One major role of psychology is to improve the lives of the people we touch. Whether through research, service, or provision of primary or secondary health care, we look forward to the day when we can adequately prevent, diagnose, and treat diseases, and foster positive states of being in balance with others and the environment. This is not an easy task; a multitude of forces influences our health and the development of diseases.

As we strive to meet this challenge, the important role of culture in contributing to the maintenance of health and the etiology and treatment of disease has become increasingly clear. Although our goals of maintaining health and preventing and treating diseases may be the same across cultures, cultures vary in their perceptions of illness and their definitions of what is considered healthy and what is considered a disease. From anthropological and sociological perspectives, disease refers to a “malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual” and illness refers to the “personal, interpersonal, and cultural reactions to disease or discomfort” (Kleinman, Eisenberg, & Good, 2006 ; p. 141). Thus, how we view health, disease, and illness, is strongly shaped by culture.

This chapter explores how cultural factors sway physical health and disease processes, and investigates our attempts to treat both psychological and sociological influences. We begin with an examination of cultural differences in the definition of health and present three indicators of health worldwide: life expectancy, infant mortality, and subjective well-being. We will then review the considerable amount of research concerning the relationship between culture and heart disease, other physical disease processes, eating disorders, obesity, and suicide. Next, we will explore differences in health care systems across countries. Finally, we will summarize the research in the form of a model of cultural influences on health.

CULTURAL DIFFERENCES IN THE DEFINITION OF HEALTH

Comparison Across Cultures

Before we look at how culture influences health and disease processes, we need to examine exactly what we mean by health. More than 60 years ago, the World Health Organization (WHO) developed a definition at the International Health Conference, at which 61 countries were represented. They defined health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” The WHO definition goes on further to say that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political beliefs or economic and social conditions” (World Health Organization, 1948 ). This definition of health is still used by the WHO today.

In the United States, our views of health have been heavily influenced by what many call the biomedical model of health and disease (Kleinman et al., 2006 ). Traditionally, this model views disease as resulting from a specific, identifiable cause such as a pathogen (an infectious agent such as a virus or bacteria), a genetic or developmental abnormality (such as being born with a mutated gene), or physical insult (such as being exposed to a carcinogen—a cancer-producing agent). From the perspective of the traditional biomedical model, the biological root of disease is primary and, subsequently, treatment focuses on addressing biological aspects of the disease.

Several decades ago, however, the biomedical model was strongly criticized by George Engel, who proposed a biopsychosocial model to understand health and disease. Engel emphasized that health and disease need to be considered from several dimensions—not just the biological but also the psychological and social (Engel, 1977 ). This biopsychosocial model is now widely accepted. Adopting a biopsychosocial approach to health means that all three dimensions are highlighted—the biological (e.g., genetic, biological, and physiological functioning of the body), social (e.g., lifestyles and activities, quality of relationships, living conditions such as poverty), and psychological (e.g., beliefs and attitudes toward health, emotions, feelings of despair, positive thinking). All are important to a more accurate and complete understanding of health.

Views from other cultures suggest definitions of health that also include more than a person’s biology. In China, the concept of health, based on Chinese religion and philosophy, focuses on the principles of yin and yang, which represent negative and positive energies, respectively. The Chinese believe that our bodies are made up of elements of yin and yang. Balance between these two forces results in good health; an imbalance—too much yin or too much yang—leads to poor health. Many things can disturb this balance, such as eating too many foods from one of the elements; a change in social relationships, the weather, the seasons, or even supernatural forces. Maintaining a balance involves not only the mind and body, but also the spirit and the natural environment. From the Chinese perspective, the concept of health is not confined to the individual but encompasses the surrounding relationships and environment—a view of health that is holistic (Yip, 2005 ). Balance between self and nature and across the individual’s various roles in life is viewed as an integral part of health in many cultures around the world. This balance can produce a positive state—a synergy of the forces of self, nature, and others—that many call health.

This notion of balance and imbalance, at least within the body, is a common concept across cultures (MacLachlan, 1997 ). The various systems of the body produce harmony or health when in balance, illness and disease when in imbalance. A theory first developed by Hippocrates, which heavily influences views of the human body and disease in most industrialized countries and cultures today, suggests that the body is comprised of four humors: blood, phlegm, yellow bile, and black bile. Too much or too little of any of these throws the body out of balance, resulting in disease. Derivatives of these terms—such as sanguine, phlegmatic, and choleric—are widely used in health and medical circles today.

MacLachlan ( 1997 ) points out that common theories of disease in many Latin American cultures involve a balance between hot and cold. These terms do not refer to temperature, but to the intrinsic power of different substances in the body. Some illnesses or states are hot, others cold. A person who is in a hot condition is given cold foods to counteract the situation, and vice versa. The Chinese concept of yin and yang shows similarities to this concept.

Incorporating balance as a positive aspect of health is also emphasized in the United States. We often hear about the importance of having a “balanced diet” and a “balanced lifestyle” (finding the optimal balance between work and play). The concept of homeostasis is all about balance—maintaining steady, stable functioning in our bodies when there are changes in the environment, for example, being able to keep blood pressure down when you are experiencing a high level of stress (such as before taking an exam). When our bodies cannot maintain homeostasis over time, illness and disease may the result. Thus, although there are differences across cultures in how health is conceived, there are also commonalities such as the notion of balance and imbalance that permeate discussions of health.

From this brief review of how different cultures define health, we can see how different attributions of what leads to good health will affect how diseases are diagnosed and treated. If we believe that health is determined primarily by biological disturbances and individual choices, treatment may primarily focus on individual-level factors. If we believe that health is determined by an individual’s relationship with others, nature, and supernatural forces, treatment may primarily focus on correcting those relationships. Importantly, our choices of coping and treatment are closely tied to our attributions of the causes determining health, illness, and disease.

Comparison Within Cultures

Concepts of health may differ not only between cultures but also within a pluralistic culture such as the United States or Canada. Mulatu and Berry ( 2001 ) argue that health perspectives may differ between individuals from the dominant or mainstream culture and those of the nondominant social and ethnocultural group. They cite the example of Native Americans, who, based on their religion, have a holistic view of health and who consider good health to be living in harmony with oneself and one’s environment. When one does not live in harmony and engages in negative behaviors such as “displeasing the holy people of the past or the present, disturbing animal and plant life, misuse of sacred religious ceremonies, strong and uncontrolled emotions, and breaking social rules and taboos” (p. 219), the result is bad health. Yurkovich and Lattergrass ( 2008 ) point out that while the WHO definition of health includes physical, mental, and social well-being, spiritual well-being is not mentioned. In Native American cultures, however, spiritual well-being—feeling connected to and in balance with the spiritual world—is a cornerstone of good health, both mental and physical. Figure 7.1 shows the Circle of Wellness, a model of health as conceptualized by Native Americans (Yurkovich & Lattergrass, 2008 ). The figure shows that, in contrast to the biopsychosocial model, spiritual well-being is central, or the focal point, for the other domains that contribute to health.

Although the concepts of health held by various ethnic and immigrant groups within the United States may differ from and even contradict the health concepts of the mainstream society, mainstream culture is also adapting and incorporating ideas of health that immigrants have brought with them, as seen in the rising popularity and interest in alternative health practices such as acupuncture, homeopathy, yoga, herbal medicines, and spiritual healing (Brodsky & Hui, 2006 ). Indeed, there is a growing field called Complementary and Alternative Medicine (CAM) that incorporates medical and health care systems and practices that are not considered conventional medicine to treat illness and promote health. According to the 2007 U.S. National Health Interview Survey (NHIS), 38% of U.S. adults used CAM in the past year, with differences by ethnic group (Barnes, Bloom, & Nahin, 2008 ). Non-Hispanic White adults reported the highest rates of using CAM (43%), followed by Asian Americans (40%), Black (26%) and Latinos (24%). And a nationwide study focusing on Asian Americans found that a majority of this population preferred using CAM rather than relying on conventional medicine to maintain health and prevent illness (Choi & Kim, 2010 ). One thing is clear: with continued migration, immigration, and globalization, our views on health are changing.

Figure 7.1 Circle of Wellness Model of Native American Health

Source: Yurkovich & Lattergrass ( 2008 ). Defining health and unhealthiness: Perceptions of Native Americans with persistent mental illness. Mental Health, Religion, & Culture, 11, 437–459.

THREE INDICATORS OF HEALTH WORLD WIDE

Life Expectancy

Three indicators of health are used worldwide: life expectancy, infant mortality, and subjective well-being. Life expectancy refers to the average number of years a person is expected to live from birth (as opposed to calculating life expectancy from, for example, age 65). Figure 7.2 shows the average life expectancy for selected countries. In 2010, a comparison of 224 countries showed that the countries with the longest average life expectancies are Monaco (90 years), Macau (84), Japan (82), Singapore (82), Hong Kong (82), Australia (82), and Canada (81). The United States is ranked 49th, at 78 years of age. Countries with the shortest life expectancies are South Africa (49 years), Swaziland and Zimbabwe (48), Afghanistan (45), and Angola (38) (CIA, The World Factbook, 2010 ).

A large part of explaining such drastic life expectancy differences is the general wealth and resources of a country (Barkan, 2010 ). Wealthier countries with greater resources have better access to better diet, nutrition, health care, and advanced technology to maintain health and prevent and treat diseases. Thus, life expectancy is lengthened. In contrast, poorer nations with the fewest resources are more likely to suffer from hunger, malnutrition, AIDS and other diseases, and lack of access to basics for survival such as clean water, sanitary waste removal, vaccinations, and other medications. Thus, life expectancy is shortened.

Figure 7.2 Average Life Expectancy in Selected Countries

Source: CIA Factbook.

Importantly, disparities in life expectancies can be even greater within one country. In the United States, for instance, life expectancy differs by ethnicity (which is usually confounded with socioeconomic status). For European Americans, life expectancy is 78.3 years. In contrast, for African Americans, this is shortened by 5 years, to 73.2 years. And when gender is taken into account, the disparities are even greater: African American males’ life expectancy is 69.5 years, compared to European American females at 80.5 years. These statistics show clear health disparities between ethnic groups in the United States. These health disparities occur in pluralistic countries where ethnic majority individuals (who, in general, have higher socioeconomic status than ethnic minorities), tend to have longer life expectancies than ethnic minority individuals. We will address possible reasons for these health disparities later in the chapter.

In general, across the globe, we are living longer. Worldwide, the average life expectancy in the 1950s was 46 years. In 2009 it was 69 years, and this is expected to increase to 75 years by 2050 (Barkan, 2010 ; United Nations Population Division, 2009 ). Nonetheless, great disparities across countries in average life expectancies mean that possibilities for good health and a long life are enjoyed by people in some countries, but not others.

Infant Mortality

Infant mortality is defined as the number of infant deaths (one year old or younger) per 1,000 live births. Figure 7.3 shows infant mortality rates for selected countries.

Comparing across 224 countries in 2010, Angola (178 infant deaths per 1,000 live births), Afghanistan (152), and Niger (115) had the highest rates of infant mortality while Bermuda (3), Singapore (2), and Monaco (2) had the lowest. The United States was ranked 46th, with 6 infant deaths for every 1,000 live births (CIA, The World Factbook, 2010 ). Compared to other industrialized countries, infant mortality rates in the United States are among the highest.

There has, however, been a steady decrease in infant mortality in the United States over the past century—from 100 infant deaths per 1,000 births in 1900, to 6 infant deaths per 1,000 births in 2010. Similar to life expectancy, however, there are disparities by ethnic group. In the United States, African American infants (14) have the highest infant mortality rates compared to other ethnic groups such as Native American (8), European American (6), Mexican (6) and Asian/Pacific Islander (5) (MacDorman & Mathews, 2008 ).

In sum, life expectancy and infant mortality rates are broad indicators of health that show diversity in health outcomes around the world. A large part of these differences can be attributed to resources that ensure access to good nutrition, health care, and treatment (Barkan, 2010 ). To add to these objective indicators of health, researchers have focused more recently on an important subjective indicator of health—happiness, or subjective well-being.

Figure 7.3 Infant Mortality Rates in Selected Countries

Source: CIA Factbook.

Subjective Well-Being

In contrast to life expectancy and infant mortality, subjective well-being (SWB) focuses on one’s perceptions and self-judgments of health and well-being. Subjective well-being encompasses a person’s feelings of happiness and life satisfaction (Diener & Ryan, 2009 ). Diener and Ryan ( 2009 ) state the importance of this subjective aspect of health:

· The main applied goal of researchers who study subjective well-being is the improvement of people’s lives beyond the elimination of misery. Because subjective well-being is a key component of quality of life, its measurement is crucial to understanding how to improve people’s lives. In addition, a growing body of research shows that high levels of subjective well-being are beneficial to the effective functioning of societies beyond the advantages they bestow on individuals. (p. 392)

Figure 7.4 Subjective Well-Being (SWB) and per Capita Gross Domestic Product (GNP) in 88 Countries. SWB is Based on Reported Life Satisfaction and Happiness, Using Mean Results from All Available Surveys Conducted 1995–2007

Source: Inglehart, Foa, Petersen, & Weltzel ( 2008 ). Development, freedom, and rising happiness: A global perspective (1987–2007). Perspectives in Psychological Science, 3(4), pp. 264–285, Copyright © 2008 by Sage Publications. Reprinted by permission of SAGE Publications.

Importantly, subjective well-being is positively related to physical health. In one study, researchers infected healthy people with a virus for the common cold. The findings showed that those who reported higher levels of SWB were less susceptible to the virus than those with lower levels of SWB (Cohen, Doyle, Turner, Alper, & Skoner, 2003 ). Others have found that people reporting higher SWB have stronger immune systems, fewer heart attacks, and less artery blockage (Diener & Biswas-Diener, 2008 ). These findings support studies showing that higher SWB may lead to a longer life expectancy (Danner, Snowdon, & Friesen, 2001 ). It’s worth noting that one reason why SWB may be related to better physical health is that people with higher SWB also tend to engage in healthier lifestyles (Diener & Biswas-Diener, 2008 ; Diener & Ryan, 2009 ).

The big question is, then: What predicts subjective well-being? In other words, what makes people happy? Many studies have examined whether affluence, or material wealth, is related to happiness. Figure 7.4 shows levels of SWB in relation to per capita gross domestic product (GDP) across 88 countries.

An interesting pattern emerges in Figure 7.4 . The Latin American countries report higher SWB than would be expected based on their GDP; the former communist countries, lower SWB than would be expected. Thus, economic factors account for some, but not all, of the variation in levels of happiness across countries. Research on SWB broadens our assessment of health beyond objective indicators such as life expectancy and infant mortality. It will be important in future research to examine how these three health indicators relate to one another, painting a more complete picture of variations in health and well-being around the world. We now turn to studies that have focused on specific factors that influence health and disease.

GENETIC INFLUENCES ON PHYSICAL HEALTH AND DISEASE

While some diseases can be linked to mutations of a single gene (e.g., cystic fibrosis, sickle cell anemia), most diseases are linked to complex, multiple factors that include mutations in multiple genes that interact with environmental factors (e.g., stress, diet, health-related behaviors). Some of the most common complex-gene diseases are cancer, high blood pressure, heart disease, diabetes, and obesity (NIH, Genetics Home Reference).

The Human Genome Project, an international collaboration, completed one major aim of their project in 2003: to identify all 20,000–25,000 genes in human DNA (U.S. Department of Energy Genome Programs, http://genomics.energy.gov ). This groundbreaking work has opened new avenues for exploring the role of genetics to understand disease. It has also spawned a renewed interest into whether racial/ethnic/cultural groups may differ in their genetic makeup and whether some groups are more genetically vulnerable to certain diseases compared to others (Frank, 2007 ). For instance, sickle cell anemia is more common among African American and Mediterranean populations than Northern European, while the opposite is true for cystic fibrosis. Because humans living in the same geographical area tend to be more genetically similar to one another compared to those from a distant geographical area, this may explain some of the cultural variations we see in certain disease prevalence rates. Nonetheless, individuals of a particular racial or cultural background are not consistently genetically similar to other individuals of the same racial or cultural background. Indeed, there appears to be more genetic variation within racial and cultural groups than between (Jorde & Wooding, 2004 ).

Research that examines how genes and environment interact over time (for instance, by adopting a biopsychosocial approach) is our best chance at illuminating why some diseases appear more often for some cultural groups compared to others. Francis ( 2009 ) argues for multilevel, interdisciplinary research programs to address questions such as how community, social, and societal forces contribute to how genes are regulated and expressed. By multilevel, Francis is arguing for an investigation on how genes interact with environments on various levels—cellular, individual, group, and societal. And by interdisciplinary, she is arguing that a collaboration of researchers should come from various fields—genetics, biology, psychology, sociology, and public policy. Ideally, future research should adopt multilevel, interdisciplinary research efforts to clarify the complex relation of how genes, environment, and culture interact and contribute to health and disease.

PSYCHOSOCIAL INFLUENCES ON PHYSICAL HEALTH AND DISEASE

In the last two decades, psychology as a whole has becoming increasingly aware of the important role that culture plays in the maintenance of health and the production of disease processes. This awareness can be seen on many levels, from more journal articles published on these topics to the establishment of new journals devoted to this area of research. This increased awareness is related to a growing concern with psychosocial determinants of health and disease in general.

A number of important and interesting studies have documented the linkage between psychosocial factors and health/disease states. Andrew Steptoe and his colleagues in the U.K. have highlighted the links between unemployment and mortality, cardiovascular disease, and cancer; between negative life events and gastrointestinal disorders; between stress and the common cold; between bereavement and lymphocyte functions; between pessimistic explanatory styles and physical illnesses; between positive mood and heart rate and blood pressure; and between psychological well-being and mortality (e.g., Chida & Steptoe, 2008 ; Dockray & Steptoe, 2010 ; Steptoe, Dockray, & Wardle, 2009 ; Steptoe, Hammer, & Chida, 2007 ; Steptoe, Sutcliffe, Allen, & Coombes, 1991 ; Steptoe & Wardle, 1994 ). Indeed, the field has come a long way in demonstrating the close relationship between psychosocial factors and health/disease outcomes.

In multicultural countries such as the United States and the U.K., researchers have focused on health disparities . Health disparities are differences in health outcomes by groups, for instance, between males and females, people of different ethnicities, and people of lower and higher socioeconomic status (SES). Disparity refers to the fact that one group shows worse (or better) health outcomes compared to another. Health disparities can result from social factors, such as a person’s level of education, income, or occupational status (e.g., being employed versus unemployed or underemployed). Nancy Adler and her colleagues (e.g., Adler, Boyce, Chesney, Cohen, Folkman, Kahn, & Syme, 1994 ; Adler & Rehkopf, 2008 ) have provided strong evidence that SES is consistently associated with health outcomes. People of higher SES enjoy better health than do people of lower SES (see Figure 7.5 ). This relationship has been found not only for mortality rates, but for almost every disease and condition studied. Adler and colleagues suggest that health-related behaviors such as smoking, physical activity, and alcohol use may explain the relation between SES and health, as these behaviors have all been linked to SES. In addition, psychological characteristics such as depression, stress, and social ordering (one’s relative position in the SES hierarchy) may also explain the relationship between SES and health. Interestingly, one’s subjective perception of SES appears to better predict health and change in health rather than an objective assessment of SES (Singh-Manoux, Marmot, & Adler, 2005 ).

Figure 7.5 Mortality Rate by Socioeconomic Status Level

Source: Adler, N. E., T. Boyce, M. A. Chesney, S. Cohen, S. Folkman, R. L. Kahn, and S. L. Syme. Socioeconomic Status and Health: The Challenge of the Gradient, American Psychologist, 49(1), pp. 15–24, 1994. Copyright © American Psychological Association. Adapted with author permission.

An important psychosocial factor that may contribute to health disparities by ethnic group is perceived racism and discrimination. One striking health disparity is the high rate of infant mortality for African American babies compared to other ethnic groups, as presented earlier in the chapter. Research indicates that this disparity may be linked to stress-related health outcomes such as high blood pressure (hyptertension) due to perceived racism and discrimination (Brondolo, Rieppi, Kelly, & Gerin, 2003 ; Krieger, 1999 ; Mays, Cochran, & Barnes, 2007 ). Perceived racism has been consistently linked to poorer physical health (such as a greater incidence of cardiovascular disease) among African Americans (Mays et al., 2007 ). For African American women, racism-related stress and poorer physical health may subsequently contribute to negative pregnancy outcomes and explain some of the disparity between African American and European American infant mortality (Collins, David, Handler, Walls, & Andes, 2004 ). In a racially stratified society such as the United States, racism is a pervasive psychosocial stressor that has been consistently linked to poorer physical health across various ethnic minority groups, contributing to significant health disparities.

In sum, research of the past several decades has demonstrated convincingly that psychosocial factors play an important role in maintaining and promoting health, and in the etiology and treatment of disease. Still, many avenues remain open for future research, including establishing direct links between particular psychosocial factors and specific disease outcomes, and identifying the specific mechanisms that mediate those relationships. Hopefully, research of the upcoming decades will be as fruitful as that of the past several decades in providing much-needed knowledge about these processes.

Social Isolation and Mortality

Some of the earliest research on psychosocial factors in health and disease processes examined the relationship between social isolation or social support and death. One of the best-known studies in this area is the Alameda County study (Berkman & Syme, 1979 ), named after the county in California where the data were collected and the study conducted. Researchers interviewed almost 7,000 individuals to discover their degree of social contact. Following the initial assessment interview, deaths were monitored over a nine-year period. The results were clear for both men and women: Individuals with the fewest social ties suffered the highest mortality rate, and people with the most social ties had the lowest rate. These findings held even when other factors were statistically or methodologically controlled for, including the level of physical health reported at the time of the initial questionnaire, the year of death, SES, and a number of health-related behaviors (such as smoking and alcohol consumption).

The Alameda County study was one of the first to demonstrate clearly the enormous impact that psychosocial factors have in the maintenance of physical health. Since then, many studies have found the same pattern: Individuals with few social supports tend to have poorer health. Further, it is the perception of having few social supports, or feeling lonely, that is important. Some people who have few social supports are not lonely, and some people with many social supports do feel lonely. A recent review shows that feeling lonely is linked to a host of health problems (Hawkley & Cacioppo, 2010 ). People who report being lonely at more periods of time in their lives (such as during childhood, adolescence, and young adulthood), age faster on a number of indicators including body mass index, systolic blood pressure, cholesterol levels, and maximum oxygen consumption. All of these indicators are linked to cardiovascular health risks. It truly is the case, then, that loneliness weakens the heart.

SOCIOCULTURAL INFLUENCES ON PHYSICAL HEALTH AND DISEASE

Cultural Dimensions and Diseases

In addition to psychosocial factors, parallels can be drawn linking cultural factors and the development of diseases such as cardiovascular disease. Marmot and Syme ( 1976 ) studied Japanese Americans, classifying 3,809 subjects into groups according to how “traditionally Japanese” they were (spoke Japanese at home, retained traditional Japanese values and behaviors, and the like). They found that those who were the “most” Japanese had the lowest incidence of coronary heart disease—comparable to the incidence in Japan. The group that was the “least” Japanese had a three to five times higher incidence. Moreover, the differences between the groups could not be accounted for by other coronary risk factors. These findings point to the contribution of cultural lifestyles to the development of heart disease.

Triandis, Bontempo, Villareal, Asai, and Lucca ( 1988 ) took this finding one step further, using the individualism-collectivism cultural dimension and examining its relationship to heart disease across eight different cultural groups. European Americans, the most individualistic of the eight groups, had the highest rate of heart attacks; Trappist monks, who were the least individualistic, had the lowest rate. Of course, this study is not conclusive, as many other variables confound comparisons between Americans and Trappist monks (such as industrialization, class, and lifestyle). Nevertheless, these findings again highlight the potential contribution of sociocultural factors to the development of heart disease.

Triandis and his colleagues ( 1988 ) suggested that social support or isolation was the most important factor that explained this relationship, a position congruent with the earlier research on social isolation. That is, people who live in more collectivistic cultures may have access to stronger and deeper social ties with others than do people in individualistic cultures. These social relationships, in turn, are considered a “buffer” against the stress and strain of living, reducing the risk of cardiovascular disease. People who live in individualistic cultures may not have access to the same types or degrees of social relationships; therefore, they may have less of a buffer against stress and are more susceptible to heart disease. The study by Triandis and his colleagues ( 1988 ) was especially important because it was the first to examine the relationship between cultural differences and the incidence of a particular disease state.

Still, this study is limited in that they have focused on only one aspect of culture—individualism versus collectivism—with its mediating variable of social support. As discussed in Chapter 1 , however, culture encompasses many other important dimensions, including power distance, uncertainty avoidance, masculinity, tightness, and contextualization. Another limitation of the previous research is that it has looked almost exclusively at mortality rates or cardiovascular disease. Other dimensions of culture, however, may be associated with the incidence of other disease processes. If members of individualistic cultures are indeed at higher risk for heart disease, for example, perhaps they are at lower risk for other disease processes. Conversely, if collectivistic cultures are at lower risk for heart disease, they may be at higher risk for other diseases.

Matsumoto and Fletcher ( 1996 ) investigated this possibility by examining the relationship among multiple dimensions of culture and multiple disease processes, opening the door to this line of study. These researchers obtained the mortality rates for six different medical diseases: infections and parasitic diseases, malignant neoplasms (tumors), diseases of the circulatory system, heart diseases, cerebrovascular diseases, and respiratory system diseases. These epidemiological data, taken from the World Health Statistics Quarterly (World Health Organization, 1991 ), were compiled across 28 countries widely distributed around the globe, spanning five continents, and representing many different ethnic, cultural, and socioeconomic backgrounds. In addition, incidence rates for each of the diseases were available at five age points for each country: at birth and at ages 1, 15, 45, and 65 years. To gather cultural data for each country, Matsumoto and Fletcher ( 1996 ) used cultural index scores previously obtained by Hofstede ( 1980 , 1983 ), who analyzed questionnaire data about cultural values and practices from large samples in each of these countries and classified their responses according to four cultural tendencies: individualism versus collectivism (IC), power distance (PD), uncertainty avoidance (UA), and masculinity (MA).

Matsumoto and Fletcher then correlated these cultural index scores with the epidemiological data. The results were quite fascinating and pointed to the importance of culture in the development of these disease processes. See Table 7.1 for a summary of findings. The countries in this study differ economically as well as culturally, and it may well be that these economic differences—particularly with regard to the availability of treatment, diet, and sanitation—also contribute to disease. To deal with this possibility, Matsumoto and Fletcher ( 1996 ) recomputed their correlations, controlling for per capita gross domestic product (GDP) of each country. Even when the effects of per capita GDP were accounted for, the predictions for infections and parasitic diseases, circulatory diseases, and heart diseases all survived. The predictions for UA and cerebrovascular and respiratory diseases, and MA and cerebrovascular diseases, also survived. Thus, these cultural dimensions predicted disease above and beyond what is accounted for by economic differences among the countries. Only the prediction for malignant neoplasms was not supported, indicating that economic differences among the countries cannot be disentangled from cultural differences in predicting the incidence of neoplasms.

How and why does culture affect medical disease processes? Triandis and colleagues ( 1988 ) suggested that culture—specifically, social support—is a major ingredient in mediating stress, which affects health. The findings of Matsumoto and Fletcher ( 1996 ), however, suggest a much more complex picture. Although collectivistic cultures were associated with lower rates of cardiovascular diseases, replicating the previous findings, they were also associated with death from infectious and parasitic diseases and cerebrovascular diseases. Thus, although social support may be a buffer against life stress in the prevention of heart attacks, these data suggest that there is something else to collectivism that actually increases susceptibility to other disease processes. To be sure, these other factors may not be cultural per se. Collectivism, for example, is generally correlated with geographic location; countries nearer the equator tend to be more collectivistic. Countries nearer the equator also have hotter climates, which foster the spread of organisms responsible for infectious and parasitic diseases. The relationship between collectivism and death from these types of disease processes, therefore, may be related to geography rather than culture.

Table 7.1 Summary of Findings on the Relationship Between Four Cultural Dimensions and Incidence of Diseases

Cultural Dimension	Rates of Disease
Higher Power Distance	· • Higher rates of infections and parasitic diseases · • Lower rates of malignant neoplasm, circulatory disease, and heart disease
Higher Individualism	· • Higher rates of malignant neoplasms and heart disease · • Lower rates of infections and parasitic diseases, cerebrovascular disease
Higher Uncertainty	· • Higher rates of heart disease
Avoidance	· • Lower rates of cerebrovascular disease and respiratory disease
Higher Masculinity	· • Higher rates of cerebrovascular disease

Nevertheless, these findings do suggest that individualism is not necessarily bad, and collectivism is not necessarily good, as earlier findings had suggested. The latest findings suggest, instead, that different societies and countries develop different cultural ways of dealing with the problem of living. Each way is associated with its own specific and different set of stressors, each of which may take its toll on the human body. Because different cultural ways of living both punish and replenish the body, they are associated with different risk factors and rates for different disease processes. This view may be a more holistic account of how culture may influence health and disease processes.

Future research will need to investigate further the specific mechanisms that mediate these relationships. Some studies, for example, will need to examine more closely the relationship among culture, geography, and other noncultural factors in connection with disease incidence rates. Other studies will need to examine directly the relationship between culture and specific behavioral and psychological processes, to elucidate the possible mechanisms of health and disease.

Matsumoto and Fletcher ( 1996 ), for example, suggested that culture influences human emotion and human physiology, particularly with respect to autonomic nervous system activity and the immune system. For example, the link between PD and circulatory and heart diseases may be explained by noting that cultures low on PD tend to minimize status differences among their members. As status and power differences diminish, people are freer to feel and express negative emotions, such as anger or hostility, to ingroup others. Containing negative emotions, as must be done in high-PD cultures, may have dramatic consequences for the cardiovascular system, resulting in a relatively higher incidence of circulatory and heart diseases in those cultures. A study showing that suppressing anger is related to greater cardiovascular risk (Harburg, Julius, Kaciroti, Gleiberman, & Schork, 2003 ), lends further credence to this hypothesis. Hopefully, future research will be able to address these and other possibilities.

Cultural Discrepancies and Physical Health

Although the studies described so far suggest that culture influences physical health, other research suggests that culture per se is not the only nonbiologically relevant variable. Indeed, the discrepancy between one’s personal cultural values and those of society may play a dominating part in producing stress, which in turn leads to negative health outcomes. Matsumoto, Kouznetsova, Ray, Ratzlaff, Biehl, and Raroque ( 1999 ) tested this idea by asking university undergraduates to report what their personal cultural values were, as well as their perceptions of society’s values and ideal values. Participants in this study also completed a scale assessing strategies for coping with stress; anxiety, depression, and other mood measures; and scales assessing physical health and psychological well-being. Discrepancy scores in cultural values were computed by taking the differences between self and society, and self and ideal, ratings. These discrepancy scores were then correlated with the scores on the eight coping strategies assessed. The results indicated that discrepancies between self and society’s cultural values were significantly correlated with all eight coping strategies, indicating that greater cultural discrepancies were associated with greater needs for coping. These coping strategies were significantly correlated with depression and anxiety, which in turn were significantly correlated with scores on the physical health symptoms checklist scales. In particular, higher scores on anxiety were strongly correlated with greater health problems. The results of this study, therefore, suggest that greater discrepancy between self and societal cultural values may lead to greater psychological stress, which necessitates greater degrees of coping, which affects emotion and mood, which causes greater degrees of anxiety and depression, which then lead to more physical health problems. Of course, this single study is not conclusive as it could not test for causality; future research will need to replicate these findings, and elaborate on them. They do suggest, however, the potential role of cultural discrepancies in mediating health outcomes, and open the door for new and exciting research in this area of psychology.

Culture, Body Shape, and Eating Disorders

Social and cultural factors are central in the perception of one’s own and others’ body shapes, and these perceptions influence the relationship between culture and health. Body shape ideals and body dissatisfaction (e.g., the discrepancy between one’s perception of body shape with one’s ideal body shape) has been widely studied because of links to eating disorders. For instance, greater body dissatisfaction is considered to be one of the most robust predictors of eating disorders (Stice, 2002 ). Evidence shows this link in several cultures such as the United States (Jacobi et al., 2004 ; Stice, 2002 ; Wertheim, Paxton, & Blaney, 2009 ), Greece, (Bilali, Galanis, Velonakis, Katostaras, & Theofanis, 2010 ) and China (Jackson & Chen, 2011 ).

The International Body Project is a large-scale, cross-cultural study involving 26 countries from 10 world regions (North America, South America, Western Europe, Eastern Europe, Scandinavia, Oceania, Southeast Asia, East Asia, South and West Asia, and Africa) to assess body weight ideals and body dissatisfaction (Swami et al., 2010 ). In this project, almost 7,500 individuals were surveyed. The method to assess body weight ideals and dissatisfaction was Thompson and Gray’s ( 1995 ) line-drawing figures of women. Nine figures, ranging from very thin to very overweight, were presented. Female participants were asked to select the figure that most closely resembled their actual body shape, the figure that they would like to be (their ideal body shape), and what they perceived as the most attractive to males. To measure body dissatisfaction, a difference score between actual and ideal preferences was calculated. In addition, males were asked to select the drawing that they found most attractive. Several interesting findings emerged. One finding is that in nine of the ten world regions (the exception was in East Asia), males were more likely to select a heavier figure as attractive more so than females. Meaning, that females were more likely to believe (falsely) that males preferred a thinner body shape than was actually the case.

Another finding that supported earlier research was that in areas that were less economically developed (lower SES), such as in rural areas, heavier bodies were preferred. Conversely, in higher SES areas, thinner bodies were preferred. The authors suggest that in lower SES areas where resources (food, wealth) are scarce, being heavier is an indicator of greater resource security. The authors conclude that there may be fewer between-culture differences in body weight ideals and body dissatisfaction (at least between broad groupings such as “Western” and “non-Western” cultures) but rather, body weight ideals and body dissatisfaction appear to be more consistently linked to SES. Thus, targeting areas for eating disorders should rely also on the consideration of SES characteristics of a region. One limitation of this study was that it focused only on women’s body dissatisfaction and did not include men’s. Future research should also include men as body dissatisfaction is widespread and increasing among men, yet it is still under recognized (Jones & Morgan, 2010 ). Future research will also need to establish the links between perceptions of body shape and actual health-related behaviors in order to document the degree to which these perceptions influence health and disease processes.

Body weight ideals and body dissatisfaction have been heavily researched because of their robust link to eating disorders. Although there is a perception in the United States that disordered eating occurs only with affluent, European American women, more recent evidence suggests that this is not the case. In a recent review of the literature, researchers reported that ethnic minority females are also at risk for developing eating disorder symptoms or syndromes (Brown, Cachelin, & Dohm, 2009 ). The review suggests that African American, Latino, and Asian American females show similar prevalence rates to European American females for some eating disorders (such as binge eating disorder) but lower rates for others (anorexia nervosa and bulimia) (Brown, Cachelin, & Dohm 2009 ). And because ethnic minority women may have different body ideals, the common notion that pressure for thinness contributes to greater risk for eating disorders may not hold for ethnic minority women. Future research should search for risk factors beyond pressures for thinness to explain why ethnic minority women are also at risk for eating disorders.

Studies have also focused on exposure to Western culture in relation to body dissatisfaction, eating attitudes, and behaviors. For instance, findings from the International Body Project showed that women who reported more exposure to Western media also reported greater body dissatisfaction (Swami et al., 2010 ). And a recent review of 36 countries found that body dissatisfaction is greater among those living in affluent countries with a Western lifestyle (defined as high-consuming with an individualistic orientation) (Holmqvist & Frisen, 2009). In line with these findings, a study of Pakistani females determined that exposure to Western culture significantly predicted more disturbed eating attitudes (Suhail & Nisa, 2002 ). And a study of Mexican American females found that those who reported greater orientation to Anglo American culture also reported higher levels of eating disorders (Cachelin, Phinney, Schug, & Striegel-Moore, 2006 ).

Collectively, these studies demonstrate that attitudes toward body size and shape, and eating, are influenced by culture. Cultural values, attitudes, beliefs, and opinions about wealth, abundance, beauty and attractiveness, power, and other such psychological characteristics are likely significant factors in determining attitudes toward eating, thinness, and obesity. These latter attitudes, in turn, most likely have a direct effect on health-related behaviors such as eating, diet, and exercise. The research also suggests that these tendencies may be especially prevalent in the United States (Holmqvist & Frisen, 2009). Nonetheless, such tendencies are not solely an American or Western phenomenon. Cross-cultural research has pointed to similarities between Americans and members of other cultures—for example, the Japanese (Mukai & McCloskey, 1996 )—in their attitudes toward eating and preoccupation with thinness. Indeed, although the prevalence of eating disorders in Japan is still lower than in the United States, it has risen significantly in the last 20 years (Chisuwa & O’Dea, 2009 ).

Culture and Obesity

In addition to eating disorders, increasing attention has been paid to the rapidly growing rates of overweight and obesity around the world, especially among children and adolescents. This is a concern, as most overweight and obese children and adolescents become overweight and obese adults and are subsequently at much greater risk for serious health problems such as cardiovascular disease, diabetes, and cancer. Obesity has been an increasingly important public health concern across many countries in recent years.

Figure 7.6 Obesity Rates for Adults in Selected OECD Countries

Source: OECD (2010), Obesity and the Economics of Prevention: Fit not Fat—United States Key Facts. http://www.oecd.org/document/57/0,3343,en_2649_33929_46038969_1_1_1_1,00.html

The WHO’s definition of overweight is body-mass index (BMI; calculated as the weight in kilograms divided by the square of the height in meters) at or above 25; for obesity, it is a BMI at or above 30. Data show that the United States has the highest rate of obesity (adults and children) compared to other economically similar countries (see Figure 7.6 ). In the United States, from 1974 to 2000, the obesity rate quadrupled for children (ages 6 to 11) and doubled for adolescents (ages 12 to 19) (Ogden, Flegal, Carroll, & Johnson, 2002 ). The trend has now stabilized (Ogden & Caroll, 2010 ). Currently, it is estimated that almost 1 in 6 children and adolescents (2-19 years) and more than 1 in 3 adults are obese. Two main factors that may explain this disparity are diet (consumption of fast food and soft drinks) and (lack of) exercise. For instance, researchers suggest that the rising epidemic of obese American children and adolescents is partly due to increases in soft-drink consumption in the past several decades (Malik, Schulze, & Hu, 2006 ). In addition to unhealthy drinks, many American children and adolescents eat unhealthy foods—both in school and out. Many school lunches in the United States consist of high calorie, low-nutrient foods; one study found that children who ate school lunches regularly were more likely to be obese than those who did not (Eagle et al., 2010 ). Studies have also found that about one-third of American adolescents eat at least one fast-food meal a day and that as they get older (from early to late adolescence) their consumption of fast food increases (Bauer, Larson, Nelson, Story, & Neumark-Sztainer, 2009 ; Bowman, Gortmaker, Ebbeling, Pereira, & Ludwig, 2003 ). In sum, differences across cultures in food choice, behaviors, and lifestyles play a role in contributing to these striking differences in rates of overweight and obesity.

Future research will need to tackle the difficult question of exactly what it is about culture that influences attitudes about eating and stereotypes about thinness and obesity. Further study is also needed to determine where cultures draw the line between healthy patterns and disordered eating behaviors that have direct, negative impacts on health. And certainly, our body of knowledge will also benefit from a greater focus on tying specific eating behaviors to specific health and disease outcomes, and attempt to link culture with these relationships.

Culture and Suicide

No other behavior has health consequences as final as suicide—the taking of one’s own life. Psychologists, sociologists, and anthropologists have long been paying careful attention to suicide, and have studied this behavior across many cultures. The research to date suggests many interesting cross-cultural differences in the nature of suicidal behavior, all of which point to the different ways in which people of different cultures view not only death, but life itself. And although risks for suicide are complex, the role of culture may also be important.

One of the most glorified and curious cultures with regard to suicidal behavior is that of Japan. Tales of Japanese pilots who deliberately crashed their planes into enemy targets during World War II stunned and mystified many people of other cultures. These individuals clearly placed the welfare, spirit, and honor of their country above the value of their own lives. To be sure, such acts of self-sacrifice were not limited to the Japanese, as men and women on both sides of war reach into themselves in ways many of us cannot understand to sacrifice their lives for the sake of others. But the Japanese case seems to highlight the mysterious and glorified nature of some acts of suicide in that culture.

Among the most glorified acts of suicide in Japan (called seppuku or harakiri—the slitting of one’s belly) were those of the masterless samurai swordsmen who served as the basis for the story known as Chuushingura. In this factual story, a lord of one clan of samurai was humiliated and lost face because of the acts of another lord. In disgrace, the humiliated lord committed seppuku to save the honor of himself, his family, and his clan. His now masterless samurai—known as ronin—plotted to avenge their master’s death by killing the lord who had humiliated him in the first place. Forty-seven of them plotted their revenge and carried out their plans by killing the lord. Afterward, they turned themselves into authorities, admitting to the plot of revenge and explaining the reasons for their actions. It was then decided that the only way to resolve the entire situation was to order the 47 ronin to commit seppuku themselves—which they did. In doing so, they laid down their lives, voluntarily and through this ritualistic method, to preserve the honor and dignity of their clan and families. Although these events occurred in the late 19th century, similar acts continue in Japan today. Some Japanese businessmen have committed suicide as a way of taking responsibility for the downturns in their companies resulting from the economic crisis in Japan and much of Asia.

Japan is by no means the only culture in which suicide has been examined psychologically and cross-culturally. Kazarian and Persad ( 2001 ) note that “suicide has been in evidence in every time period in recorded history and in almost every culture around the world. It is depicted, and reasons for its committal described, in tribal folklore, Greek tragedies, religious, philosophical, and historical writings, literature, modern soap operas, and rock music” (p. 275).

Many studies point to profound sociocultural changes as a determinant of suicidal behavior. Leenaars, Anawak, and Taparti ( 1998 ), for example, suggest this factor as an important influence on suicide rates among Canadian Inuits, primarily among younger individuals. Sociocultural change and disconnection with cultural history has long been identified as a predictor of suicide among Native Americans (Isaak, Campeau, Katz, Enns, Elias, Sareen, & Swampy Cree Suicide Prevention Team, 2010 ), whose suicide rates are higher than those of other Americans, especially among adolescents and young adults (Centers for Disease Control and Prevention, 2011 ). Stresses associated with social and cultural changes have been implicated in the suicide rates of many indigenous cultural groups around the world (Lester, 2006 ).

In addition to sociocultural change, one study examined the role of Hofstede’s cultural dimensions in predicting suicide incidence rates (Rudmin, Ferrada-Noli, & Skolbekken, 2003 ). The researchers examined data for 33 countries gathered every 5 years over a 20-year period (between 1965 and 1985). The researchers found that the cultural dimensions of power distance, uncertainty avoidance, and masculinity were negatively correlated with rates of suicide. In contrast, the cultural dimension of individualism was positively correlated with rates of suicide. The findings are further complicated, however, by showing that gender and age moderated these correlations. The researchers argued that the cultural dimensions are linked to suicide through many pathways—by affecting a person’s thinking and emotions surrounding suicide, by influencing social institutions and organizations that may contribute to suicide, or by associations with other variables such as economic or political contexts, genetics, toxins, or climate. Although the link between culture and suicide is complex, this study attempts to pinpoint how certain cultural dimensions may foster specific beliefs or contexts that can either buffer or exacerbate rates of suicide across cultures.

China has one of the highest suicide rates in the world. And in contrast to almost every other country in the world, females in China are more likely to commit suicide than males. Zhang et al. ( 2010 ) argue that one reason for this unique gender difference is that females living in rural areas of China face intense psychological strain because of conflicting social values. On the one hand, gender equali-tarianism is promoted through a communist philosophy, while on the other, gender inequality, biased negatively towards females, is promoted through Confucian philosophy. Thus, they argue, females in particular are torn between these competing and contrasting philosophies, resulting in enormous psychological frustration and stress which may ultimately contribute to higher rates of suicide.

One factor that may be closely related to culture and suicide is religious beliefs. Kelleher, Chambers, Corcoran, Williamson, and Keeley ( 1998 ) examined data from suicide rates reported to the WHO and found that countries with religions that strongly condemned the act of suicide had lower reported rates of suicide than countries without religions that strongly condemned suicide. However, the researchers also suggested that the reports may have been biased. Those countries with religious sanctions against suicide may have been less willing to report and record suicides. A more recent analysis of the WHO data showed that the links between culture, religion, and suicide are more complex (Sisask et al., 2010 ). In general, Sisask and colleagues found that those who reported being part of a religious denomination and who perceived themselves to be religious (subjective religiosity) were less likely to engage in suicide ideation and attempts. It may be the case that being part of a religious denomination protects against suicide by providing social integration (having connections with other people) and regulation (moral guidelines to live by) (Durkheim, 1997/ 2002 ). Organizational religiosity (a person’s involvement in his/her religious denomination as measured by attendance in worship services), however, showed differential effects across cultures—in some countries it showed a protective effect, in others no effect, and still others inconsistent or even a risk effect. The researchers concluded that culture and religion do play important roles in understanding suicide but the relations are not straightforward.

Cross-cultural research on suicide over the past few decades has given us important glimpses into this difficult yet fascinating topic. Still, many questions remain unanswered. What is it about culture that produces differences in suicidal behaviors, and why? Why are there still considerable individual differences in attitudes toward suicide even in cultures where it is relatively more acceptable? Despite the glorified stories concerning suicide in Japan, for instance, there is still a relatively strong stigma against it and intense prejudice toward the mental disorders related to it, resulting in reluctance to seek help (Takahashi, 1997 ). When may suicide be an acceptable behavior in any culture? Given recent and ongoing advances in medical technology, such questions that involve medicine, culture, and ethics are bound to increase in prominence. Future research within and between cultures may help to elucidate some of the important decision points as we approach these questions.

Up until now, we have discussed the importance of sociocultural factors, describing how cultural values and beliefs provide a context for understanding health and the development of disease. For pluralistic countries such as the United States, another important issue is how these cultural values and beliefs may change with the acculturation process that immigrants and their families undergo. These changes may have profound consequences for health.

Acculturation and the Immigrant Paradox

On an individual level, acculturation refers to the process of individual change and adaptation as a result of continuous contact with a new, distinct culture (Berry, 2003 ). In Berry’s model of acculturation, two dimensions are important to consider: to what extent are individuals involved with the heritage culture and to what extent are individuals involved with the dominant, or mainstream culture. Thus, to understand how individuals with an immigrant background view health, it is important to first assess how connected and involved they are both with their heritage culture and dominant culture. To illustrate, one study asked a group of Chinese Americans about their perceptions of health and also measured their level of acculturation by gathering information on generational status, language spoken, religious affiliation, and endorsement of traditional Chinese values (Quah & Bishop, 1996 ). The researchers found that those who rated themselves as being more Chinese believed that diseases were a result of imbalances in the body, such as excessive cold or excessive heat, in line with traditional Chinese views of illness. Those who rated themselves lower on being Chinese, in contrast, believed that diseases were a result of viruses, in line with the Western biomedical view of illness. The researchers also found that those who believed in the traditional Chinese views of health and disease were more likely to turn to a practitioner of traditional Chinese medicine when seeking medical help. And those “less” Chinese were more likely to turn to a mainstream medical practitioner. Thus, an immigrant’s level of acculturation will determine, to some extent, his or her views on health and disease, and, importantly, the help they seek to treat poor health.

Acculturation also adds complexity to many health-related behaviors and outcomes. For instance, greater assimilation in the United States (being U.S. born or adopting more mainstream American values and behaviors) relates to positive behaviors (e.g., increased utilization of health services), negative behaviors (e.g., increased alcohol and drug use, poorer diet), or has mixed effects (e.g., related to both greater and fewer depressive symptoms) (Lara, Gamboa, Kahramanian, Morales, & Bautista, 2005 ; Salant & Lauderdale, 2003 ). Some of the mixed finding can be partially attributed to the multiple ways that acculturation is conceptualized and measured. Some studies examine proxies for acculturation (such as country of birth) while other studies use more in-depth measures, assessing acculturation values and behaviors for the heritage culture as well as mainstream culture. Nonetheless, despite inconsistencies in the measurement and conceptualization of acculturation, studies do show that acculturation is clearly linked to health—and sometimes in surprising ways—as discussed below.

One intriguing phenomena that has received considerable attention in the United States and Canada is the immigrant paradox . Immigrants face a multitude of challenges. Compared to non-immigrants, they are more likely to have lower education, lower resources, live in poverty, experience adaptation challenges in terms of learning the language, customs, and lifestyles, experience discrimination, and are of lower status because of being a minority (Berry, 2003 ). Nonetheless, despite these challenges, researchers have found that immigrants, compared to non-immigrants, appear to do better on a number of measures of health. This is the paradox—that immigrants do unexpectedly better than non-immigrants in regards to health and that further assimilation leads to worse health outcomes (Sam, Vedder, Liebkind, Neto, & Virta, 2008 ). For instance, large scale studies of Latinos in the United States showed that foreign-born (immigrant) Latinos are healthier than U.S. born Latinos in terms of lower infant mortality rates, less obesity, and longer life expectancy (Hayes-Bautista, 2004 ; Mendoza, Javier, & Burgos, 2007 ). What can explain the immigrant paradox? Scholars have suggested several factors where immigrants have an advantage: healthy behaviors (e.g., better diet, less drug use), social support (close family, kin, and community bonds), and immigrant selectivity (those who immigrate are the ones who are healthier) (Padilla, Hamilton, & Hummer, 2009 ; Suarez-Orozco, Rhodes, & Milbourne, 2009 ). It will be important for future research to examine why immigrants seem to lose this protectivity and experience deteriorating health with each succeeding generation. This knowledge will be important for understanding how to reverse this negative trend.

Summary

Taken collectively, a growing literature is showing an increased awareness of socio-cultural influences on a host of variables that ultimately have implications for health and disease. These include variables such as cultural definitions of health, attributions and beliefs about the cause of disease, and preferences with regard to life styles. And for pluralistic countries with significant immigrant populations, understanding the role of acculturation to health is essential. Contemporary health practitioners and the institutions in which they work—clinics, hospitals, laboratories—have become increasingly sensitized to these issues, and are now struggling with the best ways to understand and incorporate them for maximum effectiveness.

DIFFERENCES IN HEALTH CARE AND MEDICAL DELIVERY SYSTEMS

In this final section, we review how countries differ in how they deliver health care services to their populations. Different countries and cultures have developed their own unique ways of dealing with health care. A country’s health care delivery system is a product of many factors, including social and economic development, technological advances and availability, and the influence of neighboring and collaborating countries. Also affecting health care delivery services are a number of social trends, including urbanization, industrialization, governmental structure, international trade laws and practices, demographic changes, demands for privatization, and public expenditures.

National health systems can be divided into four major types: entrepreneurial, welfare-oriented, comprehensive, and socialist (Roemer, 1991 ). Within each of these general categories, individual countries vary tremendously in terms of their economic level. For instance, the United States is an example of a country with a relatively high economic level that uses an entrepreneurial system of health care, characterized by a substantial private industry covering individuals as well as groups. The Philippines and Ghana also use an entrepreneurial system of health care, but have moderate and low economic levels, respectively. France, Brazil, and Burma are examples of high-, moderate-, and low-income countries with welfare-oriented health systems. Likewise, Sweden, Costa Rica, and Sri Lanka have comprehensive health care systems, and the former Soviet Union, Cuba, and China have socialist health systems.

A quick review of the countries listed here suggests that cultural differences are related to the type of national health system a country is likely to adopt. It makes sense that an entrepreneurial system is used in the United States, for example, because of the highly individualistic nature of American culture. Likewise, it makes sense that socialist systems of health care are used in China and Cuba, given their collectivistic, communal nature. However, cultural influences cannot be separated from the other factors that contribute to the existence of national health care systems. In the complex interactions among culture, economy, technology, and government, social aspects of culture are inseparable from social institutions.

A MODEL OF CULTURAL INFLUENCES ON PHYSICAL HEALTH: PUTTING IT ALL TOGETHER

In this chapter, we have reviewed a considerable amount of literature concerning the influence of culture on health and disease processes. This research will affect the ways in which we deliver treatment and other services to people of varying cultural backgrounds, and the type of health care systems we create. It has also made scholars in the field more sensitive to the need to incorporate culture as a major variable in their studies and theories. Understanding the role that culture plays in the development and treatment of disease will take us a long way toward developing ways of preventing disease in the future.

Figure 7.7 A Model of Cultural Influences on Health and Disease

So, just how does culture influence physical health and disease processes? Figure 7.7 summarizes what we know so far. We know that different cultures have different definitions of health and disease, and different conceptualizations of the body. We have reviewed a considerable amount of research that shows how culture relates to a number of diseases around the world. This literature complements the already large body of literature that highlights the importance of genetics and other psychosocial determinants of health and disease. We have also seen how individual cultural discrepancies may be related to health, and how culture influences specific behaviors such as eating, obesity, and suicide. Finally, although this chapter has focused primarily on the role of psychological and sociocultural factors in health and disease, we cannot ignore the contributory roles of the environment (temperature, climate) and available health care systems in promoting health and well-being.

Figure 7.7 is meant to provide a general overview of the factors—both genetic and cultural—that influence health. All these aspects will need to be fleshed out in greater detail, then tied together into a comprehensive and systematic whole to further our understanding of health and disease processes. Future research will also need to operationalize health according to dimensions other than mortality rates or incidence rates of various diseases. Incorporating cultural, genetic, environmental, social, and psychological factors in determining what leads to good health is an enormous job for the future, but it is one that we must work toward if we are to arrive at a clearer and more complete picture of the relative contribution of all these factors. A deep understanding of how culture influences our views of health, illness, and disease is vital to improving our ability to meet the health needs of culturally diverse populations.

EXPLORATION AND DISCOVERY

Why Does This Matter to Me?

· 1. How do you define good health for yourself? Does your definition resemble the WHO definition of health? Does it incorporate other aspects of health that are not mentioned in the WHO definition?

· 2. Many cultures have the notion of “balance” in their definitions of good health. In your definition of health from the previous question, did you mention the notion of balance? If yes, in what areas of your life is it important to have balance in order to maintain or promote good health?

· 3. What makes you happy? Do you think that at different times of your life, different things made you happy? Do you think that your happiness relates to better physical health? Or do you think better physical health leads to your happiness?

Suggestions for Further Exploration

· 1. We discussed three indicators of health that have been studied worldwide—infant morality, life expectancy, and subjective well-being. What other indicators do you think are important for assessing a country’s health and well-being? How would you measure it?

· 2. The immigrant paradox has been extensively studied in the United States and Canada. The paradox refers to the finding that immigrants tend to do better than native-born individuals on a number of health indicators despite the many challenges associated with immigration. Do you think you would find the immigrant paradox in other countries with large numbers of immigrants? Think about how health beliefs, behaviors, norms, and social structures and institutions of different countries may affect whether health outcomes of immigrants versus native-born individuals may differ.

· 3. Choose a health outcome (such as obesity or other disease). Adopting a biopsychosocial perspective, identify and describe biological, psychological, and social factors that may contribute to the development of the health outcome.

GLOSSARY

acculturation

The process of individual change and adaptation as a result of continuous contact with a new, distinct culture.

biomedical model

A model of health that views disease as resulting from a specific, identifiable cause such as a pathogen (an infectious agent such as a virus or bacteria), a genetic or developmental abnormality (such as being born with a mutated gene), or physical insult (such as being exposed to a carcinogen—a cancer-producing agent).

biopsychosocial model

A model of health that views disease as resulting from biological, psychological, and social factors.

disease

A malfunctioning or maladaptation of biologic and psychophysiologic processes in the individual.

holistic health

A perspective on health that considers the physical, social, environmental and sometimes spiritual needs of the individual.

health disparities

Differences in health outcomes by groups such as between males and females, African Americans and European Americans, and people of lower and higher socioeconomic status (SES).

homeostasis

Maintaining steady, stable functioning in our bodies when there are changes in the environment.

illness

Personal, interpersonal, and cultural reactions to disease or discomfort.

immigrant paradox

Despite the many challenges of adapting and adjusting to a new country, immigrants tend to show better physical health compared to nonimmigrants, and, with further assimilation, further negative health outcomes.

infant mortality

The number of infant deaths (one year of age or younger) per 1,000 live births.

life expectancy

Average number of years a person is expected to live from birth.

pathogen

An infectious agent such as a virus or bacteria.

subjective well-being

A person’s perceptions and self-judgments of his or her health and well-being that includes feelings of happiness and life satisfaction.