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Cultural differences. Health Psychology. The value placed on health.

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Cultural differences

Health Psychology


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The value placed on health

  • Although people around the world value good health, people in some countries, such as France and Italy, seem to feel that health is more important than do people in other countries, such as Lebanon and Turkey (Diaz-Guerrero, 1984). It seems reasonable to assume that the more people value their health, the more likely they are to take care of it.


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Causes of illness

  • The ideas people have about the causes of illness also show changes across history and culture. In the Middle Ages people thought evil spirits were responsible for illness. Today, educated people in technological societies generally reject such ideas. But less sophisticated people often do not, as the following excerpt shows:


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Causes of illness

  • I’ve heard of people with snakes in their body, how they got in there I don’t know. And they take ‘em someplace to a witch doctor and snakes come out. My sister, she had somethin’, a snake that was in her arm. She was a young woman. I can remember her bein’ sick, very sick, and someone told her about this healer in another little town. And I do know they taken her there. This thing was just runnin’ up her arm, whatever it was, just runnin’ up her arm. You could actually see it. (Snow, 1981, p. 86).


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Religion

  • Religion is an aspect of culture. Many religions in the United States include beliefs that relate to health and illness. For instance, Jehovah’s Witnesses reject the use of blood and blood products in medical treatment (Sacks & Koppes, 1986). Christian Scientists reject the use of medicine totally, believing that illnesses are cured only by mental processes in the sick person. As a result, the sick person needs prayer and counsel as treatment to help these processes along (Henderson & Primeaux, 1981).


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Religion

  • Some religions include specific beliefs that pro­mote healthful lifestyles. Seventh-Day Adventists, for example, believe that the body is the “temple of the Holy Spirit.” They cite this belief as the reason people should take care of their bodies. Adventists abstain from using tobacco, alcohol, and nonmedically prescribed drugs. In addition, they promote in fellow members a concern for exercise and eating a healthful diet (Henderson & Primeaux, 1981).


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The health of ethnic minorities

  • The health of ethnic minorities has been largely ignored or unrecognised. There are two main reasons why this state of affairs has developed in this country,

  • (i) When mass immigration from the Caribbean and Asia started to this country after the Second World War (1939 - 1945), concerns were expressed that “new” immigrants brought disease into the country and created the risk of epidemics. Research, however, failed to support this and so the health service lost interest in ethnic health.


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The health of ethnic minorities

  • (ii) Changing view of ethnic minorities; as the ethnic groups became established in Britain, they were no longer seen as newcomers or classic immigrants. Instead they were viewed as just another part of the community without any specific needs.


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The health of ethnic minorities

  • McNaught (1987) argues, however, that people from ethnic minorities do have specific needs, including:

  • (a) genetic issues, for example sickle cell disease, diabetes

  • (b) incidence of common disorders, for example above average levels of hypertension and stroke (Africa and Caribbean), heart disease and diabetes (Asia)

  • (c) interaction with health workers, for example the ways we describe illness


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Different types of culture

  • Hofstede (1980) identified four basic dimensions which can he used to compare different cultures:

    • 1 power-distance; which is to do with how far people in authority are expected to exercise their power. For example, do you consider your boss to he a colleague, or does he or she seem to be much more powerful than you?


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Different types of culture

  • 2 uncertainty-avoidance, which is to do with how far people like things to be clear and orderly, with everyone knowing their place. People in some cultures, (though not British culture) can tolerate a high level of change and uncertainty, and do not experience anxiety and stress as a result.

  • 3 individualism: which is to do with how far the culture encourages personal (or individualistic) ambitions and concerns, and how far people are seen as members of a collective group.


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Different types of culture

  • 4 masculinity-femininity; Hofstede suggested that masculine cultures emphasise performance and money above all else, whereas feminine cultures value the quality of life, and consider environmental issues to be important.


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ontologies of suffering

  • Shweder et al (1997) describes 7 general systems of understanding, which they have turned into ontologies of suffering.

  • (ontologies refer to different ways of describing and understanding knowledge about suffering, in this case)


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TABLE1Causalontologiesofsuffering (Shwederet al.,1997)

Causal ontologies

Explanatory references

Therapy

Biomedical

Western: genetic defects, hormone imbalances, organ pathologies, physiological roots, impairments

Non-western: humours, bodily fluids, juices

Direct or indirect ingestion of special substances, herbs and vitamins, chemical compounds

Direct or indirect mechanical repair (e.g. surgery, massage emetics) of damaged fibres or organs

Interpersonal

Western: harassment, abuse, exploitation

Avoidance or repair of negative interpersonal relations

Sociopolitical

Non-western: sorcery, evil eye,

Oppression, political domination, adverse economic or family conditions

Talismans, magic black magic

Social reform

Psychological

Unfulfilled desires and frustrated intentions, forms of fear

Intrapsychic and psychosocial interventions, e.g. meditation, therapy

Astrophysical

Arrangement of planets, moon or stars

Wait with optimism for change

Ecological

Stress, environmental risks

Reduction of stress and environmental hazards

Moral

Transgressions of obligation or duty, ethical failure

Unloading one’s sins, confession reparation


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Ontologies of suffering

  • Murdock (1980) conducted a survey of the explanations of illness in 139 societies. He found that in Africa there was a preference for explanations based upon moral transgressions. In East Asia, the preference was for interpersonal explanations and in the Mediterranean region he found that witchcraft explanations for death and suffering were widespread.

  • Park (1992) suggested that the three worldwide explanations for health were interpersonal, moral and bio medical.


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Ontologies of suffering

  • In Western societies the dominant moral discourse is autonomy, which focuses on the rights of the individual. As Porter (1997) argued: “the West has evolved a culture preoccupied with the self, with the individual and his or her identity, and this quest has come to be equated with (or reduced to) the individual body and the embodied personality, expressed through body language”. So in health care the rights of the individual patients have paramount importance.


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Ontologies of suffering

  • Individualistic cultures emphasise the separateness and uniqueness of its members whereas collectivist cultures emphasise group needs and inter-connectedness (Matsumoto et al. 1996). For example, in Hindu society the community and divinity discourses are more prominent. An understanding of these dimensions is important for understanding cultural variations in health belief systems.


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Ontologies of suffering

  • Different societies have developed various health belief systems. Sometimes the knowledge is confined to experts such as doctors and nurses. So there are expert or technical belief systems as opposed to the traditional folk or indigenous systems. The systems interact and are in a process of constant evolution.


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Ontologies of suffering

  • Kleinman (1980) proposed three overlapping sectors to describe any health care system: the professional, the folk and the popular. The professionals would be people like doctors and nurses, the folk sector refers to the non-professional, non-bureaucratic, specialist sector (e.g. fringe medicine) and the popular sector refers to the beliefs held amongst ordinary people (lay beliefs).


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Chinese views of health

  • The Chinese perspective views health as the result of a balance between and within the various systems both internal and external to the person. Disease is perceived as the consequence of disharmony or disequilibrium. This view of health and illness reflects a broader worldview which emphasizes interconnectedness and balance (Quah and Bishop, 1996). Chinese medicine rests upon the religion and philosophy of Taoism.


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Chinese views of health

  • According to this view the universe is a vast and indivisible entity and each being has a definite function within it. Each being is linked in a chain in harmony. ‘Violating this harmony is like hurling chaos, wars, arid catastrophes on humankind — the end result of which is illness’ (Spector, 1991, p. 243). The balance of the two basic powers of yin and yang governs the whole universe including human beings.


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Chinese views of health

  • Yin is considered to represent the male, positive energy, which produces light and fullness. Conversely, yang is considered the female, negative force, which leads to darkness and emptiness. A disharmony in yin and yang leads to illness. A variety of methods including acupuncture and the use of herbal medicines can be used to restore this harmony.


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Chinese views of health

  • Within Chinese culture human suffering is traditionally explained as the result of destiny or ming. Cheng (1997) 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’ (p. 240).


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Chinese views of health

  • 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.


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Chinese views of health

  • Buddhist and Taoist beliefs are also reflected in Chinese medical belief systems; for example, good deeds and charitable donations 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 — reciprocity and retribution (Cheng, 1997). In mutual relationships reciprocity or give and take is expected. When this does not occur some form of retribution will take place.


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Chinese views of health

  • These views of health and illness are not only codified within Chinese medicine but influence everyday lay beliefs about health and illness both in China and in Chinese communities around the world. Several examples illustrate this. Cheng (1997) conducted interviews with a sample of Chinese workers in Hong Kong who had sustained hand injuries. He found that many of the workers, especially the older ones, explained their injuries in terms of fate or predestination. For example, one worker said:


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Chinese views of health

  • ‘The injury was predestined. You were bound to be hurt no matter how careful you were. Something like a ghost blinded your eyes. No way for you to be careful! It couldn’t be escaped in any way!’


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Chinese views of health

  • Others referred to the role of retribution for some wrong, which the individual may have committed in a previous life. One mentioned the role of his pa-tzu or horoscope. Admittedly, this did not mean he was condemned to misfortune. If he changed his life course then the pairing with his pa-tzu may become more harmonious. His belief in the role of fate enables the person to escape blame for the event but still maintain a belief that they have control over their lives.


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Childbirth pain and culture

  • A further example of the different descriptions of experience and symptoms comes form cross-cultural studies of childbirth. Taylor (1986) gives a brief summary of these differences and describes how in some cultures, for example Mexico, women have an expectation that childbirth will be painful.


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Childbirth pain and culture

  • The Mexican word for labour (dolor) means sorrow or pain in contrast to the English word, which means work. Taylor suggests that this fearful expectation is followed by painful deliveries with many complications. In contrast, Taylor cites the culture of Yap in the South Pacific where childbirth is treated as an everyday occurrence. Yap women are reported to carry out their normal tasks until they begin labour, at which point they go to a childbirth hut and give birth with the assistance of one or two other women.


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Childbirth pain and culture

  • After the birth, there is a relatively brief rest period before the woman resumes her regular tasks. In this community, complications are reported to he rare. Taylor suggests that expectations are an important factor in the experience of childbirth, and these expectations come from cultural stories and customs.


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African medical systems

  • In Africa, a wide range of traditional medical systems continues to flourish. These include a mixture of herbal and physical remedies intertwined with various religious belief systems.


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African medical systems

  • As Porter (1997) notes, belief systems which attribute sickness to ‘ill-will, to malevolent spirits, sorcery, witch­craft and diabolical or divine intervention . . . still pervade the tribal communities of Africa, the Amazon basin and the Pacific’ (p. 9).


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African medical systems

  • In a more developed assessment Chalmers (1996) summarized the African view as reflecting ‘a belief in an integrated, independent, totality of all things animate and inanimate, past and present’ (p. 3).


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African medical systems

  • As with other traditional health systems a central concept is balance. ‘Disturbances in the equilibrium, be they emotional, spiritual or interpersonal, may manifest in discordance at any level of functioning’ (Chalmers, 1996, p. 3).


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African medical 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.


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African medical systems

  • In addition, magical influences can be 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.


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African medical systems

  • Rather than the individualistic orientation of western society, 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 or her family or community. ‘The nuclear family, the extended family, the community, the living and the deceased as well as their ultimate relationship with God are intimately linked in the African view of health and illness’ (Chalmers, 1996). Thus intervention may be aimed not only at the sense of balance of the individual but also of the family and the community.


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African medical systems

  • Horton (1976) described how traditional medical treatments in Africa focus on social factors even when diagnosing infectious diseases. ‘They look for the person who has fallen out with the patient, and who might therefore have “cast a spell” on them. This seems bizarre to Western minds, yet actually makes perfect sense when the person is seen in a more holistic context. In a traditional society, with a relatively high rate of infant mortality, those who grow to adulthood tend to have a high natural immunity to disease.


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African medical systems

  • So if someone falls sick, the question is not where the germ came from, but how his or her immune system has been weakened to the extent that the illness can take hold. Research suggests that one of the consequences of prolonged stress is to reduce the effectiveness of the immune system. In traditional communities the primary sources of stress comes from disturbed interactions with other people. So when the traditional medicine practitioner tries to find out whom the person has quarrelled with lately, and to solve their dispute and so lift the spell, this is actually an extremely practical method of treatment.


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African medical systems

  • As with other medical systems, immigrant communities have brought their health beliefs to their new countries of residence. Landrine (1997) criticized studies of North American health beliefs, which have largely ignored the distinctive culture of black Americans. Semmes (1996) noted that African slaves maintained their pre-slavery health beliefs, practices and indigenous healers.


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African medical systems

  • When they gained emancipation black Americans found they were denied access to medical care. As a consequence they relied on their indigenous healers and over time developed a unique African-American folk medicine. He suggests that in contemporary North America many blacks are returning to this medical system as they feel rejected or excluded by what they perceive as the racism of white American health care.


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Australian aborigines

  • McElroy & Townsend (1985) cite an account of the acute terror experienced by an Aborigine who believed he was the victim of an attack by a ‘sorcerer’ and that death was inevitable.

  • The man who discovers that he is being boned by an enemy is indeed a pitiable sight.


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    Australian aborigines

    • He stands aghast, with his eyes staring at the treacherous pointer, and with his hands lifted as though to ward off the lethal medium, which he imagines is pouring into his body. His body begins to tremble and the muscles twist involuntarily.


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    Australian aborigines

    • He sways backward and falls to the ground, and after a short time appears to be in a swoon; but soon after he writhes as if in mortal agony. From this time onwards he sickens and frets, refusing to eat and keeping aloof from the daily affairs of the tribe.


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    Australian aborigines

    • Unless help is forthcoming in the shape of a countercharm, his death is only a matter of a comparatively short time.


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    Australian aborigines

    • The man is neither poisoned nor shamming. McElroy & Townsend (1985) say that when such patients are admitted to hospital they do not respond well to treatment. In one case of ‘boning’, a man refused to eat and drink until he died.


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    Australian aborigines

    • The doctors decided that his death was suicide through voluntary rejection of fluids. His tribe, however, believed he had died because he had broken a taboo. Another explanation of his behaviour is provided by the reformulated learned helplessness theory.


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    Australian aborigines

    • The faulty cognitions of the man have led him to believe that there is no way out of the spell and he must die. It does not matter what he does; the outcome is death.


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    Australian aborigines

    • These negative cognitions are thus responsible for an individual’s demise, just as positive beliefs have been found to contribute to the efficacy of hypnosis and acupuncture.


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    Exercise and activity

    • Sport is particularly promoted in North American society. There the muscular physique is presented as the ideal male form. Luschen et al (1996) notes that the emergence of bodybuilding exercises which are aimed at building muscular strength and fitness “reflects a bodily culture that is in line with American values of masculine prowess”.


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    Exercise and activity

    • They add that “activities like American football, weights lifting, and boxing set a premium on brute physical force and places much less emphasis on endurance and relaxation”.


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    Exercise and activity

    • Access to fitness gyms is restricted to those with money although there has been a move in some countries to make exercise the subject of a doctor’s prescription, for example, in the UK.


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    Exercise and activity

    • Aggressive sporting activities, such as rugby, are also promoted among the middle-class as a training ground for developing an aggressive business attitude and a way of making useful social contacts.


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    Exercise and activity

    • Certain forms of Christianity have traditionally held a negative view of excessive concern about the body. It has been suggested that this is a reason for the poorer performance of Catholic societies in sporting events (Curtis and White, 1992).


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    Exercise and activity

    • Conversely, in more Protestant or secular societies concern with the body shape and performance is promoted.


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    Longevity: cross cultural differences

    • In the USA and the UK only three people out of every 100,000 live to be over 100. In Georgia, among the Abkarsians, 400 out of every 100,000 people live to be over 100, and the oldest recorded Abkarsian was 170.


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    Longevity: cross cultural differences

    • Weg (1983) suggests that their longevity is due to the following factors:

      • genetics

      • vigorous work roles and habits

      • a diet low in saturated fat and meat and high in fruit and vegetables

      • they drink no alcohol, nor smoke nicotine

      • they have a high level of social supports

      • They report low stress levels.


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    Sociocultural differences in pain behaviour

    • Cross country comparison of behavioural and emotional functioning of chronic back pain

      • US – greatest overall impairment

      • Italians, NZ – 2nd greatest overall impairment

      • Colombian and Mexican – least overall impairment

      • Same objective degree of impairment


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    Sociocultural differences in pain behaviour

    • David Mechanic (1978) review

      • Jewish Americans more likely to seek help, accept sick role, do prevention

      • Mexican-American – ignore some major, magnify minor symptoms

      • Irish-American – stoic, deny pain


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    Ethnicity and Health

    • In the USA, Blacks suffer more from heart disease, cancer, liver disease, diabetes and pneumonia. They are also more likely to die from violence (Markides 1983). In Britain CHD amongst male Asians is 36% higher than the national average, and is 46% higher for Asian women.


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    Ethnicity and Health

    • The difference was most marked for Asians between the ages of 20 and 39 years; CHD rates were two to three times higher than whites (Balarajan and Raleigh 1993). For British Afro-Caribbeans the incidence of strokes amongst men is 76% higher than the national average and 110% higher for Afro-Caribbean women.


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    Ethnicity and Health

    • Mortality through hypertension is four times higher than the national average, and seven times higher for Afro-Caribbean women. Cancer rates have been lower amongst Afro-Caribbeans, but is now rising (Barker and Baker 1990).


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    Ethnicity and Health

    • There are also differences in health behaviour. American Black women smoke less and drink less than white women (Gottlieb and Green 1987). In the UK few women from ethnic minority groups smoke. Amongst men alcohol-related morbidity is high for Asians of Punjabi origin.


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    The interaction of genetics with lifestyle

    • Type II diabetes is a disorder, which appears to have a genetic component, but is also influenced by environmental factors like lifestyle and, in particular, diet. In the U.S.A. there are about 1.5 million people of Native American heritage.


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    The interaction of genetics with lifestyle

    • One of the dramatic changes in the health of this group of people has been the increase of diabetes, which was relatively unheard of before 1930 but has now reached almost epidemic proportions. In the Pima tribe, for example, it is estimated that half of the people over the age of 35 have diabetes.


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    The interaction of genetics with lifestyle

    • According to Kaplan et al (1993), the development of diabetes in these people is related to obesity. As people increase their weight so they increase their risk of developing Type II diabetes. It is possible that this group of people is genetically predisposed towards diabetes, but it only develops if the people become overweight.


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    The interaction of genetics with lifestyle

    • If these people maintain their traditional lifestyle then the diabetes does not develop. However, their lifestyle has changed due to the unemployment imposed on them by industrial society and, as a result, the diabetes comes out.


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    Ethnicity and body size.

    • Ethnicity and body size may also be as­sociated with- adolescents’ eating preferences. From a cultural perspective, African Americans have been shown to view individuals with larger body sizes more favorably than do Whites (Kumanyika, 1993).


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    Ethnicity and body size.

    • Research has demonstrated that about 50% of African American women are obese (Wadden et al., 1990). Although obesity is equally prevalent among White and African American females during child­hood, by adolescence the rate of obesity increases considerably for African American females (Wadden et al., 1990).


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    Ethnicity and body size.

    • According to the National Heart, Lung, and Blood Institute’s [NHLBI’s] Growth and Health Study (NHLBI Growth and Health Study Research Group, 1992) African American girls (ages 9—10 years) were significantly taller, heavier, and had greater central body skinfold measures than did White girls.


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    Ethnicity and body size.

    • Such differences in body size have been linked to earlier physical maturation in African American girls (NHLBI Growth and Health Study Research Group, 1992). For Mexican Americans, the prevalence of obesity is greater than in the general population and approximately 4 to 6 times higher than in Whites (Stern et al., 1982).


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    Ethnicity and body size.

    • Garb and Stunkard (1975) have also reported the prevalence of obesity to be very high among Navajo children. These data suggest that certain ethnic groups may be at greater risk for obesity; however, the specific influences of genetic and environmental factors are not yet known.


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    Poverty and health

    • 1. Those in the lower classes have more stresses in the form of daily hassles (Myers et al 1974).

    • 2. The less well off have fewer resources to mediate these stressors, and therefore less control over their environment. Lack of control being a source of stress (see stress notes).


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    Poverty and health

    • 3. Social support is less available to those in the lower social classes (Adler et al. 1994)

    • Overall it is the relative poverty that matters. People in Cuba are poor, but enjoy good health, because they are nearly all equally poor (Wilkinson 1992).


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    John Henryism

    • A study on hypertension found that Black men living in high stress environments (high unemployment, high crime, low incomes) had higher blood pressure than those living in low stress environments (James et al, 1987). This relationship between environmental stress and blood pressure was not found in White men.


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    John Henryism

    • James suggested that the high blood pressure was a response to an active coping style used by some Black men who tried to change their environment.


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    John Henryism

    • He developed a psychometric scale to measure this active coping style and named it the John Henry Scale, after a legendary Black worker who had battled against the odds to win a physical contest but then dropped dead from physical and mental fatigue.


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    John Henryism

    • James found that Black men who scored high on his scale of John Henryism were 3 times more likely to have hypertension


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    John Henryism

    • The coping strategy that is measured in this scale concerns gaining control over your life and changing your circumstances. For many people this is a sign of good health, and for the White men in the study, a high score on the John Henryism scale did not coincide with hypertension.


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    John Henryism

    • The Black men with the high score, in fact, tended to he satisfied with their lives and perceive their own health to be good.


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    John Henryism

    • James suggests that the attempt to heroically change your circumstances when you have very little power to make any real difference can have a damaging effect on your health. This makes an interesting addition to the discussion about locus of control.



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