Introduction: reason we’re adapting Refield’s definition is because it


There has been no consensus on the definition of
culture (The Lancet Commissions, 2014), but the
anthropologist Robert Redfield defined culture as “conventional understandings,
manifest in act and artefact” (Redfield, 1941). The reason we’re
adapting Refield’s definition is because it has a specific perspective when
approaching the abstract term “culture”. Redfield’s definition does not imply
that a group of people who share the same language and location must share a
given value, but it depends on the practice of their understandings (The Lancet
Commissions, 2014).
For example, if a group of people use a certain medical plant in their
healthcare, that does not imply that this practice of the plant is equally
distributed to all members of the group (The Lancet Commissions, 2014).

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To consider culture and health, we must define
the term global health inequality. Global health inequality was discussed
broadly in the most recent World Health Organisation conference on social
determinants of health in 2011. The report indicates that there is a
37-year-gap in life expectancy between countries worldwide. For example, a
child born in Malawi has a life expectancy of 47 years while a child born in
Japan has a life expectancy of 83 years (World Health Organization, 2008). The conference also
sheds light on the amount health inequalities cost countries based on
information from the European Parliament (WHO, 2011). It is estimated
that European countries has expenditure of 1.4% of GDP caused by health
inequalities (European Parliament , 2011) compares to 1.9% of
GDP for defense expenditure (European Defence Agency, 2010).


It has been established in literature that
disparities in health have four causes that apply worldwide (Graham, 2007). The first reason is
individual behaviour such as eating habits and physical activity, the next
reason is the health provider’s knowledge and attitude towards illness and
patients. A third reason is the structure of the health system within the
country or community. Lastly, the cultural values of that society and their
perspective on different aspects of health (Graham, 2007) such as women’s sexual and reproductive
health, or psychiatric and mental health. That last reason is what we’re focusing
on in this paper.


In this essay, we will explore how culture can
be a determinant of health, and how much public policies and interventions take
local cultures into consideration during the implementation of health projects.
We will then explore cultural approaches to women’s health and mental illness
using global examples to show the contrast in practice and perspectives across


Culture as a health determinant & Health
Public Policies & Interventions:

The definition of health is cultural (The Lancet
Commissions, 2014).
Societies have various ideas about healthcare in terms of diagnosis and
treatment, which means health should not be defined by measures of clinical
care and disease (The Lancet Commissions, 2014). The Lancet
commission of health and culture (2014) examined three domains that relate to
health practices and culture which are cultural competence, health
inequalities, and communities of care. Then they identified twelve findings
that were deemed priorities of healthcare provision. One of the top findings
was that culture should not be neglected in health and health-care provision,
and that culture should become central to care practices. They give an example
of how health is perceived dependent on the culture by suggesting that,
“Germans might define low blood pressure as an illness as much as a health
benefit; North Americans might use antibiotics to excess; and French people
might spend government health funds on spas and homoeopathy.” (The Lancet
Commissions, 2014, p. 1609).


Cultural beliefs have been included in health
and well-being discussions for over twenty years (Graham, 2007). In McKinlay’s metaphor of health
determinants, he places culture in the upstream factors along with social and
environmental factors (Graham, 2007). Other models of dissecting health
determinant factors exist, and they place culture on the macro-level that
influence people’s well-being (Graham, 2007) by influencing their behavior and the
way they approach healthcare (Kreuter &
McClure, 2004).


Culture can affect people’s decisions whether
they were directly related to health such as seeking professional help or
indirectly as in eating habits or tobacco smoking which are top health risks in
developing countries (Kreuter & McClure, 2004). The indirect effect
stems from people’s values of kinship and collectivism which majorly shape the
way communities keep their systems of togetherness functioning, and by applying
that on health, it can be inferred how this has health implications on those
attending to their group’s values and needs at the expense of their own
wellbeing (Kreuter & McClure, 2004).


Furthermore, cultural values can represent an
obstacle in the progression of health and social improvement (Metusela, et
al., 2017).
There is a study conducted targeting refugee women from different South African
countries in Sydney Australia and Vancouver Canada (Metusela, et al., 2017). The objective of
the study was to assess the level of their Sexual and Reproductive Health
knowledge. Some of the participants were unable to use contraceptives due to
social pressures from their elders in the tribe which led to the couple’s
inability to control the number of children they had. This example reflects the
cultural prevention of access to sexual health practice to not just women but
their partners as well resulting in lack of family planning that has
repercussions on communities in low-middle income countries (Metusela, et al., 2017).


World Health Organisation has a strong attitude
towards public policies and their effect on public health, “This unequal
distribution of health-damaging experiences is not in any sense a ‘natural’
phenomenon but is the result of a toxic combination of poor social policies and
programmes, unfair economic arrangements, and bad politics” (World Health Organization, 2008, p. 1) referring to the
injustices in financial and social capital distribution among populations. A
research suggests a bias in how public policies are designed where they ignore
those disparities in health outcomes in populations, and disregard the social
factors involved in creating those differences (Mokdad, et al., 2000).


Moreover, the disparities in health outcomes
between the US general population and the immigrants from Hispanic and African
countries have been growing notably over the years with an absence of clear
plan to reduce the gap (Hogan, et al., 2012). In their paper,
they mention Shaw-Ridley’s skepticism of the motivation of some members of the
public health community when she writes, “is it possible that certain
stakeholders benefit from having a persistent problem to solve? … After many
years of … efforts and the expenditure of incalculable amounts of money, is
it ironic that these … efforts are not evident in the health status of racial/ethnic
minorities and other underserved groups?” (Shaw-Ridley & Shaw, 2010).


Scholars and practitioners agree to emphasize
the importance of incorporating cultural values in health interventions
worldwide (Asad & Kay, 2015). However, the consensus
that culture can be used to alter the design and delivery of health
interventions does not suggest how it should be done or what limitations this
has on the effectivity of those health interventions (Beckfield, et
al., 2013).
A study has been conducted focusing on how practitioners perceive culture’s
effect in the designing, implementation and evaluation of health projects (Asad & Kay, 2015). They interviewed
Non-government organisations employees from three different organisations that
work worldwide, and asked them about how they thought culture fit in each stage
of their work of applying health interventions.


One of the organisations was Oxfam America
located in Boston, USA but doing work in Mali and El Salvador where they
provide health awareness projects to help the locals manage their finances
without cutting health expenses, as well as offering knowledge about malaria
using “a locally appropriate tool” for the villagers (Asad & Kay, 2015). The evaluation of
the intervention showed significant improvement in levels of food security in
the targeted communities and malaria knowledge compared to the control communities
(Bureau of Applied Research in Anthropology, 2013) (Devietti & Matuszeski, 2008). The study (Asad & Kay, 2015) interviewed another
organization based in New York Sesame Workshop but has educational health
programs targeted at children in developing countries. The organization uses
their TV programme “Sesame Street” in different countries to promote hygiene
and good health practices (Asad & Kay, 2015). Feedback shows
vigorous improvements in knowledge and behavior regarding different public
health aspects such as malaria prevention in Tanzania (Borzekowski & Macha, 2010), hand-washing in
India (Policy Innovations, 2010), and road safety in
Japan (Borzekowski & Henry, 2011).


Women’s health and culture:

has a particularly stronger effect on women’s health due to the patriarchal
nature of decision-making in public policies, and that result in many
injustices between women and men in different countries (Moghadam, 2010). Some of those injustices are described
as prostitution and trafficking, maternal mortality, and gender-based violence (Moghadam, 2010). For example, women
in the Middle East have been subjected to that kind of injustice and (Joseph & Slyomovics, 2001) summarize it when he
wrote, “women and juniors must be embedded in familial relationships to make
most effective use of institutions in these spheres and are therefore subject
to patriarchal norms and relationships even in public spaces” (P. 5). They go
on to emphasize how it is common for women in Turkey to seek permission from
their male counterparts (fathers, brothers or husbands) before they can accept
a job offering, or pursue higher education, or get married (Joseph & Slyomovics, 2001).


Another prominent example of how culture define
women’s health is considering how the menstruation cycle is perceived in
different countries. A research conducted in Nepal about the reproductive
health problems related to the culture Chhaupadi outlined the different
societies’ perspectives on menstruations (Ranabhat, et al., 2015), for example in
south India, when girls experience their first menstruation, there are
celebrations to mark this special occasion and gifts are given to those young
girls. However, young girls face isolation from men and stigmatization in other
cultures such as Chhaupadi in Nepal (Ranabhat, et al., 2015). These different
views of stigma and discrimination against a biological event can lead to
literacy in appropriate hygiene habits, feeling of guilt and shame which has
health implications in the long and short term (Metusela, et al., 2017).


Gender role and health have been the focus of
different empirical studies over the years. Phillips mention in his paper how
life expectancy in men, in European countries, is seven years earlier than
women’s, and that 76% of the deaths recorded in his studies were because of motor
vehicle accidents, suicide, and AIDS all of which are absent from top mortality
causes of women. Contradictorily, in low-middle income countries (he studied
the African region), women have higher mortality rates due to the extremely
high birth rates and significant human rights inequalities between genders (Phillips, 2005).


We can take immigrant Hispanic women in the US
as another example of how culture influence women’s well-being. Three-quarters
of those women reported feelings of perceived discrimination related to their
Hispanic appearance or their limited English fluency and identified this as a
significant barrier to health care access and utilization (Sanchez-Birkhead,
et al., 2011),
which later in the study was pointed at as a causation of health deterioration
of Hispanic women who have been in the USA for more than five years.


In a different research targeting subjects who
have migrated to the US from Hispanic roots, the participants were asked to
describe the healthcare they’re receiving in the new country compared to their
native one. Many recounted experiences with health care providers in their
native countries and reported that they were satisfied with the friendlier,
more approachable relationship they had with the physicians there. Some of the
quotes from the studies clarify how these women perceived the doctors attending
to them: ”they do not have time to answer questions.” Esmeralda stated, ”Here
I see the office staff and everyone else that works in the office more than I
see the doctor. It is the opposite in our native countries.” (Rodr?´guez,
et al., 2005, p. 1171)


In that same study on Hispanic women in the USA,
the studied group reported feelings of distress in seeking professional help
due to facing continuous stigma in healthcare institutions (Rodr?´guez, et al., 2005). Many other studies
show significant difference in health awareness between immigrant Hispanic
women and the general USA population (Rodr?´guez, et al., 2005). That indicates that
immigrant Hispanic women undermine early screening and detection procedures
relating to several diseases such as breast cancer (Rodr?´guez,
et al., 2005).
Consequently, cultural beliefs & behavior regarding health that transfer
with those immigrant women to the USA are used in place of institutional help,
as demonstrated by the quote from one of the study’s subjects:


Yes, the herbs, the teas, the lemon with garlic, they are remedies
that really work, ….and they are a lot better than a prescription by a doctor.
Because eventually that won’t be effective anymore, because your body will
adapt to it; and then you are going to need a larger and larger dose. (Rodr?´guez, et al., 2005, p. 1171)


Many women in the same study explained how their
older female family members (i.e. mothers or grandmothers) are the main
influential sources they have on health. We have a quote from one of the
participant, ”My mom is always telling me, ‘Mi’ja my daughter, have you had
your exam? Have you had it done?”’ (Rodr?´guez, et al., 2005, p. 1171).


Mental health and culture:

attitudes and perceptions towards mental illness is an integral role in the determination
of help-seeking behaviour and administration of successful treatment and social
reintegration (J.Hugo, et al., 2003). Before we look at
different studies around the world to demonstrate how mental health and culture
interact, we should highlight the urgency of this topic. A WHO funded study, the
Global Burden of Disease Study, investigated the mortality and disability associated
with different illnesses (Murray & Lopez, 1997). A result of the
study ranked depression as the fourth leading cause of global disease burden in
1990 and expected to rise to second by 2020.


There has been a study in Australia concerning
mental health awareness, and the study was used to measure the literacy of a
representative sample of the general population about mental illness conducted
by (Jorm, et al., 1997a) (Jorm, et al., 1997b). They inquired about
recognition as well as management and prevention knowledge of mental illness
for the Australian population. The results showed a level of literacy regarding
those concepts which can have drastic consequences on early detection and
seeking professional help for patients. The study was then extended to offer a
public first-aid course by the authors of the study to try and reduce the level
of literacy among the lay population, the results of that course point to the
gradual decrease of mental health literacy.


South Africa, it has been estimated that every one in five people seek health
care because of an undiagnosed mental illness (Hugo, et al., 2003), yet stigma and isolation is still
prevalent regarding the mentally ill. Number of studies determining the
attitudes of different cultures in South Africa to mental illness are scarce
which prevents sociologists from inferring the correlation between cultural
views and mental health in those communities. A study conducted in South Africa
that included majorly female participants with
mean years of education being 10.54 and they all
spoke local South African languages. The study investigated the perception of
participants’ beliefs and knowledge of causes of mental illness as well as the
best method of treatment and management. About half of the respondents (49%)
reported that causes of mental illness were not a medical reason but rather due
to stress or emotional problems or relationship issues. The responses regarding
the management of mental illness were commonly described as “talking it over”
with someone rather than seeking professional help (Hugo, et al., 2003).


Many people in low-middle income countries seek
a group of methods (including religious and traditional healing) when they need
help for mental health problems (Fernando, 2014). It is even a branch that is taught in
educational institutions, for example, in Sri Lanka a psychotherapist who
studied indigenous healing can list several types of healing that focus on
mental health problems (Fernando, 2014). In the same book,
Fernando mentions that there is an overlap between medical and religious
healing in most non-western traditions (Fernando, 2014). For example, in Tibet the healing
process for madness within the ‘Tibetan Medicine’ is a combination of herbal
therapy and diet, which is what Clifford (1984) wrote about saying, “A complex
interweaving of religion, mysticism, psychology and rational medicine” (p 7).


Depression arising from grief and loss was dealt
with in Sri Lanka’s civil war by attending temples and seeking help from the
goddess Kali (Lawrence, 2003), and part of the
process was the revealing of the whereabouts of women’s loved ones by
mutterings of other people being possessed by the goddess. Lawrence comments on
this phenomenon in her book shedding a positive light over this cultural
process, “oracular revelations is a cultural confluence where many
possibilities meet—where suffering and death are acknowledged, where courage
can be instilled, where information about the future and protection might be
given” (p. 119).


We can easily see the effect of culture on
mental health provision by comparing low and middle-income countries with high
income countries and their approaches (Jong, 2014). Bereavement care is
a complicated process with a detailed conceptual framework in Scotland (Scottish Government Health Directorate, 2010) for example. The
process of providing mental support is void of spiritual or religious
affiliations. The manifesto uses the term “client” referring to the subject
suffering from grief, and outlines evidence-based steps the carer must follow
to provide the adequate support (Scottish Government Health Directorate, 2010).



People’s culture is an influential factor in
determining their health and well-being. Despite that cultures change over time
and is not restricted to geography or sharing one’s language, it can be seen
the distinction between the western and eastern cultures. Social factors and
culture correlations have not been studied thoroughly to offer a concrete
definition of how they complement (or not) each other. Further studies on the
pivotal role of culture in shaping people’s approach to health detection and
management should be funded more by governments as well as relative


In general, cultural values dictated women’s
perception of their reproductive and sexual health, and a lot of communities’
attitudes towards mental health relies on those inherited values. Some
researchers argue that health public policies are one of the enforcing factors
of cultural power over health aspects such as injustices and stigma against a
group of people with a social distinction (gender, disability, mental illness…etc.).


Governmental and non-governmental authorities currently
incorporate culture into health projects and there is ample evidence in literature
that this