The beginning of the 20th century featured an understanding of health that was dominated by a biomedical perspective, characterized by a reductionist point of view in which health was defined as the absence of illness. This view has long been replaced by a biopsychosocial model that emphasizes the role played by socio-cultural forces in the shaping of health (and illness) and related psychological experiences (Engel, 1977). In 1948, the World Health Organization (WHO) defined health as a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity, calling attention to the complexity and multidimensionality of the concept. Adding social well-being to the definition opened the way to conceptualizing the individual as a social being, with health being about more than mere physiology. This shift in the definition of health and the factors responsible for disease prevention and health promotion is mirrored by a shift in the study of health and illness in disciplines such as psychology that have traditionally focused on the individual as the unit of analysis and the force primarily responsible for avoiding disease and promoting well-being. In more recent psychological approaches to health and illness, individuals are increasingly viewed as part of a larger network of forces, significantly influenced by their socio-cultural environments (e.g., Helman, 2007; Gurung, 2010).

Developing a culturally sensitive and meaningful understanding of health and illness is important for both theoretical and applied reasons. From a theoretical standpoint, psychological models designed to understand health and illness are typically developed in the western parts of world and tested with local participants. Models can be expanded, modified, and improved by studying their generalizability across cultural groups. This exercise improves the validity of the scientific study of human psychology and thus enables models to develop and test culturally meaningful predictions.

Incorporating culture into the study of health and illness is also important from an applied standpoint. For example, developing interventions to improve health via promotive, preventive, curative, or rehabilitative activities is virtually impossible if this exercise is stripped of cultural knowledge. Further, health disparities, for example in the form of discrimination and prejudice in health care settings or vast differences in prevalence rates of certain diseases between different groups in a society, may be understood and tackled by having a better understanding of the cultural bases of such problems. Moreover, some diseases tend to be culture-specific, such as Hikokomori (prevalent in Japan) and anorexia (prevalent in developed western societies). Understanding the underlying reasons, ways of prevention and treatments for such diseases also necessitates a cultural approach to health and illness.

A framework for understanding cultural differences in psychology of health and illness

In the social sciences, culture has been defined in numerous ways. Most definitions refer to a set of contexts (e.g., structures and institutions, values, traditions, and ways of engaging with the social and nonsocial world (e.g., Shweder & LeVine, 1984) that are shared among members of a society and transmitted across generations through social learning (e.g., Richerson & Boyd, 2005). As can be seen here, such definitions of culture are typically broad and it is often difficult to decide how the concept of culture should be included in empirical work. Therefore, psychologists have proposed features of cultures to be used as organizing constructs. The most commonly used constructs to account for observed cultural differences and similarities in human psychology are individualism and collectivism (e.g., Hofstede, 1980; Kagitcibasi, 1997; Triandis, 1995). These constructs have been particularly useful for understanding cultural differences as to how people view themselves and their relationships with others. As we argue below, these differences are important in understanding cultural differences in health and illness related experiences.

In individualistic cultures, such as the United Kingdom or the United States, the dominant model of the self is an independent self characterized by self-defining attributes which serve to fulfil personal autonomy and self-expression (Hofstede, 1980; Kim & Sherman, 2007; Markus & Kitayama, 1991; Oyserman, Coon, & Kemmelmeier, 2002; Triandis, 1995). People are seen as agentic and thus responsible for their own decisions and actions. Moreover, in cultures shaped by individualism, individuals favour not missing chances over not making mistakes, focusing on the positive outcomes they hope to approach rather than the negative outcomes they hope to avoid (e.g., Lee, Aaker, & Gardner, 2000). Relationships are seen as freely chosen and relatively easy to enter and exit (Adams, 2005).

By contrast, in collectivistic cultures, such as many East Asian cultures, the dominant model is an interdependent self embedded within the social context and defined by social relations and memberships in groups (e.g., Markus & Kitayama, 1991;Triandis, 1995). People are seen as relational or communal and their decisions and actions are seen as heavily influenced by social, mutual obligations and the fulfilment of in-group expectations (e.g., Hofstede, 1980; Oyserman et al., 2002; Triandis, 1995). In such cultures, individuals tend to be motivated to fit in with their group and maintain social harmony; they focus on their responsibilities and obligations while trying to avoid behaviours that might cause social disruptions or disappoint significant others (Markus & Kitayama, 1991). They favour not making mistakes over not missing chances, focusing on the negative outcomes they hope to avoid rather than the positive outcomes they hope to achieve (Elliot, Chirkov, Kim & Sheldon, 2001; Lee et al. , 2000; Lockwood, Marshall, & Sadler, 2005). Relationships are seen as less voluntary and are relatively more difficult to leave (Adams, 2005).

It should be noted that individualism and collectivism are two of many constructs researchers use to understand cultural differences in psychological functioning and research using these constructs, by no means, captures the breadth of the growing body of research on culture, health, and illness. Other important constructs that distinguish cultures include uncertainty avoidance, masculinity, and power distance (Hofstede, 1980), tightness versus looseness (Triandis, 1995), and survival versus self-expression (Inglehart, 1997). For the current piece, however, we focus on the link between individualism/collectivism and health and illness. In particular, we discuss a few select examples of our own and other recent research that implicitly or explicitly uses an individualism-collectivism framework to cross-culturally test models of health communication and social support seeking.

Culture and health communication. Studies testing the effectiveness of health communication targeting an audience of diverse cultural backgrounds have begun to incorporate messages congruent with the audience’s prevalent cultural frame. The underlying assumption is that if health communications match culturally salient characteristics, messages will feel more relevant and therefore will be more likely to influence judgments about appropriate behaviour. Indeed, research shows that messages are more persuasive when there is a match between the recipient’s cognitive (e.g., Petty, Wheeler, & Bizer, 2000) or motivational (e.g., Cesario, Grant, & Higgins, 2004; Sherman, Mann, & Updegraff, 2006) characteristics and the content or framing of the message. For example individuals with a tendency to be more responsive to cues of reward are more convinced when presented with messages framed in terms of benefits of flossing one’s teeth, whereas those with a tendency to be more responsive to cues of threat or punishment are more convinced when messages are framed in terms of the costs of failing to floss one’s teeth (Sherman et al., 2006).

Recent research suggests that matching health communications to motivational strategies adopted at varying levels by different cultural groups is a way to positively influence health behaviour change. Recent work by Uskul, Sherman, and Fitzgibbon (2009) on the use of dental floss tested the hypothesis that health messages will be more persuasive if they are congruent with the cultural patterns of motivational strategies predominant in Western (individualistic) and Eastern (collectivistic) cultures. They drew on the literature suggesting that people from individualistic cultures are more motivated to seek positive outcomes whereas those from more collectivistic cultures are more motivated to avoid negative outcomes (Lee et al., 2000). Individualistic white British participants (who were more focused on seeking positive opportunities) were more persuaded (i.e., had more positive attitudes and stronger intentions to floss) when they received the message framed in terms of the benefits of flossing (gain-frame) than when they received the message framed in terms costs of failing to floss (loss-frame). By contrast, the collectivistic East-Asian participants (who were more focused avoiding negative contingencies) were more persuaded when they received the loss-framed message than the gain-framed message. Thus, the interplay of individual difference factors (motivational orientation), socio-cultural factors (cultural background), and situational factors (message frame) influenced important factors related to health behavior change.

To examine the effect of matching message content to culturally shaped aspects of the self, Uskul and Oyserman (in press) have employed a culturally informed social cognition framework (see Oyserman & Lee, 2008) which suggests that what comes to mind at a given moment depends on the available cues in one’s environment, and momentary cues can increase salience of culturally shaped orientations in ways of information processing. Specifically, they tested the effectiveness of culturally matched health messages after making salient the dominant cultural orientation. Matching health messages to salient cultural orientation increased persuasiveness; further, culturally relevant messages were more persuasive if they come after being reminded of one’s dominant cultural orientation. Individualist European Americans primed to focus on individualism were more persuaded by health messages associating health behavior with negative physical consequences for the self, whereas collectivistic Asian Americans primed to focus on collectivism were more persuaded by health messages associating health behavior with negative social consequences. Thus, message effectiveness can be increased by reminding potential recipients of their dominant cultural orientation.

Culture and social support. How people cope with health problems differs across cultural groups (e.g., Culver, Arena, Wimberly, Antoni, & Carver, 2004; Gurung, Taylor, Kemeny, & Meyers, 2004). Cultural differences, particularly in the use of social support, have been shown in studies comparing individuals of Asian, European-American, and Asian American backgrounds (for a review, see Kim, Sherman, & Taylor, 2008). Studies using various methods and samples from different groups with Asian heritage (Chinese, Japanese, Korean, and Vietnamese) have consistently found that Asians and Asian Americans seek less social support than European Americans (Kim, Sherman, Ko, & Taylor, 2006; Taylor, Sherman, Kim, Jarcho, Takagi, & Dunagan, 2004).

The underlying reasons for cultural differences in social support seeking center on the notion that Asian Americans are more concerned about the negative consequences that seeking support may have for their relationships. They are more concerned that support seeking will cause them to lose face, to disrupt group harmony, and to be criticized by others; these relationship concerns seem to discourage them from seeking emotional and instrumental social support from their social networks. Other potential factors such as the availability of unsolicited support and concerns regarding losing one’s independence are found not to be related to their use of social support to cope with stressors (Kim et al., 2006; Taylor et al., 2004).

Given the positive effects of social support seeking on physical well-being in the form of reduced levels of depression or anxiety during stressful times (Fleming, Baum, Gisriel & Gatchel, 1982), positive adjustment to a series of diseases such as cancer (e.g., Stone, Mezzacappa, Donatone & Gonder, 1999), and faster recovery speed from illness (e.g., House, Landis & Umberson, 1988), the finding that individuals of Asian origin tend to seek less social support than their European American counterparts may raise concerns. Research, however, shows that while Asian groups tend to avoid explicit patterns of social support seeking that involve the disclosure and sharing of stressful events typically adopted by individuals in Western cultures, they benefit from implicit social support. Implicit social support can involve actions such as merely thinking about close others or spending time and doing activities with friends without disclosing the stressor. Thus it refers to the emotional comfort that one can attain from relationships without discussing problems caused by stressful events and thus is unlikely to raise potential concerns about their relationships (Kim et al., 2008).

This interaction between cultural group and form of social support has been shown in a number of studies, including one demonstrating the beneficial effects of culturally appropriate forms of social support and the harmful effects of culturally inappropriate forms of social support at the physiological level (Taylor, Welch, Kim & Sherman, 2007). Asian Americans experienced lower levels of cortisol, a hormone usually referred to as the "stress hormone" as it is secreted in higher levels during body’s response to stress, during an acute laboratory stressor when they sought implicit rather than explicit support, whereas European Americans experienced lower cortisol levels when they sought explicit rather than implicit support. An online diary study shows that European Americans reported using explicit social support in coping with their daily stressors to a greater extent than do Koreans; Koreans reported using implicit social support to a greater extent than do European Americans (Kim et al., 2008). These findings point to the importance of exploring what social support means and its effects in different cultural groups.

A recent set of studies further underlines the need to test health-related findings in Western groups against those in groups of other cultural backgrounds. Uchida, Kitayama, Mesquita, Reyes, and Morling (2008) explored the relationship between emotional support and well-being and physical health. In their initial study of college students, a positive effect of perceived emotional support on subjective well-being was found to be weak among Euro-Americans; it disappeared when self-esteem was statistically controlled. In contrast, among Japanese and Filipinos, perceived emotional support positively predicted subjective well-being, even after self-esteem was controlled. The authors extended these findings in a second study with an adult sample using different well-being and physical health measures; in this study, perceived emotional support positively predicted well-being and health for Japanese adults, but such effects were virtually absent for American adults. Note that unlike the studies reviewed earlier showing the detrimental effects amongst Asians and Asian Americans of social support seeking (Kim et al., 2008), these studies show the beneficial effects of perceived support (i.e., support that was not necessarily asked for). As these studies illustrate, cultures vary in the impact of perceived emotional support on well-being and physical health.

Conclusion

So far, the evidence suggests that socio-cultural environments play an important role in health and illness-related outcomes. Importantly, research shows that socio-cultural factors can shape psychological constructs such as the factors that determine how people respond to health messages and use their social support networks as well as how illness-related thoughts are shaped and when behaviour is likely to change -- issues commonly tackled by psychological models of health behaviour. It is therefore essential that existing models of health behaviour are tested cross-culturally and modified accordingly. Increasing the understanding of the role of culture in health and illness would also help developing culturally sensitive and effective ways of preventing and curing disease. Despite the growing amount of research on culture and health and the preliminary attempts to collate the vast amount of knowledge accumulated in the hitherto disconnected subfields of cultural and health psychology, more research is certainly required which will help researchers, practitioners, and lay people acquire a better understanding of how the psychological experiences of illness and health are shaped by individuals’ socio-cultural environment.

References

Adams, G. (2005). The cultural grounding of personal relationship: Enemyship in North American and West African worlds.Journal of Personality and Social Psychology, 88, 948–968.

Cesario, J., Grant, H., & Higgins, T E. (2004). Regulatory fit and persuasion: Transfer from “Feeling right”. Journal of Personality and Social Psychology, 86, 388-404.