and “without reference to social structural constraints.” For the same reason he favors a multidisciplinary approach to the study of culture.
The multidisciplinary approach is indeed one of two main trends in contemporary research on the link between culture and health. Focusing on the understanding of culture and health behavior, the disciplines of sociology and anthropology have produced research findings confirming that culture or ethnicity influence health behavior and attitudes significantly. A second main trend in the literature is the wide variety of conceptual perspectives on the influence of culture, although no dominant theory has yet emerged to explain that influence systematically and comprehensibly.
Multiple angles of analysis are as important as multidisciplinary approaches. Renée Fox (Fox 1976, 1989; Parsons and Fox 1952a, 1952b) illustrated this decades ago. She demonstrated the advantages of close collaboration between sociology and anthropology in the study of health-related behavior, particularly on the aspect of culture. Fox has also contributed to the search for evidence on the impact of values and beliefs on health behavior at the micro-level through her analysis of individuals and at the macro-level by focusing on institutional aspects of medical care such as the medical school and the hospital.
A final note before moving on to culture and health: Researchers’ attention to ethnicity is now common in international studies in medicine and medical sociology. However, despite the relevance of culture in understanding patterns of health and illness behavior, the research focus in the US is more on race. Cockerham (2021b) suggests that this is due to race being used as a standard variable in almost every study in order to measure racial health disparities. Nevertheless, efforts to assist clinicians and medical researchers to appreciate the complexity of culture continue (e.g. Fox et al. 2017; LaVeist 1994; Williams 1994). The social sciences and, in particular, sociology and anthropology remain the disciplines most dedicated to the study of culture or ethnicity per se and of its association with health and illness phenomena.
CULTURE AND HEALTH BEHAVIOR
The conceptual insights of the classic and contemporary sociologists and anthropologists on the significance of culture are confirmed by research on health behavior over the past five decades. A complete review of the vast body of sociological and anthropological literature dealing with the influence of culture upon the individual’s health behavior is a formidable task beyond the scope of this chapter. Instead, I will highlight the nuances and significance of cultural variations in health behavior by discussing relevant findings within the framework of three types of health-related behavior, namely, preventive health behavior, illness behavior, and sick-role behavior. The two former concepts were proposed by Kasl and Cobb (1966). The concept of sick-role behavior was formulated by Talcott Parsons (1951: 436–8).
Preventive health behavior refers to the activity of a person who believes he or she is healthy for the purpose of preventing illness (Kasl and Cobb 1966: 246). Kasl and Cobb labeled this “health behavior” but the term preventive differentiates it clearly from the other two types of health-related behavior. Kasl and Cobb (1966: 246) defined illness behavior as the activity undertaken by a person who feels ill for the purpose of defining the illness and seeking a solution. In the sense intended for this discussion, illness behavior encompasses the time span between a person’s first awareness of symptoms and his or her decision to seek expert assistance or “technically competent” help (to borrow Parsons’ [1951: 437] term). Illness behavior, thus defined, includes activities such as initial self-medication or self-treatment and discussion of the problem with non-expert family members and others within one’s primary or informal social network. Sick-rolebehavior is the activity undertaken by a person who considers himself or herself ill for the purpose of getting well (based on Parsons 1951: 436–8). Sick-role behavior is typically preceded by illness behavior and encompasses the sick person’s formal response to symptoms, that is, the seeking of what he or she perceives as “technically competent” help. The sick person may seek technically competent or expert advice from whoever he or she perceives as or believes to be an expert including a traditional healer, modern medical practitioners, or a combination of these. Sick-role behavior also includes the relation between patient and healer, and the subsequent activity of the person as a patient.
Culture and Preventive Health Behavior
Preventive health behavior refers to the activity of a person who believes he or she is healthy for the purpose of preventing illness (Kasl and Cobb 1966: 246). In addition to the study of healthy individuals, relevant research on preventive health behavior also covers studies on substance addiction or abuse (drugs, alcohol, cigarettes), which seek to understand the path toward addiction and to identify the factors involved. The subjective evaluation of one’s own health status may propel or retard preventive action against disease. Many studies on preventive health behavior report data on self-health evaluation but it is uncommon to report variations in the cultural meaning attached to health status. As health status is, in many respects, a value, cultural variations are common in people’s evaluation of their own health status and the way in which they evaluate it.
An illustration of this phenomenon is the traditional Chinese notion of “ti-zhi” (Lew-Ting et al. 1998). “Ti-zhi” or “constitution” denotes “a long-term, pervasive characteristic that is central to their sense of self” and clearly different from the Western concept of health status. The latter is “a more temporal, fluctuating state” that varies with “the experience of illness” (Lew-Ting et al. 1998: 829). Their study illustrates the cultural similarity in the definition of constitution among people of the same ethnic group (Chinese elderly) living in two different parts of the world, Taipei and Los Angeles. In contrast, residing in the same geographical location does not secure a common meaning of health status. For example, significant cultural differences in self-evaluated health status were observed among three cultural groups living in close proximity of each other in south-central Florida (Albrecht et al. 1998).
Among the studies relevant to the prevention of substance abuse, is the work of Gureje et al. (1997). People in nine cities were interviewed on their values and perceptions concerning the meaning of drinking alcohol. The nine cities were Ankara (Turkey), Athens (Greece), Bangalore (India), Flagstaff (Arizona), Ibadan (Nigeria), Jebal (Romania), Mexico City, Santander (Spain), and Seoul (South Korea). These authors reported a “remarkable congruence” in the practitioners’ criteria to diagnose alcoholism. But they found significant variations among people across the nine cities concerning “drinking norms, especially with regard to wet and dry cultures” (1997: 209). A wet culture, they stated, is that where alcohol drinking is permitted or encouraged by the social significance attached to the act of drinking and to the social context within which drinking takes place. In a dry culture, alcohol drinking is discouraged or prohibited altogether. Their study is part of the increasing body of research findings showing that the difficulties encountered in the prevention of alcoholism and other types of substance abuse are greater in some cultures than in others (e.g. Nelson and Wilson 2017).
The investigation into the relative influence of culture upon alcohol abuse was found by Guttman (1999) to be equivocal in situations where acculturation takes place. Guttman refers to the common definition of acculturation that is, “the process whereby one culture group adopts the beliefs and practices of another culture group over time” (1999: 175). His study of alcohol drinking among Mexican immigrants in the US highlighted several problems. He found it difficult to identify clearly the boundaries between cultures sharing the same geographical area. Some studies overcome this problem by following the symbolic-interaction postulate of the importance of subjective definition of self and of the situation and correspondingly accepting the subjects’ self-identification as members of a given culture (e.g. Quah 1993). Some researchers assume that the length of time spent in the host country leads to acculturation and thus use other indicators, such as the proportion of the immigrant’s life spent in the host country (i.e. Mandelblatt et al. 1999).
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