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Lecture 4: Culture and Body-Image, Life-Style and Health
Overall key points
Commonalities and culture differences in:
- Body-image - what is perceived as attractive
- Biology - weight, length and age
- Life-style and health behaviour
- Health and medicine - views on health and illness and use of health care.
Body and lifestyle are influenced by our culture
Note that: Influence of culture on health is very broad and complex. In these notes only some of the relevant topics will be discussed. The main aim is to raise awareness of differences, open mind to variety and views other than those that are so standard to you that you wouldn't even think about them. Differences between individuals from one culture can sometimes be larger than those between cultures.
Culture and Body-Image
What is universally attractive? Evolutionary psychologists suggest preferences for visual appearances have evolutionary roots. Communalities across culture in what is perceived as attractive: clear complexion, bilateral symmetry and average features. Signs that you are healthy. People are attracted to healthy mates.
Skin signals health more directly than any other visible aspect. The cosmetics industry provides people with ways to make their complexion look clearer. People have strong aversive reactions to skin conditions. Skin conditions often associated with stigmatization. Example: 2 Nigerian girls with skin disorder were hidden to protect the other children in the family, as marriage with member of family in which the skin disorder occurs is discouraged.
Bilateral symmetry is a marker of health. When an organism develops under ideal conditions its right and left sides will be symmetrical. Genetic mutations, pathogens or stressors in the womb can lead to asymmetrical development. On average, asymmetrical faces are views as less attractive.
Faces with average features are more attractive than faces that deviate from average. Average features are less likely to contain genetic abnormalities and are more symmetrical. We can more easily process any kind of stimulus that is closer to a prototype than one that is further from a prototype. And easy processing is associated with a pleasant feeling that gets interpreted as attractive.
"Average is attractive" does not apply to aspects beyond facial features. This is seen with people's weight, height, muscles, breasts and hips. For such aspects, it's often bodies that depart from average that are seen as more attractive. The kinds of body weights that are perceived to be most attractive vary considerably across cultures.
Body-weight
In 1951, anthropologist and psychologist concluded that heavier women were universally found to be more attractive. Eg in Western Africa, the term "fat" is often viewed as complementary. The ideal woman is overweight, which is a sign of wealth and fertility, strength and beauty. Slim people are seen as weak or ill (malnutrition and infection are major causes of death). Undeveloped countries: thinner tend to be poorer.
In the modern West women who are unusually thin fit the ideal body weight. These ideas for thinner women have been more prevalent during the past few decades, while actual average body weights have increased. Rich countries: negative correlations between body weight and SES - thinner tend to be richer. People in non-Western cultures and non-Western immigrant groups adopt deviant Western body images: rise in anorexia and bulimia. Eg South Africa rising incidence of eating disorders: Zulu schoolgirls use laxatives and diet pills to "look less like their mums and more like western girls".
Media: Body-image, what is normal and how we "should" look is strongly influenced by the media. Media often portray unattainable ideals, shaped by selection of 'perfect' models, cosmetics, photographers' techniques and tricks, and photoshop. Major influence on feelings of inferiority, views on self as being abnormal, not beautiful or even ugly. Leading to use of cosmetic, braces, tanning or whitening (resulting in increased risks of (skin)cancer) and plastic surgery (resulting in the risk of cutting in a healthy body --> risk of anesthesia or infections).
Nearness and similarity
Other factors that influence what we find attractive
Propinquity effect:people are more likely to become friends with people with whom they frequently interact. Based on mere-exposure effect: the more we are exposed to a stimulus, the more we are attracted to it (conditioning and easy to process). Culturally universal mechanism.
Similarity-attraction effect: people are attracted to others if they share many similarities (eg in attitudes, economic background, personality, religion, activities). Particularly strong in cultures with high relational mobility (individualist > collectivist cultures).
Key points body-image
Features indicating good health are generally considered to be attractive. Cultural differences in views of clothing, ideal body weight and other factors. Our own body image and attraction to others is influenced by: 1) those around us, in our (sub)culture, 2) the media. We tend to like what we see near us and, depending on culture, what is similar to us.
Culture and Innate & Acquired Biological Variations
Human biology varies across cultures.
Explanations/mechanisms:
- Innate biological differences: the result of selection pressures
- Acquires biological differences: cultural effects on one's biology, independent of genes.
Humans, like all organisms, evolve due to selective pressures in their environments. Different environments have different selection pressures, leading different populations to evolve different traits. Most salient example of genetic variability of humans across different populations is skin colour.
Innate Biological Variability - Skin colour
Skin colour strongly correlates with ultraviolet radiation (UVR) that reaches different parts of the globe. Light skin allows sufficient UVR to synthesize vitamin D. Dark skin prevents over-absorption of UVR (risks of anaemia, birth defects, or skin cancer), and prevents breakdown of folic acid. Exception: Inuit (eskimos) diet rich in fish and sea mammal blubber, high in vitamin D. Skin colour is an example of geographical influences on population variation in the human genome.
Innate Biological Variability - Culture-gene coevolution
Cultural factors can influence genomic variation. Culture-gene coevolution: as culture evolves, it places new selection pressures on the genome, which also evolves in response to those pressures. Example: cow domestication has led to the development of a mutation that allows us to process milk (lactase persistence).
Culture-gene coevolution can be quite indirect: Example: farming yams in Africa required the clearing of forests: standing pools of water; malaria-carrying mosquitoes; biological adaptation of resistance; associated with sickle cell anaemia.
Acquired Biological Variability - Visual acuity
Biological traits can also be affected by cultural practices within a lifetime. Moken young children swim underwater to retrieve seafood. They have thus developed twice the underwater visual acuity as European children. This is not a genetic adaptation - European children can do the same through training.
Acquired Biological Variability - Obesity
What can explain the increase in obesity rates? 1) Genetics, 2) Greater reliance on high-calorie foods (eg fast food, sodas), 3) Larger portion sizes, 4) More sedentary lifestyle, 5) Suburban lifestyle-more driving, less exercise.
Within the West, there is considerable variation in obesity rates. France had one-fifth the obesity rate of the USA, as well as less heart disease and a longer life span. Despite French food being high in fat and sugars and despite the French having higher blood cholesterol than Americans.
French Paradox: 1) French still eat significantly less calories a day than Americans. 2) The portion sizes are also different. People eat what's given to them, portioned. Indeed, in comparison to portion sizes in France, the portion sizes in the USA are 70-80% larger and portion sizes has been continuously increasing in the USA. 3) The attitudes towards food are different: French savour their food more than Americans.
Acquired Biological Variability - Height
For example: in the late 19th century was the average height in the Netherlands 1.69 meter tall, during the late 20th century the average height was 1.83 meter. At this point the Dutch people are the tallest, it is possible that we are now rich enough to buy a lot of foods that make us grow (dairy).
US: there is a huge inequality between the wealth between people. Not everybody is rich enough to buy healthy food.
The economic wealth of a country has close ties with the height of its people. More wealth brings healthier diet (more vitamins and nutrients), especially at ages when growth spurts occur. Fluctuations of countries' height across time have coincided with broad societal change that have an impact on diet.
Acquired Biological Variability - Age
Median ages vary significantly across the globe. (The vast majority of the countries with median age of under 20 are in Africa).
Country | Median age |
Monaco | 53.1 years |
Netherlands | 42.6 years |
Syria | 24.3 years |
Niger | 15.4 years |
This is influenced by a number of factors, such as 1) social and economic development (poverty in many African countries, Monaco is incredibly wealthy); 2) birth rates; 3) disease; 4) ongoing conflict.
Key points Biological variations
Our biology/bodies are influenced by culture
- Geographical influence on selection--> innate differences in eg skin colour
- Gene-culture coevolution--> innate differences in eg lactose persistence and malaria resistance
- Current culture(incl. wealth) --> acquired differences in eg visual acuity, obesity, height, and age.
Culture and Life-style & Health behaviour
Many factors influence (cultural differences in) health (behaviour): sleep, SES, stress, control, discrimination and religion
How many hours of sleep per night do you think is necessary for good health? Current guidelines suggest around 7-9 hours a night. Before electric lighting, people's sleeping cycle actually had two phases. First, people went to sleep for a few hours a little after sunset. They woke up in the middle of the night, during which they engaged in some leisurely activities. Then they slept for a few hours again until around dawn. This also depends on culture: for example: siesta, sleeping at the heat of the day.
The recommended hours of sleep per night for infants falls within a range, 12-15 hours per night. Example: in Japan children sleep 11.5 hours a day and in New Zealand children sleep almost 13.5 hours a day. Falls within the range, so it is not wrong.
SES: with a higher income, people are more healthy. SES associated with health via several psychosocial variables:
- personality characteristics: a sense of hostility and pessimism, likely due to lower school achievement in low-SES environments (which bars people from employment opportunities), leads to poorer health.
- cognitive resources: poverty preoccupies people with having to make difficult choices and trade-offs for survival. Example: sugar cane farmers in southern India performed better on cognitive tasks after they harvested their crops compared to begore harvesting their crops.
- Attitudes towards and occurrence of unhealthy habits: fast food, smoking, less exercise
- Access to adequate health care
- Risky jobs: toxins, workplace accidents
- Stress
(Chronic) stress can affects health in multiple ways including:
- Stress leads people to engage in unhealthy habits
- Stress weakens the immune system
- Higher blood pressure and risk cardiovascular disease
Some environments can induce more stress, for example: New York City has been shown to make people more stressed. Consider also slums in India of favela in Brazil.
Control plays a big part
- Low SES --> low control --> poor health
- High SES --> high control --> good health
Not (just) actual SES, but also: subjective perceptions of wealth are predictive of health: 1) A sense of relative deprivation may lead to stress; 2) It is not how poor one is but rather how poor one feels that affects health. Example: Indians in poor province Kerala outlive poor African- Americans in USA, even though much lower incomes. They are likely to feel less poor because everyone around them is poor, while African-Americans compare themselves to fellow Americans. Particularly problematic in societies where there is great social inequality (which is increasing in many countries).
Ethnicity is also a factor implicated in the link between SES and health. In the United States, African Americans and Hispanic Americans have been studied extensively in terms of their health outcomes compared to European Americans.
Ethnicity, genetics vs discrimination - health
For many causes of death, the prevalence rates for African Americans exceed those of European Americans, particularly for hypertension and heart disease, might often be attributed to SES. Notably, this particularly affects highly educated African American men – contrary to what one might expect based on research on SES and health outcomes. Genetics? Hypertension rates are actually much higher for African Americans compared to West Africans (who have comparable rates to European Americans). Discrimination, racism - stress, puts people at greater risk for hypertension, especially those with high aspirations to achieve.
Epidemiological paradox: Hispanic Americans tend to have better health outcomes on average compared to European Americans, although they are generally of a lower SES. One explanation is that Hispanic Americans engage in healthier behaviours than European Americans: 1) Drinking and smoking less; 2) More social support from large communities; 3) High level of positive affect is a cultural norm.
Religion
Something so meaningful to a large number of people might also be good for their health. In the Judeo-Christian scriptures, there is an emphasis on caring for the physical, body as a "temple of the holy spirit". Comparable views in other faiths. Religion might positively affect physical health by: 1) encouraging healthy behaviour, such as no smoking, hence also less smoking; 2) increasing social support; 3) reducing stress and negative emotions.
Religious and spiritual involvement can have a favourable impact on a host of physical diseases and the response of those diseases to treatment. Indeed, the relation between religious and spiritual involvement and e.g.,: 1) Lower prevalence coronary heart disease; 2) Lower blood pressure; 3) Better immune function; 4) Better endocrine function. Moreover, often people turn to religion to copewith illness
Religion can also have negative effects. Although religious people tend to have a healthier diet, they also tend to eat more. Might refrain from vaccination (e.g., measles). Refrain from (timely) using life-saving medication or other interventions.
Life-style & health behaviour - Key points: Many factors influence (cultural differences in) health: Sleep, SES, Stress, Control, Discrimination, Religion. Cultural differences in life-style and health-behaviour are associated with health outcomes.
Culture and Health & Medicine
Very concept of health differs across cultures. From a western point of view, health is often conceptualized in a biomedical model, where health is seen in terms of (the absence of ) disease. Disease in turn is seen as originating from a specific and identifiable cause within, or arriving from outside, the body. Views from other cultures regard health as an imbalance between negative (yin) and positive (yang) forces in Chinese medicine, or elemental ingredients (bhutas) and waste products from food (vayu, pitta and kaph) in Indian Ayurvedic medicine. Further alternative views that diseases are due to supernatural causes, such as witches, demons, or ghosts.
Differences in western medicine: in France, the metaphor of the body is the "terrain", whick emphasizes a sense of balance. French doctors prescribe more long rests and spa visits. Use of tonics and vitamins to strengthen the immune system. Dirt and germs can strengthen one’s terrain; thus, there is less emphasis on daily bathing. The USA metaphor of the body is a machine, threatened by external factors. American doctors are more likely to do surgery (to fix malfunctioning parts). Germs are a key threat to health. Doctors prescribe more antibiotics than anywhere else.
Views of health are shaped by culture and influence actual health and use of health care. These distinctions might seem clear-cut, but people can simultaneously hold views grounded in different traditions. A patient might seek out traditional care for 1 type of complaint while seeking biomedical care for another complain, or both simultaneously. For example: yoga in the West and rise use Western medicine in Eastern cultures.
Culture-specific condition: Case in Zimbabwe: a woman is coughing and telegrams husband to come. Anthropologist Jacobson-Widding asks “Why not hospital?”. Woman was shocked, what could the doctor possibly do? Only her husband could help. Explained that she just had a miscarriage. Husband was in military service in the capital Harare, you know what men will do then ... Now that cough chirindi. His escapades would only worsen her hot condition. He had to come home immediately to sleep with her and lower the heat. Otherwise, she might die.
Culture-specific condition: Menopause (overgang): hot flashes, vaginal dryness, trouble sleeping and mood changes. A western, culture specific condition. Diagnosis does not exist in Asian cultures. Prevalence of individual symptoms also much lower in Japan. Women who see menopause as a medical condition rate it significantly more negatively than those who view it as a life transition or a symbol of aging. We can interpret the same sensations and experiences in different ways depending on culture, leading to different diagnoses and treatments .
Culturally different experiences of pain
Ethnic/ racial group differences in experimental pain perception: African Americans consistently lower pain tolerance and often lower pain threshold than non-Hispanic whites. May be influenced by: genetic differences, methodological factors (e.g., biased sampling), language issues, life-experiences.
Opioid crisis: Increase use (strong) pain killers. E.g., increase prescription opioid oxycodone from 2.8% in 2010 to 14.2% in 2017. Opioid crisis in USA (130 deaths a day, 2.1 million w opioid use disorder), also increasing in Nl. Possible reasons: 1) Changing views on pain – not wanting to accept pain as part of life; 2) Misperception of addictiveness; 3) Hospital quality judged based on pain scores. “Emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs.”
Dutch views upon seeking help from a doctor: Wait-and-see attitude: Patients wait before they call upon a doctor. Doctors are reluctant to prescribe medication or refer to a specialist. In, for example, Japan and Greece, one will contact a doctor much more quickly and receive medication, including antibiotics.
Mouth caps are commonly used in Japan. Why? To prevent spreading diseases such as cold and to protect from smog. But also: against the winter cold, prevent interaction with strangers (like earplugs), to protect privacy, to not show you didn’t put make-up or shave, fashion.
Culture & placebo effects: Ulcer disease. Improvement rates upon placebo use: Brazil 7%; Denmark & Netherlands 22%; Germany 59%. Unclear what explains these differences. To complicate matters: the placebo effect for lowering blood pressure was lowest in Germany of 32 countries examined. So cultural differences can be specific to different conditions
Placebo prescription: Frequency of placebo use in Germany, USA, UK, Sweden, Israel etc. The proportion of physicians who used a placebo (ever or min. 1x a year) varied between:
1. 17% - 80% for pure placebos (6 studies);
2. 54% - 57% for impure placebos (2 studies)
3. 41% - 99% if both pure and impure placebos were addressed (5 groups of physicians in 3 studies)
Great variability: might be partially explained by cultural differences between countries, physician’s specialization (e.g., primary care vs hospital), but ... also substantial differences in methodology (esp. specific questions asked) -> ongoing research.
Take culture into account: Vast majority of research on prevalence and appearance of illness, health behaviour, and treatment uses western (or even WEIRD) samples and grounded in western culture. WEIRD = White, Educated, Industrialized, Rich, and Democratic. Often general conclusions drawn or implied form research in these WEIRD samples. But studying people from 1 culture to draw inferences about all these factors can lead to biases and incorrect conclusions. Important to do cross-cultural research
to understand universal and culture-specific principles in health and to provide adequate care -> Include members of different culture not just as participants, but also as researchers.
Key points overall
Commonalities and cultural differences in:
- Body-image - what is perceived as attractive Biology - weight, length, age
- Life-style & health behaviour
- Health & Medicine
- Views on health and illness
- Views and use of health care
Our bodies, our health is influenced by culture in many aspects and many ways not static.
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Lecture 5: Intercultural communication in serious illness
Lecture 5: Intercultural communication in serious illness
What is serious illness is and what the role of communication in serious illness is
There is no direct explanation but, a serious illness can be explained as a condition that carries a high risk of mortality, negatively impact the quality of life and daily function, and/or is burdensome in symptoms, treatments or caregivers stress.
Examples of serious illnesses: cancer, dementia, heart failure, diabetes, lung diseases.
Importance of communication: The moment patients are diagnosed, they need good communication: what is going on, what are their options, feel they are seen, someone is caring for them (patient and family).
Patient: Priority: complaints; Outcomes: satisfaction, bereavement outcomes, how they're loved ones feel after they died.
Healthcare professionals: Intrinsic motivation: we all have intrinsic motivation for good communication. But it is difficult, especially breaking the bad news. Poor communication is related to burnout.
Communication errors are related with culture.
In the Netherlands there is a lot of focus on what the patient wants, the family comes second. Autonomy: discuss everything with the patient first, and then maybe the relatives. Don't speak about the patient without his/her permission. Tell everything clearly and honestly. The patient decides, not the family. A lot of cultures are more family-centred.
The stress-coping model of communication
It really about the 'need to know' (cognitive information) and the 'need to feel known' (affective empathy).
Cultural differences in serious illness perceptions
Illness attributions: When facing serious illness, patients attribute these illnesses to several causes. Where you attribute the illness to, is dependent of the culture.
Study among White British vs Black Caribbean MS patients in London. Two illness attributes: genetic/medical/environment vs supernatural. How people attribute their illness, could also change the information you have to give.
The role of religion: religion can play a large role in illness perceptions. Islam: disease can be a divine test and only Allah knows and need to continue aggressive treatment. Christianity: only God knows.
Knowing about these attributes/motivations is important to decide what patients need to know.
Cultural differences in patients' need to know
Legal aspects
WGBO (law): in NL doctors have the duty to inform patient as clearly as possible, if necessary, by using an interpreter. But also, the patient has the right to not know. Professional secrecy: is a patient's right: the patient decides with whom medical information can be shared.
Case study: Would you tell a 75 years old patient with cancer his life expectancy? Sweden: almost 100% would tell the patient. The Netherlands almost 90%. Belgium around 70% and Italy around 50%.
Patients need for information
Patients need for information to satisfy their 'need to know'. However, need differ between patients and change over time. It is really about tailoring.
Study Moroccan/Turkish attitudes about informing about diagnosis/prognosis. Systematic review by Graaff et al., 2012 looked at communication experiences/perceptions of Turkish and Moroccan patients with serious illness. These are the biggest groups in the NL
Patients’ attitudes
- A subset of patients does not want to be informed, mainly elderly
Turkish patients: 15-33% do not want to be informed about diagnosis/prognosis. Elderly patients do not want to be informed. Younger patients want to be informed but would not inform relatives.
- A subset of patients is indeed not informed
16-63% of Turkish patients were uninformed. 33% of Moroccan patients were uninformed. Also, in the NL, not all Turkish/Moroccan patients are informed
- The manner of being informed is important
The Dutch directness of information-provision is disliked
Relatives’ attitudes
- Family plays an important role in (not) informing patients
Numbers: 39-66% of Turkish relatives did not want patients to be informed of a bad diagnosis/prognosis. 89% of Moroccan relatives informed (compared to 33% of patients)
Reasons preference uninformed: upsetting nature, believing patients do not want to know, might hasten death, might stir gossip
Clinicians’ attitudes
- Clinicians not always inclined to inform patients, depends on several factors
Majority of Turkish oncologists (67-93%) thought that patients should be informed, many informed relatives (8-30%). Turkish physicians are more inclined to inform patients with higher SES/educational level. Trained and experienced clinicians more inclined to inform patients
- Dutch clinicians find it difficult to meet communication needs
Due to e.g. patients’ lack of knowledge & cultural patterns
Conclusion attitudes: A subset of patients does not want to be informed (eg elderly) and are indeed not informed. Family can act as gatekeeper, due to several reasons (believing patients don't want to know). Clinicians not always inclined to inform (esp untrained/younger). Dutch clinicians struggle with how to inform.
Family gatekeeping: sometimes the family determines what the patients’ needs to know, for example when the family needs to translate for the patient, they can decide which information they tell the patient. It falls under the rights of the patient to not know.
To summarize so far: stress-coping model of communications helps explain communication needs in serious illness. Serious illness attributes influenced by culture. Patients have a need to know, which give legal difficulty: right tot (not) know and cultural norms influence communication.
Explicit vs general prognostic information
Patients' attitude: Most patients want to know everything, but 20-40% prefers to remain - partly - ignorant about their prognosis.
Physicians' attitude: Reluctant to discuss time-frames. Often implicit discussion about prognosis and death, not often explicit wording used.
Preference explicit information: there is a lot of om ambiguity around what people want to know. Examples:
- "if a physician says 'Madam, in your situation, with your cancer cells and metastases we know that…'. It would be useless to hear that I will die between 1 and 10 years from now. That's not concrete enough, so they'd better say nothing then. If they say 'It's 3 years, give or take a year or two' … Yes, that is what I want to know."
- "If he says, 'there is nothing we can do', then I understand the message. You know, you know... Whether it will be 3 months, that matters of course, but he doesn't have to tell me that."
Video-experiment of valid role-played videos in which explicitness of prognostic information was manipulated. Breast cancer patients/survivors (n=51) and healthy women (n=53) participating, of which n=17 ethnic minority. Put themselves in shoes of video-patient and judged communication. --> More explicit information was more preferred; it doesn't mean that all the patients prefer it.
Explicit prognostic disclosure in Asia non-disclosure and family-centred communication is typical in Asia. Little is known about effect explicit prognostic information in Japanese women. The same kind of results were found. Explicit information gives more satisfaction and takes away some anxiety.
Clinical applications: Keep culture into consideration: ask patients and family about preferences. Be careful with prognosis, any objections with nearly all faiths (you can't take hope away, miracles can happen, a doctor doesn't know it all either). Hope for the best, prepare for the worst.
Language barrier: the importance of a professional interpreter
Informal interpreter: often family member or friend, doesn't translate everything (shame). Is unable to translate medical words to own language.
Formal interpreter: is independent, professional secrecy, can translate everything (except body language), by telephone or live.
Language problems can impede joint decision making.
Cultural differences in patient's need to feel known
What is empathy: feeling with people; I know what it is like, a connection can make something better. Never: "at least you had a son" (when the son died) or trying to put a silver lining around it.
What is important in a clinician:
- Immediate: Empathic responding to patient cues increases satisfaction, quality ratings
- Short term: perceived empathy in bad news consultations increases satisfaction.
- Long term: reassurance and discussion of patients' feelings during a cancer diagnosis consultation, decreases anxiety up till 1 year.
Empathy can provide hope. Reassurance about non-abandonment specific form of hope.
The broader effect of empathy
Patients' memory is poor: 40-80% of the information is forgotten. Can affective communication recall? Suggested pathway: via decreasing physiological arousal. People remembered more in the affective condition.
Non-verbal empathy
Importance and role of non-verbal communication might depend on culture. Non-verbal empathy might be more important in Eastern than Western cultures: more eye contact, less physical distance, clinician body oriented to patients, more smiling. Be aware, not all cultures appreciate eye-contact.
Better effects in the 'high' conditions (more eye contact, more smiling).
Patients' need to trust clinicians. Indications that immigrant patients have lower levels of trust. Is trust for immigrant patients more dependent on eye-contact, posture and smiling? Research found nothing.
Japanese replication study: higher levels of eye-contact led to a higher rating of trust and compassion. Non-verbal communication was more appreciated.
Clinical applications: empathy is important for patients. Verbal empathy (eg reassurance) can decrease stress, increase satisfaction and recall. Importance nonverbal empathy might depend on culture, but eye-contact, body posture and smiling seem to benefit most patients.
Summary
- Stress-coping model of communication helps explain communication needs in serious illness.
- Serious illness attributes influence by culture
- Patients' have a need to know and need to feel known (cross-culture)
- There are legal issues around the patients' need to know. Cultural differences in information needs and norms (family-centeredness), need to tailor explicitness (prognostic) information.
- Verbal and non-verbal empathy can influence patient outcomes universally
To conclude: Cultural attitudes/norms/needs need to be taken into account when communicating. But the need to know and feel known is universal. Ask patients and families about preferences.
Cross-Cultural Psychology of Health and Illness (18/19)
Cross-Cultural Psychology of Health and Illness (18/19)
Notes of the lectures for Cross-Cultural Psychology of Health and Illness (CCPHI) 2018/2019. If you want a word document of the notes, leave a comment and I can send them to you! :)
Lecture 3: Emotions, Motivation and Acculturation Stress
Lecture 3: Emotions, Motivation and Acculturation Stress
Emotions
Started with Darwin: Emotions and emotional expressions are universal; everyone has the same. Later there was discovered by Ekman & Friesen that there were six basic emotions: happiness, surprise, sadness, disgust, fear and anger.
How did they do the research: They asked different people, who have never met, how they would express certain sentences. These were checked with different societies.
Assessing universality: in particular, pride has been proposed to be universally recognized expression. Pride is different in that it involves much of the body, not just the face: erect posture, head tilted back, slight smile, arms extending away. Even people who are born blind, show this emotion.
What is an emotion: face, posture, subjective feeling, caused by the environment, combination of physiological reaction and cognitive,
Perspectives on emotions
- James-Lange Theory of Emotion: there is some kind of stimulus--> physical reaction from your body, cannot prevent it from happening --> emotion
- Stimulus/situation --> response --> subjective feeling
- This theory states that if there is no physiological response, there is no emotion.
- Two-Factor Theory of Emotions: Response can also be because of something else. Two different situations can lead to the same response. The interpretation makes it the emotion. Emotions are interpretations of our physiological responses. How do you attribute it? (Zie bb voor model)
Universality vs cultural variability
The JL theory predicts that emotions should be universal due to physiological similarities of all humans. If JL was right, then emotions would be universal, the same in every human being.
The Two-Factor theory predicts that emotions should vary across cultures because different cultural experiences may lead us to have different interpretations of physiological responses. If the Two-factor theory was right and it would depend on how you would interpret it, then not universal.
Do differences in emotional expressions affect emotional experiences, too?
Do people experience emotions the same? Is there a link with how emotions are expressed and how they are felt? If that is true, then you could either feel the emotion and express it and express the emotion and feel it. If the second thing is the case, then you could influence how you feel.
Facial feedback hypothesis provides one reason to expect cultural variability. The hypothesis proposes that we use our facial expression to infer our emotional state. This suggests that by making a particular emotional expression, we can think that we are experiencing the corresponding emotion. Pencil test: it suggests that our facial expressions can affect our emotional experience. This means that people who express their emotions more intensely could feel different. So: if our culture had rules regarding the intensity of our expressions (display rules), they may also affect the intensity of our emotional experiences.
Display rules dictate the intensity of expressions, when an expression is appropriate (norms learned early in life), what is accepted. Emotions are recognized correctly more often in someone from the same culture. People's brains show a greater response when seeing p.e. a fear expression on the face of someone from the same culture.
What is accepted in a culture differs a lot between individualistic cultures and collectivistic cultures.
Individualistic cultures --> the individual --> p.e. European-Canadians physiological response report feeling intense anger slow recovery of increased blood pressure.
Collectivistic cultures --> the harmony of the group --> p.e. Asian-Canadians physiological response report feeling less anger, quick recovery of increased blood pressure.
Either they experience less anger, or they report less anger or they have effective strategies (have learned better in their culture) to minimize their anger.
Expressing emotions: Physical is the same, reported intensity is the same, but how it looks is different. It appears that our bodies react the same way, culture doesn't play a role.
Life satisfaction and happiness
Cultural differences in subjective well-being can be affected by several factors:
- Wealth
- Human rights and equality
- Definition of life satisfaction
- Individualistic countries --> amount of positive emotions
- Collectivistic countries --> relate that more to how much they are respected by others for living up to norms
- Theory regarding how happy cultures think they should feel
Money: having more money makes you happier up to a certain level, above that level it doesn't matter how much money you have. Latin American countries relatively feel well, but the income/wealth is lower. That might be related to specific traits or specific upbringing.
Culture and happiness
Cultures also vary in terms of the importance that they ascribe to happiness. When presented with either a game that was fun but not useful or a game that was useful but dull: European-Canadians preferred the fun game, Asian-Americans preferred the useful game.
- Euro-Americans go for HAP emotions: enthusiastic, elated, excites, euphoric (the preferred state).
- East-Asians go for LAP emotions: relaxed, calm, peaceful, serene (the preferred state).
Benefits of happiness differ cross-culturally. Cultural difference due to preferred states, not actual states. The preferred state of emotions: the more positive emotions, the less depression (Euro-Americans). Asian-Americans don't show this effect.
Conclusion Emotions
Emotion can be examined by focusing on different aspects of emotion (expression, interpretation, experience, display, reporting). Each focus leads to different conclusions about universality and cultural variability.
Universal ---> Different:
- Physiological process (arousal)
- Experience (interpretation)
- Display or hide expression (display rules)
Motivation
Any condition that initiates, activates or maintains the individual's goal-directed behaviour.
Prevention orientation: one tries to avoid negative outcomes. Eg studying because you want to avoid having to do a non-interesting job in the future. Acculturation example: trying not to lose the values of your home-country. --> focus on weakness to avoid future failure
Promotion orientation: one strives to secure positive outcomes/ trying to obtain something that you value. Eg studying because you want to find a well-paying job in the future. Acculturation example: trying to learn the language soon after migration to obtain a sense of belonging. --> focus on successes to strive for advancement
Persistence after success or failure
Individualistic cultures: more likely to persist after success
Collectivistic cultures: more likely to persist after failure
Face: social value given by others if one fulfils obligations and expectations. Very well known in collectivistic cultures: fitting in in the societal norms to gain face. Others feeling good about you when you have things that are valued by society. So, brand-items (Gucci bags) become important to gain face. It is important to note that face is more easily lost than gained.
Different motivations: Cultures concerned more with face: people have more of a prevention orientation than a promotion orientation. Rather than focusing on feeling good about oneself, people in collectivistic societies focus on others feeling good about them. But not for all motivations!
Maslow's hierarchy of needs: basic needs are universal, no cultural differences. The more to the top will cultural diversity play a bigger role.
Control
Implicit theories of the world
- Entity theory: the world around you is kind of fixed, beyond your ability to change it
- Incremental theory: the world is flexible and responsive to your own effort
Primary control strategies: If you think your actions will be able to change the world (internal locus of control) = more common in the West
Secondary control strategies: External locus of control (the world is fixed, you should adjust) is more common in the non-western countries.
Conclusion Motivation
Concerns about face in some cultures lead them to have a prevention orientation, which is contrasted with having a promotion orientation. Motivations for behaviour (eg coping) is culturally diverse and related to p.e. control orientation.
Acculturation stress
Acculturation: adapting or not adapting to a new culture
Acculturation stress: the consequences of acculturation can be big: anxious feeling; sadness; moodiness and irritability/restlessness; insomnia; obsessive about work/school; feeling isolation or loneliness; homesickness; lower self-esteem; poor work performance; concentration problems; preoccupation about going home; continuous fear about people, food, water; increased criticism and even hatred of the local culture.
Why is migration stressful?
- The cause can be the stressor, sometimes there is war in the home country
- Migration itself
- Consequences of migration: adapting to the new customs
- Acculturation problems: experiences of loss and of conflict.
What happens when we migrate: At first: the honeymoon face experiencing a new environment, meet new people. Second: culture shock, the differences start to kick in, I like it but... And last: adjustment.
Lazarus stress model:primary: threat in terms of wellbeing (aversiveness), secondary: controllability and predictability of threat and also duration, consequences: social, psychological and physical.
there is a stressor --> person evaluates --> depended on the first appraisal, second appraisal --> stress pops up or not --> when it does: coping strategies (zie model bb).
Push and pull factors
- Push: conditions that drive people to leave their country
- Pull: driven/attracted to certain things in the new country
Cultural distance: how much two cultures differ in their overall ways of life. One line of evidence comes from language - the closer one's mother tongue is to English, the easier it is for them to learn English. Similarly, the more similar one's heritage culture is to the host culture, the less acculturative stress they experience.
Cultural fit: the degree to which one's personality is more similar to the dominant cultural values in the host culture. Evidence suggests that people who are high in extraversion fare well in largely extraverted cultures but have problems fitting in the less extraverted cultures. People with more independent self-concepts suffer less distress in acculturating to the US than those with more interdependent self-concepts.
Acculturation strategies: Two issues with implications for outcome of acculturation: attitude toward host culture and attitude toward heritage culture. These two lead to distinct strategies that affect the acculturation experience.
| Strong identification with host culture | Weak identification with host culture |
Strong identification with heritage culture | Integration / alternation Only good option | Separation Distance from majority |
Weak identification with heritage culture | Assimilation Criticize own minority | Marginalization Living in isolation |
- Integration: positive attitudes toward host and heritage culture. Participate in host culture while maintaining traditions of heritage culture. Most successful strategy - least prejudice and greatest social support.
- Separation: negative toward host but positive attitudes toward heritage culture. Minimal participation in host culture while maintaining traditions of heritage culture.
- Assimilation: positive attitudes toward host but a negative attitude toward heritage culture. Participation in host culture while leaving behind traditions of heritage culture.
- Marginalization: Negative attitudes towards host and heritage culture. No effort to engage with host and heritage cultures. Rare and least successful strategy. May characterize third culture kids.
Migration might do something to your self-concept. For biculturals, the multicultural experiences impact the self-concept in two ways:
- Blending: people's self-concepts reflect a hybrid of their two cultural worlds. Evidence suggests that, for the most part, multicultural people appear intermediate on many assessments compared to monocultural people from different cultures.
- Frame-switching: people maintain multiple self-concepts and switch between them depending on the context. Rather than blending two self-concepts, people switch between them. Such self-concepts are represented by a network of ideas in the mind.
Conclusion Acculturation
Acculturation is an extremely difficult topic to study (big variation in acculturation experiences), but due to the consequences still important. Attitudes towards host culture: U shaped, predictable phases over time, 4 acculturation strategies. Small cultural distance and a good cultural fit facilitates the integration process (less stressful). Confrontation with two (or more) cultures --> mainly two strategies occur: blending or frame-switching.
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