Culture and Health
Health Psychology in the Context of Biology, Society and Methodology
’There is no such thing as human nature independent of culture.’
Clifford Geertz (1973)
The way people think about health, become ill and react to illness is rooted in broader health belief systems that are immersed in culture. In this chapter, we provide examples of different health belief systems that have existed historically and popular belief systems of today. We consider several indigenous health systems and those of complementary and alternative medicine. Finally, we discuss some issues related to rapid cultural change in contemporary society, including racism and how culturally competent health care systems help to bridge cultural, social and linguistic barriers.
What is Culture?
We are cultural beings, and an understanding of health beliefs and practices requires an understanding of the historical and socio-cultural context that gives human lives meaning. An inclusive definition of culture has been provided by Corin (1995: 273):
a system of meanings and symbols. This system shapes every area of life, defines a world view that gives meaning to personal and collective experience, and frames the way people locate themselves within the world, perceive the world, and believe in it. Every aspect of reality is seen as embedded within webs of meaning that define a certain world view and that cannot be studied or understood apart from this collective frame.
Culture has been viewed principally in two different ways: (1) as a fixed system of beliefs, meanings and symbols that belong to a group of people who speak a common language and may also adhere to a common religion and system of medicine; (2) as a developmental and dynamic system of signs that exists in continuously changing narratives or stories. People’s reactions to illness are driven by a constant struggle for meaning in light of beliefs that are evolving across space and time. These two approaches yield very different kinds of psychological investigation.
Within psychology, the study of culture that uses the first approach is that of cross-cultural psychology. Samples of populations said to be from different cultures are compared in terms of attitudes, beliefs, values and behaviours that are viewed as stable and essential characteristics of particular cultures. This approach is illustrated by research on individualism versus collectivism by Triandis (1995) and Hofstede and Bond (1988). The study of culture that uses the second approach is that of cultural psychology and is illustrated by the work of Valsiner (2013), who views cultural psychology as:
a science of human conduct mediated through signs from beginning to end, and from one time moment to the next in irreversible time. … All phenomena of manifest kind — usually subsumed under the blanket term behavior — are subordinate to that cultural process of irresistible meaning-making (and re-making). Behavior is not objective, but subjective — through the meanings linked with it. … Human psychology is the science of human conduct and not of behavior, or of cognition. (2013: 25)
The concept of belief is a core concept in health psychology but rarely is it defined. Beliefs are viewed as:
durable and implicit; as associated with practices, choices and activities; and as bearing personal significance and import. … Belief tends to reproduce cultural norms, the precepts, expectations and values of particular times and places. … Simultaneously, within such broad cultural patternings, the belief of any given individual is produced through the mediation of that person’s particular history of social relations — with parents, carers, teachers, significant others — with which these acquired norms get inflected. (Cromby, 2012: 944—6)
Belief is viewed in social cognition models such as the theory of planned behaviour (TPB; Ajzen, 1985) as a fundamental theoretical construct, with each of the TPB’s three core constructs — attitude, subjective norm and perceived behaviour control — being underpinned by belief, an enduring, cognitive entity employed in rational thought and detached from feelings. It is often constructed and expressed as a part of discourse and narrative when asked for an account of one’s views about a topic in conversation. Beliefs are therefore constructed ’on the hoof’ as much as they are a fixed piece of dogma that underlies decisions and actions.
Yet, as we argue elsewhere in this book, beliefs are almost always associated with affect. This is the view of Cromby (2012: 954), who states:
Belief arises when social practice works up structures of feeling in contingent association with discourse and narrative. … Believing is not merely information-processing activity, and belief is not an individual cognitive entity. Belief is the somewhat contingent, socially co-constituted outcome of repeated articulations between activities, discourses, narratives and socialized structures of feeling.
Beliefs are at the core of what we mean when we talk of culture.
Health Belief Systems
As societies evolve, health belief systems develop as bodies of knowledge are constructed and exchanged among those who undergo specialized training. This gives rise to the separation of expert or technical beliefs systems from traditional, folk or indigenous systems. These two types of system are not discrete but interact, and are in a process of constant evolution. Although the majority of people in any society organize meaning-making through the use of loosely organized indigenous belief systems, the character of these is connected in some form with expert belief systems.
Kleinman (1980) described three overlapping sectors of any health care system:
· The popular sector refers to the lay cultural arena where illness is first defined and health care activities initiated.
· The professional sector refers to the organized healing professions, their representations and actions.
· The folk sector refers to the non-professional, non-bureaucratic, specialist sector that shades into the other two sectors.
Although this three-fold division is widely cited, other researchers (e.g., Blumhagen, 1980) have preferred a simpler two-fold division into professional and popular realms. The former are said to consist of systematicity, coherence and interdependence (Blumhagen, 1980: 200). Conversely, a lay health belief system can appear disconnected, inconsistent and at times plainly contradictory. This broad classification avoids an accusation that certain specialized health belief systems are classified as ’folk’ when they have limited status in society, although they may offer an extensive classification of health complaints and treatments. These two broad kinds of belief systems interact such that the lay person can draw upon more specialized knowledge but also the specialist will make use of more popular knowledge. Further, both ways of thinking about health draw upon a more general worldview located within particular local socio-political contexts. Blumhagen (1980) argues that these two kinds of health belief systems should be considered distinct from an individual belief system that a person employs to understand their personal experience of illness. Dominant expert health belief systems have the tendency to become doctrinal in nature, with principles and guidelines that inform practitioners and specialists in systems of treatment for different illnesses.
Western Health Belief Systems
Classical Views of Health
The classical view of health and illness in the West is derived from the Graeco-Arabic medical system known as Galenic medicine. This provided an expert system developed from the Greeks, in particular the work of Hippocrates and his colleagues. As we discussed in Chapter 1, the central concept in Galen’s formulation is the balance of four bodily fluids or humours: yellow and black bile, phlegm and blood. Balance is equated with health and imbalance implied ill health. The bodily fluids have been linked with: the four seasons (e.g., an excess of phlegm was common in the winter leading to colds, while an excess of bile led to summer diarrhoea); the four primary conditions (i.e., hot, cold, wet and dry); and the four elements (i.e., air, fire, earth and water). Medieval scholars added four temperaments (i.e., choleric, sanguine, melancholic and phlegmatic).
Besides focusing on understanding natural processes, the Galenic tradition placed responsibility on individuals to look after themselves. Ill health was viewed as one consequence of natural processes, not a result of divine intervention. In many ways Galen’s ideas not only prefigured but also continue to influence much of contemporary health beliefs.
Galenic ideas dominated medicine in Europe for almost two millennia. However, during the Middle Ages in Europe, Galen’s work became confined more to the learned few and other ideas based upon religion became more commonplace. Illness was often seen as punishment for humankind’s sinfulness. The Church’s seven deadly sins came to be associated with pathological conditions of the body. For example, pride was symbolized by tumours and inflammations, while sloth led to dead flesh and palsy (Thomas, 1979).
Christianity drew upon different traditions. The ascetic tradition scorned concern for the body and instead promoted acts such as fasting and physical suffering, which supposedly led to spirituality. With the Protestant Reformation this belief was replaced with the idea that the body had been given to humans by God. It was the individual’s religious duty to look after and care for the body. Illness was seen as a sign of weakness and neglect. To honour God required living a healthy life and abstaining from excess, especially in terms of sex and diet. Wear (1985) noted that religious writers frequently made reference to the body. For example, Robert Horne described the body as the ’Temple of God’ and that it was necessary to keep it pure and clean. These ideas were widely promulgated in the new Protestant Reformation. The way to heaven was through attention to health behaviour and was strongly linked to a social morality. The poor were expected to take responsibility for their condition; at the same time the rich were wrong to indulge themselves while there was so much poverty and suffering.
Despite the authority of the Church, these religious interpretations began to decline with the growth of medical science. While in terms of the expert belief system there has been increasing acceptance of a naturalistic view of disease, the moral basis of health continues to underlie much of contemporary health belief. Externalizing religious health beliefs have also been shown to influence health and well-being outcomes. For example, in a US survey of religion and health (n = 2948), belief in divine control over health has been shown to impact negatively upon health outcomes, while also contributing to a better sense of life satisfaction (Hayward et al., 2016)
Two streams of thought in knowing the world dominated during the Enlightenment. The first was the acceptance of the distinction between superstition and reason. The second was the emergence of positivism, which emphasized that science based upon direct observation, measurement and experimentation gave direct access to the real world. This approach concentrated attention on material reality and a conception of the body as distinct from the mind. A central figure was Descartes (1596—1650), who conceived the human being as composed of mind and body. The former was not open to scientific investigation whereas the latter could be conceived as a machine.
The eighteenth century saw the rise of individualism in Western society. In previous eras the group or collective organized ways of thinking and acting, which in turn was interconnected with the physical and spiritual world. Professional understanding of health and illness became more closely entwined with knowledge of the individual physical body. Foucault (1976) described how between the mid-eighteenth and mid-nineteenth centuries the ’medical gaze’ came to focus on the interior of the human body. The symptoms of illness now became signs of underlying pathophysiology. Foucault noted that the change in perspective of the physician was illustrated in the change in the patient query from ’How do you feel?’ to ’Where does it hurt?’. For this new physician the stethoscope became the symbol of having insight into the bodily interior. Treatment centred on changing the character of this physiology by either medical or surgical means.
This approach to the study of health and illness has become known as biomedicine, or ’cosmopolitan’ or ’allopathic’ medicine (Leslie, 1976). It came to dominance for several reasons, including the fact that it was in accord with a broader view of humans, its alliance with physical science and the steady improvement in the health of the population that was attributed to medical intervention. The focus on the body is in accord with the Western emphasis on the individual. Further, the separation of mind and body ’offers a subtle articulation of the person’s alienation from the body in Western society, but this alienation is found, as well, in every sphere of economic and political life’ (Benoist and Cathebras, 1993: 858). Biomedicine separates the person from the body.
Friedson (1970) described how the coming to dominance of the biological approach was not without resistance. It required strong political action to organize the profession of medicine and to take legal action against other health practitioners. Throughout there was the dismissal of alternative perspectives and the assertion that biomedicine was the central force that had led to the substantial improvements in society’s health. Biomedicine was based upon a positivist epistemology that supposedly gave it access to an outside reality. Only this approach was the true approach. All other approaches could be disparaged.
Non-Western Views of Health
Chinese Views of Health
Traditional Chinese Medicine (TCM) is greatly influenced by the religion and philosophy of Taoism. According to this view, the universe is a vast and indivisible entity and each being has a definite function within it. The balance of the two basic powers of yin and yang governs the whole universe, including human beings. Yang is considered to represent the male, positive energy that produces light and fullness, whereas the yin is considered the female, negative force that leads to darkness and emptiness. A disharmony in yin and yang leads to illness. A variety of methods including acupuncture and herbal medicines can be used to restore this harmony. There are at least 13,000 medicinal substances with 50 fundamental herbs, including the roots, twigs and leaves of cannabis, ginseng, ginger, licorice, peony and rhubarb.
Confucianism is influential in the traditional Chinese views on health. Within this culture, human suffering is traditionally explained as the result of destiny or ming. Cheng (1997: 740) quotes the Confucian teacher Master Meng: ’A man worries about neither untimely death nor long life but cultivates his personal character and waits for its natural development; this is to stand in accord with Fate. All things are determined by Fate, and one should accept what is conferred.’ An important part of your destiny depends upon your horoscope or pa-tzu. During an individual’s life, his or her pa-tzu is paired with the timing of nature. Over time these pairings change and create the individual’s luck or yun.
Buddhist beliefs are also reflected in Chinese medical belief systems. Good deeds and charitable donations, for example, are promoted. Heavenly retribution is expected for those who commit wrongs. This retribution may not be immediate, but it will be inevitable. An important concept in this respect is pao, which has two types: (1) reciprocity and (2) retribution (Cheng, 1997). In mutual relationships reciprocity is expected. When this does not occur some form of retribution will take place.
These influences are not only codified within Chinese medicine, but also influence everyday lay beliefs about health and illness in Chinese communities around the world. For example, Rochelle and Marks (2010) explored the extent of medical pluralism among Chinese people in London. The thematic analysis suggests that Chinese medicine and Western medicine were perceived as two systems of health provision and that these two systems could be used concurrently. Generally, the National Health Service was perceived to be difficult to use and concerns were expressed around communication and trust with health care providers due to language barriers. Similarly, qualitative research by Jin and Acharya (2016) suggest that yin yang balance and ’qi’ still influenced practices related to medication adherence among people of Chinese descent in the USA. Narratives also suggest that Western and Chinese medicine have strengths and limitations that can counteract each other. Participants also discussed the importance of social support and how they coped with acculturation stress, especially when health care providers failed to understand their cultural practices and beliefs.
Like orthodox medicine, TCM raises ecological and ethical concerns. TCM is a private industry worth billions of dollars and the efficacy of the treatments is largely unknown. Many rare and endangered species currently face extinction owing to the harvesting of animal parts such as tiger bone, rhinoceros horn, turtle shell and seahorses, and the cruel conditions in which the animals used as a source of medicines are kept causes suffering, e.g., the harvesting of bile from thousands of captive Asiatic black bears, which are held in small cages. The bile is the main source of ursodeoxycholic acid, which is used to treat kidney problems and stomach and digestive disorders (Lindor et al., 1994). Cruelty to animals to generate medicines within TCM is paralleled by the use of animals in the testing of new medicines in orthodox medicine.
Islamic Views on Medicine
Islam is derived from the Arabic words istaslama, which means surrender, and salam, which means peace. As such, Islam, in its religious sense, means submission and obedience to the will of God. During sickness, Muslims are expected to seek Allah’s mercy and help through prayer. They also believe that death is an inevitable part of life and that the whole creation belongs to Allah and to him is the final return.
There are specific health-related practices which Muslims follow. Health care providers need to have an understanding of general Islamic beliefs and practices to enable them to provide quality care for Muslim patients. For example, health care professionals need to be aware of the need for modesty, privacy, the appropriate use of touch and clothing, dietary requirements (e.g., Halal and fasting during Ramadan), the availability of prayer rooms, interactions with opposite-sex patients, the use of medications, shared decision-making and its impact on the family (Rassool, 2015; Mataoui and Sheldon, 2016).
It is Islamic practice to visit the sick. Culturally sensitive health care establishments find ways that enable such visits from families, friends and other well-wishers. Health care professionals need to be aware that there is Islamic guidance on end-of-life care and funeral arrangements. When treating migrant Muslims from non-English speaking countries, health care providers need to consider health literacy and linguistic barriers, which may interfere with the patient’s comprehension and ability to implement health advice when given in their non-native language (see Chapter 14).
Awareness and respect for spiritual and cultural values are important in clinical practice since these have implications on patients’ choices and engagement in health care. For example, a study by Walton et al. (2014), which explored the beliefs, perceptions and attitudes of Muslim women living in the USA, suggests that Muslim women perceive Islamic health beliefs as important and that these have an influence on their decisions to participate in medical treatment and care. Similarly, a study on reproductive health among Moroccan women suggests that although women autonomously determine their reproductive choices and behaviours, they do so based on their understanding of Islamic guidance on fertility and motherhood (Hughes, 2015).
The Ayurvedic system of medicine is based upon the Sanskrit words ayus (life) and veda (science). This system is practised extensively in India. It is estimated that 70% of the population of India and hundreds of millions of people throughout the world use Ayurvedic medicine, which is based on Hindu philosophy (Schober, 1997). Both the cosmos and each human being consist of a female component, Prakrti, which forms the body, and a male component, Purusa, which forms the soul. While the Purusa is constant, the Prakrti is subject to change. The body is defined in terms of the flow of substances through channels. Each substance has its own channel. Sickness occurs when a channel is blocked and the flow is diverted into another channel. When all channels are blocked, the flow of substances is not possible and death occurs. At this stage, the soul is liberated from its bodily prison. The task of Ayurvedic medicine is to identify the blockages and to get the various essences moving again. The different forms of imbalance can be corrected through both preventive and therapeutic interventions based on diet, yoga, breathwork, bodywork, meditation and/or herbs (Schober, 1997). The use of herbs plays a major role in the treatment and prevention of illnesses (see Table 6.1 below).
As in TCM, the Ayurvedic system informs beliefs about health and illness through the Indian sub-continent and among Indian communities everywhere. However, Ayurvedic medicine has not dominated Western biomedicine, even within India. There is a variety of other competing health belief systems in a pluralistic health culture. In an interview study of a community in northern India, Morinis and Brilliant (1981) found evidence not only of Ayurvedic beliefs, but also beliefs on ’unami’ (another indigenous health system), allopathic, homeopathic, massage, herbalist, folk, astrologic and religious systems. They note that while these systems may formally seem to conflict, participants can draw on some or all of them to help explain different health problems. Further, the strength of these beliefs is related to the immediate social situation and the roles and expectations of the community. For example, for women in some parts of Pakistan, the health belief system is a mixture of biomedicine and unami medicine, which is a version of Galenic medicine.
African Health Beliefs
A wide range of traditional medical systems continues to flourish in Africa. These include a mixture of herbal and physical remedies intertwined with various religious belief systems.
Two dimensions are paramount in understanding African health beliefs: spiritual influences and a communal orientation. It is common to attribute illness to the work of ancestors or to supernatural forces. Inadequate respect for ancestors can supposedly lead to illness. In addition, magical influences can be both negative and positive, contemporary and historical. Thus, illness can be attributed to the work of some malign living person. The role of the spiritual healer is to identify the source of the malign influence. African culture has a communal orientation. Thus, the malign influence of certain supernatural forces can be felt not just by an individual, but also by other members of his/her family or community. Thus intervention may be aimed not only at the sense of balance of the individual, but also at the family and community.
Nemutandani et al. (2015) explored HIV- and tuberculosis-related beliefs among traditional practitioners in South Africa. Findings suggest that the belief that HIV/AIDS and tuberculosis patients were bewitched was still prevalent. In particular, it is believed that HIV is caused by sexual promiscuity and that transmission of this disease is a punishment from God. Similarly, in a study exploring beliefs on family planning in Kenya, Nigeria and Senegal, it was suggested that the most prevalent beliefs were that modern contraceptives are dangerous and can harm women’s wombs (Gueye et al., 2015).
Using the 2010 Malawi Demographic and Health Survey, Sano et al. (2016) found that knowledge about prevention was associated with a lower likelihood of endorsing misconceptions around HIV transmission. Socio-demographic factors such as marital status, ethnicity, income, religion and urban or rural residence also showed significant associations with misconceptions around HIV transmission. Thus, it is important that cultural and ethnic considerations are taken into account when developing and implementing HIV education programmes in the region. (Further discussion on community-based health promotion and education on HIV can be found in Chapter 23.)
Although cultural beliefs play a crucial role in shaping health behaviour, it is important to recognize the social and structural barriers that impact upon people’s ability to utilize health education and services. For example, Lim and Ojo (2017) explored the barriers preventing women from utilizing cervical screening services in sub-Saharan Africa. Findings from this systematic review suggest that despite cultural and linguistic diversity in the region, participants reported similar barriers, such as fear of the procedure and the possibility of a negative outcome, lack of awareness, embarrassment and stigma, lack of spousal support, and other factors such as cost of accessing the service, travel costs, waiting times and negative staff attitudes. Similarly, Skinner and Claassens (2016) explored the factors that influenced initiation and adherence to tuberculosis treatment in South Africa. Poor knowledge, lack of awareness and stigma around tuberculosis and its connection to HIV were raised as key issues. Structural factors such as poverty, lack of access to transport, the need to continue working, and problems related to the poor functioning of health systems were also raised as major constraints to long-term adherence.
Popular Views of Health
Evidence from a series of studies of popular beliefs about health and illness in Western society illustrates the interaction of what can be described as the ’classic’, the ’religious’, the ’biomedical’ and the ’lifestyle’ approaches to health and illness. Probably the most influential study of Western lay health beliefs was carried out by Herzlich (1973, 2017). She conducted interviews with a sample of French adults and concluded that health was conceived as an attribute of the individual — a state of harmony or balance. Illness was attributed to outside forces in our society or way of life. Lay people also referred to illness in terms of both organic and psychosocial factors. On their own, organic changes did not constitute illness. Rather, for the layperson, ’physical facts, symptoms and dysfunctions have, of course, an existence of their own, but they only combine to form an illness in so far as they transform a patient’s life’. The ability to participate in everyday life constitutes health, whereas inactivity is considered the true criterion of illness. Herzlich’s study was seminal because it provoked further research into popular health beliefs.
Blaxter (1990) analysed the definitions of health provided by over 9,000 British adults in a health and lifestyle survey. She classified the responses into nine categories:
1. Health as not-ill (the absence of physical symptoms).
2. Health despite disease.
3. Health as reserve (the presence of personal resources).
4. Health as behaviour (the extent of healthy behaviour).
5. Health as physical fitness.
6. Health as vitality.
7. Health as psychosocial well-being.
8. Health as social relationships.
9. Health as function.
In analysing the responses across social classes, Blaxter (1990) noted considerable agreement in the emphasis on behavioural factors as a cause of illness. She commented on the limited reference to structural or environmental factors, especially among those from working-class backgrounds.
However, health beliefs go beyond descriptive dimensions to consider underlying aetiology. In a discussion of social representation theory, Moscovici (1984) suggested that people rarely confine their definition of concepts to the descriptive level. Rather, lay descriptions often include reference to explanations. Lay perceptions of health and illness can be rooted in the social experience of people, in particular sub-cultures. A study of East and West German workers found similar findings to those of Herzlich, but with an added emphasis on health as lifestyle (Flick, 1998). Similarly, in a study of Canadian baby-boomers, Murray et al. (2003) found a very activity-oriented conception of health. In another study, Campbell (2015) explored the meaning of health among older adults in the United Arab Emirates. The narratives suggest that health was embedded in culture and represented as something that is valuable and coming from God. Health was also attributed to the food they eat and was generally perceived to be better in the past.
In Western society, a metaphor that is frequently applied to health is that of self-control. This metaphor is in turn infused with moral connotations such that to become ill is not to ’take care of oneself’ (Crawford, 1980). Admittedly, health is a contested arena since release from certain controls, or even the rejection of them, can be considered a sign of good health. Conversely, the person who abides by certain controls can be perceived as unhealthy. For example, Bermejo et al. (2012) compared illness-related causal and control attributes among Germans in Germany, Spaniards in Spain and Spaniards in Germany. Findings suggested that Germans have more internal causal and control beliefs, whereas Spaniards in Germany have more fatalistic attributions. On the other hand, Spaniards in Spain placed more emphasis on social aspects of illness-related attributes. These findings illustrate the close interweaving of health beliefs and practices with culture.
Complementary and Alternative Medicine
The biomedical perspective has come to a position of dominance throughout the world, reflecting ’globalization’ more generally. Alternative health care systems tend to be disparaged and marginalized by advocates of biomedicine. Based on a positivist, reductionist perspective, practitioners of biomedicine believe that the material existence of medical science is independent of any patient’s psychological search for meaning, understanding and control. As such, alternative perspectives are seen as basically flawed. In spite of this resistance from orthodoxy, alternative professional systems of health care continue to exist in large parts of the world, especially in Asia. As migrants have moved to other countries they have taken their health beliefs with them. In the major Western metropolitan centres the availability of health care systems other than biomedicine is extensive. This has fed back into Western ways of thinking about health and illness, especially among those who are disenchanted with biomedicine. Increasingly, complementary and alternative medicine (CAM) is gaining popularity and respectability in Western health care. CAM encompasses all health systems and practices other than those of the established health system of a society.
In the USA, the National Center for Complementary and Alternative Medicine (NCCAM, 2013) categorizes CAM into two sub-groups: (1) natural products and (2) mind and body practices. Natural products often include the use of herbs, vitamins, minerals and probiotics. These products are marketed widely and are commonly sold as dietary supplements. Mind and body practices cover a diverse range of procedures that are often administered by a trained practitioner. Examples include acupuncture, massage therapy, meditation techniques, movement therapies (e.g., Feldenkrais method, Alexander technique, Pilates), relaxation techniques, spinal manipulation, tai chi, qi gong, reiki and hypnotherapy.
Harris et al. (2012) reviewed the 12-month prevalence of CAM use by the general public. They reviewed 51 published reports from 49 surveys in 15 countries. Estimates of CAM use ranged from 9.8% to 76%; and from 1.8% to 48.7% for visits to CAM practitioners. In surveys using consistent measurement methods, CAM rates have been stable, particularly in Australia (49% in 1993, 52% in 2000 and 52% in 2004) and in the USA (36% in 2002 and 38% in 2007). The three highest rates of CAM use in this systematic review were reported in Japan (76%), South Korea (75%) and Malaysia (56%). Posadzki et al. (2013a) conducted a systematic review to examine the prevalence of CAM use among patients in the UK. The review included 89 surveys, with a total of 97,222 participants between January 2000 and October 2011. Findings showed that the average one-year prevalence of CAM use was 41.1%, while the average lifetime prevalence was 51.8%. Herbal medicine was the most popular CAM, followed by homeopathy and aromatherapy.
Herbal medicine involves the use of plants and plant extracts to treat illnesses or to promote well-being. This practice has been used for thousands of years, with the first recorded use in China in 2800 BC (Brown, 2007). It is believed that this practice was derived from the Ayurvedic tradition and then later adopted by the Chinese, Greeks and Romans. With the growth of the pharmaceutical industry, herbal medicine can now be produced and marketed on a massive scale. In the UK, about one in three adults takes herbal medicine (Posadzki et al., 2013b), while in the USA it is about 20% (Bent, 2008). Some of the most commonly used herbal products, and their purpose, efficacy and risks, are summarized in Table 6.1.
Source: Adapted from Bent (2008: 856)
Data sources: Rotblatt and Ziment (2002), Fugh-Berman (2003) and Ulbricht and Basch (2005);
systematic review by Bent and Ko (2004)
Systematic reviews show inconsistent evidence on the efficacy of herbal medicine in treating various conditions. While some reviews did not have substantial evidence to support the use of herbal supplements during pregnancy (Dante et al., 2013) or to treat depression (Butler and Pilkington, 2013), others showed support for treatment of tic disorders (Yun et al., 2014), gout (Li et al., 2013) and irritable bowel disease (Ng et al., 2013). A systematic review by Li et al. (2014) showed how the use of herbal medicine can help to improve the quality of life among chronic heart failure patients. However, reviews that showed substantial findings also raised concerns regarding small sample sizes, high clinical heterogeneity, and poor methodological quality in some trials. We return here to a refrain from other chapters concerned with the evidence base for treatments: more large-scale randomized controlled trials (RCTs) are required to provide robust evidence on the efficacy of herbal medicine. At present, there is limited support for a few specific treatments but the evidence is inconclusive for many of the most popular herbal remedies.
Homeopathy is a form of CAM which involves the use of highly diluted substances to trigger the body’s natural healing system. It is based on the Latin principle similia similibus curentur, which means ’let like be cured by like’. This means that a substance that can cause symptoms when taken in large doses can also be used to treat the same symptoms when taken in smaller doses. Its origins can be traced back to the work of the German physician Samuel Hahnemann (1755—1843). During his time, medical treatments often relied on harsh procedures such as blood-letting, purging and the use of poisons. Hahnemann refused to use these techniques and experimented on himself and other healthy volunteers. He recorded the physiological effects of toxic materials such as mercury, arsenic and belladonna and then collated reports of ’cured symptoms’ based on homeopathic prescriptions of these substances. See also the discussion of placebos in Chapter 2.
Homeopathic medicine is particularly popular in Europe and in India. In the UK there are currently four homeopathic hospitals, in London, Bristol, Liverpool and Glasgow. It is much more widely used on the European continent, especially in France and Germany. Homeopathy has been used for a variety of health conditions, including asthma, ear infections, hay fever, allergies, dermatitis, arthritis and high blood pressure, and for mental health conditions such as depression, stress and anxiety. However, systematic reviews on the effectiveness of homeopathy showed inconclusive results and trials are of poor quality (Ernst, 2012; Peckham et al., 2013; Saha et al., 2013). Posadzki et al. (2012) have also commented on the potential harm of homeopathy to patients in direct and indirect ways.
Aromatherapy involves the use of essential oils from plant extracts for therapeutic purposes. This practice dates back to ancient Egyptian, Chinese and Indian traditions. French chemist and scholar René-Maurice Gattefossé (1881—1950) is considered to be the father of modern aromatherapy. He discovered the healing properties of lavender when he accidentally burned his hand while working in his laboratory. He continued to experiment on essential oils, including thyme, lemon and clove, and used these with First World War soldiers as antiseptics. In recent years, aromatherapy is being used for stress and pain relief, headaches, and digestive and menstrual problems. The essential oils can be massaged into the skin, added to warm bath water, blended into lotions or creams, or inhaled through a diffuser, vaporizer or candles. Consumers can buy oils at pharmacies or health shops or attend an aromatherapy session with a trained therapist. However, as with other CAMs, systematic reviews on the efficacy of aromatherapy have produced inconclusive results (Hur et al., 2012; Lee et al., 2012).
Perspectives on CAM
Debates around the efficacy of CAM have polarized researchers. The most basic explanation for the popular appeal of CAM is the placebo effect. The generous time, warm glow of personal attention and friendly conversation received by each individual patient with many CAM practitioners compares favourably to the brief and business-like encounters of mainstream medicine. This aspect seems particularly true in the case of cancer. For example, one Australian study found that ’CAM use appeared to be associated with high patient acceptance and satisfaction which was not related to either cancer diagnosis or prognosis’ (Wilkinson and Stevens, 2014: 139). Another positive factor in favour of CAM is that patients ’find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life’ (Astin, 1998: 1548). Arguably, the specific treatment effects per se are of marginal relevance. In light of the inconclusive evidence base, Segar (2012) outlined two main discussions around this topic. First, there were concerns regarding evidence-based medicine and whether CAM can be assessed appropriately using the currently available methods, which are based on positivist, biomedical approaches that may be incongruent with the underlying principles of CAM. Second, there were questions about whether CAM should be advocated considering that its effect may be no different from a placebo. While some commentators are concerned that CAM is pseudo-scientific, MacArtney and Wahlberg (2014: 114) argued that ’this form of problematization can be described as a flight from social science’ and could negatively represent CAM users as ’duped, ignorant, irrational or immoral’. While there is insufficient evidence from RCTs to support the efficacy of CAM, findings from qualitative research suggest that the use of CAM can promote feelings of control, empowerment and agency (Sointu, 2013).
Contrary to the polarized views among researchers, Segar’s qualitative study (2012) found that therapists and patients tend to be ’pragmatic pluralists’ who have opinions as to when CAM may be appropriate to use or not. In relation to patients’ perspectives towards CAM integration in primary care, findings from a mixed methods study by Jong et al. (2012) suggest that a majority of patients preferred a GP who is informed about CAM and, if necessary, works alongside CAM practitioners. Furthermore, a systematic review by Nissen et al. (2012) suggested that in many European countries, many hold positive attitudes towards CAM and would like to widen access and provision, including clear regulatory frameworks to ensure quality and safety. Reliable information and more involvement from biomedical health care professionals were called for to help patients to make informed choices about CAM.
In the UK, the Department of Health provides clinical guidelines for health care professionals on CAM. A systematic review by Lorenc et al. (2014) showed that a total of 60 guidelines have been produced in relation to CAM therapies. About 44% were inconclusive, mostly due to insufficient empirical evidence, while there was almost an equal proportion of guidelines either recommending or advising against CAM (19%). The World Health Organization launched a Strategy on Traditional Medicine (2014—2023) to support the development of policies and action plans to strengthen the role of CAM to improve health, well-being and people-centred health care, and to promote quality and safety of CAM through regulation and better training and skills development of practitioners. The strategy aims to build a knowledge base around CAM, regulate products, therapies and practitioners, and integrate CAM into national health care systems.
Changing Cultures and Health
In a world of rapid change and interpenetration of cultural groups and belief systems and an increasingly globalized society, health psychologists need to recognize the complexity and diversity of dynamic and interlocking systems rather than assume that our health belief systems are fixed (MacLachlan, 2000).
Box 6.1 The False Stereotype of the ’Drunken Aboriginal’
Traditionally, Aboriginal people consumed weak alcohol made from various plants. Their problems with alcohol began with the colonial invasions of the eighteenth century. Contrary to all popular stereotypes, surveys find that roughly similar proportions of Aboriginal people drink alcohol as the European colonial population. The media distort the facts and reinforce stereotyping.
Evidence shows that the lifetime risk of alcohol consumption for Australian Aboriginal and Torres Strait Islanders is similar to that of the non-indigenous population for both males and females. Similar proportions of Aboriginal and Torres Strait Islander people and non-indigenous people of the same age and sex exceed lifetime risk guidelines, apart from women aged 55-plus where Aboriginal and Torres Strait Islanders are significantly less likely than non-indigenous women to exceed lifetime risk guidelines (7% compared to 10%) (Australian Bureau of Statistics, 2014).
So where did the false stereotyping come from? One answer lies in early colonial art. The lithograph was created by Augustus Earle (1793—1838) and printed by C. Hullmandel, London, in 1830. A group of bedraggled indigenous Australians are sitting in a Sydney street. They wear ragged remnants of European clothing or simply material wraps. Empty ’grog’ bottles are scattered on the ground. Behind them there is a two-storey hotel with a kangaroo sign and another sign on the side of the building says ’George Street’. Fashionably dressed British settlers promenade down the street or stand near the hotel. Beyond is a glimpse of Sydney Harbour, with masts and rigging of sailing ships. The picture references the ’grog culture’ of the early colonial years — ’grog’ being a mid-eighteenth-century term meaning cheap alcohol. Two men gather round a bucket of ’bull’, a cheap source of alcohol made by soaking and fermenting old sugar bags.
There are about 370 million indigenous people from thousands of different cultures in all continents of the planet (United Nations, 2017). While indigenous communities cannot be encapsulated within a single definition, the United Nations (2009) used Martinez Cobo’s (1987) conceptualization of indigenous groups as:
peoples and nations which, having a historical continuity with pre-invasion and pre-colonial societies that developed on their territories, consider themselves distinct from other sectors of the societies now prevailing on those territories, or parts of them. They form at present non-dominant sectors of society and are determined to preserve, develop and transmit to future generations their ancestral territories, and their ethnic identity, as the basis of their continued existence as peoples, in accordance with their own cultural patterns, social institutions and legal system. (United Nations, 2009: 4)
Globally, indigenous peoples experience poorer health outcomes, reduced quality of life and higher mortality rates from specific diseases, such as heart disease, tuberculosis, cancer, respiratory disease, stroke and diabetes, than their non-indigenous counterparts. Indigenous populations are six times more likely to die from injuries and are disproportionately more affected by forced displacement caused by natural disasters, armed conflict and loss of their ancestral domains. They also have worse access to education, health care and social services. This trend can be observed among indigenous groups around the world, including those in North America (Ramraj et al., 2016), Australia (Marmot, 2016), New Zealand and the Pacific (Anderson et al., 2006), Latin America and the Caribbean (Montenegro and Stephens, 2006) and Africa (Ohenjo et al., 2006).
The alleged health profile of indigenous groups has been distorted by racism and racial stereotypes. This is illustrated by the alleged alcoholism rates of Australian Aboriginals (Box 6.1). Similar stereotyping occurs regarding the alcohol use of Native Americans. Direct comparisons to published alcohol consumption data from other US populations indicated that American Indians in two reservation samples may be less likely to use alcohol than are others in the USA. However, among American Indian drinkers, more alcohol was consumed per drinking occasion (Beals et al., 2003).
Governmental efforts aim to address inequalities that disadvantage indigenous communities, but in some instances these efforts are tokenistic or symbolic in nature. Living with a legacy of conquest and culture, they may even continue to subjugate indigenous people to unjust and unfair economic and educational systems (Fredericks et al., 2014). It is important to recognize indigenous ways of knowing and to value indigenous stories and narratives within their socio-cultural context to bring to the surface knowledge that is relevant, insightful and meaningful for community members. Participatory action research can be used to facilitate this process (see Chapters 7 and 17). Genuine participation, instead of tokenistic participation, can foster a sense of ownership for community members and can strengthen personal and community capabilities.
For example, Thompson et al. (2013) facilitated an arts-based participatory action research project to explore the experiences and meaning of physical activity in two remote Northern Territory communities in Australia. Semi-structured interviews were conducted with community members (n = 23) and supplemented by five commissioned paintings by community-based artists and ethnographic observations. Physical activities were often linked with work, diet, social relationships and being active ’on country’. They also were associated with educating younger generations about indigenous traditions, as exemplified in the quote below on bush walking:
That’s why we have to take them [kids, bush walking] so the old people can show them the country and the names of the place. They need to talk about and learn about the name of the places and who belongs to that place. That’s why myself and [my husband] always join in for the bush walks so when we go there they always tell us, ’well this is your great, great, great, grandmother country, or grandfather’. Like when we stayed there, [at the] first camp, we told [them] ’this place here you call your grandfather country’. (Bininj woman, aged 26—35, quoted in Thompson et al., 2013: 7)
Culturally appropriate physical activities such as bush walking, dancing and art making contribute to health promotion of the community. It is important that indigenous beliefs, knowledge and traditions are considered in the process. Furthermore, social and political issues, including those that are related with racism and discrimination, need to be taken into account since these may compound experiences and access to health care and promotion (Denison et al., 2014).
Working in the Philippines, Estacio and Marks (2012) facilitated a participatory action research project with the indigenous Ayta community to generate community knowledge about notions and experiences of health to inform action plans. The research methods were culturally sensitive and people-oriented (Pe-Pua, 2006), and were guided by the principles of Sikolohiyang Pilipino (Enriquez, 1993). These included community visits, kwentuhan (story-telling sessions), workshops and stakeholder meetings. Findings suggested that the Ayta community have a holistic concept of health that incorporates factors such as livelihood stability, good social relations, cleanliness and spiritual wellness. Health is deeply embedded within their socio-economic and political environment wherein everyday discourses revolve around the need to generate sufficient income to sustain their families’ daily needs. In the process, health promotion and education activities were developed through an alternative learning system that integrated indigenous culture-based livelihood and literacy initiatives into the action recommendations.
Racism and Health
Racism contributes to poor mental and physical health among migrants, ethnic minority groups and indigenous peoples. Research evidence suggests that everyday experiences of discrimination are related to stress that can potentially lead to chronic illnesses. Even after controlling for factors such as perceived neighbourhood unsafety, food insecurity and financial stress, these associations were consistent across various ethnic groups (Clark et al., 1999; Earnshaw et al., 2016b). Strong associations were also shown between racial discrimination and psychological distress (Halim et al., 2017). Anderson (2013) used data from the 2004 Behavioral Risk Factor Surveillance System (BRFSS) to examine the relationship between stress symptoms from perceived racism and overall health (n = 32,585). The analyses suggest that stress from perceived racism can have substantial negative consequences that contribute to poor mental and physical health days in adults. Among young people, Grollman (2012) used data from the African-American Youth Culture Survey (n = 1,052) to examine the prevalence, distribution, and mental and physical health consequences of multiple forms of perceived discrimination. Findings suggest that young people from disadvantaged backgrounds are more susceptible as a result of experiencing multiple forms of discrimination than their more privileged counterparts. As with the findings from the adult population, a systematic review showed that the relationship between perceived racial discrimination and mental health can be observed among children and young people from minority ethnic groups (Priest et al., 2013).
Health-limiting behaviours, such as poor diet, smoking and increased alcohol intake, can also manifest as a response to the chronic stress of racism. For example, low socio-economic status, racial discrimination and low acculturation (i.e., being immersed in African-American culture and communities) are known to be the major socio-cultural correlates of smoking among African-American adults (Landrine and Corral, 2015). Bermudez-Millan et al. (2016) also found that while lower income predicted lower physical activity as well as poorer sleep quality and medical adherence, racial discrimination was associated with increases in food intake and alcohol consumption.
DeLilly and Flaskerud (2012) suggested that the poor health outcomes related to perceived racial discrimination are associated with negative feelings of low self-worth and subordination. This can sometimes be manifested as depression or can be expressed through anger, hostility and aggression. Cultural values further complicate the impact of perceived racial discrimination on health outcomes by placing the emphasis on individual determination and hard work (i.e., the belief that individuals can succeed if they have the willpower or persevere enough).
Landrine et al. (2016) tested whether racial discrimination can negatively influence a person’s self-reported health and whether they will rate it in terms of social instead of health indicators. They surveyed 2,118 African-Americans and found that the majority of their respondents (81.8%) rated their health as good/excellent, while only a relatively small proportion (18.2%) rated it as poor/fair. They also found that racial discrimination did not contribute to poor self-reported health, even after controlling for demographic factors. Findings also indicate that self-reported health was associated with objective health and was more strongly linked for the low- than the high-discrimination group.
Imposing culturally insensitive health promotion activities may exacerbate the social exclusion that is already being experienced by minority ethnic groups. Ochieng (2013) conducted a qualitative study exploring the beliefs and perceptions of healthy lifestyle practices among African-Caribbean men and women. In-depth interviews were conducted with 18 participants from the north of England. Findings suggest that participants felt that messages around healthy lifestyle practices were not applicable to their everyday lived experiences since these often ignored issues related to their experiences of social exclusion, racism and ethnic identity. Health promotion programmes that use individualistic approaches are inappropriate for, and isolate, those from ethnic minority communities who practise more collectivist traditions to express their beliefs, values and identity. Thus campaigns that try to promote healthy lifestyles need to consider socio-economic and cultural contexts, including issues related to disadvantage, racism and marginalization to enable African-American and other minority ethnic groups to incorporate these messages and practices into their everyday lives (see Chapter 17).
Refugees and Asylum Seekers
According to the United Nations Refugee Agency Report (2017), over 65.3 million people were forcibly displaced worldwide in 2015. Nearly 21.3 million were refugees, the majority of whom were under the age of 18. More than half of the refugees came from war-stricken countries such as Syria (4.9 million), Afghanistan (2.7 million) and Somalia (1.1 million), with nearly 34,000 people fleeing their homes as a result of violence and conflict every day. This is the highest level of displacement on record.
The living conditions of refugees are bleak. Based on a study of 150,000 Syrian refugees living in camps in Jordan in 2014, nearly two-thirds were living below the national poverty line. Access to heating, reliable electricity and adequate sanitation were also problematic (United Nations High Commissioner for Refugees (UNHCR), 2014). It is no wonder that the physical and psychological well-being of refugees are impeded by these circumstances.
Communicable diseases are major causes of morbidity among refugees. Children under the age of 5 are most vulnerable, with cases of measles, respiratory tract infections, diarrhoea and severe acute malnutrition soaring at high levels. The risk of anaemia is also a challenge for refugee women and children. The psychological and social well-being of refugees is also a cause for concern. A systematic review exploring the psychosocial challenges of Syrian refugees in Jordan showed that psychological distress was generally experienced by refugees and was often exacerbated by environmental (e.g., financial, housing, employment) issues and psychosocial outcomes (e.g., loss of role and social support, inactivity) (Wells et al., 2016). Furthermore, in a recent study investigating the prevalence of insomnia among refugees in Jordan, it was found that the majority of refugees had moderate to severe insomnia. Incidence of insomnia was predicted by factors such as older age, living in the city of Mafraq, poor education, unemployment, and lack of access to medication (Al-Smadi et al., 2017).
Understanding the experiences of refugees and asylum seekers is important in informing plans to alleviate these issues. Participatory engagement and ethical reporting are necessary to ensure that recommendations are based on evidence that is meaningful and useful on the ground. For example, McCarthy and Marks (2010) facilitated participatory action research to explore the health and well-being of refugee and asylum-seeking children. The research process suggests that although young refugees often face many challenges in their new life, they are able to find enough strength and resilience to cope with these issues. Similarly, Haaken and O’Neill (2014) used participatory visual methods to explore the experiences of women migrants and asylum seekers in the UK. Through photography and videography, participants were able to share their stories of seeking refuge in the UK. As an outcome of the project, a 10-minute video was developed which conveyed the complexities of the asylum process and also reflected historical and social dynamics of their experiences.
Culturally Competent Health Care Systems
In the ever-changing demographic and cultural trends of ’globalized’ society, health care systems need to be able to adapt flexibly to such changes and develop cultural competence. Culturally competent health care involves developing (1) culturally sensitive staff who are able to reflect about their own beliefs and practices and acknowledge diversity in the community, and (2) culturally appropriate materials, activities and systems that address linguistic, cultural and social barriers. Cultural competence in health care asserts the importance of health service users and providers being able to communicate clearly with each other. Training health care professionals to develop skills that enable them to deal with communication issues associated with cultural, linguistic and health literacy differences may be a good way to reduce inequities in health (Lie et al., 2012). Culturally competent health care systems can do this by helping health care professionals to develop cultural sensitivity, knowledge and skills and by instilling processes that will enable them to engage meaningfully with culturally diverse patients. Systematic reviews suggest that interventions that aim to improve cultural competence among health care professionals can help to increase their knowledge of cultural issues in health care (Renzaho et al., 2013) and improve patient and clinical health outcomes (Truong et al., 2014).
In addition to culturally competent health care, diversity and inclusivity can be promoted in other social contexts. For example, Andreouli et al. (2014) explored the role of schools in promoting inclusive communities. The authors argued that intercultural exchange can be promoted by examining how communities resist stigma and discrimination on a local level. While starting on a micro level, such approaches can be endorsed to build the foundations of health-promoting communities.
1. Through access to historical documents, research psychologists can assist our understanding of the evolution of health beliefs.
2. Understanding popular health beliefs requires an appreciation of their social and cultural context.
3. The increasing development of alternative health care in Western society requires ongoing research.
4. The comprehensive and accurate measurement of perceived discrimination and its mechanisms, which contribute to poor health, require examination.
1. Human thought and practices are culturally immersed.
2. The Western view of health has moved through various stages from the classic to the religious and then the scientific.
3. The scientific view of health, or biomedicine, is the dominant view in contemporary society but other health belief systems remain popular.
4. Traditional Chinese Medicine remains popular in China and among Chinese migrants in other societies.
5. Ayurvedic medicine remains popular in parts of southern Asia.
6. In Africa a wide variety of health belief systems emphasize spiritual aspects and a communal orientation.
7. In contemporary society there is increasing interest in various complementary and alternative (CAM) therapies, such as herbal medicine, homeopathy, aromatherapy and reflexology.
8. While debates are ongoing about the efficacy of CAM, guidelines and policies are being developed to ensure quality and safety.
9. Interventions aiming to promote indigenous health need to reflect the holistic notion of health among these communities and the voice of the community itself.
10. Racism continues to contribute to poor health among migrants, ethnic minority groups and indigenous peoples.
11. Culturally competent health care must aim to adapt to changing demographic and cultural trends.