CULTURAL NORMS

Passed from one generation to the next, cultural norms are the shared, sanctioned, and integrated systems of beliefs and practices that characterize a cultural group. These norms foster reliable guides for daily living and contribute to the health and well-being of the group. As prescriptions for correct and moral behavior, cultural norms lend meaning and coherence to life, as well as the means to achieve a sense of integrity, safety and belonging. Thus, normative beliefs, together with related values and rituals, confer a sense of order and control upon aspects of life that might otherwise appear chaotic or unpredictable.

Cultural norms are woven into interpretations and expressions of health and illness through dynamic, interactive relationships at all levels of influence—from the gene to the society. Cultural norms often mediate the relationship between ethnicity and health, even effecting gene expression through such practices as marriage rules, lifestyle choices, and environmental exposures. At the individual and group levels, cultural norms have a substantial role in health-related behaviors such as dietary practices, tobacco use, and exercise. Conversely, health can influence cultural norms, as illustrated by Jewish dietary laws governing kashrut (keeping kosher) that were an adaptive response to parasitic diseases centuries ago, yet are still widely practiced today.

Cultural systems, as adaptive tools, change in response to external cues, as evident in the transmutations that occur in norms as diverse groups interact and influence one another. Practices are also adapted to new environments as a response to immigration or technology, such as the genetic engineering of foods that may increase crop resistance to disease or drought and thus alter moral messages of crop failures. Such natural occur-rences may have been interpreted as due to retribution for transgressions against the social religious order of a society. Another instance may be greater size and weight of a group after one or two generations due to an abundance of food sources (e.g., meat, vegetables, and fruit) leading to cardiovascular disease or diabetes.

An individual or group's relationship to the contemporary Western health care system is steeped in cultural norms. Utilization patterns or adherence to treatment protocols may be mediated by a traditional orientation to health and disease, by particular conceptions regarding the authority of clinicians, or by what is considered acceptable communication between patients and practitioners. Cultural differences also affect the responsiveness of the health care system to diverse patient populations. Inequities in access to adequate/optimal health care are a major cause of health disparities among racial and ethnic minorities in the United States. While the extent is not known, many inequities in health outcomes are due to incompatabilities between the beliefs, values, and cultural norms of the growing minority population segments and the culture of Western biomedicine.

Public health research has yet to fully recognize the importance of such cultural norms for health outcomes or the need to question these relationships on a broad integrated scale. Consequently, the field of public health has little to guide practice in this regard. In fact, recognition of the considerable disparities in health status associated with racial, ethnic, and cultural diversity is relatively recent. One of the first comprehensive accounts of racial and ethnic disparities in health was published in 1986, in the Report of the Secretary's Task Force on Black and Minority Health (U.S. Department of Health, Education, and Welfare 1986).

Documentation of the extent and nature of health-status differences have improved, and research and interventions targeting ethnic minorities have increased since 1985. Still, public health policies and programs often fail to address cultural and ethnic differences—as distinct from racial differences—that are critical to the delivery of health care and to the promotion of health for many at-risk communities. These persistent disparities, coupled with extraordinary demographic growth in some of the most underserved populations, led to the 1999 President's Initiative on Race which notes the critical role of "culturally-sensitive implementation strategies" (U.S. Department of Health and Human Services 1999).

One barrier to improved understanding of the role of cultural norms in health is the common failure to distinguish between race, ethnicity, and culture. These concepts are often used interchangeably, implying that racial categories have scientific validity, and that one's membership in these homogeneous racial groupings has an overriding significance to health outcomes. Neither is true. The evidence indicates that variations within cultural, socioeconomic, and political groups have far more relevance to health behavior, risk, and status than differences between groups. Progress has clearly been made, however, since the "first generation" of health promotion studies conducted from the 1960s through the early 1980s. During this time, research focused on reducing health risks through interventions aimed at broad population segments—predominately at the white middle class. Little or no differentiation was made in terms of targeting different cultural populations.

In the late 1980s and 1990s, the "second generation" of health promotion studies were immersed in racial and ethnic group differences. These studies mainly focused on descriptive and intervention studies of African-American and Hispanic populations, but they showed little ability to distinguish universal from culturally specific factors, both because of the heterogeneity of these populations and the imprecise use of the concepts of race, ethnicity, and culture.

Current theories used to explain behavior and inform health-promoting interventions, however, continue to be founded on an assumption of universality (commonalities in human behavior across groups). This monocultural view of health behavior is based on Eurocentric cultural values of autonomy and individuality, as noted, for example, in the Patient's Bill of Rights (Annas 1998) and the Belmont Report (USDHEW 1979). This focus on individuality also frames how professionals are educated to provide care and how patients are expected to respond within the system. Yet these values are based upon a particular cultural construction of reality that is antithetical to many other cultures in which the needs of the group supersede the importance of the individual. This focus on individual autonomy is increasingly recognized as too restrictive to be valid or functional to predict behavior or to design effective interventions in cultural groups other than those for whom these theories and models were developed.

The need for a "third generation" of health-promotion studies has been suggested to elucidate similarities and differences through cross-cultural research that distinguishes among more meaningful subgroups based on cultural norms and other relevant shared characteristics. In this way, interventions to improve access to care and promote health could not only be targeted more precisely to those in need, but could be tailored to appropriate cultural norms, thus providing a greater likeli-hood of acceptability, relevance, and success. With increasing clarity in the role and nature of cultural norms as they relate to health, advances will be evident in public health interventions that recognize, respect, and respond to the similarities and differences throughout all segments of American society.

Marjorie Kagawa-Singer

Rena J. Pasick

(see also: Acculturation; Attitudes; Behavior, Health-Related; Biculturalism; Community Health; Cross-Cultural Communication, Competence; Cultural Appropriateness; Cultural Factors; Cultural Identity; Customs; Health Promotion and Education; Lifestyle; Predisposing Factors; Race and Ethnicity; Theories of Health and Illness )

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