Transcript Document 7258157

Cultural differences
Health Psychology
The value placed on health

Although people around the world value good
health, people in some countries, such as
France and Italy, seem to feel that health is
more important than do people in other
countries, such as Lebanon and Turkey (DiazGuerrero, 1984). It seems reasonable to
assume that the more people value their
health, the more likely they are to take care
of it.
Causes of illness

The ideas people have about the causes
of illness also show changes across
history and culture. In the Middle Ages
people thought evil spirits were
responsible for illness. Today, educated
people
in
technological
societies
generally reject such ideas. But less
sophisticated people often do not, as
the following excerpt shows:
Causes of illness

I’ve heard of people with snakes in their
body, how they got in there I don’t know.
And they take ‘em someplace to a witch
doctor and snakes come out. My sister, she
had somethin’, a snake that was in her arm.
She was a young woman. I can remember
her bein’ sick, very sick, and someone told
her about this healer in another little town.
And I do know they taken her there. This
thing was just runnin’ up her arm, whatever it
was, just runnin’ up her arm. You could
actually see it. (Snow, 1981, p. 86).
Religion

Religion is an aspect of culture. Many
religions in the United States include beliefs
that relate to health and illness. For instance,
Jehovah’s Witnesses reject the use of blood
and blood products in medical treatment
(Sacks & Koppes, 1986). Christian Scientists
reject the use of medicine totally, believing
that illnesses are cured only by mental
processes in the sick person. As a result, the
sick person needs prayer and counsel as
treatment to help these processes along
(Henderson & Primeaux, 1981).
Religion

Some religions include specific beliefs that
promote healthful lifestyles. Seventh-Day
Adventists, for example, believe that the body
is the “temple of the Holy Spirit.” They cite
this belief as the reason people should take
care of their bodies. Adventists abstain from
using tobacco, alcohol, and nonmedically
prescribed drugs. In addition, they promote
in fellow members a concern for exercise and
eating a healthful diet (Henderson &
Primeaux, 1981).
The health of ethnic
minorities


The health of ethnic minorities has been
largely ignored or unrecognised. There are
two main reasons why this state of affairs has
developed in this country,
(i) When mass immigration from the
Caribbean and Asia started to this country
after the Second World War (1939 - 1945),
concerns were expressed that “new”
immigrants brought disease into the country
and created the risk of epidemics. Research,
however, failed to support this and so the
health service lost interest in ethnic health.
The health of ethnic
minorities

(ii) Changing view of ethnic minorities;
as the ethnic groups became
established in Britain, they were no
longer seen as newcomers or classic
immigrants. Instead they were viewed
as just another part of the community
without any specific needs.
The health of ethnic
minorities




McNaught (1987) argues, however, that
people from ethnic minorities do have specific
needs, including:
(a) genetic issues, for example sickle cell
disease, diabetes
(b) incidence of common disorders, for
example above average levels of
hypertension and stroke (Africa and
Caribbean), heart disease and diabetes (Asia)
(c) interaction with health workers, for
example the ways we describe illness
Different types of culture

Hofstede (1980) identified four basic
dimensions which can he used to
compare different cultures:

1
power-distance; which is to do with
how far people in authority are expected to
exercise their power. For example, do you
consider your boss to he a colleague, or
does he or she seem to be much more
powerful than you?
Different types of culture


2 uncertainty-avoidance, which is to do with how
far people like things to be clear and orderly, with
everyone knowing their place. People in some
cultures, (though not British culture) can tolerate
a high level of change and uncertainty, and do not
experience anxiety and stress as a result.
3 individualism: which is to do with how far the
culture encourages personal (or individualistic)
ambitions and concerns, and how far people are
seen as members of a collective group.
Different types of culture

4
masculinity-femininity; Hofstede
suggested that masculine cultures
emphasise performance and money above
all else, whereas feminine cultures value
the quality of life, and consider
environmental issues to be important.
ontologies of suffering


Shweder et al (1997) describes 7
general systems of understanding,
which they have turned into ontologies
of suffering.
(ontologies refer to different ways of
describing and understanding
knowledge about suffering, in this case)
TABLE 1 Causal ontologies of suffering (Shweder et al., 1997)
Causal ontologies
Explanatory references
Therapy
Biomedical
Western: genetic defects, hormone
imbalances, organ pathologies,
physiological roots, impairments
Non-western: humours, bodily fluids, juices
Direct or indirect ingestion of special
substances, herbs and vitamins, chemical
compounds
Direct or indirect mechanical repair (e.g.
surgery, massage emetics) of damaged
fibres or organs
Interpersonal
Western: harassment, abuse, exploitation
Avoidance or repair of negative
interpersonal relations
Sociopolitical
Non-western:
sorcery, evil eye,
Oppression, political domination, adverse
economic or family conditions
Talismans, magic black magic
Social reform
Psychological
Unfulfilled desires and frustrated intentions,
forms of fear
Intrapsychic and psychosocial interventions,
e.g. meditation, therapy
Astrophysical
Arrangement of planets, moon or stars
Wait with optimism for change
Ecological
Stress, environmental risks
Reduction of stress and environmental
hazards
Moral
Transgressions of obligation or duty, ethical
failure
Unloading one’s sins, confession reparation
Ontologies of suffering


Murdock (1980) conducted a survey of the
explanations of illness in 139 societies. He
found that in Africa there was a preference
for explanations based upon moral
transgressions. In East Asia, the preference
was for interpersonal explanations and in the
Mediterranean region he found that witchcraft
explanations for death and suffering were
widespread.
Park (1992) suggested that the three
worldwide explanations for health were
interpersonal, moral and bio medical.
Ontologies of suffering

In Western societies the dominant moral
discourse is autonomy, which focuses on the
rights of the individual. As Porter (1997)
argued: “the West has evolved a culture
preoccupied with the self, with the individual
and his or her identity, and this quest has
come to be equated with (or reduced to) the
individual body and the embodied personality,
expressed through body language”. So in
health care the rights of the individual
patients have paramount importance.
Ontologies of suffering

Individualistic cultures emphasise the
separateness and uniqueness of its members
whereas collectivist cultures emphasise group
needs and inter-connectedness (Matsumoto
et al. 1996). For example, in Hindu society
the community and divinity discourses are
more prominent. An understanding of these
dimensions is important for understanding
cultural variations in health belief systems.
Ontologies of suffering

Different societies have developed
various health belief systems.
Sometimes the knowledge is confined
to experts such as doctors and nurses.
So there are expert or technical belief
systems as opposed to the traditional
folk or indigenous systems. The
systems interact and are in a process of
constant evolution.
Ontologies of suffering

Kleinman (1980) proposed three overlapping
sectors to describe any health care system:
the professional, the folk and the popular.
The professionals would be people like
doctors and nurses, the folk sector refers to
the non-professional, non-bureaucratic,
specialist sector (e.g. fringe medicine) and
the popular sector refers to the beliefs held
amongst ordinary people (lay beliefs).
Chinese views of health

The Chinese perspective views health as the
result of a balance between and within the
various systems both internal and external to
the person. Disease is perceived as the
consequence of disharmony or disequilibrium.
This view of health and illness reflects a
broader worldview which emphasizes
interconnectedness and balance (Quah and
Bishop, 1996). Chinese medicine rests upon
the religion and philosophy of Taoism.
Chinese views of health

According to this view the universe is a vast
and indivisible entity and each being has a
definite function within it. Each being is linked
in a chain in harmony. ‘Violating this harmony
is like hurling chaos, wars, arid catastrophes
on humankind — the end result of which is
illness’ (Spector, 1991, p. 243). The balance
of the two basic powers of yin and yang
governs the whole universe including human
beings.
Chinese views of health

Yin is considered to represent the male,
positive energy, which produces light and
fullness. Conversely, yang is considered the
female, negative force, which leads to
darkness and emptiness. A disharmony in yin
and yang leads to illness. A variety of
methods including acupuncture and the use
of herbal medicines can be used to restore
this harmony.
Chinese views of health

Within Chinese culture human suffering is
traditionally explained as the result of destiny
or ming. Cheng (1997) quotes the Confucian
teacher Master Meng: ‘A man worries about
neither untimely death nor long life but
cultivates his personal character and waits for
its natural development; this is to stand in
accord with Fate . . . All things are
determined by Fate, and one should accept
what is conferred’ (p. 240).
Chinese views of health

An important part of your destiny
depends upon your horoscope or patzu. During an individual’s life, his or
her pa-tzu is paired with the timing of
nature. Over time these pairings change
and create the individual’s luck or yun.
Chinese views of health

Buddhist and Taoist beliefs are also reflected
in Chinese medical belief systems; for
example, good deeds and charitable
donations are promoted. Heavenly retribution
is expected for those who commit wrongs.
This retribution may not be immediate but it
will be inevitable. An important concept in
this respect is pao, which has two types —
reciprocity and retribution (Cheng, 1997). In
mutual relationships reciprocity or give and
take is expected. When this does not occur
some form of retribution will take place.
Chinese views of health

These views of health and illness are not only
codified within Chinese medicine but
influence everyday lay beliefs about health
and illness both in China and in Chinese
communities around the world. Several
examples illustrate this. Cheng (1997)
conducted interviews with a sample of
Chinese workers in Hong Kong who had
sustained hand injuries. He found that many
of the workers, especially the older ones,
explained their injuries in terms of fate or
predestination. For example, one worker said:
Chinese views of health

‘The injury was predestined. You were
bound to be hurt no matter how careful
you were. Something like a ghost
blinded your eyes. No way for you to be
careful! It couldn’t be escaped in any
way!’
Chinese views of health

Others referred to the role of retribution for
some wrong, which the individual may have
committed in a previous life. One mentioned
the role of his pa-tzu or horoscope.
Admittedly, this did not mean he was
condemned to misfortune. If he changed his
life course then the pairing with his pa-tzu
may become more harmonious. His belief in
the role of fate enables the person to escape
blame for the event but still maintain a belief
that they have control over their lives.
Childbirth pain and
culture

A further example of the different
descriptions of experience and
symptoms comes form cross-cultural
studies of childbirth. Taylor (1986) gives
a brief summary of these differences
and describes how in some cultures, for
example Mexico, women have an
expectation that childbirth will be
painful.
Childbirth pain and
culture

The Mexican word for labour (dolor) means
sorrow or pain in contrast to the English
word, which means work. Taylor suggests
that this fearful expectation is followed by
painful deliveries with many complications. In
contrast, Taylor cites the culture of Yap in the
South Pacific where childbirth is treated as an
everyday occurrence. Yap women are
reported to carry out their normal tasks until
they begin labour, at which point they go to a
childbirth hut and give birth with the
assistance of one or two other women.
Childbirth pain and
culture

After the birth, there is a relatively brief
rest period before the woman resumes
her regular tasks. In this community,
complications are reported to he rare.
Taylor suggests that expectations are
an important factor in the experience of
childbirth, and these expectations come
from cultural stories and customs.
African medical systems

In Africa, a wide range of
traditional medical systems
continues to flourish. These
include a mixture of herbal
and
physical
remedies
intertwined
with
various
religious belief systems.
African medical systems

As Porter (1997) notes, belief
systems which attribute sickness
to ‘ill-will, to malevolent spirits,
sorcery, witchcraft and diabolical
or divine intervention . . . still
pervade the tribal communities of
Africa, the Amazon basin and the
Pacific’ (p. 9).
African medical systems

In
a
more
developed
assessment Chalmers (1996)
summarized the African view
as reflecting ‘a belief in an
integrated,
independent,
totality of all things animate
and inanimate, past and
present’ (p. 3).
African medical systems

As with other traditional health
systems a central concept is
balance. ‘Disturbances in the
equilibrium, be they emotional,
spiritual or interpersonal, may
manifest in discordance at any
level of functioning’ (Chalmers,
1996, p. 3).
African medical systems

Two dimensions are paramount
in understanding African health
beliefs: spiritual influences and a
communal orientation. It is
common to attribute illness to
the work of ancestors or to
supernatural forces. Inadequate
respect
for
ancestors
can
supposedly lead to illness.
African medical systems

In addition, magical influences
can be negative and positive,
contemporary and historical.
Thus, illness can be attributed to
the work of some malign living
person. The role of the spiritual
healer is to identify the source of
the malign influence.
African medical systems

Rather than the individualistic orientation of western
society, African culture has a communal orientation.
Thus, the malign influence of certain supernatural
forces can be felt not just by an individual but also
by other members of his or her family or community.
‘The nuclear family, the extended family, the
community, the living and the deceased as well as
their ultimate relationship with God are intimately
linked in the African view of health and illness’
(Chalmers, 1996). Thus intervention may be aimed
not only at the sense of balance of the individual but
also of the family and the community.
African medical systems

Horton (1976) described how traditional medical
treatments in Africa focus on social factors even
when diagnosing infectious diseases. ‘They look for
the person who has fallen out with the patient, and
who might therefore have “cast a spell” on them.
This seems bizarre to Western minds, yet actually
makes perfect sense when the person is seen in a
more holistic context. In a traditional society, with a
relatively high rate of infant mortality, those who
grow to adulthood tend to have a high natural
immunity to disease.
African medical systems

So if someone falls sick, the question is not where
the germ came from, but how his or her immune
system has been weakened to the extent that the
illness can take hold. Research suggests that one of
the consequences of prolonged stress is to reduce
the effectiveness of the immune system. In
traditional communities the primary sources of stress
comes from disturbed interactions with other people.
So when the traditional medicine practitioner tries to
find out whom the person has quarrelled with lately,
and to solve their dispute and so lift the spell, this is
actually an extremely practical method of treatment.
African medical systems

As with other medical systems, immigrant
communities have brought their health beliefs
to their new countries of residence. Landrine
(1997) criticized studies of North American
health beliefs, which have largely ignored the
distinctive culture of black Americans. Semmes
(1996) noted that African slaves maintained
their pre-slavery health beliefs, practices and
indigenous healers.
African medical systems

When they gained emancipation black
Americans found they were denied access to
medical care. As a consequence they relied on
their indigenous healers and over time
developed a unique African-American folk
medicine. He suggests that in contemporary
North America many blacks are returning to
this medical system as they feel rejected or
excluded by what they perceive as the racism
of white American health care.
Australian aborigines


McElroy & Townsend (1985) cite an
account of the acute terror experienced
by an Aborigine who believed he was
the victim of an attack by a ‘sorcerer’
and that death was inevitable.
The man who discovers that he is
being boned by an enemy is
indeed a pitiable sight.
Australian aborigines

He stands aghast, with his eyes
staring at the treacherous pointer,
and with his hands lifted as
though to ward off the lethal
medium, which he imagines is
pouring into his body. His body
begins to tremble and the muscles
twist involuntarily.
Australian aborigines

He sways backward and falls to
the ground, and after a short time
appears to be in a swoon; but
soon after he writhes as if in
mortal agony. From this time
onwards he sickens and frets,
refusing to eat and keeping aloof
from the daily affairs of the tribe.
Australian aborigines

Unless help is forthcoming in the
shape of a countercharm, his
death is only a matter of a
comparatively short time.
Australian aborigines

The man is neither poisoned nor
shamming. McElroy & Townsend
(1985) say that when such
patients are admitted to hospital
they do not respond well to
treatment. In one case of ‘boning’,
a man refused to eat and drink
until he died.
Australian aborigines

The doctors decided that his death
was suicide through voluntary
rejection of fluids. His tribe,
however, believed he had died
because he had broken a taboo.
Another explanation of his
behaviour is provided by the
reformulated learned helplessness
theory.
Australian aborigines

The faulty cognitions of the man
have led him to believe that there
is no way out of the spell and he
must die. It does not matter what
he does; the outcome is death.
Australian aborigines

These negative cognitions are thus
responsible for an individual’s
demise, just as positive beliefs
have been found to contribute to
the efficacy of hypnosis and
acupuncture.
Exercise and activity

Sport is particularly promoted in North
American society. There the muscular
physique is presented as the ideal male
form. Luschen et al (1996) notes that
the emergence of bodybuilding
exercises which are aimed at building
muscular strength and fitness “reflects
a bodily culture that is in line with
American values of masculine prowess”.
Exercise and activity

They add that “activities like American
football, weights lifting, and boxing set
a premium on brute physical force and
places much less emphasis on
endurance and relaxation”.
Exercise and activity

Access to fitness gyms is restricted to
those with money although there has
been a move in some countries to make
exercise the subject of a doctor’s
prescription, for example, in the UK.
Exercise and activity

Aggressive sporting activities, such as
rugby, are also promoted among the
middle-class as a training ground for
developing an aggressive business
attitude and a way of making useful
social contacts.
Exercise and activity

Certain forms of Christianity have
traditionally held a negative view of
excessive concern about the body. It
has been suggested that this is a
reason for the poorer performance of
Catholic societies in sporting events
(Curtis and White, 1992).
Exercise and activity

Conversely, in more Protestant or
secular societies concern with the body
shape and performance is promoted.
Longevity: cross cultural
differences

In the USA and the UK only three
people out of every 100,000 live to be
over 100. In Georgia, among the
Abkarsians, 400 out of every 100,000
people live to be over 100, and the
oldest recorded Abkarsian was 170.
Longevity: cross cultural
differences

Weg (1983) suggests that their
longevity is due to the following factors:

genetics

vigorous work roles and habits

a diet low in saturated fat and meat and high in fruit
and vegetables

they drink no alcohol, nor smoke nicotine

they have a high level of social supports

They report low stress levels.
Sociocultural differences
in pain behaviour

Cross country comparison of
behavioural and emotional functioning
of chronic back pain

US – greatest overall impairment

Italians, NZ – 2nd greatest overall impairment


Colombian and Mexican – least overall
impairment
Same objective degree of impairment
Sociocultural differences
in pain behaviour

David Mechanic (1978) review



Jewish Americans more likely to seek help,
accept sick role, do prevention
Mexican-American – ignore some major, magnify
minor symptoms
Irish-American – stoic, deny pain
Ethnicity and Health

In the USA, Blacks suffer more from
heart disease, cancer, liver disease,
diabetes and pneumonia. They are also
more likely to die from violence
(Markides 1983). In Britain CHD
amongst male Asians is 36% higher
than the national average, and is 46%
higher for Asian women.
Ethnicity and Health

The difference was most marked for
Asians between the ages of 20 and 39
years; CHD rates were two to three
times higher than whites (Balarajan and
Raleigh 1993). For British AfroCaribbeans the incidence of strokes
amongst men is 76% higher than the
national average and 110% higher for
Afro-Caribbean women.
Ethnicity and Health

Mortality through hypertension is four
times higher than the national average,
and seven times higher for AfroCaribbean women. Cancer rates have
been lower amongst Afro-Caribbeans,
but is now rising (Barker and Baker
1990).
Ethnicity and Health

There are also differences in health
behaviour. American Black women
smoke less and drink less than white
women (Gottlieb and Green 1987). In
the UK few women from ethnic minority
groups smoke. Amongst men alcoholrelated morbidity is high for Asians of
Punjabi origin.
The interaction of genetics
with lifestyle

Type II diabetes is a disorder, which
appears to have a genetic component,
but is also influenced by environmental
factors like lifestyle and, in particular,
diet. In the U.S.A. there are about 1.5
million people of Native American
heritage.
The interaction of genetics
with lifestyle

One of the dramatic changes in the
health of this group of people has been
the increase of diabetes, which was
relatively unheard of before 1930 but
has now reached almost epidemic
proportions. In the Pima tribe, for
example, it is estimated that half of the
people over the age of 35 have
diabetes.
The interaction of genetics
with lifestyle

According to Kaplan et al (1993), the
development of diabetes in these
people is related to obesity. As people
increase their weight so they increase
their risk of developing Type II
diabetes. It is possible that this group
of people is genetically predisposed
towards diabetes, but it only develops if
the people become overweight.
The interaction of genetics
with lifestyle

If these people maintain their traditional
lifestyle then the diabetes does not
develop. However, their lifestyle has
changed due to the unemployment
imposed on them by industrial society
and, as a result, the diabetes comes
out.
Ethnicity and body size.

Ethnicity and body size may also be associated with- adolescents’ eating
preferences. From a cultural
perspective, African Americans have
been shown to view individuals with
larger body sizes more favorably than
do Whites (Kumanyika, 1993).
Ethnicity and body size.

Research has demonstrated that about
50% of African American women are
obese (Wadden et al., 1990). Although
obesity is equally prevalent among
White and African American females
during childhood, by adolescence the
rate of obesity increases considerably
for African American females (Wadden
et al., 1990).
Ethnicity and body size.

According to the National Heart, Lung,
and Blood Institute’s [NHLBI’s] Growth
and Health Study (NHLBI Growth and
Health Study Research Group, 1992)
African American girls (ages 9—10
years) were significantly taller, heavier,
and had greater central body skinfold
measures than did White girls.
Ethnicity and body size.

Such differences in body size have been
linked to earlier physical maturation in
African American girls (NHLBI Growth
and Health Study Research Group,
1992). For Mexican Americans, the
prevalence of obesity is greater than in
the general population and
approximately 4 to 6 times higher than
in Whites (Stern et al., 1982).
Ethnicity and body size.

Garb and Stunkard (1975) have also
reported the prevalence of obesity to be
very high among Navajo children. These
data suggest that certain ethnic groups
may be at greater risk for obesity;
however, the specific influences of
genetic and environmental factors are
not yet known.
Poverty and health


1. Those in the lower classes have more
stresses in the form of daily hassles
(Myers et al 1974).
2. The less well off have fewer
resources to mediate these stressors,
and therefore less control over their
environment. Lack of control being a
source of stress (see stress notes).
Poverty and health


3. Social support is less available to
those in the lower social classes (Adler
et al. 1994)
Overall it is the relative poverty that
matters. People in Cuba are poor, but
enjoy good health, because they are
nearly all equally poor (Wilkinson
1992).
John Henryism

A study on hypertension found that
Black men living in high stress
environments (high unemployment,
high crime, low incomes) had higher
blood pressure than those living in low
stress environments (James et al,
1987). This relationship between
environmental stress and blood
pressure was not found in White men.
John Henryism

James suggested that the high blood
pressure was a response to an active
coping style used by some Black men
who tried to change their environment.
John Henryism

He developed a psychometric scale to
measure this active coping style and
named it the John Henry Scale, after a
legendary Black worker who had battled
against the odds to win a physical
contest but then dropped dead from
physical and mental fatigue.
John Henryism

James found that Black men who
scored high on his scale of John
Henryism were 3 times more likely
to have hypertension
John Henryism

The coping strategy that is
measured in this scale concerns
gaining control over your life and
changing your circumstances. For
many people this is a sign of good
health, and for the White men in
the study, a high score on the
John Henryism scale did not
coincide with hypertension.
John Henryism

The Black men with the high
score, in fact, tended to he
satisfied with their lives and
perceive their own health to be
good.
John Henryism

James suggests that the attempt
to heroically change your
circumstances when you have
very little power to make any real
difference can have a damaging
effect on your health. This makes
an interesting addition to the
discussion about locus of control.
The end