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Cultural differences


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Title: Cultural differences

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 (Diaz-Guerrero, 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
  • Ive heard of people with snakes in their body,
    how they got in there I dont 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 is an aspect of culture. Many religions
    in the United States include beliefs that relate
    to health and illness. For instance, Jehovahs
    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).

  • 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,
  • (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

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)
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 pa-tzu. During an individuals
    life, his or her pa-tzu is paired with the timing
    of nature. Over time these pairings change and
    create the individuals 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 couldnt 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

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

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

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

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

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

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 individuals 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

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
    doctors 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,

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 Afro-Caribbeans 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 Afro-Caribbean 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 alcohol-related 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

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
    Institutes NHLBIs Growth and Health Study
    (NHLBI Growth and Health Study Research Group,
    1992) African American girls (ages 910 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