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date: 27 May 2017

Culture, a Social Determinant of Health and Risk: Considerations for Health and Risk Messaging

Summary and Keywords

We provide an overview on the role of culture in addressing the social determinants of health and risk. The fact that everyone is influenced by a set of locally defined forms of behavior means that while not overtly expressed, culture’s effects can be ubiquitous, influencing everything including the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping health and risk messaging. While the dynamic nature of culture is underestimated and often not reflected in most research, efforts to close the gap on social determinants of health and risk will require greater clarity on what culture is and how it impacts culture-sensitive health communication. Thus, the paper begins by reviewing why culture is so vital and relevant to any attempts to improve health and reduce health inequalities. We discuss what is meant by the term “culture” through a narrative synthesis of historical and recent progress in definitions of culture. We conclude by describing three distinct cultural frameworks for health that illustrate how culture can be effectively used as a vehicle through which to address culturally sensitive health communication in local and global contexts. Overall, we believe that culture is indispensable and important for addressing inequalities and inequities in health as well as for facilitating culture-sensitive health communication strategies that will ultimately close the gap on the social determinants of health and risk.

Keywords: culture, social determinants of health and risk, culturally sensitive health communication

The Social Determinants of Health and Risk

There are gross inequalities in health between and within countries that present a challenge globally (Marmot, 2005). In 2008, The World Health Organization’s (WHO) Commission on Social Determinants for Health (CSDH) developed a report entitled Closing the gap in a generation. The report moved the debate on Social Determinants to a global level with recommended actions to close the gap in social determinants of health. It provided evidence that health inequalities are the result of the circumstances in which people grow, live, work, and age, and the misalignment with the systems in place to deal with illnesses (Marmot et al., 2008). These inequities in health included conditions of early childhood and schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment in which people reside (Marmot et al., 2008). Furthermore, depending on the inequities in the condition of daily living in society, different groups will have different experiences of material conditions, psychosocial support, and behavioral options, which make them more or less vulnerable to poor health (Marmot et al., 2008). Thus, a key message from the CSDH is the importance of context-specific strategies to tackle both structural (i.e., income, education, occupation, gender, social class) and intermediary (i.e., material circumstances, psychosocial circumstances, behavioral and/or biological factors, and the health system itself) determinants that shape health outcomes (Marmot et al., 2008). Context was broadly defined among other factors (e.g., educational systems, government) to include cultural and societal values that influence health (Marmot et al., 2008). In this paper, we focus on why culture remains central to addressing social and structural determinants of health.

Although culture has always played a part in influencing health, this explicit attention by the CSDH was applauded because it shifted attention to the role that culture can play in empowering people, particularly socially disadvantaged groups, to exercise increased collective control over the factors that shape their health (Marmot et al., 2008). However, what is not clearly stated in the commission is the why, what, and how culture can play a role in closing the health gap that constitutes social determinants of health and risk. Rather, culture was relegated to the laundry list of factors that may influence health outcomes, rather than used as an integrated conceptual framework (Kagawa Singer, 2012b). In order to assess the relevance and potential benefits of culture, we conducted a review to identify and describe ways in which aspects of culture have been described in the literature to influence health with considerations for health and risk messaging. We begin by reviewing why culture is so vital and relevant to any attempts to improve health and reduce health inequalities. We discuss what is meant by the term “culture” through a narrative synthesis of historical and recent progress in definitions of culture. We conclude by describing two distinct cultural frameworks for health that illustrate how culture can be effectively used as a vehicle through which to address social determinants of health and risk in local and global contexts. While this review is not exhaustive in discussing all cultural factors influencing the social determinants of health and risk, we believe that it creates a space for culture in the discourse on social determinants of health in general and health risk communication in particular.

Why Culture?

It is generally agreed that “culture” is important to the study of health and communication. What is different is what culture means to different scholars and what exactly is meant by those who have studied and written about culture. Take the Ebola outbreak in West Africa, for example: Thiam and colleagues (2015) suggested that the situation was worsened by the inadequate communication strategy and misconceptions around the disease due in large part to ignorance of local culture and customs, which was worsened by lack of engagement of local communities in the control strategies. Put another way, culture is central to how we communicate about our fundamental human rights even though, sadly, it took so many lost lives before appreciating the role of culture in effectively controlling the Ebola outbreak (Thiam et al., 2015). Indeed, earlier reference to culture led to the shortsighted focus on blaming culture as amplifiers in the transmission, rather than building on cultural assets as was later done, such as promoting community ownership through effective mobilization as a fulcrum in controlling Ebola.

Nonetheless, before the recent Ebola outbreak, others have highlighted the importance of understanding the cultural contexts that form and nurture health behaviors and health decisions (Airhihenbuwa, Ford, & Iwelunmor, 2014). Writing about culture and health, Dutta (2007) suggested that employing a culture-centered approach to health means working from within a culture to identify the health issues that a community considers important. Napier and colleagues (2014) suggested that this includes moving beyond the narrow focus of examining culture as ethnicity or national allegiance. Instead, culture should include the shared, taken-for-granted practices that influence health and wellbeing (Napier et al., 2014). Others have argued that simplistic measurements of culture overlook culture’s potential explanatory power to describe, for example, why disparities in health continue to persist (Kagawa Singer, 2012a). Good and Hannah (2015) suggested that culture allows an examination of the myriad factors that shapes clinical presentation, doctor–patient interactions, the illness experience, or the communication of symptoms. Together, and far from considering culture to be a barrier or an obstacle, these discussions consider culture to be an asset in influencing what individuals think or do in relation to their health (Airhihenbuwa, Ford, & Iwelunmor, 2014; Good & Hannah, 2015).

Airhihenbuwa and colleagues (2014) suggested that cultural understandings of the major health problems will drive how groups identify priorities and decide on solutions. It also makes it possible to focus on promoting positive health behaviors, while working to change negative ones. This was the case in the United States where Basilio and colleagues (2016) suggested that cultural factors matters for understanding perceived vulnerability to diabetes among Latino Americans in the United States (Basilio, Kwan, & Towers, 2016). In Canada, Currie and colleagues (2013) observed that Aboriginal cultural practices and beliefs may promote and protect Aboriginal adults in an urban environment by reducing their use of illicit drugs and prescription drug problems (Currie et al., 2013). In South Africa, Iwelunmor, Zungu, and Airhihenbuwa (2010) called for rethinking HIV disclosure within the cultural context of motherhood in African societies. Likewise in Nepal, Basnyat and Dutta (2012) suggested that women (re)construct motherhood based upon their local cultural and structural contexts, and in turn act upon the alternative meanings to enact agency in their reproductive health choices in their day-to-day lives. Gill and colleagues (2016) suggested that effective public health programs are those that are culturally competent and benefit communities in meaningful, respectful ways. As a result, some scholars call for taking culture seriously in biomedical HIV prevention intervention trials (Rubincam, Lacombe-Duncan, & Newman, 2015). Likewise, with noncommunicable diseases increasing in many sub-Saharan African countries, BeLue and colleagues (2009) call for understanding the cultural framework by which these diseases are interpreted and managed as they matter for devising effective lifestyle interventions. This is because lifestyle practices cannot be addressed independently from people’s cultural backgrounds (Al-Bannay et al., 2014). For example, in West Africa, reducing consumption of salt must target the taste for bouillon cubes (e.g., Maggi cubes or Knorr) that many West Africans have acquired (Airhihenbuwa, Ford, & Iwelunmor, 2014). These taste enhancers were not always part of African cultures. Now, however, more than 90% of households in many parts of West and Central Africa use bouillon cubes in food preparation (Airhihenbuwa, Ford, & Iwelunmor, 2014). Their centrality to contemporary food cultures is a reminder that culture is never static (Kagawa Singer, 2012b).

Thus, transforming the cultural environment that, for example, encourages consumption of food taste enhancers like “Maggi” products in West Africa and may be more important than individual behavior change efforts alone for sustained action on the social determinants of health. It is from this context that we invoke the primacy of culture not only to challenge approaches to the study of health that continue to overlook or downplay its powerful influence but also to deepen and extend its possibilities with efforts to take action on the social determinants of health (Airhihenbuwa, 1994). To explore the influence of culture on individual health is “to recognize that the forest is more important than the individual tree” (Airhihenbuwa, 1999, p. 269). Also, exploring the cultural context of the forest allows one to understand and appreciate the ways in which the individual trees are shaped, as well as exploring the roles, connections, and relationships (whether positive or negative) that exist between the trees (Singhal, 2003). Understanding the impact of these cultural dynamics (Basnyat & Dutta, 2012; BeLue et al., 2009; Currie et al., 2013; Gill, Kuwahara, & Wilce, 2016; Iwelunmor, Newsome, & Airhihenbuwa, 2014; Iwelunmor, Zungu, & Airhihenbuwa, 2010) is essential with efforts to close the gap in avoidable health inequalities that arise because of the circumstances in which people grow, live, work, and age and the systems put in place to deal with these health inequalities. To do so, however, requires a clear understanding of what is culture.

What is Culture?

Culture has been defined in many ways, by numerous social science scholars from anthropology to sociology and varied disciplines in between. At the start of the 20th century, anthropologists, for example, defined culture as the way of life of a people, or as what an individual needed to know to survive in a society, or as what could be learned by an individual and passed down in a society (Hall, Neitz, & Battani, 2003). While some anthropologists viewed culture as an entity in itself characterized by a patterned set of ideas or symbols, others often describe culture as a learned behavior. Anthropologist Robert Redfield, for example, defined culture as “conventional understandings, manifest in act and artefact” (Napier et al., 2014, p. 1608) To Redfield, culture is not only focused on shared understanding but also on practices based on those understandings that make sense of beliefs held in common with others (Napier et al., 2014). On the other hand, Bronislaw Malinowski (1936, p. 440) defined culture as “nothing but the organized behavior of man.” Malinowski suggested that, culture is at the same time the minimum mechanism for the satisfaction of the most elementary needs of man while also an ever-developing system of new ends, new values, and new creative possibilities (Malinowski, 1936, 1941). More recently, anthropologists define culture as dynamic, fluid, and constructed situationally, in particular places and times (Wright, 1998).

On the other hand, sociologists like Pierre Bourdieu described culture not as a set of rules but as deeply internalized habits, styles, and skills that allow human beings to continually produce innovative actions that are nonetheless meaningful to others around them (Swidler, 1995). To Bourdieu, human beings continually re-create culture. They do so by following cultural rules, or culturally encoded skills, which are differentially distributed and ultimately reproduce the structure of inequality (Swidler, 1995). Michel Foucault examined how sets of cultural rules are made real and used to categorize and control human beings (Swidler, 1995). He shifted attention to how institutions use power to enact rules that control human behaviors and the social world. Unlike anthropologists, for sociologists, power and inequality are important elements of culture. Weber, for example, noted how power shaped ideas and that the interests of the powerful had lasting influence on culture (Swidler, 1995). Durkheim and Parsons were concerned with the ways in which shared norms and values create social order, implying that culture is a kind of system for the social control of individuals, and it works to integrate them into society to the benefit of both the individuals and society (Swidler, 1995). Clifford Geertz, a student of Parsons, argued that culture should be explored for its meanings alone (Geertz, 1966, 1973). In his classic book The Interpretation of Cultures, Geertz (1973) defined culture as “an historically transmitted pattern of meaning embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men (sic) communicate, perpetuate and develop their knowledge about and attitudes toward life” (Geertz, 1973, p. 89). To Geertz (1973), every culture is dominated by control mechanisms or a unique set of regulating ideas that shape individual behavior.

Other scholars such as Ali Mazrui (1987), in his classic book The Africans: A Triple Heritage, defined culture as “a system of interrelated values active enough to influence and condition perception, judgment, communication, and behavior in a given society” (p. 239). Edward Hall, in his book titled Beyond Culture, characterized “culture as man’s medium” (p. 16) and suggested that there is not one aspect of human life that is not touched and altered by culture. This includes personality, how people express themselves, the way they think, the way they move, how problems are solved, and how people live and function together (Hall, 1989). To Hall, it is usually the most obvious and taken for granted, and therefore least studied, aspects of culture that influence behavior in the deepest and most subtle ways (Hall, 1989). Sociologist Ann Swidler (1986) suggested that effective cultural explanations depend on understanding how culture is put to use. Far from viewing culture simply as public symbols, or entire ways of life, Swidler (1986) argued that conventional views leave us very much at a loss when it comes to studying how culture is actually put to use by social actors, how culture constrains or facilitate patterns of action, and what specific changes undermine the vitality of some cultural patterns and give rise to others (Swidler, 1986). Culture influences action by providing a repertoire or “toolkit” of resources and skills that people may use in varying configurations to solve different kinds of problems (Swidler, 1986). Thomas Sowell (1994) in his book Race and Culture suggested that culture is expressed in behavior and often revealed in the choices actually made and the sacrifices endured in pursuing some desired goals at the expense of other desired goals. Social psychologists Hofstede and McCrae (2004) suggested that cultures can be classified in relation to their characteristics with respect to individualism versus collectivism, masculinity versus femininity, power distance, and uncertainty avoidance. These characteristics are known as cultural dimensions to the description of cultures (Hofstede & McCrae, 2004). Raymond Williams, a prolific culture theorist, described “culture as ordinary, in every society and in every mind” (1958, p. 53).

In the context of health, Kagawa Singer (2012b, p. 357) suggested that culture is the “blueprint or guiding framework behind a population group’s conscious and unconscious actions, or the ‘toolkit’ for living life, solving problems, and informing decisions.” Culture, according to Kagawa Singer (2012b) is (a) learned from birth through the processes of language acquisition and socialization, (b) shared by all members of the same cultural group, (c) adapted to specific environmental and technical conditions, and therefore, (d) a dynamic, ever-changing process. In the Cultural Framework for Health (Kagawa Singer, 2012a), culture was defined as a multidimensional and multilevel process that “enables group members to make sense of their world and to find meaning in and for life” (p. 12). According to Kagawa Singer and colleagues (2012a), this multilevel nature of culture means that the patterns that emerge from different cultural systems are composed of many interrelated parts, and will differ within and between cultures. Dutta’s (2007) work on a culture-centered approach to health is based on the need for dialogue between the researcher and the community members, with the goals of listening to the voices of cultural members in suggesting culture-based health solutions. To Dutta (2007), culture “is a complex and dynamic web of meanings that is continuously in flux, as it interacts with the structural processes at the local and global levels that surround the culture” (pp. 310–311). The culture-centered approach to health communication underscores the importance of participation of community members in the articulation of health problems as a first step toward achieving change that is meaningful to community members (Dutta, 2007).

Similarly, Airhihenbuwa (2007), in his book Healing Our Differences, called for more efforts to make culture central with efforts to improve health in a manner that does not naturally couple the concept of barriers with culture. To Airhihenbuwa (2007), “the collective consciousness of a people (the culture) prepares them to deal with and sometime subvert and transform oppressive conditions in ways unknown to the oppressor” (p. 4). Public health interventions to close the gap in the social determinants of health must, therefore, be directed toward locating people’s identity in their cultural spaces so that their philosophy informs the health practices that manifest in their health behavior (Airhihenbuwa, 2007). Airhihenbuwa’s PEN-3 cultural model provides the opportunity to do so by examining cultural practices that are critical to positive health behaviors, acknowledging unique practices that have a neutral impact on health before identifying negative factors that are likely to have an adverse influence on health (Iwelunmor, Newsome, & Airhihenbuwa, 2014). In this way, cultural beliefs and practices that influence health-seeking practices are examined whereby solutions to these health problems that are beneficial are encouraged, and those that are harmless are acknowledged before finally tackling practices that are harmful and have negative health consequences (Iwelunmor, Newsome, & Airhihenbuwa, 2014).

Likewise, in a recent commission on Culture and Health by the journal Lancet, Napier and colleagues (2014) suggested that culture is a dynamic concept, sometimes visibly expressed, and sometimes not clearly defined. They argue that culture is what we “take-for-granted and do not critique or assume is universal even when we acknowledge social diversity” (p. 1610). To Napier and colleagues (2014), this taken-for-granted dimension of culture is the “single biggest barrier to advancing the highest standard of health worldwide and healthcare’s greatest hurdle” (p. 1608). Thus, the lack of recognition on the part of most researchers of their own cultural lens, will remain a major barrier in conducting studies in diverse population groups to improve health and reduce health inequalities (Kagawa Singer, 2012a).

Nevertheless, and as shown in these varied definitions, it would be impossible to proclaim one point of view on culture as the right answer to the question, “what is culture?” Instead, no definition of culture is right or wrong, even as they differentiate between what culture is and what culture does. We are of the pragmatic idea that there are multiple useful ways of defining culture, and they all acknowledge that every culture may have something positive, something unique, and/or something negative that may influence health behaviors and health outcomes (Iwelunmor, Newsome, & Airhihenbuwa, 2014). Together, we believe that knowledge of these factors is essential to eliminating inequity in health and closing the gap in avoidable health inequalities both locally and globally.

The Need for Cultural-Sensitive Communication on Social Determinants of Health and Risk

The proliferation of increasingly multiethnic societies globally presents new opportunities and challenges for communication on the social determinants of health and risk. This is also compounded with the growing recognition that effective health promotion programs targeting multicultural societies must also be culturally sensitive and consistent with the needs and cultural beliefs of individuals (Garnweidner et al., 2012). Cultural-sensitive communication on the social determinants of health and risk is not only about language issues but includes attributes such as knowledge, consideration, understanding, respect, and tailoring/targeting of information that meets the needs of diverse groups or individuals (Betsch et al., 2015; Foronda, 2008; Garnweidner et al., 2012). Betsch and colleagues (2015, p. 1) define cultural sensitive communication as “the deliberate and evidence-informed adaptation of health communication to the recipients’ cultural background in order to increase knowledge and improve preparation for medical decision making and to enhance the persuasiveness of messages in health promotion.” According to Foronda (2008), when cultural sensitivity occurs, the result is effective interaction with the client. Other benefits of culture sensitive health communication include effective intervention and client satisfaction (Foronda, 2008). Betsch and colleagues (2015) argue that culture-sensitive communication will help reduce disparities in health outcomes by making messages understandable, meaningful, and effective.

But how can researchers or health practitioners develop programs or frameworks that are capable of improving cultural sensitive communication on health and risk? Here we describe three distinctive frameworks that we believe may offer the opportunity to centralize culture in the study of social determinants of health and risk messaging.

Cultural Targeting and Tailoring of Shared Decision-Making: The concepts of targeting and tailoring provide useful starting points for developing culturally sensitive health and risk messaging. While targeting refers to the use of group-level data to create health messages for a specific audience group that is homogenous with respect to a specific health outcome, tailoring refers to the customization of information based on individual characteristics (Alden et al., 2014). A recent review paper focused on the potential of employing a two-stage framework incorporating both cultural targeting and cultural tailoring to improve patient decision making (Alden et al., 2014). Developed by Alden and colleagues (2014), the first stage recommends the use of cultural constructs, such as collectivism and individualism, to differentially target patients whose cultures are known to vary on these dimensions. Targeting within the development of decision aids occurs at the concrete level with the use of culturally relevant visual cues, colors, fonts, and linguistic issues (Alden et al., 2014). The second stage emphasizes the importance of not only targeting the decision aid content, but also tailoring the information to the individual based on clear understanding of how strongly he/she is connected to dominant cultural mindsets (Alden et al., 2014). Tailoring within the development of decision aids includes the customization of certain information following measurement of the individual on key cultural constructs such as interdependence of the tendency to view oneself in terms of relationships and/or group memberships (Alden et al., 2014). In this way, both cultural targeting and tailoring are used to develop and test decision aids that move beyond a “one-size-fits-all” approach in a multicultural world (Alden et al., 2014, p. 1). Additionally, because the absence of culturally and linguistically appropriate health communication is a central barrier to health care among people with diverse ethnic backgrounds, applying cultural targeting and tailoring may enable the development of communication that resonates with their cultural background.

The PEN-3 cultural Model: Developed in 1989 by Airhihenbuwa in response to the apparent omission of culture in explaining health outcomes in existing health behavior theories and models (Airhihenbuwa, 1989, 1990), the PEN-3 cultural model centralizes culture in the study of health beliefs, behaviors, and health outcomes (Airhihenbuwa, 1995). The model also places culture at the core of the development, implementation, and evaluation of successful public health interventions (Airhihenbuwa, 1995; Airhihenbuwa, 2007). The PEN-3 cultural model consists of three primary domains: (a) Cultural Identity, (b) Relationships and Expectations, and (c) Cultural Empowerment. Each domain includes three factors that form the acronym PEN; Person, Extended Family, Neighborhood (Cultural Identity domain); Perceptions, Enablers, and Nurturers (Relationship and Expectation domain); Positive, Existential, and Negative (Cultural Empowerment domain). The Cultural Identity domain highlights the intervention points of entry. These may occur at the level of persons (e.g., mothers or health care workers), extended family members (grandmothers), or neighborhoods (communities or villages). With the Relationships and Expectations domain, perceptions or attitudes about the health problems, the societal or structural resources such as health care services that promote or discourage effective health seeking practices, as well as the influence of family and kin in nurturing decisions surrounding effective management of health problems, are examined. With the Cultural Empowerment domain, health problems are explored first by identifying beliefs and practices that are positive, exploring and highlighting values and beliefs that are existential and have no harmful health consequences before identifying negative health practices that serve as barriers. Overall, PEN-3 helps researchers to reexamine assumptions about health-related behaviors and thus to reexamine cultural biases (Betsch et al., 2015). It has been described as a useful starting point for a cultural-sensitive approach to health communication in that it can assist in cultural targeting that responds to group differences and/or culturally tailoring of health messages that respond to individual differences (Betsch et al., 2015).

The Culture-Centered Approach (CCA) to Health: The culture-centered framework highlights the need to develop programs in ways that are consistent with a community’s cultural framework (Dutta & Basu, 2008). It suggests that efforts to improve health outcomes must address social, cultural, and environmental factors beyond the biomedical model alone (Dutta & Basu, 2008). Developed by Dutta (2007), CCA is value centered and built on the notion that the various ways of understanding and negotiating the meaning of health are embedded within cultural contexts and the values deeply connected to them. CCA also draws attention to the voices of cultural participants and suggests that community participation is the foundation for developing interpretive frameworks and health communication applications (Dutta & Basu, 2007). With CCA, cultural contexts are placed at the core of meaning-making processes, and meanings are dialogically co-constructed by researchers and cultural participants (Basu & Dutta, 2009). CCA also builds on structuration theories, which recognize the dialectical tensions between structure and agency (Giddens, 1984). While structure refers to institutional and organizational networks that determine how societies are organized, agency refers to cultural participant’s capacity to participate in day-to-day actions in response to their contexts (Dutta, 2007). CCA suggests that there is a dynamic interaction between structure and agency, and it is embedded in a cultural context that evolves through time (Dutta, 2015). CCA also recognizes that shared experience, values, and beliefs are central to the ways in which humans conceptualize the problems they consider to be important and the corresponding solutions they develop for these problems (Dutta, 2015).

Future Directions with Culture and the Social Determinants of Health and Risk

The late Nigerian scholar/novelist Chinua Achebe’s quote, “where one thing stands, another thing must stand beside it” shows remarkable foresight into the importance of context for understanding health (Achebe & Bonetti, 1989, p. 65). Also, Article 1 of the Declaration of the Principles of International Cultural Co-operation, suggests that “each culture has a dignity and value which must be respected and preserved,” and this includes the cultural factors that shape health. The study of the influence of culture on health is experiencing an unprecedented boom with recent commissions from leading health organizations, one of which focused on building a Culture of Health (Chandra et al., 2016), another on promoting a Cultural Framework for Health (Kagawa Singer, 2012a), while another argued that “the systematic neglect of culture in health is the single biggest barrier to advancing the highest attainable standard of health worldwide” (Napier et al., 2014, p. 1608). While it remains to be seen how long this boom will last, the focus on culture holds intellectual promise for revitalizing the debate on why culture matters with health and risk communication.

Thus, what is at stake now is delineating how culture can be effectively used as a vehicle through which to address communication on the social determinants of health and risk in local and global contexts. To do so will require that researchers address the following factors. First, researchers need to define what they mean by culture. While we may never come to a complete consensus on the concept, it is necessary to identify from the repertoire of definitions we have previously listed which definition is most salient to the topic under study. We believe that this practice would require researchers to be more thoughtful and specific in the use of the term and development of their measures (Kagawa Singer, 2012b). Second, we now have a list of frameworks, from Alden’s Cultural Targeting and Tailoring of Shared Decision-Making to Airhihenbuwa’s PEN-3 cultural model, and Dutta’s Culture-Centered Approach to health, which help to delineate the contextual basis of culture and how it may impact targeting and tailoring of health messages to address health behaviors and health outcomes. To the extent that the social determinants of health approach seeks to improve the conditions of daily life—the circumstances in which people are born, grow, live, work, and age—then there is a need to explicitly consider how culture may determine the motivation behind preventive health behavior or the propensity to risk behaviors (Betsch et al., 2015). This in turn will improve the evidence base for culturally sensitive health communication that are more congruent with cultural values and more applicable and understandable to members of different cultures (Betsch et al., 2015). Finally, because culture is inherently collective and embedded in practices that can powerfully shape not only individual beliefs and actions but also their knowledge of how others will interpret these actions, it cannot be left out of understanding the conditions that make people, or allow people to make themselves, healthier. With culture being a medium that influences the way we think and solve problems, the way we move, what we eat, or how we sleep, it is likely to influence health behaviors in deep and subtle ways that in turn may impact the understanding and effectiveness of health and risk messaging (Airhihenbuwa et al., 2016; Airhihenbuwa, Ford, & Iwelunmor, 2014; Hall, 1989). Thus, culture is indispensable and important for addressing inequalities and inequities in health as well as for facilitating culture-sensitive health communication strategies that will ultimately close the gap on the social determinants of health.

Discussion of the Literature

Five databases (Pubmed, Ebsco, Proquest [particularly JSTOR], Scopus, and Google Scholar) were searched for literature on culture in general, as well as the influence of culture on health in particular. The search terms include the following: “culture and definition,” “culture and health,” “culture and health behavior,” “culture and health outcome,” and “culture and health communication.” We did not conduct a systematic review of all the available literature; instead, we narrowed our search so that it reflected only available studies that either provided clear definitions on culture or the influence of culture on health or the role of culture and health communication. We also included articles from books with clear definitions on culture. The abstracts of all of the documents were screened and reviewed by one researcher. Disagreements were resolved by repeated review, discussion, and consensus of both authors. Definitions of culture abound and go back to medieval times when its primary meaning was cultivation (of the land) to classic anthropology work with the basic idea that it is something humans express and create. Attempts at a definition of culture were first expressed in the early 20th century by the anthropologist Edward Tylor, who defined culture as “that complex whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities and habits acquired by man as a member of society” (Bierstedt, 1938, p. 207). Two implications can be drawn from this definition: culture is (a) learned, and (b) part of a social context in which it is shared. Scholars have argued that the intent of this definition was to focus attention on the collective nature of social behavior, while also combating purely biological theories of human behavior and differences dominant during this era. However, and with respect to the second implication, this perspective has been criticized by many, including anthropologist Susan Wright in her article on “The Politicization of Culture,” for being rigid and autonomous, treating culture as if it were a set of ideas or meanings that are shared by a whole population of homogeneous individuals. Nonetheless, since Tylor, definitions of culture have multiplied and varied to a great degree among scholars. Many “culture is …” or “culture consists of …” definitions have been proposed and a number of them (about 164) catalogued in Kroeber and Kluckhohn’s book Culture: A Critical Review of Concepts of Definitions. Raymond Williams, one of the prolific writers of on the culture concept, wrote that “culture is one of the two or three most complicated words in the English language” (1976, p. 87). Its origin includes not only static and elitist equations of what culture is or is not but also broader notions that encompass all forms of symbolic activities. While attempts at an explanation of culture vary from one discipline to another, sociologist Ann Swidler suggested that these explanations are necessary to reinvigorate the study of how culture influences life. Within the context of health, Airhihenbuwa’s Health and Culture: Beyond the Western Paradigm and Healing Our Differences, as well as Mohan Dutta’s Communicating Health: A Culture Centered Approach, provide more detailed information on the role culture can play with actions to close the gap in the social determinants of health as well as improving health outcomes.

Further Reading

Airhihenbuwa, C. O. (1995). Health and culture: Beyond the Western paradigm. Thousand Oaks, CA: SAGE.Find this resource:

Airhihenbuwa, C. O. (1999). Of culture and multiverse: Renouncing “the universal truth” in health. Journal of Health Education, 30(5), 267–273.Find this resource:

Airhihenbuwa, C. O. (2007). Healing our differences: The crisis of global health and the politics of identity. Lanham, MD: Rowman & Littlefield.Find this resource:

Alden, D. L., Friend, J., Schapira, M., & Stiggelbout, A. (2014). Cultural targeting and tailoring of shared decision making technology: A theoretical framework for improving the effectiveness of patient decision aids in culturally diverse groups. Social Science & Medicine, 105, 1–8.Find this resource:

Dutta, M. J. (2007). Communicating about culture and health: Theorizing culture‐centered and cultural sensitivity approaches. Communication Theory, 17(3), 304–328.Find this resource:

Hall, E. T. (1989). Beyond culture. Garden City, NY: Anchor.Find this resource:

Kagawa Singer, M (2012b). Applying the concept of culture to reduce health disparities through health behavior research. Preventive Medicine, 55(5), 356–361.Find this resource:

Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. The Lancet, 372(9650), 1661–1669.Find this resource:

Napier, A. D., Ancarno, C., Butler, B., Calabrese, J., Chater, A., Chatterjee, H., et al. (2014). Culture and health. The Lancet, 384(9954), 1607–1639.Find this resource:

Sowell, T. (1994). Race and culture: A world view. New York: Basic Books.Find this resource:

Swidler, A. (1986). Culture in action: Symbols and strategies. American Sociological Review, 51(2), 273–286.Find this resource:

Swidler, A. (1995). Cultural power and social movements. Social Movements and Culture, 4, 25–40.Find this resource:

References

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