequence of the evidence-based medicine movement, biomedical research has been favoured in palliative care. This is reflected in what is considered high quality research where criteria of strength are used according to the potential for eliminating bias []. Recently, these classification levels of evidence have been debated in areas of health research where these criteria are not representative of quality []. The challenges presented by people at the end of their lives to enrolment and participation in trials in terms of retainment and ethical considerations lead to the exclusion of the most vulnerable, which is the group that is of most relevance to palliative care.

Clinical practice guidelines based on the effectiveness results of RCTs have the danger of increasing existing health inequities []. Socio-cultural knowledge is important in EoL care and we need research that generates understanding of the ways these affect illness experiences and caring and that enables the building of a discipline that is capable to respond to the needs of diverse and changing communities.

The literature from Norway was limited to publications in English. No electronic searches were carried out with other than English terms in the main databases. However, publications identified from Spain, Italy, Portugal, Belgium, the Netherlands and Germany in their respective national languages from the vernacular databases searched or those obtained by hand searches were included in the review.

On the basis of the findings of this literature scoping on cultural issues in EoL care in seven European countries we make the following recommendations for future research:. This scoping of the literature is a first comparative exploration of the cultural differences that exist in the understanding of EoL care in these countries.

There was very little work in the evidence we unearthed specifically looking at cultural issues. With the exception of some pioneering work on EoL care for ethnic minority groups in a few countries, no expertise had developed in this area. This scoping also critically appraised the research evidence on cultural issues in EoL care produced in the different countries to throw light on its adequacy as a basis for the further development of EoL care.

The work on culture presented here provides an understanding of the evolution of the concept of palliative care across several European countries, shows the different cultural norms that influence care at the EoL and gives a view of the existing diversity in what is considered good care. This type of knowledge is a legitimate and necessary part of what constitutes best evidence for the improvement of EoL care in the future.

Sub-themes of culture and EoL care across countries. PRISMA had the overall aim to co-ordinate high-quality international research into end-of-life cancer care.

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