Current issues and new directions in psychology and health: Culture and health psychology. Why health psychologists should care about culture

Over the few past decades, technical advances such as the Internet coupled with increased migration have exposed the average individual to an unprecedented level of diverse information about other people, environments and customs. These developments present particular challenges for health psychological research. In this commentary, we argue that current theorising and thinking in health psychology is outpaced by societal, system and individual changes and those behavioural scientists need to incorporate cultural variables in theory and intervention research more centrally than it is currently done. This editorial was inspired by discussions among members of the SYNERGY workshop 2007 ‘Culture, health, and illness representations’ conducted in conjunction with the annual meeting of the European Health Psychology conference.

Why should we pay attention to culture in health psychology?

The motivation to conduct cross-cultural research comes from three separate directions, which are related to a certain extent. The first is scientific: including culture might account for unexplained variance, provide insights into certain health behaviours, and eventually enrich our theories and research findings. The second motivation is practical, and comes from the reality of living in changing and multi-cultural societies. As we are confronted with individuals from different cultures in our research studies we need to adjust our methods and theories to account for and incorporate diversity. While health professionals are increasingly being trained in cultural competence in clinical settings (Helman, 1994; Henley & Schott, 1999), health psychologists similarly need to explore and update influences of culture on health care provision, health psychological theories and interventions. Third, a moral obligation to research cultural differences comes from the inter-disciplinary heritage of health psychology. In their seminal paper, Landrine and Klonoff (1992) acknowledged the importance for health psychologists to learn and incorporate the input from other aligned social sciences such as sociology and anthropology. Our evaluation of the health psychology literature on culture to date suggests that there is still room for improvement and that we might need to draw on other disciplines’ expertise more often.

The definition of culture

Before proceeding, it is necessary to examine how the construct of culture has been defined and operationalised. The terms race, ethnicity and culture have often been used inter-changeably (Watt & Norton, 2004). For example, Fernando (1991) stated that the term ‘race’ is mainly used to describe physical differences between individuals, whereas culture relates to social differences and ethnicity to psychological differences. The concept of ethnicity is often used to classify people and creates distinctions between them (Hillier, 1997), but does not further our understanding of cultural processes and similarities between different cultural groups. Hofstede (2001) defined culture as the collective programming of the mind that distinguishes one group or category of people from another. However, this definition seems to have limited utility in a world that presents the option of considerable movement of people and exchange of ideas. In our view, a definition that reflects this process might be more accurate. For example, Damen (1987) defined ‘culture [as the] learned and shared human patterns or models for living; day-to-day living patterns; these patterns and models pervade all aspects of human social interaction’ (p. 367). This definition can accommodate migration and pervasive information exchange, as individuals embrace different aspects of old and new cultures and hence develop their own unique cultural identities (Schwartz, Montgomery, & Briones, 2006).

Operationalisation of culture in health psychology research

Health researchers have used a number of proxy variables to assess culture in health-related work (Ford & Kelly, 2005). Variables frequently used are nationality, place of birth, ethnic affiliation, race, region of residence, migration history, language spoken in the home, years lived in a country, religion, dress code, education, occupation, food and media preferences (Deyo, Diehl, Hazuda, & Stern, 1985; Stephenson, 2000). Using such indicators can be acceptable if and when the research question is exploratory and aims to understand variations in perceptions and/or health behaviour. However, current cross-cultural theorists would consider this approach too simplistic and inadequate to guide any individual-based practice or any intervention research aiming to achieve long-lasting behaviour change. In order to tap into the underlying processes that characterise the culture construct for a specific population, we need to adequately assess cultural change and choices about immersion in different cultures. This is the basic challenge to conducting research that incorporates the culture construct.

Oyserman, Kemmelmeier and Coon (2002) developed a framework that operationalises culture as a multi-level process, depicting pathways from societal influences via situational determinants to individual behaviours. Although broadly conceptualised, it is nevertheless useful, as this model incorporates all relevant culture-specific influences. Where it falls short is in the domain of individual cognitions and affective responses as determinants of health behaviour. Predicting health behaviour has been the focus of health psychology research for decades and several approaches have been developed that incorporate beliefs (e.g. the health belief model), social norms, (e.g. the theory of planned behaviour) and representations and affective responses to a threat (e.g. self-regulation theory). The challenge for health psychologists now is to build on current health psychology theorising and to incorporate models and advances made from neighbouring disciplines, such as anthropology, cultural psychology, sociology and other health professions.

A framework for conducting cross-cultural research

Cross-cultural research is inherently multi-disciplinary. Health psychologists are used to working in inter-disciplinary groups and should consider including other researchers with expertise in cultural research. Members of the target group should also be included in all phases of a research project, but particularly in the formative phase. They can help to review the appropriateness of research methodologies and identify important cultural processes in their group. The value of including members of the target group should therefore not be under-estimated. It builds trust between researchers and the population under study, safeguards against stereotyping, and provides unique insights into concerns and barriers that might impact health behaviours.

Another challenge in conducting multi-disciplinary research is that different disciplines often favour different methodological approaches. Many health psychologists come from a quantitative research tradition, whereas cultural psychologists and anthropologists often favour a qualitative research approach. Stereotyping about the merits and shortcomings of both methodologies abound. Yet, these two approaches do not need to be mutually exclusive. It is possible, for example, to use a qualitative approach to assess key concerns and areas of interest among a smaller sample of individuals and then use questionnaires to validate the areas of interest in a larger sample. A reverse approach might also be possible; for example, identifying a phenomenon of interest via quantitative methods in a larger sample, and then following up with qualitative in-depth interviews of a selected group of individuals.

When interpreting results, it is very important to consider whether cultural differences arise due to differences in measurement or differences in psychological constructs. Again this underscores the importance of developing valid measures to assess the construct of culture. Finally, results need to be disseminated, not only within the scientific community but also among members of the target group. This is an important but often over-looked aspect of the research process that could, if not done properly, lead to resentment among the target populations and communities.

It is our hope that we have sensitised health psychologists for the need to include the construct of culture in their research. This is a rich and rewarding field of exploration that spans the gamut from methods and theory development to identifying new determinants of health behaviour.