Cultural Reflexivity in Health Research and Practice

Abstract

Recent public health movements have invoked cultural change to improve health and reduce health disparities. We argue that these cultural discourses have sometimes justified and maintained health inequalities when those with power and authority designated their own social practices as legitimate and healthy while labeling the practices of marginalized groups as illegitimate or unhealthy. This “misrecognition,” which creates seemingly objective knowledge without understanding historical and social conditions, sustains unequal power dynamics and obscures the fact that what is deemed legitimate and healthy can be temporally, geographically, and socially relative. We use examples from research across multiple disciplines to illustrate the potential consequences of cultural misrecognition, highlight instances in which culture was invoked in ways that overcame misrecognition, and discuss how cultural reflexivity can be used to improve health research and practice.

The past decade of health research has been marked by a growing recognition of the broader social and environmental contexts in which individuals are embedded and how those contexts shape individual risk factors and health behaviors.^1–4 Part of this shift has been a renewed focus on culture, which is an umbrella term used to characterize the values, beliefs, and practices of social groups, most notably among racial minority and other marginalized populations.⁵ Cultural assumptions have informed the design and implementation of public health interventions and health care delivery.^6,7 They have also fueled larger social and political movements that seek to alter cultural practices perceived to be unhealthy. First Lady Michelle Obama’s Let’s Move! campaign to increase physical activity and healthy eating, former New York City Mayor Michael Bloomberg’s ban on large sodas, and health insurance mandates in the Affordable Care Act are notable recent examples of campaigns to change cultural practices. In a move that recognizes and capitalizes on this awareness of cultural practices that shape health, the Robert Wood Johnson Foundation, the nation’s largest health philanthropy, recently declared that building “a vibrant American culture of health” is the new centerpiece of their philanthropic priorities directed at reducing health disparities.⁸

Movements that invoke culture and cultural change as a means to improve health and reduce health disparities may have laudable goals. In this article, however, we wish to raise awareness about the power dynamics and potential consequences of using culture to understand behavior or to change behavior through policy and practice. The process of crafting and using seemingly objective knowledge without situating it in historical and social conditions is what the French sociologist Bourdieu called “misrecognition.”⁹ The practice of misrecognition sustains unequal power relations, because actors have different opportunities to exert their cultural authority, and, in turn, it obscures the fact that what is deemed legitimate and healthy can be temporally, geographically, socially, and culturally relative.

Drawing examples from research and practice in sociology, anthropology, public health, and medicine, we argue that discourses of culture can work to justify and maintain health inequalities when actors in positions of power and authority—researchers, politicians, public health advocates, physicians—designate and take for granted their own social practices as legitimate, natural, or healthy while labeling the practices of other groups, particularly those that are marginalized, as illegitimate, unnatural, or unhealthy. In addition to illustrating the consequences of misrecognition, we also present examples of culturally reflexive scholarship that can overcome misrecognition by invoking culture in contextualized and nuanced ways. We argue that such approaches are critical to understanding and ameliorating health disparities. We conclude by discussing how the lens of cultural reflexivity can be used to improve health research and practice.

CULTURE AND DISADVANTAGE: CAUTIONARY TALES OF MISRECOGNITION

History has shown that cultural explanations for the behaviors of marginalized groups can have the unintended result of stigmatizing those groups.^10,11 This can happen when cultural practices are characterized as divergent from a dominant culture (in which dominant refers to those in a majority group or in positions of power and authority), when practices and beliefs are stereotypically assumed to characterize all members of a group, or when those practices are abstracted from their structural and relational roots.¹² Even if researchers and practitioners take care to avoid the pitfalls of misrecognition, their work can still be interpreted in these ways when it enters public discourse and the policymaking agenda. We offer examples of these adverse consequences related to the culture of poverty, medical education and clinical care, and public health campaigns.

Culture and Poverty

A well-known example of the pitfalls of misrecognition comes from Lewis’ work on the culture of poverty. Drawing from his ethnographic work in Mexican slums, Lewis argued that long-term exposure to poverty generated a subculture with a common set of attitudes, values, and practices (e.g., frequent violence and a neglect of planning for the future). Once in place, “the subculture develops mechanisms that tend to perpetuate it, especially because of what happens to the world view, aspirations, and character of the children who grow up in it.”^13(p199) As a result, Lewis argued that subcultures of poverty tend to persist even if economic conditions improve.

This argument was popularized in the US context during the 1960s in both scholarly and political discourse surrounding poverty and racial disadvantage.^5,11,14 Most famously in the Moynihan Report (The Negro Family: The Case for National Action), Moynihan et al.¹⁵ argued that the African American family was caught in a “tangle of pathology” characterized by crime and delinquency, nonmarital childbearing and divorce, and a general withdrawal from society. Moynihan provided a perhaps more balanced perspective than Lewis, by acknowledging the structural roots of disadvantage among African Americans. However, like Lewis, he argued that culture “now served to perpetuate the cycle of poverty and deprivation.”^15(p30)

Two lessons can be gleaned from the culture of poverty debate. First, scholars did not study these marginalized populations closely enough or with enough empirical rigor; they did not attempt to understand the logic behind the cultural practices they observed or the relational contexts that produced them. Instead, they assumed that people in poverty shared a common culture, and that the culture was characterized by values that diverged from those in the dominant culture. Subsequent research would reveal that there is no single “culture” for the poor (or indeed, for any group), and that most members of poor and other marginalized groups hold values that are quite similar to those in the dominant group.^5,16 Furthermore, subsequent research found that rather than contributing to a “vicious cycle” of poverty, some cultural practices associated with urban poverty were actually adaptive responses to pervasive structural disadvantages.¹⁷ The second lesson is one of unintended consequences. Many of the scholars who studied the culture of poverty were in positions of power (public intellectuals and politicians); therefore, their misrecognition of the meanings and reasons for the cultural practices they observed were influential in shaping both public perception and policy. Thus, their work fueled political arguments that policy interventions to address poverty were neither justified nor likely to succeed because the poor experienced problems of their own making.¹⁸

Culture and Health

Just as the culture of poverty literature emphasized enmeshed beliefs that reproduced poverty, public health campaigns have also emphasized beliefs in efforts to reduce health disparities. Although they may not label it as “culture,” per se, campaigns tend to frame health as lifestyles that dispose individuals to specific good or bad health behaviors.^19–21 This conception of health implies that health is about what people do and what they decide, obscuring the many ways in which health is produced independent of individual behaviors, overlooking how opportunities are restricted in some environments, and legitimizing the behaviors of those in positions of cultural authority while devaluing the behaviors of marginalized groups. For example, campaigns to change diet to reduce obesity have not always considered how local food environments structure food access, or the ways chronic stress associated with racism and material disadvantage can affect dietary habits and food metabolism.^22,23 In turn, the focus on reducing and preventing obesity can result in stigmatizing poor and minority groups in whom obesity rates are higher.²⁴

Similarly, public health campaigns have fought to reduce adolescent pregnancy in low-income minority communities as a way to improve infant and child health. Geronimus,¹² Puhl and Heuer,²⁵ and Geronimus and Korenman²⁶ argued that these campaigns are rooted in dominant (i.e., White middle class) cultural values rather than in empirical data, which, contrary to the claims of those who emphasize poor choices on the part of adolescents, suggest that young motherhood, independent of other factors, may not be associated with poor child outcomes. Furthermore, these campaigns tend to focus on the proximate behaviors associated with pregnancy (e.g., contraceptive use) and fail to recognize the structural and relational factors that contribute to contraceptive use and early fertility timing in disadvantaged areas. For example, in communities where chronic health conditions are common at young and middle ages, and where opportunities for economic advancement are slim, early pregnancy may be a logical and adaptive practice.^12,25

A third example highlights the challenges of translating cultural research into clinical settings. The medical anthropologist Kleinman recently reflected on his own unwitting contribution to problems in medical education and clinical care by promoting the role of culture in the illness experience. Kleinman²⁷ distinguished the “illness experience” from mechanistic disease processes, and emphasized the strong cultural shaping of that experience. Medical educators often reduced this notion to specific culture-bound syndromes and stereotypes of how values and norms of particular groups led to specific clinical presentations. Kleinman reflected that

what was meant to humanize care by providing room for lay voices and practices appeared instead to be reducing complex lives to limiting, biased stereotypes. . . To make matters worse, certain aficionados fetishized the illness narratives, divorcing meaning from economic, emotional and relational contexts and lived experiences of suffering.^27(p1376)

Because of the power that physicians and other health care providers have to medicalize certain behaviors, turning them into the very definitions of health and ill health, a high degree of skepticism and nuance is required when public health campaigns speak about and act on cultural practices related to health.²⁸

CULTURAL REFLEXIVITY IN HEALTH RESEARCH AND PRACTICE

Putting culture into context requires that researchers and practitioners pay close attention to local practices, social interactions, and shared meanings. By spending time with people and trying to understand them on their own terms, they observe how social actors make sense of and inhabit their environments. They observe what individuals do, the symbols and meanings they value and share, and the beliefs, speech patterns, rationalities, and frameworks that resonate in certain groups and places.^29,30 Culture, however, does not exist separately from social structure. As our following examples reveal, history, economic resources, institutions, geography, threats of violence and community disruption, and other factors interact with local behaviors and meanings. Understanding culture in this textured, nuanced, and structurally situated way—what we call cultural reflexivity—can reveal the contradictions of culture, its internal variability in particular places, and the external conditions that enable, constrain, and transform local cultural arrangements.

The lens of cultural reflexivity is central to inquiries about how and why people act in certain ways and not others. The examples in the previous section highlighted how those in power develop perspectives and practices that can stigmatize and pathologize the behaviors of marginalized groups. Instead, by situating individuals within their immediate social worlds, scholars can make sense of how people understand their predicaments and engage with their surroundings on their own terms, thus offering more complex answers to difficult questions like: Why do mothers living in conditions of extreme deprivation in a Brazilian shantytown neglect their children in ways that seem to contribute to high rates of child mortality? Why do homeless drug abusers in San Francisco, California, face high rates of HIV and other transmittable diseases, yet still share needles and other paraphernalia? Why do families remain in neighborhoods exposed to toxic pollution despite visible evidence of poor health in kin and neighbors? Researchers have utilized reflexive, locally situated notions of culture to tackle these difficult questions.

For example, Scheper-Hughes studied the tension between maternal love and child death in a Northeastern Brazilian community of Alto do Cruziera, a place that in 1965 had only 5000 inhabitants but more than 350 child deaths, and in 1987, had a 23% child mortality rate.³¹ Based on years of engagement with the area in many different roles, from Peace Corps volunteer to community development worker and eventually engaged friend and ethnographer, she witnessed, over a period of decades, a level of parental neglect that was disturbing to her. In the context of poverty, extreme malnutrition and a pervasive uncertainty of child survival, she saw an absence of maternal instincts and attachments that are believed to be culturally universal. Child death had become such a normal part of everyday life in Alto do Cruziera that mothers had learned to distinguish between thriving and weaker children, prioritizing love and meager resources for the former, while allowing the latter to succumb to their presumably inevitable fate as “angel babies” who were subsequently buried with little fanfare or mourning.

The abandonment and neglect that Scheper-Hughes observed was so extreme that it could easily provoke moral outrage. However, her anthropological training taught her analytical objectivity and provided tools to uncover how local rationalities and ethics take hold in specific places and under particular scenarios. She broadened the scope of her research to take into account the intersection of structure and culture to better understand how and why conditions of severe deprivation, violence, and death make certain actions and reactions possible. She was able to couch her ground-level findings in the history and formation of the place, its relationship to the sugar plantation economy, threats of drought and limited water access, as well the medicalization of hunger, where babies diagnosed with “nervos” were treated with tranquilizers instead of food. Overall, Scheper-Hughes was able to make sense of the conditions in which people expect children to die and assume that “infants and babies are easily replaceable or that some infants are born ‘wanting’ to die.”^31(p20)

This suspension of moral judgment, focusing on how people and their relationships are produced from their surroundings, is fundamental to understanding how culture works. In their decade-long study of homeless heroin addicts in San Francisco, Bourgois and Schonberg described their own efforts to

strategically suspend moral judgment in order to understand and appreciate the diverse logics of social and cultural practices that, at first sight, often evoke righteous responses and prevent analytical self-reflection.^32(p7)

Spending years on the streets, living and working in a community of homeless addicts, Bourgois and Schonberg learned to see the world from the addicts’ points of view. They found that addicts’ street behaviors were not simply “self-destructive or immoral,”^32(p82) but rather they resulted from shared methods and local meanings of survival, which included figuring out how to find, pay for, and exchange health-endangering drugs. Physical addiction meets economic deprivation in this highly constrained “moral economy” of street survival.

However, the account by Bourgois and Schonberg is also revealing in an additional way. They untangled the tensions between the homeless moral economy and broader public health campaigns. The homeless were regularly advised by health care workers about sanitary drug use, such as the dangers of sharing needles and the importance of cleaning cookers with bleach. However, these campaigns overlooked the centrality of the local context, and the fact that from the perspective of homeless addicts, sharing—both sharing residue from cookers and used needles with others—was considered ethical and even central to building local reputations as generous users under constrained conditions. Bourgois and Schonberg were able to see how harm-reduction specialists in the fields of medicine and public health made “rational” knowledge available that relied on widespread assumptions about “disciplined” selves, but “fail[ed] to address the constraints on choice that shape need, desire, and personal priorities among the indigent.”^32(p106)

The tensions between distinct worlds of knowledge production can lead to distrust, because hierarchical relations often put people and places at odds. The formation of local community knowledge and the distribution of professional or state-produced knowledge about health and wellbeing can result in misrecognition of pervasive social problems. Another example is found in a Buenos Aires shantytown called Flammable, studied by Auyero and Swistun over many years.³³ There, residents lived in the shadows of major petrochemical companies that polluted the area. However, local residents, aware of pervasive health problems of friends, neighbors and family, were also constrained by the contradictions they saw in the distribution of information. Although they had long-standing pride and loyalty to their local community, they also received competing advice from doctors, lawyers, state representatives, and plant managers about the dangers they faced and who was to blame. The result was a recurring local culture of confusion, which Auyero and Swistun described as “toxic uncertainty,” that led residents to ignore and even to misidentify commonplace health problems resulting from exposure to high levels of lead, cadmium, and other harmful chemicals; it also hindered meaningful social organization or protest.

IMPLICATIONS FOR HEALTH RESEARCH AND PRACTICE

Some common pitfalls can occur when culture is taken for granted by health researchers and professionals who have authority to classify and explain the behaviors of marginalized groups. First, they tend to ignore cultural practices that are locally produced (often in the context of material deprivation), social ties that are unobserved by outsiders, and other forms of social disadvantage. Second, they forget that the types of practices they advocate as legitimate and normal are not absolute truths, but are locally produced, reflecting the viewpoints of those in positions of cultural and institutional authority that can change over time or across places. These conceptual shortcomings can easily result in attaching moral value to particular cultures and devaluing others. Awareness of these shortcomings can lead to more effective interventions from public health professionals and better care from health care professionals. In the following, we illustrate several promising avenues for action.

Foster Research–Practitioner Partnerships

Health practitioners have limited time and usually only see patients in one context, typically a health care setting. Partnerships with researchers who are “in the field” with the patient population can yield new insights that lead to more effective interventions. Rather than describe and label practices such as child abandonment, needle sharing, or remaining in a toxic environment as “pathologies” because they do not fit with the cultural logics of those in socially advantaged positions in society, researchers like Scheper-Hughes, Bourgois and Schonberg, and Auyero and Swistun dug deeper into the multiple contexts that enabled and constrained the actions and interpretations of those they studied. By suspending their own cultural conceptions of right and wrong, these researchers found that seemingly pathological cultural practices made sense in the context of local social structures and illuminated the broader systems of inequality that created such structures.

Such work can have concrete benefits for health practitioners. For example, Bourgois and Schonberg discovered that the heroin in San Francisco generated soft-tissue infections, and the resulting abscesses were the main reasons for admissions to local emergency departments (which were unaware of this because they did not tabulate data on such infections). There was no national standard of care for infections caused by injection drug use, and the patients complained of extremely invasive procedures that led them to treat their own abscesses and delay seeking medical attention, ultimately resulting in long and expensive hospital stays.³⁴ A connection between Bourgois and Schonberg and a local physician led the medical community to discover for themselves that injection drug users’ fears of doctors’ mutilating procedures were leading them to delay seeking medical care. The hospital transitioned to a simple outpatient incision-and-drain procedure for most cases, which decreased hospital admissions for the infections by a third, reduced operating room procedures by more than two-thirds (saving approximately $9 million dollars), and improving patient satisfaction.³⁵

Partnerships between researchers and practitioners can be institutionalized through the development of specific curricula in medical education on socially vulnerable populations that include social scientists who are “in the field” as teaching staff. They can also be formalized by integrating researchers (and other persons embedded in the community) into medical practitioners’ case conference presentations and discussions of practical clinical strategies. For example, one San Francisco hospital now routinely brings in an “attending anthropologist.”³⁶

Promote Cultural Health Research

Health researchers should consider formal qualitative components to their research projects. Mixed-methods designs have the potential not only to uncover what works (or does not work), but why such findings occur and how they fit within the broader contexts of patients’ lives. Qualitative research projects can serve as pilot studies that inform larger quantitative studies; they can occur concurrently to explain quantitative findings as they unfold, or they can occur as standalone endeavors.³⁷ Such research designs have become increasingly popular for evaluating social policy interventions for government assistance programs.³⁸ This approach could be translated productively to health and health care research as well.^39,40

One challenge to such qualitative research designs is obtaining funding. Health researchers and professionals should advocate higher funding priorities for qualitative and other culturally sensitive research. (Certain nonprofit funders, such as the Robert Wood Johnson Foundation, have started to do so.⁴¹) A related challenge is that funding agencies often do not know how to evaluate qualitative research designs. Progress has been made on this front among some funding organizations; for example, the National Science Foundation has developed standards for evaluating qualitative research and included more qualitative researchers on review panels.⁴² Such developments could be extended to the funders of health research.

Look for Syndemics

Although traditional biomedical perspectives tend to treat diseases as distinct, there is growing recognition that certain diseases tend to cluster, and to interact with one another, within particular populations.⁴³ Examples of such syndemics include diabetes–infection linkages; substance abuse, violence, and AIDS⁴⁴; hookworm, malaria, and HIV/AIDS⁴⁵; asthma and infectious disease⁴⁶; malnutrition and depression⁴⁷; and multiple sexually transmitted infections.⁴⁸ Looking at the clustering and interactions of disease can point to common social conditions that make them more likely, although here, too, the risk of inferring a simple culture story is high.

For example, Singer et al.⁴⁹ used qualitative life history and focus group methods as part of a 5-year mixed-methods study to explain the existence of a sexually transmitted disease syndemic among low-income African American and Puerto Rican young adults in Hartford, Connecticut, and Philadelphia, Pennsylvania. They found that respondents were pessimistic about the long-term commitment of their romantic relationships because of multiple overlapping economic and personal disadvantages. This led them to “hedge their bets” by having multiple partners over relatively short periods of time. Furthermore, the use of contraception was seen as a sign of mistrust; sexual partners signaled commitment to their relationships by desisting contraceptive use.^50–52

Although sexually transmitted disease and pregnancy prevention efforts have successfully taught participants about condom use,⁵³ the research by Singer et al. suggested that the relationship contexts of condom utilization raised continuing opportunities for disease transmission and pregnancy that education and informational campaigns did not adequately address. This example illustrates how a cultural lens can explain why health conditions coexist and why behaviors may not change in response to informational campaigns or to increased access to health-promoting resources. A more nuanced understanding of structural conditions and social relations also raises the possibility that behavioral change may not be desirable: once local meanings and rationalities are understood, some behaviors can be seen as rational and adaptive, especially when understood in the context of structural conditions or socioeconomic realities.

Build Connections Across Institutions

If health conditions are rooted in broader social systems, another way to expand the context of health delivery is to build connections with other institutions that are intertwined with the patient population. These connections will foster more effective interventions than an agency simply targeting what it perceives as individuals’ poor decision-making. For example, the Camden Coalition of Healthcare Providers identified that a small number of patients used a disproportionate amount of health care.⁵⁴ Recognizing that readmissions and chronic conditions were fundamentally tied to issues of poverty, housing instability, and inadequate social support, they developed a care management program that targets “super utilizers” with intensive case management services, including social workers and community health workers, and links medical care with social service provision.⁵⁵

This intervention is currently being evaluated in a randomized control trial and being expanded to additional cities.⁵⁶ Other potential institutional connections include jail and prison populations, contraceptive and reproductive health organizations, and nonprofit housing agencies.

Empower Patients and Communities

The authority to classify certain cultural practices as legitimate is linked to institutional power, and health care practitioners have the unique power to classify illness, disease, and health. Rather than assume we know why people engage in “unhealthy” practices or what is best for patients, we should actively question our own assumptions. A culturally reflective perspective acknowledges that our understandings of patients reflect the current cultural practices of those in authority positions, and potentially misrecognizes the reasons why some social groups do not adopt practices that we perceive to be healthy. Building on the idea of a patient-centered care model, including patients’ voices and perspectives in the decision-making process has the potential to offer more effective (and potentially more cost-effective) interventions and treatment options.^57,58 Likewise, community-based health promotion campaigns can employ participatory approaches that incorporate the voices of community members and are sensitive to the health constraints that affect their day-to-day lives.⁵⁹