involving alcoholism and other health disorders among immigrants and ethnic minorities is their concurrent exposure to multiple cultural influences. In this regard, Guttman’s finding in the US is similar to findings in other countries. He observed that immigrants “are participants not only in the dissolution of older cultural practices and beliefs but are also constantly engaged in the creation, elaboration, and even intensification of new cultural identities” (Guttman 1999: 175). However, the presence of multiple cultural influences does not necessarily lead to the creation of new identities. Other outcomes are possible, such as one outcome I label pragmatic acculturation: the borrowing of cultural elements (concepts, ways of doing things, ways of organizing and planning) and adapting them to meet practical needs. Pragmatic acculturation is practiced in the search for ways to prevent illness, or trying different remedies to deal with symptoms (illness behavior), or seeking expert help from healers from other cultures (Quah 1985, 1989a, 2003, 2008). Individuals “borrow” healing options from cultures other than their own, but they may or may not incorporate those options or more aspects of the other cultures into their lives permanently. The borrowing and adapting is part of the ongoing process of dealing with health and illness. Solutions from other cultures tend to be adopted, or adapted to one’s own culture, if and for as long as they “work” to the satisfaction of the user.
Yet another angle of analysis in the study of culture and health is the identification of cultural differences in health behavior among subgroups of a community or country assumed to be culturally homogeneous. Such is the case of differences commonly found between “rural” and “urban” ways of life and ways of thinking in the same country. Lyttleton’s (1993) study of preventive health education on AIDS in Thailand illustrates well the urban–rural divide. The message of public preventive information campaigns designed in urban centers was not received as intended in rural villages. The concept of promiscuity that was at the center of the Thai AIDS prevention campaigns was associated by the villagers with the visiting of “commercial sex workers” only and not with the practice of “sleeping with several different village women” (1993: 143). The misperceptions of preventive public health campaigns occur between the rural, less educated, and dialect-speaking groups on the one hand, and the urban, educated civil servants and health professionals who design the campaigns, on the other hand. The misperception of the campaign message is not the only problem. An additional serious obstacle to reach the target rural population is the medium used to disseminate preventive health information. The Thai villagers perceived new technology including television broadcasts from Bangkok as “belonging to a different world – both physically and socioculturally” and, consequently, “increased exposure to these messages simply reinforces the [villagers’] perception that they are not locally pertinent” (Lyttleton 1993: 144). The search for, and testing, of effective approaches to “culturally tailored” health interventions continues (e.g. Galbraith et al. 2016; Kikuzawa et al. 2019; Miller et al. 2019).
Culture and Illness Behavior
As mentioned earlier, illness behavior refers to the activity undertaken by a person who feels ill for the purpose of defining the illness and seeking a solution (Kasl and Cobb 1966). What people do when they begin to feel unwell, the manner in which people react to symptoms, and the meaning they attach to symptoms vary across cultures.
Reviewing the work of Edward Suchman (1964, 1965) on illness behavior and ethnicity, Geertsen and his colleagues (1975) concluded that there was indeed an association between the two phenomena. They found that “Group closeness and exclusivity increases the likelihood” of a person responding to a health problem “in a way that is consistent with his subcultural background” (1975: 232). Further detailed data on the correlation between ethnicity and illness behavior was reported by, among others, Robertson and Heagarty (1975); Kosa and Zola (1975); and by Sanborn and Katz (1977) who found significant cultural variations in the perception of symptoms. In fact, the relative saturation of the literature regarding the ethnicity-illness behavior link was already manifested in Mechanic’s observation in the late 1970s: “Cultures are so recognizably different that variations in illness behavior in different societies hardly need demonstration” (1978: 261).
Nevertheless, research on the association between culture and illness behavior continues (e.g. Nelson and Wilson 2017; Versey et al. 2019). One important theme is mental illness, given that symptoms are primarily manifested through alterations in what is culturally defined as “normal” or “acceptable” social interaction. A prominent contributor to the study of culture and mental illness is Horacio Fabrega (1991, 1993, 1995). Summarizing the crux of research in sociology and anthropology, Fabrega states that “empirical studies integral to and grounded in sound clinical and epidemiological research methods … have succeeded in making clear how cultural conventions affect manifestations of disorders, aspects of diagnosis, and responses to treatment” (1995: 380).
The reactions of others, particularly family and significant others, play an important part in determining how the symptomatic person defines and handles symptoms and healthcare options (e.g. Perry et al. 2016). Such reaction varies across cultures. McKelvy et al. (1997) found that, in contrast to Americans, “the Vietnamese traditional culture has a much narrower definition of mental illness.” They are more tolerant of behavioral disturbance triggered by distress, defining someone as mentally ill only if the person is “so disruptive” that he or she “threatens the social order or the safety of others”. Even then, the family is the first source of care, which may include “physical restraint.” The person is taken to the hospital only if the family is unable to control him or her (1997: 117).
From the perspective of psychiatry research, the cultural definition of symptoms tends to determine the disease outcome. Hahn and Kleinman (1983) proposed that beliefs in the etiology and prognosis of disease are as important to disease causation as microorganisms or chemical substances. In the case of the sudden nocturnal death syndrome or SUNDS among the Hmong refugees in the US, Adler (1994: 26) explains: “in the traditional Hmong worldview the functions of the mind and the body are not dichotomized and polarized.” He identified a series of pathological circumstances leading to SUNDS. As refugees, the Hmong lost their traditional social support and were pressed to adapt to a different culture. Adler (1994: 52) found that “severe and ongoing stress related to cultural disruption and national resettlement” as well as “the intense feelings of powerlessness regarding existence in the US,” and their “belief system in which evil spirits have the power to kill men who do not fulfill their religious obligations” together led “the solitary Hmong male” to die of SUNDS.
Illness behavior typically involves a “wait-and-see” attitude as the first reaction to symptoms, followed by self-medication; if the problem is judged to have worsened, then the person might be prepared to seek expert advice. In this process, cultural patterns of behavior may be superseded by formal education. In a comparative analysis of Chinese, Malays, and Indians, I found that education explains the practice of self-medication with modern over-the-counter medications better than culture. There was a significant difference among the three groups in the keeping of non-prescription and traditional medications at home. Yet, education served as an “equalizer” for self-medication with modern (i.e. Western) medicines. The more educated a person is, the more inclined he or she would be to practice self-medication with “modern” over-the-counter medicines before (or instead of) seeking expert advice, irrespective of his or her ethnic group (Quah 1985). A similar finding was reported in the treatment of malaria in the Philippines (Miguel et al. 1999).
Culture and Sick-Role Behavior
To recapitulate what was discussed in the first section, sick-role behavior 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 encompasses the sick person’s response to symptoms, in particular, the seeking of what he or she perceives as “technically competent” help (to borrow Parsons’ term), as well as doctor–patient or healer–patient interaction. Lyle Saunders (1954) was among the first sociologists to observe
