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Despite its popularity, such freewheeling applications of culture cannot be presumed to be innocuous nor justifiable. We examined the concept of "culture," and more specifically "acculturation," in current literature on Hispanic health.3 We found that data interpretation in these articles commonly invokes widely held cultural stereotypes about Hispanics to explain health status. These studies almost never include indicators of the specific cultural traits in question, but instead assume that by knowing someone's ethnic identity or national origin, their beliefs and behaviours can reliably be inferred. But is this a reasonable assumption? What do we know, for example, about the family life of people who happened to choose "Mexican" or "non-Hispanic white" on a survey form? These groups are highly heterogeneous, and cultural beliefs and behaviours do not track well with ethnicity.4-6
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In attempting to interpret racial and ethnic variation in statistical data, otherwise rigorous health researchers seem mysteriously drawn to a complex and nebulous concept: culture. "Culture" has recently emerged in health literature as a common default explanation, especially in research on certain groups, such as Mexican Americans, who are popularly thought to be particularly culture-driven.
For example, Bridget Grant and co-workers1 recently examined data from a national survey of psychiatric disorders in foreign-born and US-born Mexican Americans and non-Hispanic whites. In an innovative approach, their analysis considers immigration status, producing interesting and unexpected findings. They report that immigrants, both Mexican and non-Hispanic white, have lower rates of psychiatric disorders than do non-immigrants, and that US-born Mexican Americans have lower rates than US-born non-Hispanic whites. To interpret these correlations, they follow what has become a popular trend in health research: they suggest that traditional Mexican culture somehow protects people of Mexican descent from ill-health. Specifically, they propose that because the traditional Mexican family is close-knit and supportive, it may provide a buffer from mental illness. Without any measure or observation of family life or familial structure, they conclude that their findings point to "what appear to be the protective effects of culture and the deleterious effects of acculturation". This is but one example of a common practice in current health research: to routinely attribute positive, negative, or neutral health-outcomes in ethnic minorities to traditional culture acting as a source of dysfunction or as a therapeutic panacea.2
Despite its popularity, such freewheeling applications of culture cannot be presumed to be innocuous nor justifiable. We examined the concept of "culture," and more specifically "acculturation," in current literature on Hispanic health.3 We found that data interpretation in these articles commonly invokes widely held cultural stereotypes about Hispanics to explain health status. These studies almost never include indicators of the specific cultural traits in question, but instead assume that by knowing someone's ethnic identity or national origin, their beliefs and behaviours can reliably be inferred. But is this a reasonable assumption? What do we know, for example, about the family life of people who happened to choose "Mexican" or "non-Hispanic white" on a survey form? These groups are highly heterogeneous, and cultural beliefs and behaviours do not track well with ethnicity.4-6
Attributing variable health-outcomes to unexamined cultural differences requires several major leaps of faith. We must first assume the cultural trait is significantly different between the subgroups; next that it co-varies with the presence or absence of the disorder being studied; and finally that the trait can affect the outcome in question. Although perhaps plausible, accepting such an explanation brings us far afield from the study itself. It would seem more parsimonious to seek insight about the observed correlations among variables included in the study, thus minimising the number of assumptions made.
When the income and educational status of the groups studied are radically different, as is often the case when comparing ethnic minorities to non-Hispanic whites, one might begin by considering more carefully the effect of class status.7 For example, rather than asking what there is about being Mexican that keeps people healthy, one might consider what there is about the better-educated higher-income non-Hispanic whites that might explain their greater morbidity. Or could it be simply the effect of middle-class culture? Are people in this group more likely to have experience with psychotherapy and thus be more conversant with the psychometric instruments used, more hyper-vigilant about their mental states, and more willing to discuss them with strangers? Although such an exercise might seem plausible and interesting, the filament of reality slips gradually further away, as the tale is spun further from the variables at hand.
But why have such fanciful tales about the nature and effect of Hispanic culture so readily and uncritically entered the common parlance of a genre otherwise committed to the rigorous measurement and modelling of carefully constructed variables? Health researchers, like everyone else, are subject to the influences of their society, their best efforts to be objective and neutral notwithstanding. Our society has a long legacy of stereotypes and prejudices about certain ethnic groups, and it is not at all surprising that, without critical vigilance, "cultural and social stereotypes and presumptions derived from historically specific folk notions of difference"8 find their way into the routine musings of health researchers studying minority populations. It is troubling when such ideas enter our public discourse cloaked in a mantle of scientific objectivity. While merely reflecting the social constructs carried by those who generate them, these ideas become elevated to the level of scientific concepts, and might serve to legitimise what are no more than unexamined stereotypes.
1 Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Anderson K. Immigration and lifetime prevalence of DSM-IV psychiatric disorders among Mexican Americans and non-Hispanic whites in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry 2004; 61: 1226-33.
2 Santiago-Irizarry V. Medicalizing ethnicity: the construction of Latino identity in a psychiatric setting. Ithaca: Cornell University Press, 2001.
3 Hunt LM, Schneider S, Comer B. Should "acculturation" be a variable in health research? A critical review of research on US Hispanics. Soc Sci Med2004; 59: 973-86.
4 O'Connor BB. Promoting cultural competence in HIV/AIDS care. J Assoc Nurses AIDS Care 1996; 7 (suppl 1): 41-53.
5 Harwood A. Acculturation in the postmodern world: implications for mental health research. In: Malgady R, Rodriquez O, eds. Theoretical and conceptual issues in Hispanic mental health. Malabar, Florida: Krieger, 1994: 3-18.
6 Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med 1999; 130: 829-34.
7 Krieger N. The ostrich, the albatross, and public health: an ecosocial perspective-or why an explicit focus on health consequences of discrimination and deprivation is vital for good science and public health practice. Public Health Rep 2001; 116: 419-23.
8 Stanfield JH. Methodological reflections: an introduction. In: Stanfield JH, Dennis RM, eds. Race and ethnicity in research methods. Newbury Park, CA: Sage, 1993: 3-15.
Linda M Hunt
Department of Anthropology and Julian Samora Research Institute, Michigan State University, East Lansing, MI 48824, USA
I declare that I have no conflict of interest.
Copyright Lancet Ltd. Aug 20-Aug 26, 2005