British Medical Bulletin

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British Medical Bulletin 69:21-31 (2004)
British Medical Bulletin, Vol. 69 © The British Council 2004; all rights reserved

Culture and the risk of disease

William W Dressler

Department of Anthropology, The University of Alabama, Tuscaloosa, AL, USA

Correspondence to: William W. Dressler, Professor of Anthropology, P.O. Box 870326, The University of Alabama, Tuscaloosa, Alabama 35487-0210, USA. E-mail: wdressle{at}tenhoor.as.ua.edu

	Abstract

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
Decades of research have demonstrated that disease risk varies in relation to culture. Much of this research has focused on blood pressure, given its relative ease of measurement under difficult field conditions. Community average blood pressures in more developed, industrialized societies are higher than those in less developed, traditional societies. These differences can be accounted for only in part by differences in body composition and nutrient intake. A portion of the difference is accounted for by more direct effects of culture on individual behaviour and physiology. This chapter reviews this evidence. Approaches to this research have included studies of communities differing in exposure to modernizing influences; studies of sociocultural stresses generated within the process of social change and modernization; and, studies of how individual differences in the ability to act on shared cultural models (referred to as ‘cultural consonance’) are associated with disease risk. Clinical implications of these results are briefly discussed.

	Introduction

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
Writing in 1929, C.P. Donnison summarized measurements of blood pressure taken among several ethnic groups in East Africa. Based on a sample of 1000 individuals ranging in age from 15 to over 60 years old, he noted that age-specific average blood pressures were remarkably low, compared to the accumulating evidence from Europe and North America. He concluded that: "the native African ... has probably for a large number of generations lived in a manner that has undergone but very slight change. The European and American populations have ... seen revolutionary changes in their mode of living in a very few generations ..."¹. He hypothesized that the psychological stress of culture change contributed to the increased blood pressures in industrial society.

The stress and culture change hypothesis has proven irresistible to researchers and a productive avenue of investigation over the past 75 years. In this chapter, I will briefly review some of the evidence demonstrating differences within and between societies in disease risk consistent with this hypothesis. I will then review more specific studies employing models of psychosocial stress, and conclude with some observations regarding future directions in research.

Working cross-culturally often means working under demanding field conditions. The relative ease and accuracy with which blood pressure can be measured under such conditions has meant that much of the available research focuses on it as an outcome measure. This review will maintain this focus, although newer techniques for the collection of blood and salivary samples have made possible the analysis of other relevant variables, such as circulating cortisol and cell-mediated immune status. Some reference to this research will be included as well.

	Societal differences in disease risk

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
A large number of studies continued the logic of Donnison’s original effort (see Dressler² for a review). That is, blood pressures are collected within a relatively isolated, traditional society, such as the Amondava of Brazil, and the results are compared to an industrialized urban centre, for example in Italy³. Generally speaking, in traditional societies community average blood pressures are low and show little increase with age. In interpreting the findings, appeals are made both to the psychosocial implications of culture change and to changing patterns of diet and exercise. While these sorts of comparisons are of some interest, the sociocultural differences between an Amazonian tribal people and urban Italians are so great that interpreting the observed differences in blood pressure can only be highly speculative.

More controlled forms of investigation grew out of studies of modernization and migration in the 1960s and 1970s⁴. It was hypothesized, principally by the epidemiologist John Cassel and his colleagues^5,6 that, within a single society, communities that differed in the degree of exposure to influences emanating from urban industrial centres would show corresponding differences in community average blood pressures. Similarly, they hypothesized that migrants from more traditional societies to more modern settings would show an increase in blood pressure compared to nonmigrants.

The research by McGarvey and Baker⁷ provides a good synopsis of this kind of work. These investigators selected three communities in Samoa for comparison. A community in Western Samoa was highly traditional, practicing subsistence agriculture. The community was organized along traditional lines of extended kinship and chiefly authority, with little influence of formal educational institutions or missionaries, and primary use of the Samoan language. For comparison, they selected two communities in more modernized American Samoa. At the extreme was the urbanized community of Pago Pago, the capital of American Samoa. There, Samoans worked in canning factories or for the US government. Kinship emphasized the nuclear family and the status of traditional chiefs was weakened. English was the language of everyday use. As an intermediate community, they selected a rural community in American Samoa that was connected to Pago Pago by road. Whereas subsistence agriculture and elements of traditional social and political structure were maintained, formal education and the connection to the urban area brought modernizing influences. Finally, they selected a community of Samoan migrants to Hawaii for comparison.

These investigators found significant differences in community average blood pressures between the traditional community and those communities exposed to modernizing influences (on the order of 10 mmHg for men and 5 mmHg for women in systolic blood pressure). They adjusted statistically for obesity, which left the results unaltered. This study shows that, whereas differences in diet and physical activity contribute to the increase in blood pressure (since obesity measures also vary across the gradient of modernization), they cannot account for all of the differences. Other studies using a similar research design (reviewed elsewhere^2,4) have shown that changes in the intake of specific nutrients (e.g. sodium, potassium, calcium) contribute to, but do not account completely for, these differences.

Therefore, the hypothesis that cultural changes accompanying migration and modernization are somehow stressful and lead to increased disease risk cannot be rejected. Cassel and his colleagues^5,6 suggested the following sociocultural process to account for these outcomes. Referring to migration, they argued that the migrant arrives in a novel social setting with an understanding of the world and set of expectations for others’ behaviours learned in her own society; however, that knowledge of how to function in society (which is a very useful definition of the concept of culture⁸) is ineffectual in the new setting. This will lead to confusion in her understanding of the world and possible conflict in social interaction. She must adapt to the new setting by learning a new set of cultural norms. All of this is taxing and stressful for her and can elicit physiologic responses in the form of acute elevations of blood pressure. To the extent that she adapts and learns a new culture, the long-term effects should be minimal. If, however, the period of adaptation is extended, with ineffective resolution, then sustained changes in blood pressure will result. The same argument can apply to persons living in a community exposed to significant change in their own lifetime.

Research on modernization, migration and blood pressure led to many new insights; however, it was hampered by a number of problems. One problem was the very concept of modernization, which has been largely discredited, primarily because communities undergoing social change often do not achieve the end that the term modernization implies; rather, many communities in the developing world are trapped in situations of political and economic dependency and marginality. A second problem is that modernization (and even migration) remain ecological concepts; that is, they apply to groups of people and leave little insight into what occurs at the level of the individual.

	Sociocultural models of stress

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
To deal with these limitations of research on modernization and disease, and to examine the stress and culture change hypothesis more closely, researchers turned to theories of psychological stress⁹. Stress theory places emphasis on social environmental demands (or ‘stressors’) to which individuals have to adjust, as well as on the resources, including both social and psychological resources, that individuals mobilize to cope with those demands, emphasizing especially social resources (or ‘social supports’). This theoretical orientation provided a means to go beyond the aggregate theoretical constructs of modernization research and determine how sociocultural factors affect the individual. Cassel¹⁰ in his later writings embraced this view, especially the so-called "buffering model" of social support. To describe this model, Cassel (in a brilliant rhetorical move) borrowed the term "host resistance" from infectious disease epidemiology. He argued that we all are subject to stresses every day; who falls ill depends less on those stresses than on the ability to resist those stresses, and resistance depends primarily on the availability of social support. Therefore, two subpopulations are described. One subpopulation with adequate social support will show little increase in disease outcomes with increasing exposure to stressors. The other subpopulation with little social support will show increased risk with increasing exposure to stressors.

But, just what is a stressor, and just what is social support? The tradition of research in European and North American middle classes generally answers these questions by emphasizing the primacy of the individual and her perception (or, in psychological jargon, ‘appraisal’) of a situation. In short, anything can be stressful (or supportive) if the individual perceives it as so. Space precludes a thorough critique of this perspective (but see an early thoughtful assessment by Brown¹¹); suffice it to say that in cross-cultural research, emphasis was placed less on what was idiosyncratically meaningful to individuals, and more on what was collectively meaningful within communities. In part this was a function of the guiding anthropological perspective employing the concept of culture. As noted before, culture consists of that knowledge that one must possess to function adequately in society. Implicit in this definition is the notion of shared knowledge or meaning. Social relationships run smoothly because individuals share an understanding of those relationships (which is not to say that sharing is complete, only that there is some level of sharing). Therefore, cross-cultural research looked first for those dimensions of daily life that were collectively meaningful in a community, and then to determine how these dimensions could create the kinds of demands, or offer the kinds of supports, thought important in theories of psychological stress. Also, researchers were led to look for factors central in the process of social change.

For example, in research in the West Indies, Dressler¹² argued that the inevitable result of social change was a transformation of indicators of social status. Traditionally, higher status (or prestige) accrued to older persons (especially men) who were relatively prosperous, but who were seen to be thoughtful and articulate leaders in the community. With the advent of social change, local communities were increasingly drawn into the orbit of Euroamerican consumer markets, with new definitions of prestige being placed on the visible evidence of success in that market. Above all, this meant visibly adopting a consumer lifestyle (including consumer durables and related behaviours). Depending on the level of economic development in the society, this could mean little more than being able to buy a radio and a refrigerator, and to be knowledgeable of political events outside the local community; nevertheless, the qualitative shift in the definition of what counts as prestige was clear. At the same time, there is built into the process a paradox. Few developing economies provide sufficient access to economic resources (e.g. wage-paying jobs) for all persons to be able to act on these changing status aspirations. This leads to a problematic incongruence between status aspirations and the economic resources to achieve those aspirations. Whereas definitions of status and the means to achieve that status are changing, cultural definitions of social support are more conservative, embedded in traditional patterns of social structure. Therefore, the persons with the highest risk of elevated blood pressure were those persons whose attempts to achieve higher status were thwarted, and who had the least access to traditional social supports.

This sociocultural model of the stress process has been replicated in studies of blood pressure in Samoa^13,14; among Samoan migrants to northern California¹⁵; in an African American community in the rural southern USA¹⁶; and, in research in Mexico and Brazil^17,18. More recently, McDade¹⁹ developed a technique for measuring cell-mediated immunity using blood that can be collected under field conditions. Among Samoan adolescents those with the greatest status incongruence showed the greatest compromised immune function.

These studies represent an advance over studies of modernization and disease in that the process by which sociocultural factors are thought to influence disease risk are more precisely specified. Also, some studies^14,19 measured alternative explanatory variables (such as dietary intake of specific nutrients thought to influence blood pressure), and found that adjusting for these variables made no difference in the results. All of the studies pay close attention to the cultural context of the research. In each context, basic theoretical constructs (i.e. status incongruence, social support) are operationalized with different measures, because the aim is to understand as precisely as possible what represents, for example, social status or social support in each setting, and then to measure those constructs as sensitively as possible in terms of local collective representations.

At the same time, from the standpoint of identifying precisely the way in which culture influences disease risk, these studies still lack a certain specificity. Primarily, the concept of culture is important in terms of identifying social and economic conditions that are generally thought to be stressful (or supportive). Culture defines context. Yet, the original hypothesis offered by Cassel et al⁵ identified a more direct pathway by which culture influenced disease risk, in the form of a problematic dissonance between the culture in which an individual was socialized, and the culture to which she must adapt. Recent theoretical and methodological developments offer an avenue to investigate this more direct effect of culture on individual belief, behaviour and biology. Studies incorporating these developments are reviewed next.

	Cultural consonance and disease risk

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
These most recent studies on culture and disease risk use a cognitive definition of culture. This definition derives from Goodenough’s⁸ definition of culture as that knowledge that one must possess to function adequately in society, but it incorporates as well recent insights from cognitive science^20,21. From this perspective, culture is conceptualized as a series of models for every domain of importance in the everyday lives of persons. So, for example, there are models for mundane activities (e.g. going to a shop, getting a driving licence); there are models for how basic social institutions function (e.g. how a marriage and family are constituted, appropriate workplace comportment); and, there are abstract models for the broadest domains of human life (e.g. models of the supernatural). Cultural models are not exhaustive compendia of knowledge, but rather stripped down, schematic outlines that can guide our behaviour in any specific setting. To be sure, in any specific setting, precise information has to be filled in. So, for example, our own and others’ expectations for our behaviour will be different in the local supermarket than in the high-end clothiers; nevertheless, a basic model of how small-scale commercial transactions are handled will help us to navigate a particular set of social interactions in order to achieve our goals (i.e. getting a litre of milk or a pair of socks).

Any individual will possess her own models that represent how the world works. One component of those models derives from her own biography, that specific set of influences during childhood and adolescence that shaped her view of the world. The other component of those models can be attributed to the collective or shared understandings that form the traditions of her society. These are cultural models, and what makes them cultural, and what gives them causal force in the world, is the consensus within society that this is, indeed, the way that the world works²². This is not to say that consensus is complete nor that some cultural models are not bitterly contested. But the degree of consensus or the degree to which cultural models are contested are empirical issues.

The theory of cultural models provides a link from the aggregate concept of culture as social tradition to the individual, because the aggregate social tradition is a function of the pattern of sharing of cultural models in society. The degree of consensus on a model and the degree to which individuals share in that consensus can be estimated quantitatively using the cultural consensus model, developed by Romney et al²³. Working from the pattern of agreement regarding some domain, using a relatively small number of respondents, the cultural consensus model provides an estimate of the degree of agreement in that domain. The higher the agreement, the more reasonable the inference that the individuals share a model of that domain.

Linking cultural models to human biology requires another step. Individuals do not simply know and understand things about the world that they share with their fellows, they also do things. Cultural models are guides to action in the world. But, for a variety of reasons, individuals will be variably able to act on shared cultural models. Dressler²⁴ refers to this as "cultural consonance," defined as the degree to which individuals approximate, in their own beliefs and behaviours, the shared cultural models in some cultural domain.

The associations of cultural consonance and health have been explored in two major projects, one conducted in the African American community in the rural southern USA^25,26, and one conducted in southern Brazil^27–30. Each project was carried out using similar methods. First, using traditional anthropological techniques of ethnographic research, the salient components of two cultural domains were identified. These were the domains of lifestyle and the domains of social support. Lifestyle is defined as the accumulation of material goods and the adoption of related behaviours that signify having been a success in life in terms of the standards of the community. Social support refers to the perceptions that help and assistance can be sought within one’s social network. Then, using small samples of respondents, the cultural consensus model was used to confirm that models of these domains were shared in the community. The cultural consensus model also provides an estimate of the relative importance of the elements of the domain. In each setting, the results indicated that the shared cultural model described a lifestyle that could be described as one of modest domestic comfort, as opposed to one of conspicuous consumption. For social support, each model described an ideal pattern of access to social support beginning within the most intimate bonds of family and friends, and emanating out to include more distant kinds of relationships. While these general patterns of results were similar across the studies, the precise elements and configuration of elements for the cultural models were specific to the society studied. Also, in each study, care was taken to test for possible intrasocietal differences in cultural consensus; none were found.

Next, epidemiological surveys were carried out, collecting data on blood pressure, diet, body composition and the cultural factors. For the epidemiological survey, individuals were asked if they owned or engaged in the behaviours deemed important in the cultural model of lifestyle, and if they sought social support in the pattern described by the cultural model of social support. Then, the degree to which these behaviours corresponded to the ideal behaviours described in the cultural models for the domain could be quantified. In each study, it was found that the higher an individual’s cultural consonance in each domain, the lower her blood pressure, adjusting for usual covariates (age, sex, body composition) and for potential alternate explanatory variables (including conventionally-measured psychological stress, socio-economic status and nutrient intake). The magnitude of the differences was large. For example, in the lowest category of both cultural consonance in lifestyle and cultural consonance in social support in Brazil, mean systolic blood pressure was 138 mmHg, versus 118 mmHg in the highest category of both cultural consonance in lifestyle and cultural consonance in social support.

So, these results indicate that, net of other possible influences on blood pressure, living in accordance with widely shared cultural models is associated with lower blood pressure. Why are the cultural dimensions of lifestyle and social support important? In modern society, lifestyles are ways of communicating one’s position in the status hierarchy in mundane social interactions. Lifestyles become, as it were, a way of performing socio-economic status in everyday social life. Social support, on the other hand, is an essential resource for dealing with life’s daily insults, large and small. Another way to refer to these dimensions are distinction (lifestyle) and affiliation (social support). In fact, these are probably phylogenetically old dimensions of hominid social life, ones that we share with contemporary nonhuman primates. Sapolsky’s³¹ latest data on free-living baboon troops show that variation in position on these two dimensions of distinction and affiliation are associated with differences in circulating cortisol and long-term health of the baboons. Similarly, Decker’s³² data show that West Indian men who are perceived by their peers as more consonant with the ideal person in that community have lower levels of circulating cortisol than men who are not consonant with that ideal. It may be that a particular pattern of physiologic reactivity has an evolutionarily old association with variation in the social environment involving distinction and affiliation.

Why do some people have low cultural consonance? Results indicate that lower cultural consonance is a function of low socio-economic status; furthermore, cultural consonance mediates the association of socio-economic status and health outcomes^25,27.

	Summary and implications

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
In certain respects, research on culture and disease risk has come full circle. Inspired by the insights of Cassel and his colleagues, researchers working globally have tried to understand how culture can alter the risk of disease. Results from broad social comparisons led to detailed investigations of culturally defined stresses and resistance resources in various settings. Then, newer theoretical and methodological developments provided the opportunity to make operational Cassel’s original hypothesis (something he himself was unable to do). The results of research on cultural consonance and health suggest that the degree to which individuals are able to enact the prototypical behaviours encoded in cultural models is associated with better health.

From the standpoint of clinical medicine, there are a number of implications of these results. With respect to the results associated with disease risk, an understanding of cultural consonance can lead to a better understanding of the ways in which the total life circumstances of the patient influence her health. Patients arrive in the clinic not only with a particular pattern of health problems and health behaviours. Rather, they carry with them the accumulated weight of their daily lives, and an understanding of how an individual patient may be struggling, not necessarily to succeed in some upper middle class sense, but rather simply to have a decent life, can help to understand her life situation.

More practically, however, the concept of cultural consonance is an extremely flexible one that can assist in understanding a number of issues. For example, Chavez and his colleagues have examined the cultural models of reproductive cancers in the multiethnic setting of Southern California (USA)³³. They demonstrated, in a sample including physicians, Anglo women, and Hispanic migrant women, a clear distribution in the sharing of these cultural models. Anglo women and physicians shared a portion of their understanding of reproductive cancers, as did Anglo and Hispanic women; but Hispanic migrant women and physicians shared very little of their understanding. They then calculated the cultural consonance in beliefs about cancer in a large sample and looked at the correlation of that consonance with the receipt of screening tests (pap smears). But because there were three separate cultural models of cancer, there were three measures of cultural consonance. They found that if Hispanic women were more consonant with the physicians’ understanding of cancer, they were less likely to receive a screening test. Conversely, if they were consonant with the Anglo women model, they were more likely to receive a screening test. Space precludes a detailed discussion of these results, but the implication is clear. In a complex society, with different and sometimes competing cultural models, how individuals align themselves with one or another model, and what the implications of that alignment are for their health, is far from straightforward.

In the final analysis, a better understanding of culture, both in the aggregate sense of social tradition, and in the individual sense of cultural consonance, can only help to improve health and health care.

	Acknowledgements

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 
Preparation of this chapter was supported in part by a research grant from the National Science Foundation (USA), BCS-0090193.

	References

Top Abstract Introduction Societal differences in disease... Sociocultural models of stress Cultural consonance and disease... Summary and implications Acknowledgements References

 

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