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than explaining, differences and, because of worse outcomes, examining the deleterious aspects of minority cultures while ignoring potential strengths.
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DEFINING AND OPERATIONALIZING CULTURE IN HEALTH RESEARCH
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For the health researcher interested in culture, the complexity of the construct coupled with a fragmented and politicized arena is daunting. A consensual definition of culture remains elusive (Kao, Hsu, & Clark, 2004), and numerous schools exist, each with its own values, preferred methodological approaches, and agendas. Opinions vary regarding whether culture is thought to exist within or outside of individuals (Kao et al., 2004) and whether understanding will be most rapidly advanced with etic approaches (searching for universals across groups) or emic approaches (examining factors that are unique to a specific group). However, most researchers accept that culture is transmissible or learned (Purnell & Paulanka, 1998); that it reflects an integrated, shared whole (Brach & Fraser, 2000; Pachter, 1994); and that it circumscribes aspects of a common language, history, geography, beliefs, attitudes, values, behaviors, and customs. Making matters more complex is the fact that individuals operating within a given cultural frame of reference vary in the degree to which they subscribe to the associated norms (Landrine & Klonoff, 1992). Variation occurs within the classifications
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The importance of culture to health has been recognized for some time (Kleinman, Eisenberg, & Good, 1978; Pachter, 1994), and the field has grown to encompass a vast and fragmented literature. Early work has offered support for several observations that provide a backdrop to the current chapter. First, studies of culture have historically been the purview of anthropologists and sociologists; health psychologists have paid little attention to culture (Landrine & Klonoff, 1992). Perhaps, consequently, culture has often been treated as a backdrop to health behavior, and the specific aspects of culture that are relevant to outcomes remain to be clarified. However, although culture–health links are complex, many of the most intriguing influences reflect the instantiations of culture in psychological functioning. Second, even when health psychologists have studied culture or diversity, most work has concentrated on documenting disparities. Although the overlap between ethnic and cultural groupings is imprecise, disparities exist for outcomes ranging from diet, obesity, and exercise to cardiovascular disease, diabetes, asthma, HIV/AIDS, and cancer (Myers, Kagawa-Singer, Kumanyika, Lex, & Markides, 1995; Yee, Castro, Hammond, John, & Wyatt, 1995). Estimates have suggested that eliminating disparities could save upward of 30% of medical care costs among minorities (LaVeist, Gaskin, & Richard, 2009). However, a focus on disparities has tended to push research toward documenting, rather
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We thank Malcolm Johnson for his assistance in developing this work as well as Arielle Riutort and Sara Gioia for their help in sourcing literatures. http://dx.doi.org/10.1037/14187-007 APA Handbook of Multicultural Psychology: Vol. 2. Applications and Training, F. T. L. Leong (Editor-in-Chief) Copyright © 2014 by the American Psychological Association. All rights reserved.
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outcomes they are interested in, (b) vary normatively, and (c) are amenable to systematic measurement.
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The culture and health literature has blossomed in recent years. Studies have examined an increasing range of outcomes, an increasing number of more and less specific cultural groupings, and an increasing number of possible cultural constituents and mechanisms through which culture may affect health. For those interested in health, one useful approach is to organize observations at a series of outcome-meaningful intersections. In this chapter, we review intersections between culture and health at six points in the disease initiation and treatment process—primary causation, secondary causation, symptom sensitivity, screening behavior, treatment decision making, and adherence (see Figure 7.1). Given space limitations, our goal in describing these intersections is not to provide an exhaustive review but rather to present illustrative works and analyses that highlight the types of issues, characteristics, and questions relevant to each intersection. As will become clear, despite robust differences across subpopulations, most research has not offered explanations that are based in culture.
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CULTURE AND HEALTH OUTCOMES: AN ORGANIZING FRAMEWORK
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that psychologists use (Flores, 2000), and beliefs and practices likely reflect an amalgamation of the individual’s specific experiences and normative cultural values (Landrine & Klonoff, 1992). Cultures exist within a series of interdependent units— national culture, rural culture (Hartley, 2004), street culture (Barry, Ensign, & Lippek, 2002), poverty culture (Kao et al., 2004), family culture, and so on. Descriptively, racially based cultural groupings are imprecise both in terms of their association with biological risk factors (e.g., BRCA1–BRCA2 breast cancer gene variants) and their links to outcomerelevant, culturally varying factors. Groupings such as Black and White or, more recently, the classifications of European American, African American, Hispanic, Asian/Pacific Islander, and Native American Indian are arbitrary (LaVeist, 1994; Phinney, 1996). The African American grouping, for example, often encompasses U.S.-born African Americans and immigrant or nonimmigrant people of Caribbean or African descent, groups that have distinct cultural frames for health-relevant behavior (Consedine, Magai, & Horton, 2005) and, in some cases, different outcomes (Soto, Dawson-Andoh, & BeLue, 2011). To understand the relevance of culture to health, researchers must first sample with greater specificity (Yee et al., 1995). Studying well-defined groups is one way to increase the chance that the samples discussed share core characteristics such as language (Consedine, Magai, & Conway, 2004); samples that do not gloss over (Trimble, 1991) differences are needed. Typically, culture and ethnicity are treated as global factors that act on outcomes in some direct yet nonspecific manner (H. Betancourt & Lopez, 1993; see also Dilworth-Anderson, Goodwin, & Williams, 2004). To identify the proximal factors through which culture operates, the cultural “Black Box” must be unpacked (Alvidrez, Azocar, & Miranda, 1996; Phinney, 1996). Uncovering the psychological instantiations of culture will allow researchers to maintain a normative science while informing interventions that are tailored, accessible, and acceptable to those in the greatest need. Rather than try to measure culture as a totality, researchers should concentrate on assessing the particular aspects of culture that (a) are relevant to the specific
CULTURE AND PRIMARY CAUSATION To the extent that culture covaries with racial/ethnic groupings, some groups may be at risk either through the unequal distribution of genetic risk factors or through characteristics that have a direct impact on the body. For example, the frequency of BRCA1 and BRCA2 mutations is higher among Ashkenazi Jews (Struewing et al., 1997). Similarly, cardiovascular reactivity is greater among African Americans (J. K. Murphy, Alpert, Moes, & Somes, 1986). In many instances, however, such characteristics covary with, rather than constitute a part of, culture; such areas continue to be actively researched. For example, although the cardiovascular reactivity evident among some minorities had been thought to be responsible for hypertension disparities (Matthews et al., 2004), recent suggestions
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continental United States found that African Americans reported a higher body mass index (28.54) than either European Americans (26.57) or women of African descent from islands in the Englishspeaking Caribbean (27.52; Consedine, Magai, Conway, & Neugut, 2004). In addition to contributing directly to health risks, culturally embedded dietary patterns may also contribute to obesity across groups. Diet is influenced by cultural factors (Kittler & Sucher, 2003) as well as by geography, socioeconomic status, and food availability (Swinburn, Egger, & Raza, 1999). African American cooking culture, for example, involves elements of American, British, French, and Spanish cuisines. Meals are typically larger and higher in fat (Borrud, McPherson, Nichaman, Pillow, & Newell, 1989) and salt (Kittler & Sucher, 1989), but lower in fiber (Myers et al., 1995), fruits and vegetables (Gorin & Jacobson, 2001), and vitamins (Borrud et al., 1989). Although no U.S. data have differentiated among subpopulations of African descent, U.K. studies have suggested subpopulation differences in food preparation as well as in fat and carbohydrate intake (Sharma & Cruickshank, 2001). Such data are illustrative of the connections between culture and behaviors that have a direct impact on health. In addition to being differentially valued in different cultural groups (Kemper, Sargent,
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have been that poorer recovery from arousal may be more important (Dorr, Brosschot, Sollers, & Thayer, 2007). Although both reactivity and recovery parameters may be influenced by culture, work in this line is uncommon and has been slow to develop.
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Figure 7.1. Model describing six points at which culturally varying parameters may relate to health outcomes. From Handbook of Emotions (3rd ed., p. 677), by M. Lewis, J. Haviland-Jones, and L. Feldman-Barrett (Eds.), 2008, New York, NY: Guilford Press. Copyright 2008 by The Guilford Press. Adapted with permission.
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Because culture provides the framework within which people interpret more and less desirable states of health and understand the health–behavior links, aspects of culture have implications for understanding patterns of health-promoting and healthdeleterious behaviors. Rates of hypertension are increasing, with a large portion of the rise accounted for by increasing body mass and variations in awareness, treatment, and control (Cutler et al., 2008). One study of more than 10,000 individuals of African descent reported steadily increasing prevalence, from 16% in West Africa to 26% in the Caribbean and 33% in the United States (Cooper et al., 1997); consistent links to obesity and sodium and potassium intake were evident. Differences in obesity between groups of European and African descent have been well established. Body mass indexes among Caribbean people have also been high (Tull et al., 2001), and recent U.S. data have been troubling. One study examining subpopulations in the
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Cultural membership is associated with marked differences in attitudes toward the medical establishment and testing. Haitian health-related culture, for example, appears to encourage a dynamic in which group members report feeling sick only when it interferes with work (DeSantis, 1993), do not understand preventive visits (Harris, 1987), and will not accept treatments that do not include medication (Lefley, 1981). Most minority cultural groups have low trust in health care systems and their providers (Thompson, Valdimarsdottir, Winkel, Jandorf, & Redd, 2004) and a low likelihood of engaging in genetic testing, clinical trials (Brawley & Tejeda, 1995), offering organs for transplant, visiting the dentist, or vaccinating against influenza (Corbie-Smith, Thomas, Williams, & Moody-Ayers, 1999; DeFreitas, 2010). African American men with higher medical mistrust are more likely to delay routine check-ups and blood pressure and cholesterol screenings (Hammond, Matthews, Mohottige, Agyemang, & Corbie-Smith, 2010). A further example of how culture may affect health is found in the cancer screening literature. Studies contrasting U.S.-born African Americans with Caribbean people of African descent have shown frequency differences in mammography (Consedine, Magai, & Neugut, 2004; KudadjieGyamfi & Magai, 2008), digital rectal and prostatespecific antigen tests (Consedine, Christie, & Neugut, 2009; Consedine, Morgenstern, KudadjieGyamfi, Magai, & Neugut, 2006), colorectal screenings (Consedine, Ladwig, Reddig, & Broadbent, 2011), and breast self-exams (Kudadjie-Gyamfi, Consedine, Magai, Gillespie, & Pierre-Louis, 2005). Hispanic women screen for breast cancer less frequently than White women (Vernon et al., 1992), with studies of Hispanic subpopulations illuminating
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Given that much care seeking arises in response to the experience of symptoms, cultural variation in symptom interpretation is important. Cultural differences may reflect variations in sensitivity (Boulet, Oddens, Lehert, Vemer, & Visser, 1994), recognition or knowledge (J. R. Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003), interpretation or meaning (Canino et al., 1987; Pachter, 1994), reporting (Consedine, Magai, Horton, & Brown, 2012), or interactions between biological and cultural factors (Melby, Lock, & Kaufert, 2005). Cultural differences have been seen in areas including pain (Sheffield, Biles, Orom, Maixner, & Sheps, 2000), responses to alcohol (Wolff, 1972), and menopausal vasomotor symptoms (Thurston et al., 2008). Pain sensitivity appears to be greater among Blacks in U.S. research (Edwards, Doleys, Fillingim, & Lowery, 2001; Sheffield et al., 2000) and among South Asians (Allison et al., 2002). One study of 1,034 Chinese, Malaysian, and Indian women after a cesarean (Tan et al., 2008) found greater pain reporting and morphine use among Indian women. Although culture-based interpretations of these differences are lacking, to the extent that symptoms drive help seeking (Consedine, Krivoshekova, & Harris, 2007), research on how people from diverse backgrounds attend to, interpret, and report physical symptoms is urgently needed. Intriguingly, the manifestations of systemic distress also vary culturally (Escobar, 1995; Isaac et al., 1995). Medically unexplained symptoms are more common among Hispanics (Escobar & Gureje, 2007) and immigrant (vs. native) Hispanics in the United States (Escobar, Waitzkin, Silver, Gara, & Holman, 1998). Groups also vary in how depressed mood manifests (Baker, Espino, Robinson, & Stewart, 1993; Koenig et al., 1992). Distress appears to differentially emerge in somatic channels among Black minorities, perhaps because of a
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cultural valuation of the protection of psychological health (Jackson, 2002) or as a response to greater physical illness threat (Hunter & Schmidt, 2010). Research of this kind has illustrated how ostensibly the same symptoms may reflect distinct idiopathic and psychological processes in distinct cultural groups.
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Drane, Valois, & Hussey, 1994), variation in body types and composition characteristics may have distinct genetic, metabolic, nutritional, and ecological origins.
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may help explain the typically greater delay to initiation (Hershman et al., 2006). Other cultural factors may compound mistrust. Among some Asian groups, for example, the perception of illness as a family problem rather than an individual problem and a view of treatment as shaming may increase the latency before treatment is sought or preclude it all together (Candib, 2002; Leong & Lau, 2001). In contrast to the patient-centered approach in Western medicine (Blackhall et al., 1995; S. T. Murphy et al., 1996), people from more collectivistic cultures (e.g., Mexican or Korean American) tend to take a more family-centered approach to decision making in which family are actively consulted or expected to be involved. Such a decision-making style may reflect cultural differences in conceptualizations of the problem as familial rather than individual as well as the influence of filial values among Asian cultures and familismo among some Latino cultures (del Río, 2010; Searight & Gafford, 2005). In some contexts, the family may protectively keep news of serious or terminal illness from the patient or favor more indirect means of communication. Bosnian immigrants in the United States, for example, experience the truth-telling approach of Western medicine as exceptionally harsh (Searight & Gafford, 2005). Cultural dynamics and preferences can direct the flow of information among health care providers, patients, and patients’ families such that the course and outcomes of treatment decision making are affected. Increasingly relevant is research on treatment termination decisions, particularly at the end of life. The norms and values regarding death are profoundly embedded in culture. Empirically, researchers know that cultural groups vary in their knowledge about, attitudes toward, and possession of advance directives (Hern, Koenig, Moore, & Marshall, 1998; Kagawa-Singer & Blackhall, 2001), with people from minority cultures being less likely to know about (or have favorable opinions) of advance directives (S. T. Murphy et al., 1996). Because cultures contain richly developed norms regarding life and death, the decisions that patients and families prefer as well as the means by which they are arrived at can be expected to vary commensurately. Given the complexity of
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further differences within groups (Mandelblatt et al., 1999; O’Malley, Kerner, & Johnson, 1999). The cancer-screening disparities literature has provided a well-developed case study illustrating both how researchers have approached the question of culture and denoting how far researchers have yet to go. Epidemiological approaches typically ascribe the origins of disparities to a combination of demographic and structural factors. However, modeling has consistently shown that controlling for such factors does not statistically account for group membership effects, a fact that has pushed researchers to consider culturally embedded factors such as cancer worry, embarrassment, and fatalism. Latino (Barton Laws & Mayo, 1998) and Haitian (Brown, Consedine, & Magai, 2006) cultures, for example, incorporate a large degree of health-related fatalism, a characteristic that may explain the low cancer screening in such groups (Consedine, Morgenstern, et al., 2006). Conversely, embarrassment and norms regarding exposure represent key barriers within Black Caribbean culture (Consedine et al., 2009; Holt et al., 2009; Robb, Solarin, Power, Atkin, & Wardle, 2008). Many Caribbean cultures are proscriptive regarding intimate examinations; men from this region may avoid screening because of associations with homosexuality and anal sex (Goldman, Diaz, & Kim, 2009; Winterich et al., 2009). Recent studies have shown that modeling such variables statistically explains disparities across cultural groups (Magai, Consedine, Conway, Neugut, & Culver, 2004), implying that they may represent core cultural barriers to health behaviors.
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Cultural contexts influence treatment decision making, including the types of decisions made (initiating or discontinuing treatment), who makes decisions (e.g., family, doctor, patient), the processes by which decisions are arrived at, and whether illnesses and treatments are discussed at all (Blackhall et al., 1999; Blackhall, Murphy, Frank, Michel, & Azen, 1995; S. T. Murphy et al., 1996; Searight & Gafford, 2005). Although the origins of treatment delay are complex, greater mistrust in most minority groups
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As populations become more globalized, disparities better documented, and health resources stretched, research at the culture–health interface has increased. An inspection of articles incorporating the terms culture and health in SCOPUS from 1918 to 2010 (see Figure 7.2) showed a near-exponential increase, with most work occurring in the past 20 years. Given such increases, this chapter provides a timely opportunity to briefly consider some areas in which culture and health research may come to produce the greatest benefits. Given space limitations, we concentrate on five areas—model generalizability testing, the concept of fit, minority status, culture of both patients and providers, and cultural characteristics as both risk and resource.
Model Generalizability Testing One area that shows promise in providing indications of how aspects of culture may affect health
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Research on adherence to treatment and medication regimens has provided ample evidence of culture’s influence. Despite exceptions, minorities have poorer adherence to treatments for HIV (Boarts, Bogart, Tabak, Armelie, & Delahanty, 2008; Thrasher, Earp, Golin, & Zimmer, 2008), diabetes (Shenolikar, Balkrishnan, Camacho, Whitmire, & Anderson, 2006), breast cancer (Gwyn et al., 2004; Magai, Consedine, Adjei, Neugut, & Herschman, 2008), high cholesterol (Schrott, Bittner, Vittinghoff, Herrington, & Hulley, 1997), and psychological issues (Opolka, Rascati, Brown, & Gibson, 2003), among others. Considerable overlap exists between culture and the array of socioeconomic, social, and psychological factors influencing adherence (Magai, Consedine, Neugut, & Herschman, 2007). The fact that nonadherence is a problem across multiple cultural groups implies that factors from the broader multicultural context may also be germane. Experiences of discrimination may be interpreted within cultural frames of reference, increase medical mistrust (see the section Culture and Health Screening earlier in this chapter), and reduce adherence (Thrasher et al., 2008). Discrimination itself predicts poorer adherence to HIV medication among both African Americans and
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Whites (Bogart, Wagner, Galvan, & Klein, 2010; Casagrande, Gary, LaVeist, Gaskin, & Cooper, 2007), and stigma experienced in relation to disorders such as depression may also reduce adherence (Interian, Martinez, Guarnaccia, Vega, & Escobar, 2007). Thus, cultural differences in compliance with provider treatment recommendations may be affected by the contextual forces at play in the individual’s social environment (e.g., racism, poverty). We return to this issue in the following discussion.
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the topic and the increasing odds of medicalized later life and death, emically informed work documenting the specific aspects of diverse cultures and their links to relevant outcomes is urgently needed.
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Figure 7.2. Rates of culture and health publication in SCOPUS database, 1918 to 2010. 124
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justification for caregiving predicted changes in health over time (Dilworth-Anderson et al., 2004). Interestingly, however, African Americans—a group that values kin care (Lawton, Rajagopal, Brody, & Kleban, 1992)—reporting either high or low cultural justification had the poorest health. It may be that the negative effect of caregiving mastery among African Americans reflects John Henryism, a synonym for prolonged, high-effort coping with difficulty (Dilworth-Anderson et al., 2004). Fit-related interpretations are being made with increasing frequency. Work has suggested that emotions may have different meanings or index different aspects of people in different groups (Consedine et al., 2005), perhaps varying in the extent to which they fit sociocultural contexts (Consedine, Magai, et al., 2006). In this view, because the meaning associated with different emotional experiences varies across groups, the health outcomes may also vary. Finally, work using the concept of cultural consonance has found that when a successful lifestyle is defined consensually (in this case, as the relative ability to accumulate consumer goods and the adoption of associated behaviors), the individual’s approximation of this lifestyle was inversely associated with blood pressure, depressive symptoms, and stress (Dressler, Balieiro, & Dos Santos, 1998; see also Tsai, Knutson, & Fung, 2006).
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outcomes is examining whether established predictors are associated with outcomes equally across cultural groups. However, rather than merely ensuring that research is more inclusive or seeking to replicate instrument structure and the relations between variables, designs in which the links between culturally varying factors and outcomes are examined for group moderation may extend knowledge in general. Work linking negative emotion and health, for example, has shown that links are moderated by ethnicity. In one study, although trait anger and emotion inhibition predicted greater symptoms in a diverse sample of 1,364 women, the effect of anger was reduced among all minority cultural groups: African American, Caribbean, Dominican, Haitian, and Eastern European women; the effect of inhibition was reduced among Eastern European women but greater among Dominican women (Consedine et al., 2005). Although many interpretations of such variation are possible, the core point is that the approach generates discrepancies that must then be explained, forcing models that were developed in the context of majority participants to broaden and become more inclusive. In addition, however, we should also note that generalizability testing is only one approach to the question of health in context and that the approach must be systematically supplemented with works based in an in-depth cultural understanding of specific groups. Seeking to impose an a priori theoretical structure on the processes underlying health across groups runs the risk of obscuring culturally critical values, norms, and behaviors that might be important. However, by synthetically conducting generalizability testing of established models (an etic approach) in tandem with designs positioned in terms that are meaningful to the individuals in question (an emic approach), culture can be more richly incorporated into research conduct.
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Cultural Meaning and the Concept of Fit One approach that has considerable potential is to systematically examine the meaning respondents ascribe to symptom items (Canino et al., 1987) or psychological predictor variables (Consedine et al., 2005; Consedine, Magai, et al., 2006). For example, caregiving mastery and the degree of cultural
Culture of Both Patients and Health Care Providers Patients and physicians often hold distinct models of health and illness and, as a consequence, may interpret and respond to symptoms differently (Pachter, 1994). The beliefs of each party are structured by a cultural context from which they cannot be separated and without which they cannot be understood (Landrine & Klonoff, 1992). Some researchers have suggested that understanding disparities requires consideration of the culturally based attitudes, beliefs, and practices of both minority populations and health professionals (Thomas, Fine, & Ibrahim, 2004). The Western view construes illness as an intra personal event caused by natural agents such as genes, viruses, bacteria, and stress (Landrine & Klonoff, 1992); such views are not common. One 125
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spirituality, benefit finding, and fatalism as well as areas regarding typical patterns of coping and emotion regulation. Religious participation, for example, is more common in minority cultural contexts and generally predicts better outcomes (Koffman, Morgan, Edmonds, Speck, & Higginson, 2008). However, spirituality tends to covary with fatalism, which, in most instances, predicts poorer health behavior, perhaps suggesting that this characteristic may be beneficial in terms of the direct pathways while simultaneously acting to deter preventive and screening behaviors, adherence, or both. The literature has recently seen some studies that have attempted to leverage culture-specific characteristics to address disparities (Fisher, Burnet, Huang, Chin, & Cagney, 2007), and a strengths perspective has increasingly been evident in research (Bell-Tolliver, Burgess, & Brock, 2009). One study of breast cancer screening, for example, attempted to capitalize on the premium placed on self-reliance in African American and Caribbean groups by creating a specific framed message emphasizing empowerment (Consedine, Horton, et al., 2007). Ironically, although this frame did not lead to greater screening among African American women, lower-income women in the empowerment condition reported greater breast self-examination and mammography at 12 months. Thus, rather than attempt to improve disparities by shifting the health cultures of minority groups toward a more Western model, matching the characteristics of minority cultural groups with public health interventions designed to enhance the receptivity and acceptance of health interventions may provide a useful supplement (Thomas et al., 2004).
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report found that only four of 189 cultures included natural causation, with most citing supernatural causes (Murdock, 1980). Minority cultural groups are thought to hold more macro-level, interpersonal, and supernatural views of illness in which diseases are viewed more as interpersonal processes than as intrapersonal entities (Landrine & Klonoff, 1992). Given that cultural competency is defined as the recognition of, and appropriate response to, key cultural features that affect clinical care (Flores, 2000), an understanding of both patient and physician culture (and their intersections) is critical.
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In general, attempts to incorporate cultural frameworks and understanding into the study of health have been driven by disparities, the drive to make interventions more relevant to diverse groups, or both. This focus has led to a tendency to extensively document the negative aspects of minority cultures, with reduced attention being paid to features that may be health promoting. Most disparities, for example, occur between a majority culture and several minority cultures, with those from minority groups experiencing disproportionately greater risks and burdens. In some views, disparities result from the pervasive effects of racism and discrimination. Racism and discrimination affect health both directly (e.g., lower quality care provided to minority individuals) and indirectly via racism-associated poverty, exposure to environmental hazards, structural barriers, access to resources, and education (Mio, Barker-Hackett, & Tumambing, 2009). Currently, separating the relative contributions of culture from the effects associated with being a minority culture is difficult, and future work at the culture–health interface might benefit by attempting to disentangle these potentially separable aspects. As with most phenomena, however, the cultural characteristics for which some evidence has accumulated tend to be double edged (i.e., having both positive and negative effects) in terms of their impact on health processes. A short list of such characteristics might include independence and selfreliance (Consedine, Horton, Magai, & Kukafka, 2007), a constellation of factors surrounding
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CONCLUDING REMARKS That cultures vary in ways that have implications for health is clear. Less clear is the question of which specific aspects of membership in which cultural groups are those that place people at risk or have health-promoting effects. To move beyond the current understanding of the culture–health interface, several steps are needed. First, health researchers must begin to sample with greater specificity such that they identify culturally homogeneous and
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Baker, F. M., Espino, D. V., Robinson, B. H., & Stewart, B. (1993). Assessing depressive symptoms in African American and Mexican American elders. Clinical Gerontologist, 14, 15–29. doi:10.1300/ J018v14n01_03
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Alvidrez, J., Azocar, F., & Miranda, J. (1996). Demystifying the concept of ethnicity for psychotherapy researchers. Journal of Consulting and Clinical Psychology, 64, 903–908. doi:10.1037/0022006X.64.5.903
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Barry, P. J., Ensign, J., & Lippek, S. H. (2002). Embracing street culture: Fitting health care into the lives of street youth. Journal of Transcultural Nursing, 13, 145–152. doi:10.1177/104365960201300208
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Barton Laws, M., & Mayo, S. J. (1998). The Latina Breast Cancer Control Study, Year One: Factors predicting screening mammography utilization by urban Latina women in Massachusetts. Journal of Community Health, 23, 251–267. doi:10.1023/A:1018776704683
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Bell-Tolliver, L., Burgess, R., & Brock, L. J. (2009). African American therapists working with African American families: An exploration of the strengths perspective in treatment. Journal of Marital and Family Therapy, 35, 293–307. doi:10.1111/j.17520606.2009.00117.x Betancourt, H., & Lopez, S. (1993). The study of culture, ethnicity, and race in American psychology. American Psychologist, 48, 629–637. doi:10.1037/ 0003-066X.48.6.629
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explanatorily meaningful groupings in their work. Making this task more profoundly complex is the fact that culture, ethnicity, and race-based groups overlap and are further conflated with demographic differences. Because experimental designs are infrequently used in studies of culture and health, it is difficult to examine cultural constituents in isolation from multiple confounds. Clearly, cultural membership is not exclusively defined by poverty, education, access, and the like. Therefore, researchers must begin to methodologically and statistically disentangle cultural effects from their sociodemographic backgrounds. Finally, rather than exert further effort identifying characteristics that are specific to a particular group or outcome, research needs to begin to systematically identify culturally varying factors that cut across groups and outcomes. To date, cross-cultural research has had limited success in this area, with only the individualism– collectivism characteristic having gained any serious traction. Other approaches to identifying cultural characteristics are available, however (Lamoreaux & Morling, 2012), and should be considered in studies of health. Such considerations noted, interpreting health behaviors and their associated predictors within a cultural frame of reference holds considerable promise. Because they operate from within substantively different cultural frames, people from different cultural groups may differ in their knowledge of diseases and treatment options; how they organize, label, and respond to symptoms; their expectations for care provision; how systemic dysfunctions are manifested; and in the practice of health-promoting and health-risk behaviors. Culture acts as a lens through which symptoms, decisions, medical contacts, treatments, and outcomes are interpreted; hence, cultural membership can exert a powerful influence on behaviors, including those related to health.
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