Assessing Personal Concepts to Improve Health Health is not merely the absence of disease or distress; it is also a positive state of physical, emotional, mental, personal, and spiritual well-being and a balance with nature and the social world. This notion of health as a relationship between the individual and his or her environment illustrates that what constitutes health differs from person to person and culture to culture. In some cultures, obesity is viewed as unhealthy and low body fat as healthy; for other cultures, it is the reverse: obese people are viewed as healthy and skinny people as sickly. Because percep- tions of health are functional and related to the ability to carry out everyday activities, there is both cross-cultural and intracultural (within-culture) variation in the concept of health. People of different educational levels, social classes, and occupations (e.g., ware- house workers versus clerks) have different everyday activities and expectations about well-being. Self-assessments (see Self-Assessment 1.1 for examples) of health beliefs and behaviors provide an enhanced awareness of health concerns that facilitate the work of providers and empower patients. Differences in health conceptions affect the medical consultation process, but providers are often unaware of or ignore these differences, assuming that patients accept the medical view. Ignoring patients’ perceptions under- mines providers’ ability to relate to patients to understand their concerns and to get them to accept treatments. Effective health care requires that practitioners understand patients’
perceptions of health so that they can be integrated into treatment. Patients’ perspectives are essential for developing prevention services because the recognition of conditions and the use of resources depend on people’s perceptions of what constitutes a threat to health.
Awareness of the cultural basis of one’s own health beliefs can facilitate relations of providers with patients and vice versa. Awareness by providers that their self-care practices often fall outside the biomedical paradigm can facilitate insight into clients’ behaviors and promote empathy between provider and patient. If providers do not conform to the biomed- ical paradigm—agreeing that there is only biological cause of disease and depending on physicians for care—there is little reason to expect that their clients will. Health concerns can be best understood in relationship to culture. Biomedical views of health based strictly on biology impair understanding of underlying causes of disease that result from social conditions.
how government policies lead to poor children’s lack of access to pediatricians. These interactions among many parts of the natural systems are mediated by culture; the com- plex aspects of these interactions are illustrated through cultural systems models, which detail the many aspects of the physical, social, and cultural environments that affect health and well-being.
Biopsychosocial Model of Health
A biopsychosocial model was introduced by Engel (1977, 1980) as a corrective to the biomedical focus on disease as basically a physiological condition. The biopsychosocial model (see Figure 1.1) portrays health as related to both natural and cultural environments,
FIGURE 1.1.
Biocultural Interactions: Hierarchy of Natural Systems Source: Adapted from Engel, 1980, and Brody, 1973.Biosphere Homo sapiens
Cultures Nation (Societies)
Subcultures
Communities and Organizations Family
Interpersonal Networks Person
(Somatic, Social, and Psychic) Nervous System Organs or Organ Systems
Tissues Cells Organelles
Molecules Atoms Subatomic Particles
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involving biological as well as psychological, social, and cultural contributions to patients’
psychosocial factors and relationships to the health care system. A more inclusive scien- tifi c approach to the study of health requires addressing biological, psychological, social, and other cultural determinants that affect health and the physical environment. The bio- psychosocial model presupposes many infl uences on health, including a number of aspects of culture—society, nation, community, and family—that affect biological processes.
Addressing psychosocial dynamics also improves provider-patient relations and commu- nication because understanding patients’ complaints requires a perspective that links the individual to the social and cultural environments within which conditions are experienced and interpreted.
Human functioning within physical environments, cultural infl uences, and hierarchi- cal physiological systems enables our health to be affected through infl uences at levels above us (e.g., political decisions regarding health care funding) or below us (e.g., con- taminants absorbed by our lungs). Humans’ biological processes operate in relationship to many infl uences from the social, cultural, and physical environments, causing disruptions of homeostasis (balance). These relationships allow perturbations induced at one level (e.g., discrimination-induced interpersonal stress or beliefs about exposure to germs or threats about terrorist attacks) to affect our psychological and biological well-being. Social stress and its physiological effects may be evoked by social or psychological factors and affect our organs and tissues. Political events may provoke psychological distress—for instance, stress in our interpersonal relations. Effects in the environment, such as the weather, can affect our moods and relations with others—and make our joints hurt! The numerous factors that impact health require general models to organize our considerations of the diverse inputs.
Cultural Systems Models
Culture provides the core conceptual framework for understanding all of human behav- ior, including health behavior. Cultural concepts provide an important corrective to the prevalent view that biology determines health, behavior, and intergroup differences. The effects of culture are found throughout human life, shaping even biologically based needs such as reproduction, diet, and elimination. Culture affects health through risk factors , conditions associated with an increased likelihood of diseases (e.g., smoking), and pro- tective factors , behaviors that reduce disease risks (e.g., sexual restrictions such as monogamy). These cultural effects occur within a system of material, social, and mental (belief) relations that provide mechanisms through which cultural effects are basic to health conditions.
Cultural perspectives are essential to understanding ethnic differences in health status.
Why, for instance, do African Americans have rates of mortality due to cardiovascular dis- ease (CVD) that are about twice the rates for Hispanic Americans? These differences refl ect infl uences of culture operating as risk and protective factors. African Americans face risks that come from numerous aspects of the environment—physical, social, and cul- tural. In this book, we explore these cultural dynamics of CVD for African Americans, summarizing at the end of each chapter some of the principal implications derived from the material covered.
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Cultural effects on health are part of a system linking the physical environment, social institutions, and biology. Although they also include the physical environment, I refer to these systems as cultural systems models out of recognition that culture shapes our understandings of and interactions with the physical environment, including having effects on the physical environment. Similar cultural systems models have been proposed by physicians, nurses, and public and community health practitioners (Brody, 1973;
Engel, 1977, 1980; Blum, 1983; Leininger, 1991, 1995; Baer, Singer, and Johnsen, 1986;
Sallis and Owen, 1998), who use cultural systems approaches as conceptual frameworks for addressing health, disease, and care in relationship to the ecology , the total physical and social environment. These models also incorporate demographic, technological, eco- nomic, political, and other social conditions that affect the physical environment.
To understand the relationships of organisms to their physical environments, cultural systems models are essential because they are mediated through sociocultural systems.
Cultural models direct attention to the many conditions that affect health. Cultural sys- tems approaches expand the biopsychosocial perspective in recognizing social factors as fundamental causes of disease. The biopsychosocial approach called attention to the indi- vidual psychosocial determinants while neglecting the broader social factors that are fun- damental causes of disease and necessary concerns in prevention efforts.
Cultural systems models help explain the many factors that affect health by illus- trating conditions affecting the causes and distributions of disease and the responses of individuals and health care systems. Economic, political, and other social conditions, as well as cultural values, beliefs, and meanings, have active roles in the causation of disease and the allocation of remedies. Cultural beliefs and resources, sickness and healing roles, and the distribution of resources affect an individual’s experience of a condition. Cultural beliefs and technological, economic, and political priorities are refl ected in treatment. Effectively addressing health requires understanding the struc- tural components of cultural systems and their infl uences on health. Cultural systems approaches to health examine the interaction of the physical and sociocultural environ- ments. The “environment” is not merely physical but fundamentally cultural, which includes economic, familial, community, class, political, and religious dimensions and their effects on the physical environment.
Physicians, nurses, and public and community health practitioners (Brody, 1973;
Engel, 1977, 1980; Blum, 1983; Leininger, 1984; Baer, Singer, and Johnsen, 1986; Sallis and Owen, 1998) have proposed similar systems approaches as conceptual frameworks for addressing health, disease, and care in relationship to the ecology. These models also incorporate demographic, technological, economic, political, and other social conditions that affect the physical environment. Cultural systems perspectives prominent in commu- nity health include the “environment of health” or “force-fi eld paradigm” (Blum, 1983;
Evans and Stoddart, 1994), which views health as a product of the relationships among many subsystems or fi elds:
■ The physical environment, including sanitation, housing, environmental toxicity, and the physical infrastructure of health care
■ The social environment, including family, work, class, education, and social networks
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■ Persons’ individual behavior, especially lifestyle, that links them to the environment
■ Medical care services, part of the social environment with a special role in health
■ The genetic and biological level
These interdependent fi elds (or subsystems) affect one another, operating through natural resources, the population and its ecological balance, and cultural systems medi- ating human interaction with all of the fi elds: for example, resources, social networks, and medical services. Environmental infl uences include the reciprocal infl uences of human impacts on the environment (such as contaminants) and stressors produced by social conditions (such as crime). Lifestyle and behavioral factors affecting health involve many cultural and social dimensions, including risk behaviors, social support, and individual activities. The multiple determinants of health and their dynamic rela- tionships illustrate that health is not strictly a function of disease, biology, or genetics but rather their complex interaction with social, economic, political, and other cultural conditions that produce the individual’s behavior and biological conditions. Blum (1983) emphasized hereditary forces as last in order of relative importance for health and the environment, including physical, economic, and social dimensions, as having the greatest impacts on health.
Public health models of health (Sallis and Owen, 1998) emphasize the need to address interrelated levels, including the intrapersonal (psychological), interpersonal (primary groups, especially family), and institutions in community and society. For example, effec- tive programs for improving health must address a spectrum of levels, going beyond per- sonal and interpersonal approaches in identifying how cultural and ecological factors interact in producing infl uences on health.
Systems perspectives are important because health behavior is not merely a function of microlevel interpersonal interactions of family and community; they are also affected by our mesosystems linkages between our microlevel interpersonal relations and the macrolevel resources such as political power and societal resources that affect health.
Does your family know how to obtain welfare, disability payments, or food assistance?
These are mesolevel linkages to resources provided at the macrolevel by governments.
Do you know how to obtain scholarships and grants to pay for medical school? These, too, are mesolevel linkages. Cultural approaches to health emphasize the necessity to direct interventions at the various environments that infl uence health and risk behaviors.
Health problems created by ecological conditions such as air pollution and poverty can- not be eradicated in the clinical setting but only by altering those macrosystem conditions.
Clinical services are not passive agents affecting health but resources mediated by economic and political factors, especially health policies (e.g., who gets to receive federal funding for health services: individuals or only local governments and hospitals?). When there is government funding for public health, who are the real benefi ciaries, the poor who receive free immunizations or the stockholders of the companies who may receive mil- lions or even billions of dollars for providing the vaccines? Political effects on health are revealed in the enormously greater public investment in hospitals and biomedicine versus
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public health activities and community health centers that can more directly affect the occurrence of disease. Public health approaches are more cost-effective in preventing dis- ease, with systemic interventions such as public service announcements or free clinics affecting a large population, rather than the individuals seen in clinical treatment. Public health interventions directed at groups and communities require culturally informed approaches that use information on the environment, community dynamics, health resources, and social networks.
Sociocultural Theories of Disease
How does culture produce health consequences? In medical anthropology, explanations of the cultural effects on health have emphasized three basic theoretical approaches that supplement the biomedical approach:
■ Medical ecology theories concerned with interactions with the ecology, the total environment affecting human adaptation, using human genetics and group behavior as principal levels of explanation
■ Political economy and critical medical anthropology approaches that show how social relations, economic resources, and power are determinants of disease and dis- ease outcomes through producing risks and distributing resources
■ Cultural theories concerned with how beliefs, values, and customs are determinants of disease, operating through symbolic processes that have effects on biological levels
These three approaches are all concerned with the impacts of culture on biology, as illustrated in Hahn’s (1995) discussion of mediation, production, and construction mod- els of sociocultural disease causation.
Mediation Mediation approaches refl ect perspectives similar to the biopsychosocial approach, emphasizing how sociocultural factors affect people’s exposure to pathogens.
Mediation models of sociocultural infl uences on health are partially recognized in bio- medicine, manifested in the concern with health infl uences of lifestyle and personal hab- its (e.g., effects of diet, drugs, and sex on health). Mediation models view sociocultural effects on health as the differential distribution of the population with respect to the envi- ronment, risk factors, economic resources, occupational hazards, social activities, and other conditions that produce diseases and provide resources to ameliorate their effects.
Cultural behaviors and social conditions affect exposure to pathogens and access to treat- ments, differentially affecting the well-being of different segments of the population (e.g., poor versus rich). These medical anthropology approaches are exemplifi ed in the medical ecology perspectives presented in Chapter Seven.
Production Production perspectives emphasize how social conditions produce health maladies through the distribution of risks and resources and by social and symbolic effects on biology. Production perspectives recognize a stronger cultural determination of health in its potential to cause biological disorder. Cultural practices such as contamination, work
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conditions, drug use, and unsafe sex directly cause disease. Culture directly affects biolog- ical processes through psychosomatic reactions, social stress precipitating the disruption of cardiac function, and social conditions (e.g., industrial waste, traffi c, and labor acci- dents). Hahn suggests that the “production” model is ridiculed in biomedicine because it is seriously misunderstood and contradicts biomedicine’s model of biological determinism.
Production perspectives challenge the traditional biomedical paradigm by showing the social and mental effects on physiological processes. Cultural infl uences provide more than just mediation of people with respect to risks: “sociocultural effects are causal in the same way that environmental carcinogens, toxins, and bacterial and viral pathogens are” (Hahn, 1995, p. 76). The placebo phenomena exemplify the cultural production of biological responses (see Chapter Eight).
Construction Construction approaches elucidate that a culture constructs how its mem- bers think about health conditions and their social, moral, and cosmological implications and, consequently, constructs their experience of health maladies. Construction perspec- tives emphasize that culture affects health, illustrated in the relationship of symptom recognition to cultural values and social norms. Cultural criteria determine whether a given condition is construed as a disease or is viewed as falling within normal human variation. This cultural determination also occurs in the activities of biomedical practition- ers who defi ne relevant symptoms and interpret them. Culture is the basis of this “social labeling,” where diagnosis involves a social process in which individuals are given dis- ease labels. Ethnomedicines produce cultural realities of health by providing models of what diseases exist and their signifi cance, causes, and available treatments. Construction approaches may also present models similar to production perspectives, noting that peo- ple’s beliefs can have physiological consequences, as discussed in Chapter Nine.
The different approaches to the relationship of culture to health also refl ect theoretical and practical differences among medical anthropology. Should health be primarily concerned with addressing biological conditions? Or should we address the political and economic forces that produce contamination, food shortages, and available services, conditions that affect health? Should alternative medicine practices be accepted as equal in effi cacy to biomedicine, or should they be opposed as outdated superstitions? Should medical anthro- pology help physicians with cross-cultural competency skills, or should they help patients develop an understanding of the politics of medicine to better resist medicine’s political control? Despite their differences, the various approaches all use concepts of cultural systems and systems models with multiple domains to assess the many factors affecting disease and health.