Chapter 11 Culture and Health PDF

11 Culture and Health CHAPTER CONTENTS Cultural Differences Culture and Obesity in the Definition of Health...

11 Culture and Health CHAPTER CONTENTS Cultural Differences Culture and Obesity in the Definition of Health Culture and Suicide Comparison across Cultures Acculturation and the Immigrant Paradox Comparison within Cultures Summary Three Indicators of Health World Wide Differences in Health Care and Medical Delivery Systems Life Expectancy Infant Mortality A Model of Cultural Influences Subjective Well-Being on Health: Putting It All Together Genetic Influences on Physical E X PL O R AT I O N A ND D IS C OV E RY Health and Disease Why Does This Matter to Me? Suggestions for Further Exploration Psychosocial Influences on Physical Health and Disease Sociocultural Influences on Physical Health and Disease Cultural Dimensions and Diseases Cultural Discrepancies and Physical Health Culture, Body Shape, and Eating Disorders 254 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   255 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 disease A malfunctioning “malfunctioning or maladaptation of biologic and psychophysiologic processes in the or maladaptation of biologic and psychophysiologic pro- individual” and illness refers to the “personal, interpersonal, and cultural reactions cesses in the individual. to disease or discomfort” (Kleinman, Eisenberg, & Good, 2006; p. 141). Thus, how we illness Personal, interper- view health, disease, and illness, is strongly shaped by culture. sonal, and cultural reactions This chapter explores how cultural factors sway physical health and disease to disease or discomfort. processes, and investigates our attempts to understand genetic, psychosocial, and sociocultural influences. We begin with an examination of cultural differences in the definition of health and present three indicators of health worldwide: life expec- tancy, infant mortality, and subjective well-being. We 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 explore differences in health care systems across countries. Finally, we 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, biomedical model A in which 61 countries were represented. They defined health as “a state of complete model of health that views physical, mental, and social well-being, and not merely the absence of disease or disease as resulting from a infirmity.” The WHO definition went on further to say that “The enjoyment of the specific, identifiable cause such as a pathogen (an infec- highest attainable standard of health is one of the fundamental rights of every human tious agent such as a virus being, without distinction of race, religion, political beliefs or economic and social or bacteria), a genetic or conditions” (World Health Organization, 1948). This definition of health is still used developmental abnormality (such as being born with a by the WHO today. mutated gene), or physi- In many Western countries, views of health have been heavily influenced by what cal insult (such as being many call the biomedical model of health and disease (Kleinman et al., 2006). Tradi- exposed to a carcinogen—a tionally, this model views disease as resulting from a specific, identifiable cause such cancer-producing agent). as a pathogen (an infectious agent such as a virus or bacteria), a genetic or develop- pathogen An infectious mental abnormality (such as being born with a mutated gene), or physical insult (such agent such as a virus or bacteria. 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, subse- biopsychosocial model A model of health quently, treatment focuses on addressing biological aspects of the disease. that views disease as result- Several decades ago, however, the biomedical model was strongly criticized by ing from biological, psycho- Engel, who proposed a biopsychosocial model to understand health and disease. logical, and social factors. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  256  Chapter 11 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., life- styles 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 for 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. Maintain- ing 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— holistic A view of health a view of health that is holistic (Yip, 2005). Balance between self and nature and across that focuses on the inter- the individual’s various roles in life is viewed as an integral part of health in many cul- connections between the individual, his or her rela- tures around the world. This balance can produce a positive state in mind and body— tionships, environment, and a synergy of the forces of self, nature, and others—that many call health. spiritual world. This notion of balance and imbalance, at least within the body, is a common con- cept across cultures (MacLachlan, 1997). The various systems of the body produce harmony and health when in balance, and 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, sug- gests 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. Another type of balance, common in theories of disease in many Latin American cultures, concentrates on hot and cold (MacLachlan, 1997). 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. In many cultures, then, we often hear about the importance of having a “bal- anced diet” and a “balanced lifestyle” (finding the optimal balance between work homeostasis Maintain- and play). The concept of homeostasis is all about balance—maintaining steady, sta- ing steady, stable function- ble functioning in our bodies when there are changes in the environment. When our ing in our bodies when there are changes in the bodies cannot maintain homeostasis over time, illness and disease may result. Thus, environment. 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 dis- cussions of health. From this brief review of how different cultures define health, we can see how different beliefs of what leads to good health will affect how diseases are diagnosed and treated. If we believe that health is determined primarily by biological distur- bances and individual choices, treatment may primarily focus on individual-level Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   257 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. Health perspectives may differ between individuals from the dominant or mainstream culture and those of the nondominant social and ethnocultural group (Mulatu & Berry, 2001). Native Americans, for exam- ple, have a holistic view of health and consider good health to be living in harmony with oneself and one’s environment. Poor health results 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. 52). Yurkovich and Lattergrass (2008) pointed 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 con- nected to and in balance with the spiritual world—is a cornerstone of good health, both mental and physical. Figure 11.1 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 a pluralistic country 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 popu- larity 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 incorpo- rates medical and health care systems and practices that are not considered conven- tional medicine to treat illness and promote health. According to the U.S. National Health Interview Survey the percentage of U.S. adults doing yoga, one of the most popular CAM practices, has steadily increased in the last decade (Clark, Black, & Figure 11.1 Circle of Wellness Model of Native American Health Physical Mental Source: Yurkovich & Lattergrass (2008). Defining health and unhealthiness: Perceptions of Native Americans with persistent mental illness. Mental Health, Religion, & Culture, 11, 437–459. Spirit Social Emotional Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  258  Chapter 11 14 2002 12 2007 2012 10 8 Percent 3 11.2 6 4 2 7.9 3 7.2 1 6.3 5.2 5.4 2 3 3.3 2.0 1.3 0 18-44 45-64 65 and over Age 95% confidence interval. 1 Significantly different from 2007 and 2012 (p < 0.05). 2 Significantly different from 2012 (p < 0.05). 3 Significantly different from 2002 and 2007 (p < 0.05). NOTE: Estimates are based on household interviews of a sample of the civilian noninstitutionalized population. SOURCE: CDC/NCHS, National Health Interview Survey, 2002, 2007, and 2012. Figure 11.2 Percentage of U.S. Adults Reporting Doing Yoga in the Last Year. In Each Age Group There Is an Increase between 2002 and 2012, with the Largest Increase in the 18–44 Age Group, Almost Doubling in the Last Decade Stussman, 2015). See Figure 11.2. One thing is clear: with continued migration, immi- gration, and globalization, our views on health and how best to promote good health, are changing. Three Indicators of Health Worldwide Life Expectancy Three indicators of health are used worldwide: life expectancy, infant mortality, and life expectancy ­ subjective well-being. Life expectancy refers to the average number of years a person is Average number of years a expected to live from birth (as opposed to calculating life expectancy from, e.g., age 65). person is expected to live from birth. Figure 11.3 shows the average life expectancy for selected countries, estimated for 2014. A comparison of 223 countries showed that the countries with the longest aver- age life expectancies were Monaco (90 years), Macau and Japan (85), S ­ ingapore (84), San Marino, Andorra, Hong Kong (83), Switzerland, Guernsey, and Australia (82). The United States was ranked 42nd, at 80 years of age. Countries with the shortest life expectancies were Swaziland and Afghanistan (51), Guinea-Bissau, South Africa (50), and Chad (49) (CIA, The World Factbook, 2014). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   259 100 90 Average Age Life Expectancy 80 70 (Years) 60 50 40 30 tia ad o n da S. il q ia a an a e an az di bw ric ac pa Ira liv U. oa na Ch st ist bo Br on Af Bo Ja ki ba an Cr Ca m Pa M h m gh Ca ut Zi Af So Figure 11.3 Average Life Expectancy in Selected Countries Source: CIA Factbook. A large part of explaining such drastic life expectancy differences is the general resources of a country (Barkan, 2010). Wealthier countries with greater resources have better access to better diet, nutrition, health care, and advanced technology to main- tain 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 hun- ger, malnutrition, AIDS and other diseases, and lack of access to basics for survival such as clean water, sanitary waste removal, vaccinations, and other medications. Nations experiencing war and other disasters experience disruptions that challenge survival. Thus, life expectancy is shortened. Importantly, disparities in life expectancies can vary widely within a country. In the United States, for instance, life expectancy differs by ethnicity (which is usu- ally confounded with socioeconomic status). In 2011, for European Americans, life expectancy was 79 years. In contrast, for African Americans, life expectancy was 75 years. When gender was taken into account, the disparities were even greater: ­African American male life expectancy was 72 years, compared to European American females at 81 years (National Center for Health Statistics, 2011). These statistics show clear health disparities between ethnic groups in the United States. We will address possible reasons for these health disparities later in the chapter. 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). Nonethe- less, great disparities across countries in average life expectancies mean that possi- bilities for good health and a long life are enjoyed by people in some countries, but not others. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  260  Chapter 11 Infant Mortality infant mortality The Infant mortality is defined as the number of infant deaths (one-year-old or younger) number of infant deaths per 1,000 live births. Figure 11.4 shows infant mortality rates for selected countries, (one year of age or younger) per 1,000 live births. estimated for 2014. Comparing across 224 countries, Afghanistan (117 infant deaths per 1,000 live births), Mali (104), and Somalia (100) had the highest rates of infant mor- tality while Norway (3), Japan (2), and Monaco (1) had the lowest. The United States was ranked 169th, with six infant deaths for every 1,000 live births (CIA, The World Factbook, 2014). 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 six infant deaths per 1,000 births in 2010. Similar to life expectancy, however, there are disparities by ethnic group. African American infants have the highest infant mortality rates (14 infant deaths per 1,000 births) 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 differ- ences 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, research- ers have focused more recently on an important subjective indicator of health— happiness, or subjective well-being. 120 100 Number of Deaths per 1,000 Live Births 80 60 40 20 0 an ria a os l t a m a es n o pa yp d in in pa ac do at La ist ge an Ne Ch nt Eg on Ja St ng an Ni Rw ge M d gh Ki Ar ite Af d Un ite Un Figure 11.4 Infant Mortality Rates in Selected Countries Source: CIA Factbook. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   261 Subjective Well-Being In contrast to life expectancy and infant mortality, subjective well-being (SWB) subjective well-being focuses on one’s perceptions and self-judgments of health and well-being. Subjective A person’s perceptions and self- judgments of his or her well-being encompasses a person’s feelings of happiness and life satisfaction (Diener health and well-being that & Ryan, 2009). Diener and Ryan (2009) state the importance of this subjective aspect includes feelings of happi- of health. ness and life satisfaction. The main applied goal of researchers who study subjective well-being is the improvement of people’s lives beyond the elimination of misery. Because subjec- tive 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 function- ing of societies beyond the advantages they bestow on individuals (p. 392). 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 find- ings 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 supported studies showing that higher SWB may lead to a longer life expectancy (Diener & Chan, 2011). It is 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? One major variable studied is affluence, or material wealth. Material wealth (as measured in greater household income) predicts an increase in satisfaction with one’s financial situation, greater purchasing power, and greater optimism about the future (Diener Tay, & Oishi, 2013) These three factors pre- dict greater SWB, for both richer and poorer countries. Figure 11.5 shows levels of SWB in relation to per capita gross domestic prod- uct (GDP) across 88 countries. An interesting pattern emerges. 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. Recent work on SWB shows that other nonmaterial factors such as feeling respected, having social support from friends and family, and feeling satisfied with the amount of freedom one has in life, are all related to greater SWB across many cultures (Ng & Diener, 2014). Thus, in addition to having enough material resources, our sense of autonomy and connection to others are essential to our happiness. 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, Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  262  Chapter 11 Puerto Denmark 4.25 Rico Iceland Switzerland Colombia Ireland Mexico Sweden Netherlands U.S.A. 3.75 El Salvador New Australia Canada Luxembourg Guatemala LATIN AMERICAN Britain Zealand 3.25 Venezuela Saudi Cyprus Finland Austria Norway Nigeria Arabia Belgium Domin. Brazil 2.75 Ghana Rep. Uruguay Argentina Singapore West Germany Trinidad France Indonesia Japan Chile 2.25 Philippines Taiwan Portugal Spain Israel Italy East 1.75 Vietnam China Peru Czech Rep. Germany SWB Index Slovenia Kyrgyzstan Poland Greece Mali Iran Turkey 1.25 South S. Korea Bangladesh Africa Burkina India Algeria 0.75 Croatia Hungary Zambia Serbia Uganda Egypt 0.25 Pakistan Jordan Slovakia Tanzania Macedonia EX- Azerbaijan –0.25 Rwanda COMMUNIST Estonia Latvia –0.75 Lithuania Georgia Russia Bulgaria Romania –1.25 Belarus Albania Ukraine –1.75 Iraq Moldova Armenia Zimbabwe –2.25 0 5 10 15 20 25 30 GDP per Capita in Thousands of Dollars, Five Years before Survey Figure 11.5 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. health-related behaviors). Some of the most common complex-gene diseases are can- cer, 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, eth- nic, or 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 Medi- terranean populations than Northern European, while the opposite is true for cystic fibrosis. Because humans living in the same geographical area tend to be more genet- ically similar to one another, this may partially explain 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; also recall our discussion of race in Chapter 1). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   263 culture Figure 11.6 cultural psychology The Cultural Neuroscience Framework, Integrating Theory and Methods from Cultural Psychology, Neuroscience, and Genetics. The mind Aim Is to Understand How Culture, Mind, Brain, and Genes Interact social-cognitive-affective neuroscience to Produce Human Cultural Variations on Different Times Scales: brain Situation (in the Moment), Ontogeny (Individual Development) and Phylogeny (Species Development) imaging genetics Source: Chiao, J. (2009). Cultural neuroscience: The once and future discipline. genes In J. Chiao (Ed.) Progress in brain research, 178, 247–304. situation-ontogeny-phylogeny Research that examines how genes and environment interact over time is our best chance at illuminating why some diseases appear more often for some cultural groups compared to others. Francis (2009) argued for multilevel, interdisciplinary research programs to address questions such as how community, social, and societal forces contribute to how genes are regulated and expressed. Multilevel investigations study how genes interact with environments on various levels—cellular, individ- ual, group, and societal. Interdisciplinary investigations include a collaboration of researchers from various fields—genetics, biology, psychology, sociology, and public policy. In the last decade a new field of inquiry adopts this type of complex, multilevel and interdisciplinary approach, namely, cultural neuroscience. Researchers in this cultural neuroscience field combine recent advances in neuroscience with principles of cultural psychology An emerging research field that combines recent and population genetics to understand the dynamic relations among culture, behav- advances in neuroscience ior, mind, brain, and genes (see Figure 11.6). Chiao, a leading theorist and researcher with principles of cultural in cultural neuroscience, has studied why some cultures emphasize individualism psychology and population versus collectivism as a result of both environmental factors (e.g., pathogen preva- genetics to understand the dynamic relations among lence) and genetic selection (Chiao, Cheon, Pronpattananangkul, Mrazek, & Blizin- culture, behavior, mind, sky, 2013). Her studies suggest that people living in areas around the world with a brain, and genes. higher prevalence of infectious diseases (such as in hotter climates) are more likely to be more collectivistically oriented. Being more collectivistically oriented emphasizes connections with in-group members, which may serve as a way to reduce the spread of infectious diseases coming from outgroups. Studies in cultural neuroscience, then, aim to uncover how culture, genetic selection, and environmental pressures interact, leading to cultural traits (such as holding more individualistic or collectivistic orien- tations) that are adaptive for a particular environment. 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 Psychology as a whole has become increasingly aware of the important role that cul- ture 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 to the emergence of new fields such as cultural neuroscience. This increased awareness is related to a growing concern with psychosocial determinants of health and disease in general. Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  264  Chapter 11 Some of the earliest research on psychosocial factors in health and disease pro- cesses 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. 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. Those with the most social ties had the lowest. 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, socioeconomic status (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 enor- mous 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 sup- ports are not lonely, and some people with many social supports do feel lonely. Cur- rent reviews show that feeling lonely is linked to a host of health problems (Hawkley & Cacioppo, 2010; Steptoe & Kivimäki, 2013). 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 such as coronary heart disease, hypertension, and stroke. It truly is the case that loneliness weakens the heart. A number of other important and interesting studies have documented the link- age between psychosocial factors and health or disease states. Steptoe and his col- leagues in the United Kingdom 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 bereave- ment and lymphocyte functions; between pessimistic explanatory styles and physi- cal illnesses; between positive mood and heart rate and blood pressure; and between psychological well-being and mortality (e.g., Chida & Steptoe, 2008; ­D ockray & Steptoe, 2010; Steptoe, Dockray, & Wardle, 2009; Steptoe, Hamer, & 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 or disease outcomes. In multicultural countries such as the United States and the United Kingdom, health disparities ­ researchers have focused on health disparities. Health disparities are differences in Differences in health out- health outcomes by groups, for instance, between males and females, people of dif- comes by groups such as between males and females, ferent ethnicities, and people of lower and higher SES. Disparity refers to the fact that African Americans and one group shows worse (or better) health outcomes compared to another. Health dis- European Americans, and parities can result from social factors, such as a person’s level of education, income, people of lower and higher or occupational status (e.g., being employed versus unemployed or underemployed). socioeconomic status (SES). Adler and her colleagues (e.g., Adler, Boyce, Chesney, Cohen, Folkman, Kahn, & Syme, 1994; Adler & Rehkopf, 2008) have provided strong evidence that SES is con- sistently associated with health outcomes. People of higher SES enjoy better health than do people of lower SES (see Figure 11.7). This relationship has been found not only for mortality rates, but for almost every disease and condition studied. Adler and colleagues have suggested that health-related behaviors such as smoking, physi- cal activity, and alcohol use may explain the relation between SES and health, as these Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   265 (a,b) (c,d) Annual Infant c death rate mortality a 50 30 d 40 25 30 20 b 20 15 10 10 1 2 3 4 5 6 7 Highest Lowest Socioeconomic Status Note: (a) Annual death rate per 1,000 male (Feldman, Makuc, Kleinman, & Cornoni-Huntley, 1989), (b) Annual death rate per 1,000 female (Feldman et al., 1989), (c) Infant mortality per 1,000 live births male (Susser, Watson, & Hopper, 1985), (d) Infant mortality per 1,000 live births female (Susser et al., 1985). Figure 11.7 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. 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 subjec- tive perception of SES appears to better predict health and change in health rather than an objective assessment of SES (Singh-Manoux, Marmot, & Adler, 2005). An important psychosocial factor that may contribute to health disparities by ethnic group is perceived racism and discrimination. One striking health dispar- ity is the shorter life expectancy for African Americans versus other ethnic groups. This disparity may be linked to stress-related health outcomes such as high blood pressure (hypertension) due to 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) and premature biological aging among African Americans (Chae, Nuru-Jeter, Adler, Brody, Lin, Blackburn, & Epel, 2014; Mays et al., 2007). For ­African American women, racism-related stress and poorer physical health may sub- sequently contribute to negative pregnancy outcomes and explain some of the dis- parity between African American and European American infant mortality (Collins, David, Handler, Walls, & Andes, 2004). Notably, the negative effects of racism can carry on even to the next generation. 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 signifi- cant health disparities (Pascoe & Richman, 2009). Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  266  Chapter 11 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. 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 participants into groups accord- ing to how “traditionally Japanese” they were (spoke Japanese at home, retained tra- ditional 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 Ameri- cans, 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. 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 individualis- tic 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. Of course, this study was not conclusive, as many other variables confounded comparisons between Americans and Trappist monks (such as industrialization, class, and lifestyle). Nevertheless, the study was important because it was the first to examine the relationship between cultural dimensions and the incidence of a particular disease state. Since this initial study, other researchers have expanded the focus of cultural dimensions beyond individualism and collectivism and have included many other diseases. Other dimensions of culture 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 pro- cesses. 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 Copyright 2017 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. Due to electronic rights, some third party content may be suppressed from the eBook and/or eChapter(s). Editorial review has deemed that any suppressed content does not materially affect the overall learning experience. Cengage Learning reserves the right to remove additional content at any time if subsequent rights restrictions require it.  Culture and Health   267 this possibility by examining the relationship among multiple dimensions of cul- ture 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 (WHO, 1991), were compiled across 28 countries widely distributed around the globe, span- ning five continents, and representing many different ethnic, cultural, and socio- economic 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 gath