Sunday, December 17, 2006

The Role of Cultural Health Beliefs in Public Health Practice: What the Health Belief Model Isn’t Telling Us– Jessica J. Harvill


The topic for the December 2004 volume of the American Journal of Public Health was “Health Disparities: The Importance of Culture and Health Communication” (Thomas, 2004). In the Editor’s Choice opening section, Stephen B. Thomas, PhD, from the Centre for Minority Health at the Graduate School of Public Health from the University of Pittsburgh decries “Efforts to eliminate health disparities must be informed by the influence of culture on the attitudes, beliefs, and practices of not only minority populations but also public health policymakers and the health professionals responsible for the delivery of medical services and public health interventions designed to close the health gap” (Thomas, 2004). And yet, despite this impassioned cry for consideration to be given to cultural health beliefs and the medical practices that arise from those beliefs there has still been little consideration given to the role of culture and of acculturation when it comes to actually designing public health theoretical models (Abraido-Lanza, 2006). Instead, models of health behaviour such as the Health Belief Model (HBM) remain the cornerstone of public health theory.

I challenge that the Health Belief Model does not give enough cultural consideration to public health practices and interventions. In addition, the HBM does not give enough credence to traditional medical and alternative medical practices that 34% of the adults in the United States currently utilize (Astin, 1998). Rather, it focuses on aspects of health promotion such as “perceived susceptibility”, “perceived severity”, and “perceived benefits” (Rothman, 2006), totally disregarding the fact that in surveys about traditional and alternative medicine usage, most respondents reply that they use those therapies over traditional medical ones because they feel more comfortable with the alternative therapies, and can have more control to personalize their therapies (Park, 2002), reasons that can not be placed within the categories of health determination found in the HBM.

In a 1998 study on the relationship between traditional/alternative treatment use and medical treatments, it was found that “negative attitude towards or experiences with conventional medicine were not predictive of alternative health care use” (Astin, 1998) and that “the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs and philosophical orientations towards health and life” (Astin, 1998). This implies that people are not turning to alternative medical interventions as a desired alternative to western medical treatments, but instead are using them in a combined, hopefully complimentary fashion. This holistic health paradigm does not have a place in the HBM and similar public health theories, and that fact is providing a disservice to ethnic minorities and traditional medical practitioners, as well as to the public health professionals that are attempting to serve them. As seen in the three case examinations below, the HBM does not do enough to legitimately consider alternative health beliefs, especially those related to traditional and alternative medical practices. It is up to current and upcoming public health professionals to acknowledge and consider these limitations, and to work on designing a new theory of health behaviour that better suites the needs of all the people that those in the public health profession serve.

Case 1: Health Beliefs and Home Remedies Among African Americans
In a 2004 study, Becker et al. found that 70% of African Americans reported at their family had utilized home remedies at some point (Becker et al., 2004). Further observation found that home remedies and self-care “develop[ed] throughout the life course, and that such behaviour varies according to an individual’s group affiliation in habits, beliefs, and practices that constitute a cultural way of life” (Becker et al., 2004). Yet, despite these figures, the HBM gives no consideration to these home remedies and they role they play in the overall health paradigm of many African Americans.

Another example of this can be found in analyses of the cultural dimensions of high blood pressure in African Americans. On average, African American males have higher arterial blood pressure than whites, even adjusting for age, socioeconomic status, and access to healthcare (Dressler and Bindon, 2000). Yet, despite these numbers, most public health interventions geared towards African Americans focus on the same behaviour changes as interventions gears towards other primary ethnic groups found in the US. These interventions continue to focus solely on biological aspects of health, such as diet and exercise, without considering crucial cultural aspects, such as the fact that the role of extended family and social support is much more important in African American communities than generally found in white communities with similar socioeconomic backgrounds (Dressler and Bindon, 2000). Anthropological studies on health consequences and cultural consonance in African American communities have shown that “the degree to which an individual is able to approximate in his or her own behaviour the cultural models for the domains of lifestyle and social support” (Dressler and Bindon, 2000) is directly correlated to improvements in overall cardiovascular health, as measured by blood pressure. These cultural factors, independent of the more medically-driven interventions often found in public health, have been shown to help improve health in a demographic that has been continuously shown to be under-served by the public health and medical communities. And yet, public health theories such as the HBM still do not allow for fact that health can be directly correlated to cultural factors, as well as to biologic ones.

Case 2: Traditional Health Beliefs and Ethnomedicine among the Hmong
Like many eastern societies, the Hmong place a particular emphasis on familial relationships. Family groups are generally large with the oldest man serving as the head of the patrilineal/patrilocal household (a wife will change her allegiance to her husband’s male ancestors). In the term of medical care, the patient and immediate family will all have a say, but the final decision for both diagnosis and treatment will come from the head of the household (Rairdan and Higgs, 1992). This group dynamic of medical decision making is an integral part of many Hmong families, but it is something that is given little consideration to in the HBM, which puts great stock in the idea of ‘self-efficacy’, or the belief that an individual must have a belief in their own capabilities in order to institute behavioural changes (Rothman, 2006). In a culture which places greater emphasis on the importance of the group, or family, than the individual, a theory of health behaviour that focuses on the individual and the individual’s ability to motivate him or herself would not effectively communicate desired health behaviours to the target individual.

Another factor which can affect the applicability of aspects of the health belief model such as perceived susceptibility and cues to action is the differences in communication found between the west and traditional Hmong culture. For many Hmong, respect is an important sociocultural factor and age, education and authority all define how Hmong interact with each other and with public health workers. Communication should be formal, and any sense of informality or casual attitude is considered very rude, especially if the person to whom one is conversing is elderly (Raridan, 1992). This can cause complications in communication because it is also considered very impolite to disagree with someone, especially if they are of higher status then yourself. This often results in a positive response to any query or question. For example, is it possible that when asked a question such as “do you think you are likely to contract this disease” or “do you regularly visit a physician for health check-ups” it would be culturally appropriate for a Hmong to reply in the affirmative. Unlike western communication norms this positive response is not considered agreement, but rather acknowledgement that they have heard what was being communicated (Rairdan and Higgs, 1992). A public health worker without knowledge of the cultural implications of these responses may believe that they have managed to engage the Hmong person in a health promotion program, when in fact they were just acknowledging that the public health worker was speaking to them.

The conduction of invasive medical tests, especially those that involve the collection of body fluids, are also a major point of conflict between Hmong patients and western medical practitioners. Hmong beliefs state that there is a finite level of blood available, and that if any is extracted from the body it can never be replaced (Fadiman, 1997, Raridan, 1992, Westmeyer, 1988). Because of this, excessive or unnecessary medical tests should be avoided if at all possible. Many Hmong living in the United States have had enough interactions with western medicine to adapt to their practices, and most will consent to a blood draw if necessary. It is important that the purpose for each test and how that purpose relates to the immediate physical symptoms be explained to the patient in order to obtain consent for the blood or fluid draw. This belief is such an integral part of some Hmong’s spiritual and personal beliefs that it would be culturally incompetent and ethically wrong for a public health professional to dismiss them as irrational or inconsequential to public health practice. Instead, against health belief model’s notion of perceived barriers, public health practitioners should focus on health communication models that allow for cultural flexibility and conservative determination of invasive medical practices. For example, if working on a program for early diabetes detection, the emphasis should be on working with the healthcare providers to draw the minimum amount of blood necessary for accurate testing and work on developing programs of clear communication telling exactly how much blood will be drawn and for what purposes the drawn blood will be used, more than on dissuading Hmong believers that their cultural considerations don’t have a role in the western healthcare system.

By not acknowledging the important role of culture of medicine, the HBM is missing many of these important considerations that public health providers should be aware of when designing, implementing, and evaluating public health interventions. Utilizing a public health policy that takes into consideration cultural competency, ethnomedical practices, and that accepts variations in health culture is a public health approach which can be vital to improving health disparities seen amongst many ethnic minority groups in the US. The lack of consideration given to these points of views in conventional public health theory is not only a disservice to the population that we as public health workers are trying to serve, but harmful to us as a profession by promoting a legacy of arrogance and insensitivity.

Case 3: Health Culture and Treatment Compliance Among Vietnamese Refugees
Like recent Hmong immigrant, many Vietnamese new to the United States and other Western countries find themselves operating within an entirely different health paradigm than they are used to. Key differences in health interpretations between many recent Vietnamese immigrants and the western public health community can include the cultural interpretation of diseases and therapies as ‘hot’ or ‘cold’, the role of family members in encouraging or discouraging initiation of and compliance with western medical care (like the Hmong, most if not all decisions will ultimately be made by the head of the household, and not necessarily the patient or targeted person), and the community perception of the disease and/or treatment (Ito, 1999).

These key differences in the perception of health and wellness can make it difficult for public health officials to not only communicate their own health goals, but to understand the current health practices of the population that they are wishing to intervene in. One public health study on TB beliefs among recent Vietnamese immigrants concluded that there was little or no use of traditional medicine for the disease (Carey et al. 1997), but did not take into consideration that it would have been considered very rude to mention any traditional medicines that were being used to treat the illness to a western healthcare worker. In this case, the absence of reference to traditional or alternative treatments does not necessarily negate their absence, but as the investigator was working within the health belief model, these types of considerations did not enter into their investigation or intervention strategy.

Although the use of competent medical translators can provide basic information on tuberculosis transmission and infections for those who need it, social and cultural views of disease further complicate the issue. However, where the health belief model might block these cultural views as perceived barriers that need to be changed, a culturally sensitive interpretation shows how a competent public health professional can work within the health belief systems of the Vietnamese population to design and implement programs that can communicate the importance of using and adhering to western treatment regimes, while at the same time allowing for traditional treatments that meet other physical, mental, and cultural needs of the target population.

As seen in Case 1, too often when public health professional think of alternative and traditional medicine, they do not consider the cultural implications of the healthcare treatments. Instead they focus on scaring, threatening, and blackmailing people into participating in specific health behaviours within the western medical paradigm. Theories such as the HBM consider culture only as an avenue of communication to help ‘convince’ people with alternative belief systems to participate in the health behaviour that they are promoting, without exploring other, more culturally sensitive methods, of achieving the same health behaviour. This approach is seen not only when dealing with groups that are recent immigrants to the US, but in groups that have a long history within the US and a high level of acculturalization, such as African Americans.

The United States currently has a population of approximately 200,000 Hmong people, primarily concentrated in several dozen communities across the country (Fadiman, 1997). As with many groups, minority ethnic people immigrate to new countries and they bring their traditional ways of life with them, including cultural traditions, kin relationships and medical practices. As seen in Case 2, in the case of the Hmong these traditional beliefs vary, in some cases greatly, from the western norm, and there can be a steep learning curve of acculturation especially for individuals who immigrate to western countries in adulthood. These cultural factors can have a large influence on health behaviour and “acculturation may affect health behaviours as a consequence of coping responses to discrimination and poverty: loss of social networks; exposure to different models of health behaviour, and changes in identity, behavioural; and chances in identity, behavioural prescriptions, beliefs, values, or norms” (Abriado-Lanza, 2006). By examining these traditional health practices in comparison to western medical practices and common public health interventions, it is possible to explore how certain aspects of the HBM fail to give proper consideration to culturally imperative health practices and how this lack of consideration results in health disparities amongst immigrant communities.
The notion of perceived susceptibility, or of whether or not an individual feels like they are likely to get a disease, is one of the key concepts of the Health Belief Model (Rothman, 2006). An example of this was found in Case 3 and its examination of perceptions of tuberculosis in recent Vietnamese immigrants. A common illustration of this concept is the statement ‘I’m not gay, so why should I worry about HIV?’ In a case such as this, the traditional intervention would be the development of an education program which explains the many methods of HIV transmission, and how all people who engage in ‘risky behaviours’ have the potential to get the disease, not just those who are gay, or who are junkies. Although this is a good start, when dealing with sociocultural beliefs and interpretation of health and disease, lack of education is not the issue. Instead, it is the “health culture or sociocultural context in which the patient is immersed and how it affects his or her interpretations of the origins and meanings of disease and decisions about compliance or non-compliance with medical treatments” (Ito, 1999) that has the greatest influence on perceived susceptibility.

As all three cases show, the HBM is negligent in a vital area of public health practice: the role of culture on health and healthcare. Instead of relying on the HBM’s narrow views of health and health communication, public health practitioners need to being developing and implementing public health theories and approaches that consider a more holistic approach to health, disease, and communication: approaches that give culture the consideration that it deserves.

Changing US demographics lend need to public health theories that broaden the HBM to incorporate other, non-traditional cultural medical approaches. Although individual public health practitioners have called to integrate cultural sensitivity and public health practice, there has been very little reflection of this call seen in public health theory. Old standbys such as the Health Belief Model continue to disregard the high level of usage of traditional and alternative health practices in the communities which it is supposed to be serving, encouraging public health professionals to develop attitudes where the goal is to communicate around traditional health beliefs, rather than work with those beliefs to develop a holistic health paradigm for ethnic minorities and other people who do not totally ascribe to the western healthcare system. As the three cases examined above show, the health belief model and similar theories are not serving the health needs of, and is even alienating, large chunks of the American public. It is up to public health professionals to research, develop, test, and implement culturally considerate theories of public health belief.

Works Cited

Abraido-Lanza, Ana F, Adria N. Armbrister, Karen R. Florez, and Alejandra N. Aguirre Toward a Theory-Driven Model of Acculturation in Public Health Research. AJPH 2006; 96(8):1342-1346.

Astin, John A. Why Patients Use Alternative Medicine: Results of a National Study. JAMA 1998;279(19):1548-1553.

Becker, Gay, Rahima Jan Gates, and Edwina Newsom Self-Care Among Chronically Ill African Americas: Culture, Health Disparities, and Health Insurance Status. AJPH 2004; 94(12): 2066-2073.

Bodeker, Gerard and Fredi Kronenberg A Public Health Agenda for Traditional, Complementary, and Alternative Medicine. AJPH 2002; 92(10): 1582-1591.

Carey, James W, Margaret J. Oxtoby, Lien Pham Nguyen, Von Hunh, Mark Morgan, and Marva Jeffery Tuberculosis Beliefs Among Recent Vietnamese Refugees in New York State. Public Health Reports 1997; 112:66-72.

Dressler, William W. and James R. Bindon The Health Concequences of Cultural Consonance: Cultural Dimenions of Lifestyle, Social Support, and Arterial Blood Pressure in an African American Community. Am Anthropologist 2000; 102(2): 244-260.

Fadiman, Anne. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. Farrar, Straus and Giroux, 1997.

Henry, Rebecca R. Measles, Hmong, and Metaphor: Culture Change and Illness Management Under Conditions of Immigration. Med Anthropol Q 1999; 13(1):32-50.

Ito, Karen L. Health Culture and the Clinical Encounter. Vietnamese Refugees’ Responses to Preventive Drug Treatment of Inactive Tuberculosis. Med Anthropol Q 1999; 13(3): 338-364.

Park, Constance M. Diversity, the Individual, and Proof of Efficacy: Complementary and Alternative Medicine in Medical Education. AJPH 2002; 92(10): 1568-1572.

Rairdan, Betty and Zana Rae Higgs When Your Patient is a Hmong Refugee. Am J of Nursing 1992; 92(3):52-55.

Rothman, EF. The SB 820 Course Reference Book. Boston, MA: Boston University School of Public Health, 2006.

Silenzio, Vincent M.B. What Is the Role of Complementary and Alternative Medicine in Public Health. AJPH; 92(10): 1562-1564.

Thomas, Stephan B, Michael J. Fine and Said A. Ibrahim Health Disparities: The Importance of Culture and Health Communication. AJPH 2004; 94(12):2050.

Westermeyer, Joseph. Folk Medicine in Laos: A Comparison Between Two Ethnic Groups. Soc Sci Med 1988; 27(8):769-778.


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