What would be an example of a cultural difference that may affect ones health?

To augment the rigor of health promotion research, this perspective article describes how cultural factors impact the outcomes of health promotion studies either intentionally or unintentionally. It proposes ways in which these factors can be addressed or controlled in designing studies and interpreting their results. We describe how variation within and across cultures can be considered within a study, e.g. the conceptualization of research questions or hypotheses, and the methodology including sampling, surveys and interviews. We provide multiple examples of how culture influences the interpretation of study findings. Inadequately accounting or controlling for cultural variations in health promotion studies, whether they are planned or unplanned, can lead to incomplete research questions, incomplete data gathering, spurious results and limited generalizability of the findings. In health promotion research, factors related to culture and cultural variations need to be considered, acknowledged or controlled irrespective of the purpose of the study, to maximize the reliability, validity and generalizability of study findings. These issues are particularly relevant in contemporary health promotion research focusing on global lifestyle-related conditions where cultural factors have a pivotal role and warrant being understood.

INTRODUCTION

The need to increase awareness of culture as a variable in health promotion research is germane for three reasons. First, health promotion research is mostly conducted in high-income countries that are experiencing unprecedented immigration of people from diverse cultures. The populations of the countries of North America and Europe, for example, have become increasingly culturally diverse. Second, research related to lifestyle-related conditions given their global prevalence and enormous social and economic burdens (Dean et al., 2011; World Health Organization, 2011) is a global priority. Lifestyle practices cannot be addressed independently from people's cultural backgrounds. And, third, health promotion research often originates from investigators in high-income and western countries whose personal cultural biases and perspectives influence their lenses of scientific inquiry.

Despite the need to consider culture as an important variable in health research, debate persists regarding the elements and definition of this construct. Culture has been defined in many ways, for example, ‘an historically transmitted pattern of meaning embodied in symbols, a system of inherited conceptions expressed in symbolic forms by means of which men (sic) communicate, perpetuate and develop their knowledge about and attitudes toward life’ [(Geertz, 1973), p. 89]. Another definition of culture is ‘a socially constructed and historically transmitted pattern of symbols, meaning, premises, and rules’ [(Philipsen, 1992), pp. 7–8].

According to Triandis (2004), culture is classified as either objective or subjective. Objective culture ‘refers to the institutional aspects of culture, as such as political and economic systems, and to the products of culture, such as art, music, cuisine, and so on’ [(Landis et al., 2004), p. 151]. Subjective culture, on the other hand, ‘refers to the experience of social reality formed by the experience of the social reality formed by a society's institutions-in other words, the worldview of a society's people’ [(Landis et al., 2004), p. 151]. A contemporary definition of culture is ‘a system of meaning that guides the construction of reality in a social community’ [(Cheney et al., 2004), p. 76].

Purnell, in his book Guide to Culturally Competent Health Care (Purnell, 2009) notes that ‘major influences that shape people's worldview and the extent to which people identify with their cultural group of origin are called the primary and secondary characteristics of culture. The primary characteristics are nationality, race, color, gender, age, and religious affiliation. The secondary characteristics include educational status, socioeconomic status, occupation, military experience, political beliefs, urban versus rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, reason for migration (sojourner, immigrant, or undocumented status), and length of time away from the country of origin’ [(Purnell, 2009), pp. 3–4].

For the purposes of this article, we have selected a definition of culture that includes many agreed upon elements, that is, ‘patterned ways of thinking, feelings, acquired and transmitted mainly by symbols, consisting of the distinctive. Culture is often confused with ethnicity, which categorizes people based on their physical characteristics, place of birth, name, language, history and origins, religion, and nationality’ (Isaacs, 1975). In turn, cultural variation reflects a collection of variables that define the uniqueness of individuals within groups based on race, ethnicity, symbols, traditions, language and customs (Kim, 1993).

Cultural sensitivity is another key construct fundamental to health promotion research. It can be defined as ‘sensitivity to the characteristics of a culture or to the dynamics of a social group’ [(Marin, 1993), p. 151] and is achieved with increased awareness of cultural differences in relation to norms, beliefs and values (Ridley et al., 1994). Sensitizing researchers about their views in relation to their cultures sensitizes them to cultures other than their own. Second, researchers who are aware of their personal biases may be more likely to identify their biases when studying other cultures.

This article examines the proposition that health promotion research is often cross-cultural serendipitously as well as by design. We argue that by systematically considering the impact of culture on the elements of their study proposals, investigators can augment their outcomes. Specifically, we describe how variation across cultures can be considered within a study including the conceptualization of research questions or hypotheses, sampling with respect to methodology and in constructing and administering tools such as surveys and interviews. In describing these elements, we provide multiple examples of how cultural factors affect the interpretation of a study's results.

Culture and research paradigms

Qualitative researchers argue that qualitative methods are those of choice for universal studies designed to explore the influences of social, cultural and historical contexts on health (Veugelers et al., 2001). Given that physical, mental and emotional wellbeing are influenced by cultural contexts, culture in itself has become of greater interest in health studies (Boddington and Raisanen, 2009). Similar to the evolution of universal health as a construct that accounts for cultural variation is health disparity or unequal delivery of healthcare, researchers in health disparity are adding ‘socio-cultural beliefs and values’ to their definition of health disparity [(Fink, 2009), p. 354]. The same trend can be observed in measures designed to examine quality of life, one's subjective experience of one's health overall (Saylor, 2004). Favoring one theoretical approach over others should not necessarily limit adopting culture into health promotion research. Rather, a study's goal(s) and objective(s) shape the way culture informs its methodology.

Culture in health promotion research

Culture can be conceptualized as either static or dynamic (Aneas and Sandin, 2009). Static aspects of culture ‘remain relatively constant’ whereas the dynamic aspects of culture ‘shift over time’ (Martin and Nakayama, 2010, p. 75). For instance, based on the dynamic perspective, relationships ‘are constantly in flux, responding to various personal and contextual dynamics’ [(Martin and Nakayama, 2010), p. 391], and individuals' identities changes over time. The static perspective, on the other hand, is based on the premise that relationships are structured by cultural ideologies and identities are fixed entities within individuals (Martin and Nakayama, 2010). In short, culture is a dialectical conception (Martin and Nakayama, 2010). In contrast to the dynamic conceptualization of culture that perceives culture as homogenous, and relationships and individual identities change in response to changes in time and contexts, the static culture involves homogeneity, predictable relationships and generalizability from individual-based experiences (Levy et al., 2001).

Because the dialectical nature of culture can be challenging to researchers, scholars of culture have suggested quantitative tools to study the static aspects of culture and qualitative methods to study the dynamic ones (Aneas and Sandin, 2009). When studying nutritional behaviors among cultural groups, for example, demographic characteristics such as religion and ethnicity can be quantified as predictive variables. If a researcher wants to examine how religious beliefs affect eating patterns of a cultural group however, qualitative methods may be preferable. Until recently, biomedical research relied almost exclusively on quantitative methods. This may reflect reductionisitic analysis and the belief that objective reality is achieved by controlling external factors to study the variables of interest. Alternatively, others argue that reality is framed by ‘a complex interaction between the objective and subjective worlds’ [(Eckersley, 2007), p. 194] and culture in itself is a primary predictor of health.

Given these trends, we argue that attention to culture-related variables at all levels across various types of research studies could augment not only their scientific rigor but also the richness of their quality. To illustrate these points, we describe examples at these various levels, i.e. inception of a study and formulation of its research questions, the design, sampling, analysis and interpretation of the study results.

CULTURE AS A VARIABLE IN THE RESEARCH PROCESSES

According to Hofstede (Hofstede, 1981), cultures can be classified in relation to their characteristics with respect to individualism versus collectivism, masculinity versus femininity, power distance and uncertainty avoidance. These characteristics are known as cultural dimensions to the description of cultures. Cultural dimensions have been useful tools to study cultures.

Individualism versus collectivism refers to ‘the form of the relationship between the individual and the collectivity in a given society’ [(Bochner and Hesketh, 1994), p. 236], and based on these two opposing notions, people from Asian cultures like Japan are collectivistic and they ‘give priority to ingroup goals rather than to personal goals’ (Triandis, 2004). In some circumstances however, individuals can have both individualistic and collectivist traits if they grew up in collectivistic cultures and later lived in individualistic cultures or the reverse happened (Triandis, 2004). Moreover, prosperity and affluence in collectivistic cultures make people more adaptable to individualistic traits over time (Triandis, 2004).

Similar critique applies to other dimensions of culture. Masculinity versus femininity refers to the definition of gender roles in a culture in relation to the biological sexes of men and women. In masculine cultures, men are expected to be ‘assertive, ambitious, and competitive, to strive for material success’ whereas women are expected to care for the domestic chores and their families. In feminine cultures, gender roles of men and women are overlapping and not necessarily defined by their biological sexes [(Hofstede, 1984), p. 390]. With women having comparable education to men in masculine cultures, however women are adapting to social roles that are similar to men's. Masculine societies are gradually becoming feminine, and the distinction between masculinity and femininity is dissipating.

Other dimensions of culture are power distance, defined as ‘the degree of inequality existing between a less powerful and a more powerful person’ [(Bochner and Hesketh, 1994), p. 235]; and uncertainty avoidance, which refers to societal tolerance of ambiguity and uncertainty. According to these two notions, Asian cultures like Japan are distinguished from western cultures like the USA by being hierarchically structured and regulated by tight rules and norms (Triandis, 2004). As cultures modernize and astride to democracy however, power is being distributed and cultures are becoming closer with respect to accepting diverse rules from various groups in a given society.

In the following sections, we examine the role of cultural factors at each level of the health promotion research process.

The research problem

Typically, scientific studies first conceptualize the research problem. Intercultural studies classify research methods in two categories. The culture-specific (emic) approach is where the research problem focuses on a particular culture and generalizations made within the contextual boundaries of that particular culture (Morris et al., 1999; Aneas and Sandin, 2009). For example, the findings of a study on the relationship between religious beliefs and eating preferences of a Buddhist community in Canada may be distinct from the findings of a similar study with a sample of Buddhists in Thailand. Another way to study the relationship between religion and eating preferences is to use demographic data to determine whether people's adherence to their religion predicts such preferences. Using demographic information to study culture in this manner is referred to as a culture-general (etic) approach (Morris et al., 1999; Aneas and Sandin, 2009). In this view, the goal is usually to understand the impact of culture on people's attitudes and behaviors (Schaffer and Riordan, 2003; Aneas and Sandin, 2009). To further illustrate this point, an Israeli study examined parents' compliance with home rehabilitation therapy for children with disabilities. Bedouin parents tended to adhere less to home therapy for their children than Jewish parents (Galil et al., 2001). Because these findings cannot be generalized to Jewish and Bedouin parents in countries other than Israel, these findings could be used to make cross-cultural comparisons (LeCompte and Goetz, 1982; Aneas and Sandin, 2009). In the example of eating preferences in Buddhist communities, Buddhist communities in Canada can be compared with those in Thailand. Such comparisons may elucidate similarities and differences among cultures and expand knowledge.

Sampling

Sampling techniques in cross-cultural research are governed by two rules. One, an identical representation of a culture is only achieved when the population of that culture is homogeneous (Sekaran, 1983; Lonner and Berry, 1986; Ember and Outterbein, 1991). Two, the purpose of a study and the distinctiveness of study participants are two determinants of the sampling methods (Sekaran, 1983; Lonner and Berry, 1986; Sivakumar and Nakata, 2001). Contrary to the traditional belief that random sampling is more representative of a population than structured sampling, in cross-cultural studies where the aim is to make comparisons based on culture, structured sampling such as stratified sampling and systematic sampling may be more justifiable.

Systematic sampling in biomedical research will improve a study's reproducibility. By replicating a study across cultures, researchers can better assess the generalizability of their findings. Complex cultural factors in scientific studies of experimental designs can be measured by systematic sampling of the target population. Systematic sampling in scientific research will enable researchers to define the uniqueness of the study sample and later replicate the study. Non-random sampling techniques, e.g. convenience and purposive sampling, can be useful to systematically define the culture of a population in health promotion research.

Cultural dimensions are less apparent in cultures where immigration is in flux. When people emigrate, they experience a range of enculturation processes. Although some become more acculturated through successive generations, others choose to live in enclaves for expediency, and the transmission of their traditions including religion and language continue to be transmitted from one generation to the next (Landis et al., 2004). The degree to which each generation is acculturated to the adopted country's traditions varies widely, thus, cannot be assumed. One means of sampling individuals from cultural groups in western countries is to categorize them as traditional, transitional and acculturated (Lonner and Berry, 1986; Hubert et al., 2005).

With respect to immigration to Arab countries, immigration to these countries has diversified communities and, in places, has contributed to ethnic and cultural segregation. This has given rise to discrimination and other social problems. Fargues argues that expatriates living in Arab countries have limited residential rights (Fargues, 2011). Expatriates in the Arab countries are foreign workers with temporary residencies, low job security and not allowed to have an access to citizenship or participate in the society (Fargues, 2011). Arabs interact with foreign workers in the workplace only; foreign workers in Arab countries are integrated into the economic structure but excluded from the social one (Skok and Tahir, 2010; Fargues, 2011). The transition from the traditional structures from the time Arabs lived as tribes to modern times post oil discovery may contribute to Arabs attitudes to the treatment of immigrant workers as minorities (Fargues, 2011).

Selecting a sample representative of a culture varies with and within the social and political situations of the countries where cultural groups are targeted. For instance, the culture of Arab countries such as Iraq, Kuwait and Saudi Arabia are more homogeneous than western cultures. This assumption is attributed to the fact that Arab countries are unified by one language, religion and ethnicity, whereas in western countries, immigrants come from multiple ethnic and religious backgrounds with various cultural norms and values (Lonner and Berry, 1986; Trimble, 1990; Harris et al., 2009).

When sampling, researchers need to distinguish ethnicity and culture as overlapping constructs. Ethnic categories such as race, language and nationality can be used to represent elements of a culture but not define it (Bradby, 2003). In the previous example, people in Arab countries more likely descend from one ethnic category, whereas in a mosaic culture, such as the USA and Canada, an American or Canadian can be virtually of any ethnicity or combination of ethnicities. Sampling in multicultural countries constitutes unique methodological considerations. Because of practical considerations and resources, e.g. convenience and time, however, optimal sampling may be compromised. Nonetheless, it behooves researchers to address this at a limitation.

Contemporary health promotion research largely depends on volunteers. Volunteers are often recruited through posters and signs in public places and clinics. Readers of the advertisement self-select and decide whether they phone or contact a research coordinator. Although common practice in western cultures this method may be a barrier to recruitment in other cultures. First, it relies on an individual having the necessary literacy skills to understand the poster. Second, volunteering for research studies is not a common practice in non-western cultures due to factors such as trepidation and distrust. Third, should an immigrant respond to the notice, it is likely that a base level of communication skills is required, and potential participants can be excluded at this stage due to inadequate communication skills which are important for safety, following instructions and adhering to a regimen. Fourth, adhering to a regimen and/or the requirement to return for a follow-up visit can be foreign to people in some cultures. Fifth, signing a consent form can be daunting and formidable for people in some cultures, thus may discourage participation. Overall, recruiting study participants through self-volunteering, e.g. responding to notices and posters (which respects individuals' right to select and not be coerced), may exclude potential immigrant groups who comprise the mainstream population; or, in other cultures, will only attract a minimal number of participants, potentially educated or familiar with this as a western practice.

Comparable to variations among cultures, individual differences within cultural groups warrant consideration. For example, one way of sampling adolescents to study their sexual practices is clustering regions of a geographic region into strata and randomly selecting schools from each region. Random selection of students from each school, however, does not exclude differences with respect to sexual beliefs, views and practices as a result of individuals' acculturation experiences. One way to measure the impact of acculturation experiences in this example is to replicate the study in another age group, e.g. university students and comparing the results of both age groups. A key question is ‘how can we ensure a representative sample of students when their identities change over time through their acculturation experiences?’ Answering this question makes the traditional way of categorizing individuals based on the duration of their acculturation experiences spurious.

Surveys

Familiarity with a nation's research enterprise through media reports on biomedical breakthroughs varies within and between cultures. People in cultures that have less exposure to the translation of research advances or access to media reports about findings of health promotion research may be less comfortable with the research process. This is supported by the work of Barata et al. [(Barata et al., 2006), p. 487] who noted that ‘lack of accessibility due to fewer opportunities to hear about individual research projects’ makes people suspicious of researchers and unwilling to participate. Moreover, in cases where researchers are from cultures different than the culture of participants, participants may be concerned about the image of their culture and withhold responses that portray their culture negatively (Sekaran, 1983). Researchers therefore need to establish rapport and trust with study participants to make them comfortable with the process and willing to provide valid information. Interestingly, using incentives to encourage participation may not work well across cultures. Whereas people in western cultures often welcome incentives, particularly financial, some cultures view incentives suspiciously as a bribe and being offensive (Rosenthal, 1963).

In accordance with the universal code of ethics, the Helsinki Declaration has highlighted cultural differences to researchers that could lead to participant exploitation (WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects). Participants are not exempt from giving their consent to participate in cultures where people are illiterate. In this case, researchers need to explain the study to participants transparently including a literate advocate or family member who could consent and sign as needed on a person's behalf.

In cross-cultural studies, translation approaches usually provide semantic rather than literal translation. Translators pay particular attention to the equivalence of concepts, items and measures such as scales and factor scores (Sperber et al., 1994). An established translation method is back translation where translators with proficiency in the two dialects/languages translate research items from the source language to the target one (McGorry, 2000). Then, translators translate the items back to the original language. In this way, culturally insensitive items can be revised, as well as their validity evaluated based on systematic comparison of the original version and the back translated version. Providing a dialectical translation to research consent forms may help illiterate participants to better understand the research process and their rights to withdraw before giving consent to participate.

Interviews

Participants' responses to questionnaires or interview questions are reflected by their cultural values or what is called ‘cultural response set’ (Matsumoto, 1994; Clarke, 2001; Fischer, 2004). In Chinese culture, for instance, inner strength may be viewed as a virtue and ill health caused by sins committed by the ill person or his or her family (Waxler-Morrison et al., 2005). To avoid embarrassment and save face, Chinese people may avoid acknowledging pain to healthcare providers (Waxler-Morrison et al., 2005). Although the impact of cultural response set is not always avoidable, researchers can minimize its influence by being aware of participants' cultural attitudes (Matsumoto, 1994; Fischer, 2004).

A noteworthy example of cultural attitudes toward health is the stigma associated with psychological and neurological illnesses in South East Asian cultures. In these cultures, the parents of children with mental health problems may hide related diagnoses from healthcare providers to save face and protect their children's marriage prospects (Waxler-Morrison et al., 2005). Similar attitudes have been reported in Middle Eastern cultures where people may be unwilling to admit psychosocial complains to avoid social stigma (Becker et al., 2002; Becker, 2004; Hamdan, 2009; Harakati et al., 2011). Stigma in these cultures encourages people to use socially acceptable forms of illnesses such as headache and fatigue to report consciously or unconsciously their psychosocial health problems (Al-Krenawi and Graham, 2000). Knowledge of such attitudes can help reduce response bias and potentially invalid responses and results.

Another example that illustrates the need for researchers to understand cultural considerations is the issue of cultural attitudes toward gender. In some Muslim cultures, men may prefer to confer with men, and women with women (Al-Shahri, 2002). In Bedouin cultures, women are expected to veil their faces and not expose their faces to men, even in the form of a photograph (Yehia, 2002). In both situations, researchers are advised to modify their research process in a way that does not violate these cultural norms. Muslim participants should decide on whether researchers of the same gender will interview them and whether they prefer to be segregated on this basis. When using Photovoice® method (Wang et al., 1998) with Bedouin women, researchers need to inform female participants if male researchers will view their photographs. Women may not agree to participate in such a study, thus informing them of such a possibility before they sign consent is ethically required. Cross-cultural research ethics highlight the need to modify research methods to the cultural needs of the people being studied.

To be culturally sensitive, we recommend paying attention to the language used by researchers when examining cultures. In questionnaires, researchers may need to avoid using both medical terms and questions directly addressing mental health. Instead of asking participants, for example, ‘Have you ever been diagnosed with depression?’ a researcher might ask, ‘Have you ever been diagnosed with health problems related to your mood?’ Engaging participants in pilot work before initiating the study will help researchers ascertain participants' cultural attitudes and avoid language that may lead participants to give biased responses. Communicating with participants will help to develop trust and rapport.

CONCLUSION

Because culture profoundly impacts health, lifestyle choices, perception of healthcare and health seeking behavior, cultural factors need to be considered in designing health promotion studies. However, the dimensions of culture remain hotly debated, which contributes to challenges in describing how cultural variations need to be considered in health research, particularly health promotion. Health care researchers could benefit from cultural knowledge to date although this remains limited, given they are not trained as interculturists. In this article, we described how researchers can account for cultural variations in their studies and minimize serendipitous contaminating cultural influences and skewing the results in some unforeseen way. We discussed issues related to cultural variation throughout a study's process including its inception and research questions or hypotheses, methods of sampling and developing and administering surveys and interviews. Given lifestyle-related conditions closely associated with cultural factors and are a global priority, we suggest that cultural factors be addressed in health-related studies. Finally, the interface between health care and cultural factors points to a rich and fertile collaboration between health practitioners and researchers, and anthropologists, sociologists and others in intercultural studies in the pursuit of best practices.

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