Researching Cultural Differences in Health

Sheila Hillier, David Kelleher, Mrs Sheila Hillier

• Publisher: Routledge
• Year: 2002
• eBook ISBN: 9781134832750
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Significant concerns about the poor health and prevalence of chronic illness amongst a number of ethnic minority populations have led to heightened debates about how best to improve the situation. For some the answer is to see their experiences as part of the general social class inequality in health, but recent evidence questions the extent to which social class can explain the variations in health which ethnic minorities experience.
Researching the Cultural Differences in Health offers a range of accounts of how people in ethnic minority groups perceive and manage their illness. Some of the chapters focus on Bangladeshi, and other South Asian groups, as well as Afro-Caribbeans and Irish people.
The illness conditions discussed include diabetes, hypertension, sickle-cell disorder, mental illness and coronary heart disease. This book will provide invaluable reading for those involved in providing health services for ethnic minorities, and all lecturers and students in medical and nursing education as well as those studying sociology and social administration.

Chapter 1
Considering culture, ethnicity and the politics of health

Sheila Hillier and David Kelleher

To cite ‘culture’ is merely to divert attention from the real objects of concern.

(Francis 1993: 193; quoted in Smaje 1995)

It seems incredible looking back, that while attention focused on the ‘specific problems’ of ethnic minority groups . . . an epidemic of coronary heart disease was sweeping the South Asian community and was the underlying cause of up to fifty percent of deaths. Why did this go unnoticed?

(Bhopal 1993: 5; quoted in Smaje 1995)

Between them, these two quotations sum up the reasons why researching cultural differences in health may be regarded, at worst, as obscuring the impact of racism upon the health of minority ethnic communities and the health services available to them. At best, the activity could be regarded as an irrelevance, concentrating upon exotic difference or trivia. That ethnicity as an heuristic device for considering inequality or simply for the articulation of difference by which modes of domination or empowerment are produced under certain social conditions is a defensible research position is the theme of this book.

The 1991 census included a question about ethnic groups, and respondents were requested to describe themselves in terms of eight listed groups or to identify another to which they felt they belonged. The data is now beginning to be analysed and the collection of such statistics is justified on the grounds that this is a way of revealing the levels of socio-economic disadvantage from which ethnic groups suffer as well as presenting an overview of the health status of minority ethnic populations. The definitions of ethnicity were pragmatic, based on a mixture of skin colour, religion, national origin and self-definition, all of which are, at a commonsense level, deemed salient aspects of the classification of difference in contemporary Britain. Yet to many this is unsatisfactory, although often for opposing reasons. On the one hand, merely to draw attention, at an official level, to ethnic difference problematises ethnicity rather than focusing upon the racism which, it is argued, is the common experience of non-whites in Britain today. Another and contrary objection highlights the oversimplification of such categories as ‘Indian’, although it might be argued that these are an improvement on the use of ‘Asian’. Such an objection seeks to increase difference in order to make categories representative of variety. It is obvious that any categorisation, however subtle, is, at best, an imperfect way of representing the reality of humankind. It is also clear that ethnicity is a shifting category which can change over time, whether defined by individuals themselves or by others. Therefore we must expect definitions to change and the relevance of some categories to increase or disappear, although current experience suggests that a proliferation of ‘ethnicities’ may well be the norm for the coming years. Whilst it is accepted that racism in social relations, which has a distinct class character, cannot be written off as ‘failure to understand another’s culture’, this should not inhibit attempts to analyse cultural matters.

Government policies with regard to ethnicity and health policy have shown rather glacial movement over the last 30 years since the issue of ‘immigrant’ use of health services was first raised in 1965. Gradually, policies of assimilation have given way to an acknowledgement of pluralistic accommodation as now expressed in the Patient’s Charter. This contains a specific emphasis on the need for awareness of and respect for ‘religious and cultural beliefs’, and recent writings in the health field display a willingness to take the issue of ethnicity seriously, together with the consequences for flexibility of provision that this entails. However, translating such intentions into practice lags far behind and displays all the difficulties of unclear goals and lack of appropriate knowledge and training that characterises the general relationship between research, policy and effective action. NHS reforms, which have put the burden of commissioning services responsive to Health of the Nation targets on localities, have brought the issue of dealing with both the special and the general health needs of ethnic minority groups into focus; this immediately raises the question of patterns of utilisation, and the accessibility and appropriateness of ways of providing services. It has been suggested by a number of writers that so far the emphasis upon higher mortality rates (but fewer deaths) for diseases like TB (relative risk) has provided an inappropriate focus, that representation of members of ethnic minorities in health authorities is negligible, and the suspicion remains that patterns of socio-economic disadvantage will continue to be a major determinant of health outcomes, whether or not attention is paid to special or common needs within a framework of the understanding of ethnic characteristics.

In a recent comprehensive review of the available evidence, Smaje (1995) concluded that despite a wealth of literature on the health and health status of minority ethnic groups, patterns of health experience are inadequately described, let alone explained. It seems, therefore, far too early to close off the possibility that some aspects of minority health experience may be illuminated by considering values, beliefs, customs and lifestyles. That some of the work so far has been limited, dealing with stereotypes and occasionally pathologising minority cultures by assuming a majority norm, as suggested by a number of writers (Pearson 1983; Donovan 1986; Ahmad 1993), largely means it is bad social science, which does little to develop any understanding. Perhaps the point should be made, therefore, that most of the material has been produced within a biomedical framework, and an epidemiological one at that. Such a paradigm is not usually noted for the theoretical subtlety of its sociological categories. There seems room for a more complicated view of culture – that which is shared, believed and produced, as Rickword, stressing historical influences, suggests, ‘the inherited solution to vital problems’ (Rickword 1978: 103) or shared solutions to common problems. Ethnicity may or may not correspond with a particular culture. Sharing a culture does not imply merger between ethnic groups. Nor does common ethnic origin imply uniformity of culture. Therefore the two terms do not map directly onto each other. None the less, they are closely related. Brah has suggested that ‘ethnicity emerges out of shared conditions – economic, political, cultural – to construct cultural narratives about these conditions which invoke notions of distinctive genealogies and particularities of historical experience’ (Brah 1994: 812).

In the debates surrounding the value of such concepts as ‘culture’ and ‘ethnicity’ one is reminded of discussion a quarter of a century ago about the value of ‘gender’ as a category of analysis. It is difficult to imagine any piece of work which disregards gender today; but similar arguments occurred about the primacy of class over gender inequalities. In the event, ‘gender’ has proved durable throughout sociology, and has valorised methods and studies which emphasise the grounded experiences of the subject (Cook and Fonow 1990). Such studies continue to add to our understanding of health beliefs and experiences of and responses to illness (Cornwell 1984), which suggests that studies of relationships between culture, ethnicity and health are likely to be particularly successful and interesting when they lay emphasis upon the meanings and interpretations through which people make sense of their world. This material is most likely to be accessed by qualitative methods. This is not to suggest that there is no place for survey research or social epidemiology, but that the current imbalance needs to be addressed in researching cultural differences in health.

Most of the chapters in this book are case studies of health beliefs and behaviours in a variety of minority ethnic groups living in the United Kingdom – the majority in London. Although all chapters consider various methodological and theoretical issues raised by the studies which are reported, two chapters (those by Ahmad and Kelleher) take up these matters in greater detail, discussing points that have been raised in this chapter, and developing the arguments.

Ahmad argues that the volume of research on ‘race’ and health has not produced dividends either in terms of explaining differences in health experience or in improving provision to minority ethnic communities. He is critical of research that locates explanations for inequalities in health in ideas of cultural or biological pathology and which ignores the socio-political context. He considers the prospects for a more radicalised and empowering research agenda which will take into account the interplay of structural and cultural factors as elements of the context in which minority ethnic communities exist.

Kelleher’s chapter deals with the complexity involved in disentangling material and cultural factors in minority ethnic groups and the difficulties surrounding the term ‘ethnicity’ itself, which is hard to define and whose subjects may change according to different context. He defends the idea of ethnic identity as an integrating concept for individuals, one which bestows a sense of belonging to a real or imagined community, psychological security and a range of goals. At a more practical level, he illustrates the importance of an understanding of attitudes and beliefs in providing appropriate health interventions. To this end, he advocates the use of ethnographic study and discusses the reasons for and against ‘matching’ researchers with the ethnic group that is the focus of the study.

The remaining seven chapters report a series of small-scale studies. The studies have a number of common themes or focuses. No less than three (Hillier and Rahman; Kelleher and Islam; Lambert and Sevak) are concerned to a greater or lesser degree with the Sylheti-speaking Bangladeshi population of Tower Hamlets. This group may rightly feel, as Hillier and Rahman report, that they have been somewhat overresearched without any notable improvement in health services. The dangers of exploiting ethnic populations for research purposes are ever present. In the research described by Hillier and Rahman it seemed clear that, where they existed, needs for advice and help with children’s problems were not being met. Many people were unaware of services or were not referred on. In any case, they might be fearful of the close association between ‘help’ and the legal framework of child protection, as well as being less than wholehearted in their acceptance of the diagnoses of Western psychiatry. This chapter provides the raw material from which a more responsible service might be constructed, but it does not develop detailed recommendations.

Elizabeth Anionwu’s work is also concerned with the acceptability of services. She reports the feelings of patients who are, among other things, research subjects for treatments of painful and unpredictable blood disorders. Since these disorders occur overwhelmingly in particular ethnic groups, she argues strongly that counsellors of a similar ethnic background to patients should be employed in explanations of treatment and in support. She describes a survey of counsellors, most of whom felt that ethnic origin was important in providing an appropriate service. There are practical implications to such a proposal, and Anionwu notes the lack of a counsellor capable of speaking any of the South Asian languages. The service she describes has now been set up in a number of UK cities, but still lacks the full complement of trained people.

The issue of ‘matching’ professionals and patients by ethnic group is also touched on by Hillier and Rahman, who note that referrals to the local child psychiatry service increased once Bengali and Bangladeshi professionals were employed. It remains unclear whether this was due to a greater willingness on the part of patients to be referred, or to the greater credibility with referrers which such employees conferred on the clinic. There is a strong suggestion in both Anionwu and Hillier and Rahman’s chapters that, to be acceptable, services for ethnic minorities are likely to need to include members of those minorities. A different view, which is discussed by Kelleher, is the possible limitation of ethnic minority professionals/ carers by directing them towards ethnic minority services. And it is self defeating and ethnocentric to argue that cultures are so impenetrable that only those born within them can understand their members. Acceptance of such a view would also render volumes such as this as valueless.

To take people’s views of themselves either as individuals or as a group, their ‘internal definition’ of themselves, privileges the social resource aspects of ethnicity. The use of qualitative methods, as in most of these studies, where data is collected through face-to-face interviews, produces one version of social reality. It is important to remember, however, that ethnicity as a definition and the identification of cultural difference is something which is also done by outsiders. These same outsiders, in many cases the majority, have access to power and resources which may be denied to the group which is being defined and ‘seen’; definition of others from the standpoint of power may have implications for how groups construct their identity. The conflict between ethnicity as resource and ethnicity as liability remains (Jenkins 1995).

Many of the chapters in this volume are concerned with the health beliefs of various ethnic groups and the impact of definitions of illness upon their daily lives. Morgan, and Pierce and Armstrong, in their studies of small samples of African-Caribbean patients, draw attention to the way hypertension and diabetes are defined and explained and to how dietary and activity restrictions are interpreted. Many of the views appear to be influenced by people’s origins in the Caribbean, particularly concerning the use or dangers of certain foods and a general tendency to be sceptical of dietary advice bearing little relation to their own knowledge.

Lambert and Sevak make the important point that the oftenobserved ‘cultural differences’ can be exaggerated and that, when interviewed, Punjabi and Gujarati people show a wide range of views about the causation of illness. Certain themes emerge from all these accounts, however; worry, tension and stress, and the importance of hereditary and family history are all seen as relevant to health. The writers note that such explanations are characteristic of ‘lay’ health beliefs in general. In Morgan’s chapter, the only one to compare the views of African-Caribbean and white patients, she notes that both groups regard stress or tension as the major cause of their ill health.

Religious belief as a way of dealing with and making sense of illness is discussed in a number of chapters (Hillier and Rahman; Lambert and Sevak; Kelleher and Islam). Belief in God and submission to God’s will has sometimes led to misapprehensions for which the ethnocentric term ‘fatalism’ is used. These accounts make clear that illness or emotional disturbances are not passively accepted as being beyond individual control and that each person has a responsibility to look after their health and their God-given body. Lambert and Sevak make the point that intensity of religious belief may be found in many groups and that the pious in all groups may have more in common than less religious persons of the same ethnicity or religion.

Critics of cultural approaches to health, such as those cited at the beginning of this introduction, suggest that writers have focused on the marginal rather than the central health views of ethnic minorities, which in many cases resemble those of the majority. The blood disorders suffered by the patients in Anionwu’s chapter are more likely to occur in ethnic minority groups, but no one could convincingly argue that to be concerned with them was merely a concern with ‘exotic’ health conditions. Indeed, the argument is the reverse: insufficient attention has been paid to these matters. Kelleher and Islam consider a group of Bangladeshi patients in Tower Hamlets. This group has a high prevalence of non-insulin-dependent diabetes. The group is also a Muslim community concerned to live by the laws of Islam. The study describes how it goes about the process of integrating the medical treatment regime with halal/haram distinctions and other cultural ideas about food.

Tower Hamlets is one of the few areas in the United Kingdom where there is a growing youthful population. The attitudes of Bangladeshi parents towards behavioural and emotional problems of their children are considered by Hillier and Rahman. Psychiatric services are among those most heavily criticised for racism in practice. In a speciality where individuals’ own constructions of reality as well as the construction that others put on their behaviour are part of the matter under study, social and cultural settings are of great importance. But how are ...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• TABLES
• CONTRIBUTORS
• CHAPTER 1: CONSIDERING CULTURE, ETHNICITY AND THE POLITICS OF HEALTH
• CHAPTER 2: THE MEANINGS OF HIGH BLOOD PRESSURE AMONG AFRO-CARIBBEAN AND WHITE PATIENTS
• CHAPTER 3: CHILDHOOD DEVELOPMENT AND BEHAVIOURAL AND EMOTIONAL PROBLEMS AS PERCEIVED BY BANGLADESHI PARENTS IN EAST LONDON
• CHAPTER 4: A DEFENCE OF THE USE OF THE TERMS ‘ETHNICITY’ AND ‘CULTURE’
• CHAPTER 5: AFRO-CARIBBEAN LAY BELIEFS ABOUT DIABETES: AN EXPLORATORY STUDY
• CHAPTER 6: THE HEALTH OF THE IRISH IN ENGLAND
• CHAPTER 7: IS ‘CULTURAL DIFFERENCE’ A USEFUL CONCEPT?: PERCEPTIONS OF HEALTH AND THE SOURCES OF ILL HEALTH AMONG LONDONERS OF SOUTH ASIAN ORIGIN
• CHAPTER 8: ETHNIC ORIGIN OF SICKLE AND THALASSAEMIA COUNSELLORS: DOES IT MATTER?
• CHAPTER 9: THE TROUBLE WITH CULTURE
• CHAPTER 10: ‘HOW SHOULD I LIVE?’: BANGLADESHI PEOPLE AND NON-INSULIN-DEPENDENT DIABETES