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Why Should Researchers Care About Culture?
Paying Attention to Culture Can Help Identify Research Gaps
The dazzling technologies associated with genetic research, together with the promise that genetic investigations hold for the cure of many diseases, have vaulted this field into its current preeminent position. Cross-cultural study, however, can be an important antidote to overly enthusiastic promotion of overly reductionistic models of illness. Our survey of the mental health of the Serer included not only a structured interview but also standardized blood pressure readings. One of the strongest findings reported in the research literature at the time (the early 1970s) was that blood pressure increased with age and that this trend was much stronger among US blacks than among US whites. Genetic difference was the favoured explanation. However, the Serer in Senegal did not have a steep rise in blood pressure with age. Indeed, their age slopes were even more benign than those shown by US whites (22). By contrast, the anthropologist Norman Scotch had conducted a study of blood pressure among the Zulu of South Africa in the early 1960s and had reported a steep, age-related rise in blood pressure similar to that observed by US-based researchers (29). In attempting to reconcile these contradictory findings, my colleagues and I argued that the official apartheid then being practiced in South Africa and the unofficial but palpable apartheid in the US might be placing their respective victims of racism, marginalization, and lack of opportunity at risk for elevated blood pressure (22). Conversely, in the black republic of Senegal, the Serer enjoyed relative freedom and access to opportunity.
The field of genetics has even more cachet today than it had in the 1970s. In this context, recent research highlighting a link between the risk of hypertension and psychological states such as depression, most particulary among blacks (30), and other studies suggesting a possible relation between experiences of racial discrimination and hypertension among African Americans (31,32) are extremely important. The findings illustrate a potentially important contribution by sociocultural factors to a “physical” problem; they demonstrate why researchers should think about context and how considering context can help militate against reductionism in explaining the health disorders of humankind.
Culture can and should inform clinical trials. Zhang-Wong and colleagues found that white men suffering a first episode of psychosis required higher dosages of haloperidol to control their symptoms than did their ethnically Asian counterparts (33,34). These investigators also found that drug requirements for white women were in the same range as those for ethnic Asians of either sex. The irony is apparent: although prescribing manuals and prescribing habits tend to be based on studies of white men, this group in fact represented the deviant cases in the studies by Zhang-Wong and others. Methods employed in clinical trials must account for ethnocultural variation; alternatively, the reported results must be qualified by explicit statements about the generalizability of results derived from investigations wherein research designs have made insufficient accommodation for ethnocultural variation.
Canadians pride themselves on their multiculturalism, on the fact that Canada was the first country in the world to enact a multiculturalism law, and that struggles within Canada to achieve equity have not erupted into the violence and chaos troubling many other countries. Achievement has, however, failed to keep pace with nationalistic rhetoric—a fact that is nowhere more apparent than in health research. The National Longitudinal Study of Children and Youth (NLSCY), conceived and carried out by Human Resources Development Canada and Statistics Canada, is an example. The NLSCY inception cohort—25 000 children aged 11 years and under—purportedly represents Canadian children. However, the NLSCY sample contains only about 600 immigrant or refugee children, despite the fact that almost 20% of children in the study age range who currently live in Canada were either born outside the country or were born to immigrant families.
If whatever is found about the health and development of native-born children also applies to their immigrant and refugee counterparts, the latter’s underrepresentation may be justifiable. There are, of course, difficulties in identifying and recruiting immigrant samples, and the expense of translating study instruments is not inconsiderable. These factors militate against including immigrant and refugee children in surveys. However, a publication by our research team reveals the perils of extrapolating results based on native-born children to other populations (35). Our analyses compared the mental health of children living with native-born parents and that of their counterparts living in foreign-born families. We also compared the mental health effects of poverty in both NLSCY subsamples.
The data revealed some grim facts. When the NLSCY began, 13% of all families in Canada were living in severe poverty. The situation was even worse among immigrant families resident in Canada for less than 10 years: 33% were living well below the officially defined poverty line. Since poverty is one of the most powerful risk factors for children’s mental health, it would be logical to predict higher rates of mental and behvioural problems among immigrant children, compared with the national sample. The results, however, reveal a curious and potentially important paradox: although immigrant children were almost 3 times more likely to live in poverty than their nonimmigrant counterparts, they had fewer mental health and behavioural problems.
Surprises like this argue in favour of studies to address some important questions raised by these preliminary results. Does the good news about the mental health of immigrant children—who have, like native-born children, been spared atrocities—also apply to refugee children, many of whom have been exposed to horrific events no child should ever be forced to experience? Are there particular strengths in immigrant families that protect children, despite economic disadvantage? Does the good news about immigrant children persist, or does their apparent resilience eventually succumb to the indisputable stresses of immigrant life in Canada, such as discrimination (36,37) and the high rates of un- and underemployment experienced by their parents (38)?
Culture Shapes Research Paradigms
In the 1960s, the vocabulary of research began to change. Before this time, the lines were clear: there were investigators and there were subjects, and the former studied the latter. However, new words began to creep into the research vocabulary—words like “participants” instead of “subjects.” Similarly, “partnerships” appeared—a term connoting research as a collaborative enterprise rather than a relationship in which one party to research is ascendant over another. Partnership also implies that benefits have to be shared.
Affirming devotion to the new paradigm of research as a partnership rather than an enterprise in which a privileged few satisfy their intellectual curiosity is easy—so easy, in fact, that the sentiments are in danger of becoming cliches. Partnerships are usually more difficult to practice than to advocate. I offer the following personal experience to demonstrate that working with communities in a responsible and responsive fashion is not only necessary but more than worth the bother.
Flower of Two Soils is an investigation of mental health and academic achievement among First Nations children living on 2 Canadian reserves and 2 US reservations (17,39,40). Before beginning the fieldwork for this study, I recruited community advisory panels of educators, leaders, and tribal elders to help guide the project throughout the 3 years of data-gathering. One day, during a meeting on a Chippewa reserve, I asked the community advisory panel to look over the mental health measures I proposed to use. The measures of psychopathology were the most current and most widely accepted instruments to assess depression, anxiety, attention deficit disorder, and conduct disorder (17). To all this, I had added something new: measures of psychological health that I felt were much needed (39,40). I was proud of this instrument, a potent brew with a base stock of state-of-the-art psychophathology measures and added ingredients that I thought would not only contribute something new to the field but would also please a community used to having its negative characteristics amplified and its strengths—both as individuals and as a collective—ignored. The committee members, however, were decidedly underwhelmed. Although they reassured me that there was nothing wrong with the proposed questions, they kept telling me that something was missing. The “something” was, however, “too hard to explain.”
Hours passed in desultory discussion. The northern sunlight changed to a dark purple twilight, but no one bothered to switch on the overhead lights. With no cue that I can now recall, someone suddenly said to me, “Do you ever take your kids to funerals?” Oddly enough, I had recently been wrestling with this issue, following the death of an aunt. I explained to the group why I had decided against taking my 3 sons to the funeral: they were very young and had not experienced any losses, not even the death of a pet. I did not think they were ready to deal with death. As the group became shrouded in shadows, the discussion became increasingly surreal. A disembodied female voice said, “You know, we take our kids to funerals. We do it all the time.” I replied that I had heard about that. “D’you know why we do it?” another voice challenged and, without waiting for a reply, continued, “You probably think we’re morbid. We’re not. Funerals aren’t for the dead; they’re for the living. When somebody dies, the whole community goes over to the house to let the family know they’re not alone. That’s why we take our kids. It’s never too early for them to learn that they have a duty to the community.”
Then came the final word: “That’s what we’ve been trying to tell you all afternoon. All those things you want to measure about kids have to do with them as individuals. One of the problems our kids have in your schools is that they’re taught that they have to compete to survive. We teach them that they have to be responsible to the community; that way, they’ll not only survive but so will everyone else. That’s what we mean by mental health.”
No amount of reading about Chippewa culture would have made either the revelation or the resultant action possible. The committee and I developed a new mental health scale, which we called Community Mindedness, and which has subsequently proved to have satisfactory psychometric properties (data not yet published).
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