One major role of psychology is to improve the lives of the people we touch.

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.

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