The term sociocultural means involving or relating to social and cultural factors, such as ethnic and income variations within and across nations. The World Health Organization collects epidemiological data on sociocultural differences in health by regions of the world (WHO, 2008). They reported, for instance, that the incidence rates (per 100,000 population) for certain forms of cancer are much higher in some regions than others. The incidence rates for lung and colon cancers are low for Eastern Mediterranean nations (21 countries, including Morocco, Pakistan, and Saudi Arabia) and high for Western Pacific nations. Sociocultural health differences also occur within specific countries. In the United States, for example, Whites and American Indians have about 2 1/2 times the incidence rate for kidney cancer as Asian Americans. And among males, African Americans have far higher rates of lung and prostate cancer than any other ethnic group. The differences we see in illness patterns between countries, regions or ethnic groups result from many factors including heredity, environmental pollution, economic barriers to health care, discrimination-based negative emotions, and cultural differences in people’s diets, health-related beliefs, and values. Although people around the world value good health, not all people have the attitudes, environments and access to health care that promote good health.
Sociocultural Differences in Health Beliefs and Behavior
Differences across history and culture can also be seen in the ideas people have about the causes of illness. Recall our discussion of the widespread beliefs in the Middle Ages that evil spirits caused illness. Today, educated people in technological societies generally reject such ideas. But less sophisticated people often do not.
I’ve heard of people with snakes in their body, how they got in there I don’t know. And they take ‘them someplace to a witch doctor and snakes come out. My sister, she had something’, a snake that was on her arm. She was a young woman. I can remember her being sick, very sick … This thing was just running’ up her arm, whatever it was, just running up her arm.
A disadvantaged person in the United States gave this account, which is typical of the level of knowledge generally found in people in underdeveloped regions or countries. This is important to recognize because the large majority of people in the world live in underdeveloped societies.
The United States has been described as a melting pot for immigrants from every corner of the world. Immigrants carry with them health ideas and customs from their former countries. For example, many Chinese immigrants have entered their new country with the belief that illness results from an imbalance of two opposing forces, yin and yang, within the body. According to this view, too much yin causes colds and gastric disorders, for instance, and too much yang causes fever and dehydration. Practitioners of traditional Chinese medicine try to correct an imbalance by prescribing special herbs and foods or by using acupuncture, in which fine needles are inserted under the skin at special locations of the body. Immigrants and others with these beliefs often use these methods when sick instead of, or as a supplement to, treatment by an American physician. They may also pressure their family members to do this, too: a pregnant Chinese woman who was a registered nurse ‘‘followed her obstetrician’s orders, but at the same time, under pressure from her mother and mother-in-law, ate special herbs and foods to ensure the birth of a healthy baby’’.
Religion is an aspect of culture. Many religions include beliefs that relate to health and illness. For instance, Jehovah’s Witnesses reject the use of blood and blood products in medical treatment. Christian Scientists reject the use of medicine, believing that only mental processes in the sick person can cure the illness. As a result, sick persons need prayer and counsel as a treatment to help these processes along. These beliefs are controversial and have led to legal conflicts between members of these religions and health authorities in the United States, particularly when parents reject medical treatments for life-threatening illnesses for their children. In such cases, the physician and hospital can move quickly to seek an immediate judicial decision.
Some religions include specific beliefs that promote healthful lifestyles. Seventh-day Adventists, for example, believe that the body is the ‘‘temple of the Holy Spirit’’ and cite this belief as the reason people should take care of their bodies. Adventists abstain from using tobacco, alcohol, and nonmedically prescribed drugs. In addition, they promote in fellow members a concern for exercise and eating a healthful diet. Although it is clear that cultural factors play a role in health, our knowledge about this role is meager and needs to be expanded through more research.
Certain mental illnesses are found throughout the world and in every culture; others are culture-bound or culture-specific. Schizophrenia, for example, has the same prevalence universally, whereas anorexia nervosa is seen mainly in western industrialized countries. That some psychiatric disorders appear to be relatively or largely culture-specific adds a further complication in determining normal from abnormal.
In China, for example, there is a stigma to being labeled mentally ill and depression is relatively unknown. But the Chinese are not immune from complaints of feelings of exhaustion, sleep disturbances, inability to relax, and other signs that in the west would be part of the depressive syndrome. In China, however, the condition is diagnosed as neurasthenia, a medical diagnosis attributed to a depletion of nervous energy. In Japan, too, reported levels of depression are low, in part because of the culture of stoicism in which one does not complain about vague signs or symptoms that might be diagnosed as depression.
In South Asia low mood as a symptom of depression is reported less than the white Europeans and American people. Here there are more somatic expression of depression has been found.
Expression of symptoms using the different idioms for real meaning, perception and association of symptoms with illness also vary from culture to culture. Help seeking way, health seeking behavior, payment for treatment, pattern of communication between physician and patient, model of physician patient relationship in clinical setting, legal aspects, political commitments, social capital, role of media, economic conditions vary in respect of culture that ultimately affects the stakeholders.
Beginning with Sigmund Freud, psychoanalysts have applied their insights to cultural data. In his 1913 work Totem and Taboo, Freud described the earliest humans as a group of brothers who killed and devoured their violent primal father. This criminal act and the so-called totem meal made the brothers feel guilty. Consequently, they formulated rules to prevent similar acts from occurring, and these rules were the beginning of social organization. Carl Gustav Jung’s writings include many anthropological references, especially to archaeology and mythology. In Symbols and Transformations, written in 1912, Jung traced patients’ fantasies back to earliest human artifacts. Neither Freud nor Jung had field experience, but Erik Erikson did. Erikson is best known for his psychocultural biographies of Mohandas Gandhi and Martin Luther and for his 1950 book Childhood and Society, in which he attempted to integrate individual psychosexual development with cultural influences. Many of his conclusions were based on his experiences with the Pine Ridge Indians in the Dakotas and the Yurok Indians in Oregon.
In her Coming of Age in Samoa, published in 1928, Mead described a society in the South Pacific in which adolescent turmoil widely believed at the time to be universal appeared not to exist. This was the result, she argued, of the unusual Samoan culture that nurtured open, nonpossessive sexual relationships among adolescents, encouraged communal child rearing, and denigrated aggressiveness and competitiveness. Growing up was so easy, she stated, because of the general casualness of the whole society. Widely publicized and discussed, Mead’s observations helped to entrench a belief in cultural determinism that persisted for decades. Research has shown, however, that Mead’s methodology was seriously flawed, and her conclusions were questionable. When Mead went to Samoa at the age of 23, she spoke no Samoan language, and her data were based, not on direct observation, but on the hearsay reports of adolescent and preadolescent girls from nearby villages.
Rather than an idyllic paradise of free love among gentle people, most observers, including Samoans themselves, describe a competitive society marked by interfamily and intervillage networks in which female virginity is highly prized at the time of marriage. Ample evidence (e.g., teenage delinquency and suicide rates) shows that during the 1920s, adolescent turmoil was not only present, but pronounced. One critic has described Mead’s Samoan study as an example of how as evidence is sought to substantiate a cherished doctrine, the deeply held beliefs of those involved may lead them unwillingly into error.
The absolute cultural determinism advocated by Mead arose in response to the absolute biological determinism of an earlier generation. Neither extreme is believed credible by behavioral researchers today.