Cultural Factors

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CULTURAL FACTORS

Culture encompasses the set of beliefs, moral values, traditions, language, and laws (or rules of behavior) held in common by a nation, a community, or other defined group of people. Culturally determined characteristics include: the language spoken at home; religious observances; customs (including marriage customs that often accompany religious and other beliefs); acceptable gender roles and occupations; dietary practices; intellectual, artistic, and leisure-time pursuits; and other aspects of behavior. In the United States, and in other nations with large immigrant populations, there is a wide range of cultural diversity, religious beliefs, customs, and values, reflecting the scattered origins of the people. The "melting-pot" concept of nationality reduces this diversity with successive generations, but considerable variation remains—distinguishing rural from urban, African American from European, East Asian from South Asian, religious believers from secularists.

Anthropoligists and epidemiologists have identified many associations between culture, customs, and risks to health. Those who, for religious reasons, abstain from tea, coffee, alcohol, and tobacco have smaller risks of getting cancer of the gastrointestinal or respiratory tract than others of similar social, economic, and residential background. Seventh-day Adventists, who are strict vegetarians and are very health conscious have low death rates from coronary heart disease when compared to neighbors of similar socioeconomic backgrounds. Though often called "lifestyle factors," in such cases these differences are culturally determined because the related behaviors are associated with religious beliefs and practices. Jews who practice circumcision have lower incidence and death rates than gentiles from cancer of the male genital tract, perhaps related to sexual hygiene and reduced risk of infection with carcinogenic viruses.

Many cultural characteristics, and the health states related to them, are associated with education, occupation, income, and social status. These factors influence one's awareness of the world, and whether one will seek improvement or accept things as they are. Well-educated white-collar workers may be more aware of the benefits of exercise than those lacking education—they are more likely to play than watch sports, and are more likely to have better-paying jobs that enable them to afford sporting equipment. Values related to these perceptions also shape the relative priority accorded to intellectual versus athletic pursuits, motivating some working-class parents to encourage their children to study and remain in school in hopes of a better life for the children than the parents have had. The clash of competing values between environmental sustainability and economic development also has a cultural component. Appreciation of the fact that health is ultimately dependent on the integrity of the earth's life-supporting ecosystems is part of a value system. Such values may sometimes be over-ridden by short-term priorities such as job security or financial gain.

Much can be learned about the linkages between culture and health by studying migrant populations, whose culture of origin is often very different from the culture into which they migrate. Japanese migrants to California and Hawaii were found to have higher rates of coronary artery disease than their counterparts in Japan. Part of this difference could be attributed to changes in risk factors such as diet, weight, and cholesterol levels. However, loss of a stable, cohesive social environment also appears to have contributed to the rise in prevalence of coronary artery disease in the migrant groups. In another study, blood pressure values among African Americans from the southern United States who migrated to an urban environment were compared with that of urbanborn African Americans. The longer the period of city life, the higher was their blood pressure. Many studies have shown that immigrants have higher rates of mental illness, probably due to the tremendous stresses of living in a new cultural environment. Cultural groups that have a strong group identity and cohesion seem to be somewhat protected against this type of stress.

Culturally shaped illnesses are disorders that reflect the social, political, and moral worlds of the patient. They also often represent ways in which deep cultural messages are transmitted through the medium of the human body. For example, among Latino populations in Central America and the United States, anthropologists describe "ataques de nervios," an illness characterized by symptoms such as shaking, a feeling of heat in the chest, difficulty in moving the limbs, and parasthesias. Among Latino immigrants in the United States, anthropologists have linked the illness to the sense of social and political disempowerment that these people experience. Other culturally shaped illnesses include: "heart distress" in Iran; "semen loss" in South Asia; and "susto" in Latin America. Anthropologists study the symbolic meaning of symptoms within specific cultural contexts in order to understand the cultural messages these illnesses express.

Cultural context can profoundly affect the transmission of disease. A tragic example is the spread of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), particularly in Africa, where economic necessity shapes choices that are often hazardous to health. The combination of limited education, migratory labor that separates men from their wives and families, and the breakdown of traditional family networks creates a context in which men may seek multiple sexual partners. Women often lack the social power to negotiate condom use, and their need for economic and social survival outweighs the risk that they know they are taking by having unprotected intercourse. In Thailand, where culturally condoned intravenous drug use is widespread among the large population of sex workers, HIV/AIDS and other blood-borne viral diseases became epidemic in the 1990s, creating a national public health emergency.

The health of girls and women is particularly sensitive to cultural influences. In societies where women are able to make decisions for themselves, especially about their education and their reproductive choices, have longer life expectancy, lower fertility rates, and better overall health. When political totalitarianism and religious zealotry flourish, women usually suffer oppression disproportionately compared to men, and this can adversely affect their health and longevity.

Patriachal values can also be harmful to the health of girls and women. Such values have a pervasive influence in many settings, mainly in traditional agricultural societies, but also in some urbanized economies. In some strict Islamic societies where girls and women are segregated and allowed to appear in public only if totally covered from head to toe, deprivation of sunlight can impair the cutaneous synthesis of vitamin D, causing a deficiency of this vitamin and putting the women at risk for rickets or osteomalacia.

Another cultural practice with severe health consequences is female genital mutilation, which is performed on young girls in many African and Middle Eastern nations. In its most extreme form, the procedure can be life threatening. It deprives women of sexual fulfillment and makes childbirth a hazardous process for both mother and infant. While performed in many predominantly Islamic countries, this procedure is not a religious ritual, and is not condoned by any Islamic scripture. Anthropologists have described the complex cultural meanings of ritual purity associated with female genital mutilation that serve to perpetuate this practice despite its serious adverse effects on health. The majority of women and men in cultures that perform genital mutilation support the continuation of the practice which makes change all the more difficult. Both international and national efforts are underway to stop or change this practice, with some of the most promising initiatives coming from within the cultures themselves. Female genital mutilation was banned in the United States in 1995, and is also outlawed in Britain, France, Canada, Sweden, Switzerland, and some African countries.

In Western societies the female body is often altered for cultural reasons. Women in the nineteenth century constricted their waists and compressed their breasts with rigid corsets. Many women today wear high heels and tight shoes that deform their feet, with painful consequences in old age. Some undergo painful cosmetic surgery in the quest for an idealized physical form, with reshaped ears, eyes, and nose; facelifts; liposuction; and breast implants. Some girls and women strive to achieve a very low body weight, a modern, culturally shaped notion of beauty that has supplanted the former "ideal"—the plump female form depicted in the paintings of Rubens and Renoir. The pursuit of very low body weight may be associated with the development of anorexia nervosa, an illness that can be fatal. Men in Western society in the late twentieth century also began seeking an "improved" body image by taking muscle-enhancing steroids or having muscle grafts to enlarge pectoral and calf muscles.

In modern industrial societies an adolescent culture has developed. This culture often fosters rebelliousness and defiance of adult authority figures, leading some young people to smoke, take drugs, and expose themselves to dangerous and unhealthy practices. Such actions have, unfortunately, often been encouraged by the tobacco industry and advertisers of beer and other alcoholic drinks. The pervasive influence of the media, especially television, in almost all contemporary societies projects cultural values and behavior that emanate from the American entertainment industry. Many of these messages, such as encouraging the use of mood-altering substances and sexual promiscuity, are potentially harmful to health.

Public health specialists must be aware of these and other cultural trends, and they must endeavor to mobilize beneficial cultural influences while discouraging unhealthy ones. The task of public health professionals is particularly challenging when influential and economically motivated interests glorify aspects of culture that are harmful to health.

Karen Trollope-Kumar

John M. Last

(see also: African Americans; Anthropology in Public Health; Asian Americans; Assimilation; Cultural Anthropology; Ethnicity and Health; Folk Medicine; Hispanic Cultures; Race and Ethnicity; Theories of Health and Illness; Traditional Health Beliefs, Practices; Women's Health )